lectures" ON THE THEORY AND PRACTICE PHYSIC. BY JOHN BELL, M.D., Member of the American Med. Association, and of the Med. Soc. of the State of Pennsylvania , Fellow of the College of Pliysiciansof Philadelphia; Member of the American Philosophical Society, and of the Georgofili Society of Florence, etc., etc. AND BY WILLIAM STOKES, M.D., "/ Lecturer at the Medical School, Park Street, Dublin; Physician to the Meath Hospital, etc., etc. FOURTH EDITION, REVISED AND ENLARGED. IN TWO VOLUMES. VOL. II. PHILADELPHIA: ED. BARRINGTON AND GEO. I). HASWELL. 1848. [Entered, according to Act of Congress, in the year 1848, by Barrington and Haswell, in the Clerk's office of the District Court for the Eastern District of Penn- sylvania.] WPj CONTENTS OF VOL. II. DISEASES OF THE RESPIRATORY APPARATUS. LECTURE LXXXIV. DR. BELL. More satisfactory diagnosis of Thoracic Diseases in late years — Auscultation and Percussion—Auscultation properly includes percussion—Its application to diag- nosis—Laennec the father of auscultation—The physical laws from which it is de- duced—Chief sounds elicited by the pulmonary apparatus: I. During respiration: II. By the voice: III. By coughing : IV. Those of an adventitious kind.—The first class, or the Respiratory, subdivided into two orders, the simple and the compound— The simple includes the respiratory or vesicular sound or murmur, also called puerile respiration, the bronchial and tubal or blowing, the cavernous and the amphoric—Origin and diagnostic value of these sounds—The compound sounds, or rhonchi, are moist and dry—of the moist are the mucous or moist bronchial, cavernous, sub-mucous and humid with continuous bubbles—These explained—Cr.pitant or moist crepitant, sub-crepitant, or rhonchus redux, cavernous—Pulmonary crumpling sounds—The dry rhonchi are classed under the head of sibilant and sonorous—Explanation of these terms—II. Vo- cal Auscultation gives natural and morbid bronchophony, also cegophony, pectoriloquy and amphoric resonance—III. Sounds in Coughing—The bronchial, cavernous and amorphic, and metallic tinkling—IV. Adventitious Sound—These are friction sounds, viz: the grazing, friction proper and grating—Table of morbid phenomena of respira- tion coexisting with inspiration and expiration—Sounds of the heart and vascular murmurs modified by the 9tate of the Iung3—Theories of M. Beau and Dr. Skoda—M. Beau's views of resonance explained—Objections—Dr. Skoda's views of consonance applied to vocal sounds—His division of the sounds in respiration—Stethoscope, and manner of conducting auscultation . ■ . • . .25 LECTURE LXXXV. DR. BELL. Physical Diagnosis of Pulmonary Diseases (Continued).—Percussion—Denned— Avenbrugger its discoverer for diagnosis in thoracic diseases—Corvisart—Piorry— Two varieties, immediate and mediate—Mode of using immediate percussion—Divi- sions of mediate percussion—Plexirneter—Substitution for it of a finger or fingers —Chief percussing agents, a hammer and the fingers—Directions for mediate percus- sion—Percussion of the chest—Different regions in which it is practised—Postures of the patient and physician in percussing the different thoracic surfaces—What found on percussion—A verifying of different states of the lungs and pleural cavity—Diffe- rent sounds in different regions of the chest—Two chief divisions of sound on percus- sion of the chest, viz., increased sonorousness and diminished sonorousness or dulness— Auscultatory percussion—Autophonia—Succussion—Inspection—Measurements—In- struments for—Two sides of the chest seldom quite symmetrical—Comparison—Value of comparison—Application of, to diseases of the chest—Sources of physical diagnosis —Improved diagnosis not always immediately productive of improved therapeu- tics .......... 39 LECTURE LXXXVI. DR. BELL. Diseases of the Respiratory Apparatus—Extensive operation of the causes of these diseases and large number of persons exposed to them—Chief causes; atmospherical vicissitudes and neglect of hygiene—Community of causes affecting the several parts iv CONTENTS. of the air-passages, and community of organic function and morbid action of the mu- cous membrane lining these passages—Inferences from the study of the diseases 01 one part applicable to those of the other parts—Division of the diseases of respiration into three heads : those of the air-passages; of the parenchyma of the lungs; ana of the pleura or serous envelope.—Coryza—Its synonyms—Divisions—simple and ulcerative—Varieties of the simple; acute and chronic—Acute coryza—■Anatomical characters—Symptoms—Local for the most pari, sometimes general superadded—-Ex- tension of inflammation to adjoining parts of the mucous system—Coryza in infants —its dangers —Consecutive coryza —Progress —Diagnosis — Prognosis—Causes— Treatment— Modifications in acute coryza.—Oz^na, the ulcerative species of coryza— Fetor not a distinctive feature—Anatomical characters—Symptoms—Progress—Diag- nosis—Distinction between ozeena and polypus—Inspection and exploration—Etiology —Cases—Treatment—Local and general . . • • • .47 LECTURE LXXXVII. DR. BELL. Laryngitis, or Cynanche Laryngea—Its varieties—Erythematic Laryngitis—General mildness of the disease and simplicity of its treatment—Catarrhal Laryngitis—Chiefly dangerous in infants—Its treatment—Acute Edematous or Sub-mucous Laryngitis—A most formidable disease—Its symptoms—Respiration and deglutition both affected ; and afterwards the cerebral functions—Duration—Edema of the glottis not a separata disease—Two varieties of acute laryngitis established by Cruveilhier—Is not of fre- quent occurrence—Treatment actively and speedily antiphlogistic—Venesection— General Washington'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 laryngotomy—Mortality from acute laryngitis . . . . .53 LECTURE LXXXVIII. DR. BELL. Laryngitis Membranacea—Croup—Anatomical peculiarity characteristic of the dis- ease; lymphatic exudation in a membranous form in laryngeal inflammation—Phlo- gosis extends to trachea and bronchiae; 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—referable to locality, states of atmosphere, and age of the pa- tient—Seasons in which it prevails—Mortality from croup in New York, Philadel- phia, and Boston—Epidemic croup—Age at which croup is most common—Propor- tion 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—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 stimu- lating and anti-spasmodic expectorants; blisters, epithems, etc. . . 62 LECTURE LXXXIX. DR. BELL. Therapeutical Action of Tartar Emetic and of Calomel in Croup—Practitioners who have employed calomel—Venesection—its advocates—Leeching—Expectorants; 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 useful, 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 con- founded with the hot bath—The arm-bath—Antispasmodics ; the bestanti-spasmodics, venesection, tartar emetic, calomel, and the warm bath ; opium, and afterwards assa- fcetida, camphor, &c.—Topical remedies; blisters—when and where to be applied__ Stimulating liniments—Cauterization of the fauces and pharynx—Tracheotomy.__La- ryngismus Stridulus; not identical with spasmodic croup as often met with__De- scription 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—Prevention . . . .80 CONTENTS. V LECTURE XC. . DR. BELL. Chronic Laryngitis—Its synonyms—Idiopathic and symptomatic—Morbid Anatomy— Applicableness of the title, laryngeal phthisis.—Large proportion of ulcerations in the epiglottis, larynx, and trachea, in phthisical subjects—Symptoms: sensations, voice, aphonia, cough, breathing—Different species of chronic laryngitis,—a know- ledge of, necessary for prognosis and treatment—Examination of the fauces and pharynx—To determine the state of the lungs : auscultation, percussion, and expecto- rated matter—Duration of the disease—Causes: age, sex, prior disease, vocal strain,— Peculiar exposure of clergymen, — atmospherical vicissitudes, habits — Complica- tions . . . • . . . . . .96 LECTURE XCI. DR. BELL. Treatment of Chronic Laryngitis—Rest of the vocal apparatus—antiphlogistics— counter-irritants,—narcotics, mercurials, iodine, sarsaparilla, balsam of copaiva, blue mass and syrup ofsarsaparilla, sulphurous waters—Topical remedies; inhalation of simple and stimulating vapours; caustic to the parts—The author's own experience— Attention to anginose complication—Syphilitic chronic laryngitis ; mercurials, sarsa- parilla; iodine—Tracheotomy, when proper—Change of climate—attention to the digestive organs—Prophylaxis—Clergymen,—rules for their guidance—Uniform tem- perature of air—Jeffray's Respirator ...... 104 LECTURE XCII. DR. BELL. Bronchitis—Its complications with other diseases—Catarrh, a prelude to more serious disease—Importance of early attention to it—Outlines of the treatment of catarrh— The dry method of Dr. Williams—Bronchitis.—its divisions—Asthenic variety—The kind showing itself in young children, ox capillary bronchitis—Duration of acute bron- chitis—Symptoms,—appearance of the sputa—Physical signs — Percussion, indi- rectly useful—Touch, giving a sen3e of vibration—Auscultation—Modifications of sound, produced by inflamed and obstructed bronchiae—Morbid Anatomy—Causes 114 LECTURE XCIII. DR. BELL. Treatment of Acute Bronchitis—Venesection not to be pushed far—Purgatives— Emetics, of doubtful value in acute bronchitis—Tartar emetic, as a counter-stimu- lant—Rules for its use—Immediate effects various—Case—The warm bath—pedilu- vium—Blisters and other counter-irritants to the chest—Calomel in bronchilis com- plicated with abdominal disease; to which are added opium and ipecacuanha—Second stage of bronchitis, with symptoms of debility—Stimulating expectorants useful ; car- bonate of ammonia, wine whey, senega, acetate of ammonia—Calomel and a few cups, with stimulants, for congestion of a part of the lung—Diaphoresis without diaphore- tics—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—Outlines of treatment—Complications of acute bron- cliitis—Bronchitis with remittent fever, in the typhoid stage—Cooling remedies useful—Depletion and stimulation sometimes necessary at one time—Inhalation of watery vapour—Change of posture—Quinia and laudanum, for excessive bronchial secretion—Dr. Graves's practice—Sugar of lead .... 123 LECTURE XCIV. DR. BELL. Chronic Bronchitis—Description of—Expectorated matter—pus with hectic fever— Difficulty of diagnosis of chronic bronchitis with purulent expectoration—Morbid Ana- tomy—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, &c.—Treatment, modified by cause—Venesection not often required— Local bloodletting preferable—Purgatives—Antimonials—Calomel or blue mass, with VI CONTENTS. ipecacuanha and hyosciamus—Colchicum and digitalis—Iodide of potassium—Ionics with the balsams—Compound syrup of sarsaparilla with iodine or iodide of iron Counter-irritants to the chest—Inhalation of various vapours—Modification of treat- ment in complicnted chronic bronchitis—Visits to mineral springs—Change of air and climate—Prevention of chronic bronchitis . "2 LECTURE XCV. DR. BELL. Effects of Bronchitis—Nan-owing of the Bronchia—Causes—Symptoms—Obliteration of the Bronchice—Dilatation of the Bronchia—Organic changes in the tubes and air- cells—Thickening, the first change—Duration and Progress—Symptoms—Difficulty of inspiration—Obliteration of the hronchiae with shrunken pulmonary tissue—Dilatation of the bronchia? may occur very early in life—Prior diseases—Symptoms analogous often to those of phthisis pnlmonalis—Diagnosis between these two diseases—Its great difficulty—Causes—Treatment,—nearly the same as for chronic bronchitis— Ulcers of the Bronchice.—Dilatation of the Air-cells—Pulmonary or Vesicular Emphysema—Dilatation and rupture of the air-cells—Symptoms equivocal—Disease often begins in early life,—Constitutes a variety of asthma.—Influenza—Epidemic Catarrh—Epidemic Bronchitis—Closely resembles common bronchitis—Exhibits the same features, complications, and alterations—Seasons for its appearance—Is met with at all seasons—Its reputed terrestrial origin—Supposed to depend on a particular poison—Objections to this view—Treatment—Regulated by the same principles and consisting of the same remedies as'common bronchitis of the season . . 145 LECTURE XCVI. DR. BELL. Bronchial Congestion—Dry Catarrh—This with pulmonary emphysema constitutes mainly asthma—Treatment—Mild aperients, alteratives—The alkalies—Regulation of diet.—Asthma—Its proximate cause—Remote and exciting ones in general—Varie- ties compounded of the nervous and congestive—Symptoms—Designation by the term spasmodic unnecessary—True asthma always implies spasm—Organic seat and ana- tomical lesions seldom ascertained—Causes enumerated—Treatment—To vary with the complications of other diseases with asthma—Bloodletting sometimes necessary__ Emetics—Mild laxatives with narcotics—Remedies during the paroxysm—Stramo- nium extract the best—Counter-irritants—To prevent a return—Tonics, change of air, and bathing, and use of sulphurous waters—Grinder's Asthma . . 158 LECTURE XCVII. DR. BELL. Pertussis : Hooping-cough—Its double connexion—with the respiratory and with the nervous system—Analogous to asthma—Symptoms—Duration—-Two periods__the pre- cursory or catarrhal and the convulsive or hooping—Value of auscultation during the interval—Causes—Contagion the commonly recognised exciting cause__Predisposi- tion by early life—in girls more than boys—Complications—Bronchitis the most fre- quent—Morbid anatomy,—not clearly defined—Nervous origin probable—Diagnosis- Treatment—To be useful should be early and decided—Antiphlogistics followed by narcotics and anti-spasmodics—Counter-irritants to spine—Change of air__Vaccina- tion—Attention during the paroxysm.—Summer Catarrh—Summer Bronchitis- Is not different from bronchitis of other seasons, except in its more strict periodicity —Outlines of treatment—Probable prophylaxis . . . ig^ LECTURE XCVIII. DR. BELL. Hemoptysis—May be called bloody secretion—Is idiopathic or secondary; the last variety most common—Active and passive—Structural changes—Causes,__'ao-e inhe- rited predisposition, certain employments, atmospheric exposures, plethora comnres" sion of the chest—Tubercular diathesis and disease the most frequent cause__Next to this diseases of the heart—Hemoptysis often vicarious—Apoplectic congestion of the lungs, an effect from a common cause—Explanation of its origin—Sifrnvtoms— Quantity of blood discharged, variable—The physical signs few—Progress—Dias-nos ' Expectoration — Percussion — Anatomical characters—Symptoms and diseases precursory of pneumonia—Commonly the disease attacks suddenly—Is preceded sometimes by intermittent fever and cholera, measles, rheumatism and gout —follows surgical operations—Progress of sthenic pneumonia—Sudden sinking—■ Case—Prognosis and Termination—Critical evacuations and critical days—Age modi- fies results—The old and young most apt to sink under pneumonia—Part of the lung most liable to inflammation—Which side most affected—Complication with other dis- eases increases danger—Causes—External and internal—Climates and countries in which pneumonia prevails 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—Inter- nal causes—Liability of the disease to return in the same person—Tuberculous phthi- sis—ige—Young children most liable—Sex—Men much more liable than women— Treatment—Great mortality in pneumonia—Contradictory reports of different modes of treatment ..... ... 200 LECTURE CI. DR. BELL. Treatment of Pneumonia—Superiority of venesection over all other remedies—Extent of its use and frequency of repetition—Not to be deterred by the fear of interfering with critical evacuations—Circumstances which modify bloodletting—Original strength of constitution ; complication of pneumonia with other diseases—Bloodletting in the pneu- monia of infants—Purgatives—Tartar emetic—Laennec's and Louis's advocacy of— Mode and rule for using it in infantile subjects—Calomel—Revulsives and counter- irritants—Drinks ........ 210 LECTURE CII DR. BELL, Treatment of Pneumonia (Concluded)—Opium and other narcotics—Depression to be met by stimulants and mild tonics—Treatment of complications—Bilious pneumonia —Tartar emetic in their case—Regimen and drinks in pneumonia—Convalescence— Cautions requisite in—Typhoid Pneumonia—Its epidemic prevalence—Predisposing causes—Symptoms—Treatment—Depletion less used, and stimulants more freely—Com- plications to be attended to—Chronic Pneumonia—Physical signs of—Caution against much depletion in—Edema of the Lungs—A secondary disease—Symptoms and treat- ment . ....... 217 VUl CONTENTS. LECTURE CIII. DR. BELL. Phthisis Pulmonalis—Difference between phthisis and the phlegmasia? of the respi- ratory apparatus—Universality and continued prevalence of phthisis—Fearful mor- tality from the disease—Appearance of tuberculous lungs—Tubercle, its distinguish- ing anatomical trait.—Natural History of Tubercle—Its Origin and Growth De- rived from the blood—Deposited in the pulmonary cells and parenchyma—Envelopes the tissues, which preserve their normal character—Tubercles take the form of the tissues in which they are imbedded—They do not grow, in the physiological sense— Different appearances of pulmonary tubercles—Grey and yellow—Grey tubercles the most common—Miliary granulations the supposed primary form of tubercle—Changes in grey tubercle from slight causes—Appearance and characters of yellow tubercle— Frequent coexistence of the grey and yellow varieties—Grey semi-transparent granu- lations—Originate at an advanced period of phthisis—Grey semi-transparent matter does not always appear under the form of granulations—Mode of distribution of tuber- cle in the lunjjs—Miliary tubercles,—aggregated tubercles,—tuberculous infiltration— Structure and Elementary Composition of Tubercle—Resemblance between the genera- tion of tubercle and the formation of normal tissue—Dr. Wright's description—Vo- gel's additional remarks—Constant elements of tubercle,—molecular granules, adhe- sive hyaline mass, and peculiar tubercle-cells—Chemical composition—Seats of Tuber- cle—Upper lobes of the lungs most affected—Stages of or Changes in Tubercle—Of crudity, of softening or elimination and of ulceration or cavity—Maturation preceding softening—Vomica—Successive changes of tubercle described . . . 230 LECTURE CIV. DR. BELL. Phthisis Pulmonalis (continued)—Organic relations of pulmonary tubercles to contiguous and surrounding parts — Their vascular relations — Changes in the lungs caused by tubercles—Bronchitis, pneumonia, pleurisy, and pneumothorax—Pleurisy and pneu- monia intercurrent diseases — Frequency of pleuritic adhesions — Perforation of the pleura—The bronchia? greatly suffer in phthisis—Also, the following organs and tis- sues:—The arynx and trachea, the bronchial glands, the bloodvessels, the spleen, the digestive canal, the mesenteric glands, the lymphatic glands, cellular and serous tissues, the Jiver, the brain and its meninges—The larynx and trachea, the bronchial glands, the small and large intestines, and the liver, the organs most affected in pul- monary tuberculosis—The blood in phthisis ..... 242 LECTURE CV. DR. BELL. Causes of Phthisis Pulmonalis—External Causes—Climate—Difference of mortality in different countries—Consumption, a common disease in the Mediterranean climates, —also in the West Indies, and in the islands of the Indian Ocean—Consumption varies in its rates of mortality in different periods—Cold and moisture—They act chiefly by impeding the cutaneous functions—Experiments and observations by M. Four- cault—Close and impure air a common cause—Deleterious influence of confinement in close and impure air—Effects of dust given out in certain trades—Deficient or im- proper food—Habits of intemperance dispose to phthisis—Internal causes of con- sumption—Age—Sex—Hereditary predisposition—Conformation of the chest__In- fluence of inflammation of the respiratory organs—Tubercle may be formed without inflammation ...... 247 LECTURE CVI. DR. BELL. Phthisis Pulmonalis (continued)—Duration and Termination—Symptomatology__Symp- toms proper to the lungs, and symptoms depending on associated disease of other organs—Two periods of phthisis—Symptoms of the first period—Symptoms of the second period—Varieties of phthisis—Acute and latent phthisis—Cases—Symptoms of phthisis considered separately—Cough—Sputa : their microscopical appearances__He- moptysis—Dyspnoea—Pain—Fever—Thirst—Gastric symptoms—Slate of the tongue —Diarrhoea—Chronic peritonitis—Symptoms in ulceration of the epiglottis, larynx, and trachea—Pneumonia—Pleurisy—Genital functions—Cerebral disorders—__Tubercu- lar meningitis—its symptoms and progress—State of the senses—Emaciation__Per- foration of the parenchyma of the lung by bursting of tubercle—Acute and chronic phthisis—Acute inflammatory tubercle without suppuration—Bronchitic, pneumonic and hemoptysical varieties . . . , . . .261 CONTENTS. ix LECTURE CVII. DR. BELL. Symptomatology of Phthisis (continued)—Symptoms not clear in some cases of acute nor in latent phthisis—Proportion of cases of latent tubercle—Cause of latency not known.—Diagnosis—Two periods—General symptoms in first period—Order of phy- sical signs—Points to be ascertained before physical examination—Percussion—Aus- cultation—Menstruation—Contraction of the chest—Diagnosis in second period.— Prognosis—Almost always unfavourable—Alleged proofs of cure of consumption— Rogee's observations—Louis's commentaries—Boudet's confirmatory experience 271 LECTURE CVIII. DR. BELL. Treatment of Phthisis Pulmonalis—Discouraging view of the subject—Systematic divisions of treatment, into prophylactic, palliative, and curative—Prophylactic treat- ment—To be begun early in life—Attention paid to the health of the mother, or the nurse who may replace her—The child to take abundant nutriment, and moderate but not violent exercise in the open air—The warm, and then the tepid bath—Cheerful emotions encouraged, but yet suitable "restraint practised—Moderate exercise of the intellect—Watchfulness at the epoch of puberty—Various exercises, including gym- nastics ; tepid or cool bath; skin protected by flannel ; food nourishing; milk, eggs, and meat—For weak appetite, bitter infusions, and for anemia, preparations of iron— Health still delicate, travel is beneficial—Attention to ventilation in the sleeping apartment—Tone to be imparted to all the organs, and equability of functions pre- served—Palliative treatment—Complication of phlegmasia? of the thoracic organs and disorder of the digestive apparatus to be removed—Antiphlogistics succeeded by tonics —Different ideas of palliative and curative treatment—The practitioner to make hi.^ choice—Circumstances determining him—Different forms of phthisis—Localized bron- chitic variety; its treatment—Hemoptysis; its treatment—Pneumonia; its treatment— Recuperative measures—Depletion not always necessary—Diarrhoea, remedies in— Perspiration andnight sweats—Additional hygienic measures—Exercise on horseback travel ; change of scene—Benefits from change of climate overrated—Climate of East Florida—Alleged efficacy of residence in marshy countries disproved—Summary of curative treatment—Reported remedies against tubercle—Counter-irritation—Condi- tions for its use—Opening of a tuberculous cavity by perforation of the walls of the thorax .......... 284 LECTURE CIX. DR. BELL. Tuberculosis of the Bronchial Glands—Bronchial Glandular Phthisis—Morton's account of this disease, as Phthisis Scrophulosa—Studied only of late years—Different forms of—Changes in the tubercular glands—Effects of pressure of the bronchial glands on other parts—the great vessels, trachea and bronchiae, the lungs, nerves, and oesophagus—Communication between the bronchial glands and the lungs—Union of glandular and pulmonary tubercles—Symptoms—chiefly from compression—Dropsy— Hemorrhage—Alteration of the voice—Auscultation—Diagnosis—Prognosis—Causes —Age—Complication with pulmonary tubercle—The disease properly scrofulo-tuber- cular—Treatment—Curative and palliative—Prophylaxis.—Gangrene of thk Lungs —Almost always a secondary disease—Is most common in children, and attacks men more than women—Anatomical lesions—Different forms of the disease—Change of pulmonary texture by—Cavities—Stages—Concomitant lesions in the lungs and other organs—Symptoms and Diagnosis—not very distinct—Causes—Associated with pulmo- nary apoplexy—The insane most liable to the disease—Treatment—regarding it as a disease of the blood—To correct putrescence and keep up the tone of the system 299 LECTURE CX. DR. BELL. Melanosis or Melanoma—Its generic character—Its division into true and spurious— Its seats—True pulmonary melanosis—Histological elements of melanotic tumours— Causes—Deficient elimination of carbon—Concomitance between black infiltration and reparation of pulmonary tubercle—M. Guillot's observations on carbonaceous deposits in the lungs—Aged persons its chief subjects—The black colouring matter is carbon— Spurious melanosis attributed to the inhalation of carbonaceous matters—Exposure in coal mines—Dr. Makellar's observations—Dr. Graham's analysis of carbonaceous X CONTENTS. deposit—This deposit common without any special exposure—Symptoms At r& slight, afterwards cough, expectoration, sometimes dark or black sputa, hemop ysis in the last period of the disease, weak circulation, loss of appetite, diarrhoea, colliqua- tive sweats, slow pulse, dyspnoea, vertigo and syncope—General diagnosis—Post-mor- tem appearances—Black deposit at first, in the walls of the pulmonary vesicles—Oblite- ration of the minute vessels and the vesicles—Conversion of affected part of lung into a peculiar tough elastic tissue—Sometimes general infiltration of the lung with black matter—Cavities—Heart flabby and soft—Misapplication of the term black phthisis —Subjects of melanosis, not tuberculous—Treatment—Reparation of Tubercle in con- nexion with black deposits in the Lung*—Hasse's and Goillot's descriptions and conclu- sions.—Cancer of the Lungs—Cancer a malignant heterologous tumour—Its analo- gies to tubercle—Is more organised—Resemblance in the manner of softening—Ef- fects of cancer on the system—Cancer of the lung, a rare disease—Is primary or se- condary—The last most common—Primary carcinoma, mainly in one lung, and by infiltration—Secondary variety, as isolated tumours—Bones and testicles, the most frequent origin of secondary pulmonary cancer—Pleura sometimes affected—Symp- toms and Signs—Dr. Stokes's summary of .... 309 LECTURE CXI. DR. BELL. Pleurisy—Pleuritis—Its forms and complications—Chief symptoms—Fever, pain, diffi- cult breathing, hard and frequent pulse, and decubitus on the back—Even the chief symptoms not always present; and they may be present without pleurisy—Structure of the pleura—Anatomical lesions—Change in the pleurr itself,—in its secretion ; imme- diate effects of this latter—Quality and changes of secreted matters—False membranes —their characters—Tubercles and cancerous bodies—Change in the secretion and state of the lung by the effusion—Causes—Identical almost with those of pneumonia— Cleghorn's description of bilious pleurisy—Physical signs ■•—altered conformation of the thorax, dulness on percussion,—resonance of voice in auscultation—cegophony —friction sounds—Diminished vibration of the parietes of the thorax—General symp- toms—Fever, state of pulse, buffy and cupped blood—Progress, duration, and termina- tion of pleurisy—Varieties—Complications—Prognosis , 319 LECTURE CXII. DR. BELL. Treatment of Pleurisy—Bloodletting, by venesection, the first and chief remedy—In feeble habits and in advanced stages, cupping or leeching—Cupping followed by saline purgatives—Tartar emetic—Opium in full doses after venesection—Blister to the side —Purging most useful in complicated and epidemic pleurisies—Diuretics; nitre, digi- talis, colchicnm—Calomel with nitre and a little opium—Treatment of children.—Ty- phoid Pleurisy.—Puerperal Pleurisy.—Chronic Pleurisy—Not always resulting from the acute form—Symptoms and physical signs—Dilatation of the side—Diagnosis —Absorption going on—Contraction of the chest—Treatment—Calomel—Iodine—Hy- gienic measures.—Pleurodynia—Its symptoms—Diagnosis between it and pleurisy —Treatment.—Pneumothorax—Causes, symptoms, and treatment.—Hydrothorax, —Its causes, symptoms and treatment ...... 328 DISEASES OF THE HEART. LECTURE CXIII. DR. BELL. Diseases of the Heart—Position and structure of the heart—its valvular mechanism —Beat or impulse of the heart; when felt—Percussion—Various tones according to the part of the chest struck—Auscultation—Two sounds of the heart: the first caused by the systole of its ventricles ; the second by the resistance and sudden tightenina of the semi-lunar or sigmoid valves—Different organic affections of the heart—Functional disorders—Simple carditis, a rare disease—Sequences of—Softenino-—varieties and causes of—Diagnosis not easy—Treatment, similar to that of pericarditis__Perfora- tive ulceration and rupture—Recorded cases of and complications with__Aneurism ven- tricular—Thurman's summary of—Its precise seat and complications—Aneurismoi the auricles ........ 345 CONTENTS. xi LECTURE CXIV. DR. BELL. Hypertrophy of the Heart—Divisions of hypertrophy—General view of disease of the heart's cavities—Average dimensions of a healthy heart—Anatomical characters and volume of a hypertrophous heart—Change of form—Excitingcauses—Different forms and complications of hypertrophy—Connexion between hypertrophy and cerebral dis- ease, particularly apoplexy—Ossification of the cerebral arteries—Capillary conges- tion of the mucous membranes and liver—Disease of the kidneys in hypertrophy of the heart—Palpitation—Impulse heard, through the stethoscope—Hypertrophy with dilatation—Sounds of the heart and state of the pulse in hypertrophy—Arterial pulse ; its cause and characters ; modifications by hypertrophy—Causes commonly affecting the pulse—Signs of hypertrophy of the right ventricle—Treatment of hypertrophy— Abstraction of blood, short of producing anemia—Moderate and frequent abstractions to be preferred—Purgatives and diuretics—Tonics and narcotics—Perseverance in treatment of hypertrophy all-important ...... 355 LECTURE CXV. DR. BELL. Dilatation of the Heart—A consecutive disease—Two forms — Simple dilatation without thickening—Dilatation with attenuated walls—Signs and diagnosis of dilata- tion—Treatment, by moderate tonics.—Diseases of the valves and orifices of the Heart—Their connexion with hypertrophy—Large proportion on the left side—Pro- portionate size of healthy valves—Induration, ossifications, excrescence, and vegeta- tions of the valves—Atrophy or inadequacy of the heart's valves—Endocarditis the most frequent cause of valvular disease—Gout, a cause—General symptoms and effects of an alarming nature—Diagnosis—Well-defined peculiarities of pulse—Prognosis— Physical signs—Murmurs—Their varieties—Venous or continuous murmur—Venous pulse—its cause—Purring tremour or thrill—Table of the different murmurs 368 LECTURE CXVL DR. BELL. Pericarditis—Connexion between diseases of the membranes of the heart and rheuma- tism—Divisions—Anatomical appearances—Injection and redness, in patches, of the pericardium—Loss of its smoothness and polish—Milk spots or patches—not always evidence of inflammation—After plastic exudations, the pericardium is pale and rough and after repeated attacks is thickened—Effusion of serum, containing plastic matter —Gelatinous exudation, peculiarly organised—Pus after renewed inflammation—Pseu- do-plastic matter—Hemorrhagic effusion—Effusion of pus—Mixture of organisable and inorganisable matters—Tubercular formations—Muscular substance of the heart, as if macerated and wasted—Dilatation with hypertrophy of the left ventricle—Cavi- ties of the heart containing blood of different appearances—Valves thickened—Com- plications with pleurisy and pneumonia and with peritonitis— Engorgement of the liver —Kidneys affected wtih granular disease—Effusion of serum in the ventricles of the brain—Serous infiltration of the cellular tissue—Symptoms—Dulness on percussion ; arching or elevation of the cardiac region—Friction of the opposite false membranes of the pericardium against each other—Altered sounds and impulse of the heart— Pain of this organ—Palpitations and irregular circulation—Physical symptoms, the most characteristic-—Progress and Termination—Pericarditis varies in its intensity and duration—Stages of the disease—Chronic lesions in those who survive—Adhesions of the pericardium do not shorten life—Symptoms of adhesion—Diagnosis—Inferred from the collection of symptoms previously detailed—Latent pericarditis—Prognosis —Favourable termination in a majority of cases—Rheumatic cases furnish most cures —Those from Bright's disease less favourable—Cure by natural process—Causes— Exciting ones not well ascertained—Pericarditis is a consecutive disease—Most com- mon in rheumatism—Next, in frequency, in Bright's disease—Ultimate cause—altera- tion of the blood—Results of experience of different writers—Age has its influence— Males more liable than females—Pleurisy a frequent concomitant; so, also, is pneu- monia— Treatment—Antiphlogistic, with modifications—Under what circumstances venesection useful—Local depletion—Auxiliary reducing means—Tartar emetic and colchicum; incases of abdominal complication, calomel and other purgatives—Opium —Calomel as an alterative—Ptyalism often recommended—Its real value—Iodide of potassium especially useful in cases of complication with Bright's disease — Iodide of iron—Counter-irritation by pustulation and vesication of cardiac region—Great attention to the state of the skin required in the prophylaxis of pericarditis 377 Xll CONTENTS. LECTURE CXVII. DR. BELL. Diseases of the Heart (continued).—Endocarditis—By whom described—Its origin in rheumatism—Symptoms—Not always clear—Diagnosis—A frequent, concomitant ot imUlUIUOIl LI)B Sdllie 111 an mc ouwivico---xiuniiuua waguio---k'"""----

e itself—In acute cases and more advanced stage, antiphlogistics required—Calomel and laxatives—Early and free use of astringents and stimulating applications to the eye—The lecturer's own experience — Precautions in examining the eye . ..... 617 VOL. II.—2 XV111 CONTENTS. LECTURE CXL. DR. BELL. . Diseases of the Eye (continued)—b. Purulent Ophthalmia of Adults—Egyptian Uptiinai- mia—Shows itself at any time alter infancy—First and main seat, the conjunctival lining ofthe eyelids—Subsequent extension to the anterior part of the eye, including cornea and iris—Upper eyelid suffers most—The disease most noticed by military surgeons—May prevail epidemically—shows itself in schools and asylums—Symptoms —Disease divided into three stages—In the first stage, the symptoms analogous to those of catarrhal ophthalmia—The second stage brings the purulent discharge, with redness, puffiness, and elevation of the conjunctiva—In the third stage, the proper tunics of the eye are affected—Tendency of the second stage to become chronic—Pro- fuseness of the discharge—Pain great—Remissions periodical—Symptoms in com- mon with those of the ophthalmia of new-born infants—Variety in the symptoms— Disease sometimes milder, and confined to the upper eyelid—Appearances characteristic of this disease in adults—granular eruption with phlyctenule—Chronic the first form of the disease—The acute ingrafted on it—Early appearances on the conjunctival surface—Effects of purulent conjunctivitis on the tunics of the eye and the eyelids— —General symptoms, in the beginning slight; in the advanced stage, are of a febrile nature—Diagnosis—Prognosis unfavourable—Causes—Opinions divided respecting a contagious origin—Positive testimony in favour of contagion—Purulent ophthalmia has originated in persons not exposed to the disease in others—States of the weather —Crowded barracks—Close air on board ship—Treatment—In the first stage, anti- phlogistic to a certain extent—Early use of nitrate of silver and analogous remedies —Moderate exercise in the open air—In the second stage, decidedly antiphlogistic— Excision of a part of the conjunctiva—In lymphatic habits and in secondary attacks, and in a civic population, a less energetic and a mixed treatment, including tonic re- medies, the best—Topical applications, from the first, and the cold douche—Stimu- lating remedies to the eye even before the inflammation is gone—Granular conjunctiva —A constant occurrence in chronic purulent ophthalmia—Its appearances and conse- quences—Affection of the cornea—Treatment—Combination of general with topical re- medies—Vascularity and opacity ofthe cornea, common results of granular conjunctiva —Gonorrhoeal Ophthalmia —A consequence of gonorrhrea or of inoculation with gonor- rhoea! matter—Theories to explain its attack—Three forms of gonorrhoeal inflammation —Chief and most violent—Symptoms and immediate effects—Diagnosis—Prognosis— Treatment—Fearful rapidity ofthe disease—Antiphlogistics ; cauterization, and exci- sion and incision ofthe conjunctiva—Mild gonorrhoeal ophthalmia—Gonorrhoeal inflam- mation ofthe external tunics and iris—Its analogy to rheumatic ophthalmia—Simul- taneous occurrence of rheumatism with gonorrhoea and gonorrhoeal ophthalmia 626 LECTURE CXLI. DR. BELL. Diseases of the Eye (continued).—Sclerotitis—Is rheumatic—Symptoms—Redness of a pink hue, and particulardirection,—vessels running in straight lines—cornea dim, a id receiving vessels from the sclerotica—Diagnosis—Causes—The same as of rheumatism in other organs—Continuation of disease of the cornea and iris—Treatment—At first, in milder cases, purgatives and Dover's powder—In the fully formed stage, venesection, cupping, and leeching—calomel and opium—tartar emetic and nitre with opium—Calo- mel where the disease is merely suspended—colchicum with salines—iodide of potas- sium—Counter-irritants—Lotions and ointments to allay pain—When the inflammation has subsided, bark or sulphate of qninia—For chronic sclerotitis, rely on regimen, occa- sional cupping, laxatives, and quinine.—Corneitis—Structure ofthe cornea—Is sus- ceptible of inflammation—acute or chronic,—primary or secondary—Symptoms__Con- comitant affection ofthe iris—Scrofulous corneitis, occurs in young persons__Corneitis is an obstinate disease—Treatment—Antiphlogistic, with reserve and restrictions__ Local applications not of much service—Summary of treatment when disorganization is threatened—Phlyctenular or scrofulous corneitis—Changes in the cornea consequent on its inflammation—Vascularity—ulceration—chalky appearances—opacity__leucoma or albugo—Treatment of opaque cornea.—Iritis—Structure of the iris—Iritis is either pri- mary or secondary—Symptoms and pvgress—The most characteristic symptoms,—a change in the appearance and colour ofthe iris, and a red band round the cornea—In- flammation begins at the pupilary border—Changes of figure of the pupil__Sichel's opinions—Changes and effect-; from iritis—Constitutional disturbance__Causes the same as of ophthalmia in general—Particular ones, or those of diathesis__rheumatic gouty, scrofulous ; and of prior disease, as syphilis—Question of mercury, as a cause —Treatment—Antiphlogistics and mercury—Iodide of potassium in sub-acute and CONTENTS. XIX chronic iritis—Treatment in these stages—Use of belladonna and stramonium—Va- rieties of iritis—General indications of treatment.—Choroiditis—Vascularity of the choroid coat—Few external symptoms—Functional disorders—Case of the lecturer's — Treatment—In the main, antiphlogistic—but with early recourse to tonics.—Reti- nitis—Difficulty of distinguishing it from choroiditis—Causes—Case—Amaurosis— Its diversified causes—Practical inferences to guide us in the treatment of amaurosis. —Scrofulous Ophthalmia—One of the mixed forms of ophthalmia—&/mpfo77W—Is most common in children—Its organic features—Physiognomy of those affected with the disease—Organic changes—Implications of the tarsi and Meibomian glands— Treatment—Change of habitation—Moderate depletion and laxatives—Tonics—sul- phate of quinia and iodide of iron—Narcotics—Regulation of the diet—Clothing— Change of air—Collyria—pencilling the eyelids with solutions of nitrate of silver and of iodine—General plan of treatment—Disorganising inflammation of the cornea— Extract of belladonna—Erysipelatous ophthalmia—Symptoms and treatment—Pustular ophthalmia—Symptoms and treatment—Variolous ophthalmia—Time of its appearance— Treatment—Catarrho-rheumatic ophthalmia—Symptoms and treatment referable to those of catarrhal and of rheumatic ophthalmia.—Ophthalmia Tarsi—Its two varieties, catarrhal and scrofulous—Symptoms of catarrhal ophthalmia tarsi—Chronic form, or lippitudo—Entropium—Ectropium—Causes— Treatment — Scrofulous ophthalmia tarsi— has features in common with the catarrhal—Its scrofulous ones, hordeola, vesicles, or pustules and ulcers—Psorophthalmia—a wrong term—This variety may be con- nected with favus difpersusot impetigo figurata—Tylosis—Madarosis—Treatment of scro- fulous ophthalmia tarsi . ....... 637 DISEASES OF NUTRITION —CACHEXLE. LECTURE CXLII. DR. BELL. Difficulty of Classification of Diseases, termed Cachexia?—Cullen's and Cop- land's definition—Dr. Williams's explanation of morbid deposits.—Scrofula—Its multiplied relations and associations—Anatomical and histological characters—Resem- blance of the scrofulous to typhous deposit—State of the blood—Scrofulous pus— Identity of scrofulous and tubercular diseases-*-Symptoms and p-ogress—Cullen's de- finition; its incompleteness—Countenance—Swelling of lymphatic glands, cellular tissue, and joints—tumid abdomen—Irritation of the ocular, nasal, and pharyngeal mucous membrane—Swelling and other changes of the tonsils; cough; ulcerations of the tongue; disorder of the digestive mucous membrane—The sc.rotu\o\i*fades—In a more advanced stage, inflammation and ulceration of the lymphatic glands of neck— Discharge of pus and cheese-like product of tubercle—Abscess of cellular tissue— Similar cacoplastic deposits in serous membranes, and in the pancreas, liver, mesen- teric glands and urinary and genital organs—The bones, especially the extremities of long bones and the vertebra? affected—Curvature of the spine and distortion of the thorax—Scrofulous disorders of the skin, eye, and ear—Irregularity in nervous and muscular systems—Brain and senses sometimes very susceptible—Sometimes great vivacity—sometimes dulness—Intellect sometimes precocious, sometimes deficient— Irritative fever—Complicated with uterine disorders, hysteria and epilepsy—Special pathology of scrofula—deterioration of blood and deposit of granular pus and tubercle —Causes—Inherited predisposition the chief cause—Scrofula preserving its character- istic features in all countries and climates—Transmission by descent more general than supposed—Affinity between tubercle and scrofula—Acquired diseases of parents —Causes of scrofula in their children—syphilis; excessive venery; paralysis; in- sanity— Hereditariness does not pass over one generation to appear in another—Cause not unit—Difference in the age of the parents—Effects of French conscription— Crowded lodgings—impure air—defective nutriment—Examples—Scrofula prevails in the negro population—Morbid states—as the exanthemata—exciting causes of Bcrofula . . . . . . . . . . 654 LECTURE CXLIII. DR. BELL. Scrofula (Continued)—Treatment—Indications of cure—Elements of disease presented by Dr. Williams—Importance of prophylaxis—Knowledge of causes suggests means of prevention—Outlines of prophylaxis and cure—Necessity of perseverance and of time (or a cure—Proper notions respecting the tonic treatment—Purgatives to precede iron and iodine—Fresh air, wholesome food, and exercise, necessary conditions for curing scrofula—Use and effects of iodinic preparations—Small doses with large dilution to be preferred—No necessity for the large doses used by some physicians—Iodide of XX CONTENTS. iron—Mr. Phillips's success with—Most convenient form—Iodide of zinc—Hy ro- chlorate of lime—Lime-water—Arsenic, to be kept back until other remedies are tried—Alternate use of iodide of potassium and carbonate of iron, or the potassio-tar- trateof iron—Bromine—Bromides of potassium and of iron—Ointment of bromide ot potassium—Cod-liver oil—Preparations of walnut leaves—Mercury ; when admissible —When narcotics are proper—These combined with mercury or iodine Most com- mon forms or varieties of scrofula—Tabes mesenterica—Alleged connexion with ente- ritis—Outlines of treatment—White swellings—Modified treatment—Tuberculous objec- tions ofthe skin—General indications of cure, including hygienical measures 663 LECTURE CXLIV. DR. BELL. Syphilis—Lues Venerea—Its divisions into local or primary, and constitutional or se- condary syphilis—Two varieties ofthe local form—First, or gonorrhcea, not properly a syphilitic disease—Already treated of.—Local or Primary Syphilis—Symptoms; chancres or sore of genitals; characters of Hnnterian chancre; not diagnostic of syphilis ; appearance of sore varying with the tissue affected—Not different degrees of poisoning and corresponding sores—Alleged connexion between different primary sores and secondary eruption—True test of a venereal sore; inoculation propagating the like—A certain period of maturity for the poison to be transmissible; four or five days—Mistakes in diagnosis of sorejs on the genital organs and of those on other organs—Poison sometimes transmitted by the medium of a person who does not receive the contagion—Bubo, secondary to chancre and to other sores on the penis, and other causes—Inoculation, test of venereal bubo—Treatment of Primary Syphilis—Pro- phylaxis to prevent disease at all, and next to prevent progress after first symptoms— Destruction of chancre necessary, or its conversion into a common sore—Remedies— General treatment; rest and antiphlogistic regimen ; chancre persisting, the treatment required—Phagedenic ulcers—Mercurial dressings not required—Mercurial treatment of primary syphilis compared with non-mercurial—Safely and greater expedition of the latter — Mercury useful at times — Salivation unnecessary—Treatment of bubo— French practice successful before suppuration : Ricord's directions after suppuration 674 LECTURE CXLV. DR. BELL. Syphilis (Continued).—Secondary or Constitutional Syphilis—When syphilis is consti- tutional—Progress ofthe d isease in its successive stages—Hunter's description—His first and second stages correspond with Ricord's secondary and tertiary forms—Proportion of cases in which secondary symptoms occur—The less proportion the sooner the primary disease is cured—Modes of transmission of secondary syphilis—Generally not commu- nicable—Secondary symptoms in new-born children—Occasional suspension of symp- toms—Difficulty of diagnosis of secondary syphilis—Varieties of venereal eruptions— Description of—Sore throat—Treatment of Secondary Syphilis—Attention to coexisting acute diseases—These to be cured first—Derangements of function to be removed— Treatment, varying with the constitution, habits, and other diseases of the patient— Remedies in first stage or secondary form of constitutional syphilis—Mercurials use- ful ; and still more iodine—Donovan's solution—Syphilitic ulcerations—Their appear- ance and treatment—Vegetations—Treatment of.—Tertiary Syphilis—Symptoms appear late—Order of parts affected—Not transmitted hereditarily—Secondary symp- toms often disappear when hereditary without treatment—Tertiary symptoms may then seem to be primary—In tertiary symptoms, or the second stage of Hunter, the iodide of potassium the chief remedy—Attention to the symptoms of phloaosis ; • these to be met by appropriate measures—Cyanuret of mercury ; its advantages over the bichloride—General treatment and cautions . . . . 683 FEVERS. LECTURE CXLV1. DR. STOKES. —General considerations on—Erroneous modes of investigation—Importance of the labours of French pathologists—Complication of fever with local disease__Pri- mary and secondary fevers—Relation of, to local changes—tendency to spontaneous termination—Principles of treatment—Errors of Brown and Broussais—Researches of MM. Gaspard and Magendie—Their pathological conclusions—Importance of the knowledge of secondary lesions—Effect in preventing crisis—Treatment__Humoralism and solidism ....... . qqq CONTENTS. xxi LECTURE CXLVII. DR. STOKES. Intermittent Fever—Definition and character of—Phenomena ofthe 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 ....... . 698 LECTURE CXLVIII. DR. BELL. Alleged Causes of Intermittent Fever—Miasm or malaria, an imaginary cause— Periodical fever prevails under most opposite conditions for the evolution of malaria— More attention due to sensible states of the atmosphere—Slight differences in locality modify climate—Phenomena of dew—Exposure of the labourers in the Campagna di Roma—Disadvantage of the miasmatic hypothesis on the score of prophylaxis—Avoid- ance of extremes of known states of the atmosphere—The miasmatic hypothesis con- futed by Folchi in Rome and Dr. Pritchett in Western Africa—Geological Causes—Dr. Robert Jackson, Dr. Heyne—Causes pertaining to the individual and to changes in his or- gans—Age—Inhni in utero may have ague—Vitiation of the blood—Consecutive and an effect, not cause—Poisoning ofthe cerebro-spinal axis—Schultz's opinions—Disorder nnd enlargement ofthe spleen : the chief cause of intermittent fever, as alleged by M. Piorry—His propositions—Objections to—M. Piorry believes that intermittents may occur without exposure to miasm—Liver a frequent sufferer in periodical fevers— Dropsy an effect ofthe fever—So also of hyperemia, congestion, and phlogosis ofthe mucous membranes—Associated engorgement and induration ofthe mamma? in inter- mittent fever—Phlegmasia? of the respiratory passages and of the pleura and lungs are frequent complications—Periodicity, common in all the disturbances of the nervous system—Essays on by the lecturer— Type of periodical fevers—Relative proportions of quotidian and tertian types—Contradictory estimates—Quartan of comparatively rare occurrence—Marsh miasm supposed to be less the cause of the quotidian than of the tertian and quartan types—Tendency ofthe fever to return at septan periods—Time of recurrence—Each type has a tendency to recur at a particular hour, and in cases of relapse to appear at the same hour ...... 706 LECTURE CXLIX. DR. BELL. Treatment of Intermittent Fever—Remedies in the cold stage—A mild emetic— Warm drinks—Warm applications to the extremities and over the epigastrium—Inter- nal stimulants generally injurious—Laudanum or Dover's powder often does good— Bloodletting—Lecturer's experience and cases—Pressure on the extremities—Reme- dies in the hot stage—Stimulants given in the cold stage increase morbid reaction in the hot—Venesection on certain conditions—In common, cool air and drinks and affu- sion of cold water—cold enemata—laudanum—Treatment in the apyrexia, or interval between the paroxysms—The Lecturer's confidence in Peruvian bark and the sulphate of quinia—His large clinical experience with these substances—Good effects of cin- chonic preparations in enlarged spleen, with intermittent fever—Various formulae of the bark and sulphate of quinia—Dose ofthe bark—Advantages ofthe salts of quinia —Dose of—Experience in India, Algeria, and in Florida—Time of administration of the anti-periodic—Salts of quinia not active until they enter the circulation—Medium period in which to give the sulphate—Best means of introducing it into the system— Failing hy the stomach, we have recourse to its use by enemata and by endermic medication or through the skin—Also, to the mucous surface of the mouth and throat— Modified treatment in complications of gastro-enleritis and of broncho-pulmonary irri- tation and phlogosis—Danger of perseverance in tonics—Want of success from the use of mercury—Success attending venesection —Local bloodletting—Indications for its use from the spinal pathology of intermittent fever—Counter-irritation to the spine— Bloodletting alone, or mercury alone, or the cold bath alone, not to be relied on with- out bark ami its equivalent tonics—Exclusive reliance on bark or arsenic not justifiable — Abstinence sometimes brings a cure—Call for nutritive tonics and iron—Cold bath- ing— Indications for its use—Cold enemata—Several remedies besides the bark and Milphate of quinia in intermittent fever—All the tonics and astringents and bitters em- ployed on occasions— Peruvian bark or sulphate of quinia, the febrigum magnum— Other salts of quinia, and the triple ones with metallic combinations—Valerianate of quinia-lisalleged advantages—Arseniate ofquinia—Citrate of iron and quinine—Ferro cyanate of quinine—Combination of sulphate of quinia and carbonate or sulphate of iron—Iodides of quinia and of cinchona—Arsenic, or arsenious acid—its physiolo.—Exanthemata—Their general character—Close relation to diseases of the gastro-pulmonary mucous surfaces—Erythema—Its chief features, causes, and treatment—Seven varieties of acute erythema described— Chronic erythema.—Erysipelas—Its synonyms—General features—Varieties—Cuta- neous, phlegmonous, or sub-cutaneous, and the diffuse cellular inflammation—Anatom- ical changes—Lesion of internal organs—The blood—Prognosis—Causes and Treatment —Venesection or leeching; vomiting and purging; antimony, colchicum ; topical applications—Warmth and moisture—cold—blisters; lunar caustic; unguents— iodine—Erysipelas Neonatorum—Its danger and mortality—Collateral relations of erysipelas, the most important—Diffuse inflammations of the serous and mucous membranes—Connexion between erysipelas and puerperal fever or puerperal peritonitis —Reasons for believing in the identity of the two disorders—Sameness of diffuse in- flammation ofthe peritoneum and erysipelas in both sexes—Erysipelas passing from theskin to and through the entire digestive canal—Diffuse inflammation of the mucous surfaces—Epidemic erysipelas in the United States—Black Tongue—Chief features ofthe disease, involving both skin and mucous membranes—Outlines of treatment— Connexion of this epidemic with puerperal peritonitis—Great mortality of this last during the epidemic.—Roseola—its varieties—Symptoms and treatment . 858 LECTURE CLXII. DR. BELL. Exanthemata (Continued)—Different classifications of eruptive fevers—Small-pox in- cluded under this designation—Symptoms of the Exanthemata—Skin in a state of con- gestion—A similar state of the mucous membranes—Entire sentient surface in a state of irritation—Reaction in the brain and spinal marrow—Difference between the in- flammation of the cutaneous and that of the mucous membrane—Exanihemata pro- perly diseases of the cutaneo-mucons system—Precursory symptoms—Sometimes high fever with little or no eruption—Diagnosis—Difficult in the period of invasion and until the eruption is fairly established—Primary eruption—maculae and papula? —not diagnostic—Visceral complications in all—Eruption an effect of internal dis- ease—Careful study ofthe symptoms—Period of Incubation—Complications—With the several exanthemata, are associated inflammation of particular organs—Anatomical changes—Congestive inflammation ofthe dermis—Exudation of fluid—Morbid altera- tions of the mucous and serous membranes—Mortality—Very great—Tables__Treat- ment—General outlines.—Measles—Symptoms—Precursory, those of catarrh—Date of eruption—Its appearance—Diarrhoea—Period of danger from inflammation of the lungs —Varieties—Complications and Sequelae— Measles varies in intensity at different seasons —Pneumonic the most frequent complications—Entero-coiiiis—Gangrene of the lips and lungs—Meningitis—Delirium, coma and convulsions—Simultaneous appearance of measles and small-pox in the same person —Also epidemically—Chronic diarrhoea a troublesome complication—Phthisis readily developed by measles—Typhoid stale —Morbid Anatomy—The skin and mucous membranes chiefly affected__Lungs fre- quent sufferers—Causes— Contagion—Alleged communicableness by the blood and tears—Modern introduction into Europe and America—Rhazes—Doubtful results of CONTENTS. xxvii inoculation—Treatment—Simple—In the mild variety of measles—When the lungs are implicated—Antiphlogistic remedies required—Venesection—Measures required when the eruption retrocedes—The cooling regimen in small-pox and measles firstclearly laid down by Rhazes—Long anterior to Sydenham—Outlines ofthe method of Rhazes 871 LECTURE CLXIII. DR. BELL. Exanthemata (Continued).—Scarlatina—Scarlet Fever—Its characteristics—Causes— Varieties—Symptoms—of Scarlatina Simplex—of Scarlatina Anginosa—of Scarlatina Maligna—of Scarlatina sine Exanthemate—Diagnosis between scarlet fever and measles —Difficulty of distinguishing congestive scarlatina from cholera and typhous fever —Prognosis—Morbid Anatomy—Sanguineous congestions of the brain, spleen, and plates of Peyer—Also, inflammation of the fauces and air-passages—In some cases, no lesion is visible—Exfoliation of the mucous membrane of the urinary organs —Epithelial scales in the urine—Complications and Sequela—Inflammations of the different viscera—Simultaneous appearance of scarlet fever with other exanthe- mata—Rheumatism—Diphtheritis—French measles—Anasarca a frequent and trou- blesome sequela of scarlatina—Primary cause, the suspended functions of the skin —The dropsy sometimes attacks suddenly and with violence,—sometimes comes on slowly—Albumen and blood found in the urine—Often, the albumen is want- ing—Edema of the lungs—comes on suddenly—Is in the interlobular cellular tis- sue—Edema of the glottis—Pericarditis—owing to disease of the kidney in scar- latina—Suppuration of the ear—Purulent effusions into the joints—Abscesses in the soft parts—Malignant affection of the throat—Treatment—Fluctuation of opinion respecting the value of depletion—Changes in the character of the disease—The lec- turer's practice and experience—The cooling regimen, a mild emetic, cold affusion— Mild salines with tartar emetic—Phlogistic symptoms met by venesection or leeches— Cold drinks—For restlessness and wakefulness, Dover's powder—Probable cause of death in eruptive fevers—Loss of vitality or of functional action ofthe skin—Simul- taneous disease of pulmonary mucous membrane — Poisoning of the system—Oppres- sion and violence of symptoms not explicable by inflammation—Malignant, a typhoid state—Principles of practice, same as in congestive fever—Treatment of particular cases—the anginose, the cerebral—Cold affusion—sometimes tepid bathing—Stimu- lants—spirits of turpentine and carbonate of ammonia, camphor mixture, capsicum— Anasarca, treatment of—Prophylaxis ...... 885 LECTURE CLXIV. DR. BELL. Exanthemata (Continued).—Variola—Small-Pox—Variolous eruption—Varicella— Variola, or small-pox proper—The lecturer's experience in epidemic small-pox—Va- riola an acute, contagious, inflammatory disease—Varieties—Periods—Evidences of its very contagious character—Morbid Anatomy—Symptoms and Progress—Secondary fever—Coincident Exanthemata—Inoculated Small-Pox— Prognosis of Variola—Treatment —Cdoling regimen and antiphlogistics moderately used—Associated inflammation to be treated with depletion—Secondary fever, modified treatment in—Danger from sequela? of small-pox—Skin peculiarly liable to morbid impressions—Ectrotic or aborting method in variola—Prophylaxis.—Vaccinia or Cow-Pox—History—Its origin and alleged identity with variola—Protection by Vaccination—Inferences by Drs. Mitchell and Bell in favour of vaccination—Re-vaccination—Age for Vaccination— Stages of vaccine pustule—Selection of matter—Its insertion, or application—Retro- Vaccination—Number of incisions—Causes modifying development of vaccine pustule —Anatomy of the Vaccine Pustule—Vaccine cicatrix—Small-pox after Vaccination—Va- rioloid—Its origin, symptoms, and comparative frequency — Occurrence not propor- tionate to the period after vaccination ...... 898 LECTURE CLXV. DR. BELL. Rheumatism—Rheumatic Fever—Fever anterior to the local inflammation—Rather a diathesis disposing readily lo inflammation and fever—Rheumatic diathesis met with in the vigour of life—Division of rheumatism into acute and chronic—Distinction be- tween the two—Seat and Complications of Acute Rheumatism—Two chief seats, articu- lar and muscular—Extent of parts affected—Metastasis to internal organs; some- times these first attacked—Practical inference—Community of causes of external and internal rheumatic inflammation—Complication of chorea with rheumatism—Com- munity of cause in a morbid state of the blood—Cerebral affections—Puerperal rheu- matism — Syphilitic rheumatism—Acute articular rheumatism, acute arthritis—Symp- XXV111 CONTENTS. toms and Progi-ess—Constitutional disturbance great—Transfers of disease—-Sta e the blood—of the urine—Diagnosis between rheumatism and goat—Anatomical ctianges —Causes—Vicissitudes of weather—The chief predisposing cause, excess of nutrition and hematosis—Sudden and violent strain, long marches—Special predisposition— Other causes—Males more liable than females—Influence of age—Treatment t ree and repeated venesection—Must not expect to remove at once the rheumatic lever- Local bloodletting, at the part affected and at the spine ; purgatives; tartar emetic; col- chicum; the two combined ; their great depressing power; opium in large doses; nitre in large quantities; mercury, its true remedial value and time of use ; warm bath; tonics; sulphate of quinia with opium—Other varieties of rheumatism ; endo- carditis; pericarditis— Capsular rheumatism—its affinity to gout; preference for the knee—Treatment—Nodosities ofthe joints — Membranous, fibrous, or aponeurotic rheumatism—Treatment; iodide of potassium—Muscular rheumatism, is less acute than articular—Parts of the muscular system affected—Rheumatic diaphragmitis the worst—Treatment . . . . • • • .913 LECTURE CLXVI. DR. BELL. Chronic Rheumatism—Ideas to be attached to the term chronic; its relation to acute —Division of chronic rheumatism—Morbid anatomy—Symptoms—Causes—Treatment —Length of time for cure—Entire renovation of the system necessary—Classes of subjects of chronic rheumatism—Symptoms—Diagnosis between chronic rheumatism and chronic gout—Remedies,sometimes analogous to those in the acute; occasionally bloodletting; always free purging; Dover's powder; diaphoretics; colchicum; iodide of potassium ; sulphate of quinia, sometimes with purgatives preceded by blue mass or colchicum. Mixed varieties of chronic rheumatism ; blue mass with hyosciamus, &c.; bathing after various fashions ; embrocations and liniments ; ban- daging; acupuncturation ; warm and hot bathing ; sea-bathing; hygienic treatment, preventive and curative—Rheumatic paralysis—Electricity in . . . 927 LECTURE CLXV1I. DR. BELL. Gout—Podagra, &c.—Reasons for regarding gout as a febrile disease—Its affinity to rheumatism—The general or constitutional disturbance precedes the local lesion— Gouty Diathesis—Wherein predisposition to gout consists—External habit or physi- ognomy—Temperament—Modes of living—Excessive repletion and indolence the chief predisponents—Gout a disease of the rich, or of those easy in life who eat much and work little—The poor drunkard and the rich bibber—Exception in cases of certain menials of the wealthy, and labourers who drink malt liquorto excess—Vexation and strong mental emotions in general—Danger to the man of letters from free indulgence of the appetite—Inherited predisposition—Its real force—Age and sex considered— Paroxysm of gout—Warning or premonition—Disorder of the digestive organs the chief predisposing and often exciting cause—What is the special exciting cause acting on a plethoric habit—Excess of lithic acid in the blood—Proofs derived from chemis- try and physiology, and from the pathology of analogous diseases—Important infer- ence—Treatment—In acute gout, the remedies antiphlogistic—Sometimes venesec- tion, always purgatives—Colchicum with the alkalies and magnesia—Modus operandi of colchicum—Diet extremely simple in acute gout—Convalescence not to be hurried by tonics—Bathing, general and local, and frictions—Treatment of a second paroxysm analogous to that ofthe first—Change in appearance of the articular inflammation— Tendency to attack the great toe—Suppuration rare—Topical remedies of small value —Cold of doubtful propriety, if not dangerous ..... 938 LECTURE CLXVIII. DR. BELL. Chronic Gout—Its analogy to dyspepsia—Treatment analogous—Case in which direct depletion was required—Chronic gout is seen in females—Analogy to rheumatism__ Local treatment of service—Chronic gout more harassing and continued than the acute—Chalky concretions—Sediments in the urine—Irregular Gout; its sub-varieties —Admission of atonic or misplaced gout hypothetical—Comparisons of diathesis and diseases—Restriction of term gout to articular inflammation with constitutional dis- order—Prophylaxis—Conditions for prevention—Hygienic and therapeutical means__ Necessity of restricted and regulated diet—The appropriate drink—Exercise and fresh air—Perseverance in prophylaxis . . 94g LECTURES ON THE THEORY AND PRACTICE OF PHYSIC. LECTURE LXXXIV. DR. BELL. DISEASES OF THE RESPIRATORY APPARATUS. More satisfactory diagnosis of Thoracic Diseases in late years — Auscultation and Percussion—Auscultation properly includes percussion—Its application to diag- nosis—Laennec the father of auscultation—The physical laws from which it is de- duced—Chief sounds elicited by the pulmonary apparatus : I. During respiration : II. By the voice: 111. By coughing : IV. Those of an adventitious kind.—The first class, or the Respiratory, subdivided into two orders, the simple and the compound— The simple includes the respiratory or vesicular sound or murmur, also called puerile respiration, the bronchial and tubal or blowing, the cavernous and the amphoric—Orierin and diagnostic value of these sounds—The compound sounds, or rhonchi, are moist and dry—ofthe moist are the mucous or moist bronchial, cavernous, sub-mucous and humid with continuous bubbles—These explained—Crepitant or moist crepitant, sub-crepitant or rhonchus redux, cavernous—Pulmonary crumpling sounds—The dry rhonchi are classed under the head of sibilant and sonorous—Explanation of these terms—[I. Vo- cal Auscultation gives natural and morbid bronchophony, also ozgophony, pectoriloquy and amphoric resonance—III. Sounds in Coughing—The bronchial, cavernous and amorphic, and metallic tinkling—IV. Adventitious Sound—These are friction sounds, viz: the grazing, friction proper and grating—Table of morbid phenomena of respira- tion coexisting with inspiration and expiration—Sounds of the he.ut and vascular murmurs modified by the state of the lungs—Theories of M. Beau and Dr. Skoda—M. Beau's views of resonance explained—Objections—Dr. Skoda's views of consonance applied to vocal sounds—His division of the sounds in respiration—Stethoscope, and manner of conducting auscultation- Within the last quarter of a century the investigation of diseases of the organs contained in the thoracic cavity has been conducted on a much more certain basis than formerly; and some well-ascertained physical laws are now applied to guide us to a diagnosis, the general accuracy of which is in most satisfactory contrast with the vague generalities before prevailing on this subject. The means for reaching these favourable results, or physical diagnosis, are by Auscultation and Percussion, terms of which the etymology, like most of those of a scientific character, conveys a more imperfect notion of the range of subjects than they are actually intended to cover. Auscultation, literally the art of listening, now indicates a particular method of investigating the state of certain organs, by the different sounds given out when the ear is applied on or over them, or heard when the VOL. n.—3 26 AUSCULTATION AND PERCUSSION. adjoining cutaneous surface is struck by the fingers or by instruments. 10 this latter mode of investigation the term percussion is applied. Ausculta- tion enlightens us only on the physical states and changes of the organs, leaving to other modes of investigation the ascertaining of vital pheno- mena. But, as no physical change can take place in a living tissue or organ without a modification, at the same time, of its vitality, ausculta- tory results, deduced from a comparison of the healthy and morbid states of an organ, become an evidence of pathological changes, and even ofthe successive steps of these changes—from the first slightest lesion to com- plete disorganization. Auscultation is applied primarily and mainly to the acquiring of a diag- nosis of the diseases of the thoracic viscera, and also, but with less certainty of detail, of those of the abdominal viscera, pregnancy, frac- tures, injuries of the brain, and sometimes penetrating wounds of the chest and abdomen. In its application to the study of thoracic diseases it is termed pulmonary or cardiac, according as the sounds heard are elicited from the lungs or from the heart. Laennec, the first to reduce the scattered facts to a system, and who must really be regarded as the father of auscultation, based his observations on a well-known principle in acoustics ; viz., that air in passing through and impinging on tubes of various diameters with varying force, will give rise to particular sounds. He taught and, with few exceptions, his contempo- raries and successors have accredited the opinion, that the sounds heard in respiration, on applying the ear to the chest, are the results ofthe fric- tion of the air against the walls or sides of the trachea, bronchiae, and pul- monary vesicles, and, in the case of morbid changes, of dilated tubes and cavernous excavations. Modifications of these sounds will be caused by the interruption to the free passage of air through the canals by mucus or pus adherent to the sides or when detached and partly filling the cavities, or by bubbles of air engaged in mucus, &c. The distinctness and clearness as well as quality of the sounds conveyed to the ear, when it is directly applied to the chest (immediate auscultation) or indirectly by a stethoscope (mediate auscultation), will vary with the nature and amount of the tis- sues and morbid products interposed between the pulmonary tubes inter- nally and the skin externally. Hence, when the tissue of the lungs is more compact than usual, as in hepatization, or is infiltrated with fluid, or when fluid is contained in the pleural cavity, the sounds from the tubes will of course be different from those given out when the pulmonary tis- sues and its envelopes are in a normal condition. Some farther modifi- cations, as respects force and distinctness, may be expected from the greater or less thickness of the walls of the thorax, and the relative pro- portion of muscle and adeps between the ribs and skin ; but they are of less moment than the obstructions to the conveyance of sound internal to the thoracic parietes. In the details of auscultation applied to the diagnosis of pulmonary diseases, I cannot be expected to engage in this place ; and must refer you, if you are not already in possession of one or other of them to the manuals on the subject by Drs. Gerhard and Walshe,- MM. Barth and Roger, Dr. Hughes, &c, or to my Introductory Chapter to Dr. Stokes's Treatise on Diseases of the Chest, 2d Edition, recently pub- lished, and the excellent Lectures of Dr. Williams. You will find that I have indulged in some critical remarks on the want of harmony, as MODIFICATIONS OF RESPIRATORY SOUNDS. 27 respects terminology and the meaning attached to the same terms, among some of the most esteemed writers on the subject of pulmonary auscul- tation. In the main, however, there is sufficient accordance of opinion among a large majority of these to entitle their statements to confidence, so far at least as to induce you to make your own observations and thus to verify antecedent experience. The most that I can now attempt is to mention briefly the chief sounds elicited by the pulmonary apparatus, and which are heard by applying the ear on the chest or to one end of the stethoscope, the other resting on the chest. These sounds are of four kinds. I. Those given out during the process of respiration. II. Those furnished by the voice in speaking. III. Those during coughing. IV. Those of an adventitious kind or friction sounds. I. The sounds of respiration have been divided into two classes. 1. Simple sounds or murmurs. 2. Compound sounds or rattles. The first are caused, with various modifications, by the simple blowing of air; the second by the admixture of air and liquid together. The first of the simple sounds or murmurs in respiration, and character- istic of the normal state, is the respiratory, as it was termed by Laennec, or the vesicular by Andral, a term now more generally adopted. It is that of a soft and gentle, or, as it has otherwise been described, a mellow, continuous, gradually developed, breezy murmur, unattended with a sen- sation either of dryness or humidity. You are to understand, in reference to this word vesicular, that it is meant to designate the seat but not the character ofthe sound ; not one which conveys the notion of a successive dilatation of separate vesicles, or, as it is sometimes called, pure and vesicular. This sound is chiefly inspiratory ; the expiratory is not only much weaker but is of less duration. A precise estimate ofthe degree of difference between the two has been made by M. Fournet, who fixes on 10 : 2 as the ratio of their comparative intensity and duration in the healthy state. MM. Barth and Roger say 3 to 1. These two murmurs follow each other so closely, however, that they may, practically speaking, be said to be continuous. The vesicular sound is more distinct in thin than in fat or muscular, and in very young than in old subjects. In young persons, whose respira- tion is naturally frequent, the sound is more loud and slightly blowing, constituting what has been called puerile respiration, or puerile vesicular murmur. It is heard best at the anterior and lateral parts, and in the lower two-thirds ofthe posterior part ofthe thorax. In some instances, this puerile sound has a pathological signification, as when it is partial or only heard over particular portions of lung, and then in exaggerated strength to make up for the deficiencies of other parts. Hence the propriety of the term supplemental affixed to it, on these occasions, by M. Andral. Bronchial, or Tubal and Blowing, is the next modification of respira- tory sound : M. Louis terms it, an approach to the bellows sound, heard in the space between the vertebral edge of the scapula and the dorsal spine, at the level of the origin of the bronchia. This blowing respira- tion, which exists, also, though in a less degree, towards the sub-spinal fossae, is more marked on the right than on the left; a difference accounted for by the greater calibre of the right than the left bronchia. It resembles the sound produced by blowing through the hand, rounded into the form of a tube, or through a stethoscope. This bronchial is also called tracheal 28 PULMONARY AUSCULTATION. or tubal murmur or sound. It is both normal and morbid. It diners from the vesicular, not only in the degree but in the quality of sound ; it is louder, harsher, and rougher ; and has this additional peculiarity, that the intensity and duration of the respiratory sound are increased to such an extent, as to equal, in these respects, the inspiratory. M. Fournet points out the error, occasionally committed, of mistaking the pharyngeal, buccal, and nasal murmurs, for bronchial respiration produced in the regions to which the ear or stethoscope is applied. The correction is made by causing the patient to change the form of the openings of those parts during the auscultation, and to vary the degree ofthe rapidity with which the air enters them. Closely allied to bronchial respiration, and by M. Andral described as one of its varieties, is the blowing or puffing respiration, which gives a sensation as if the air was drawn during inspiration from the observer's ear or from the surface of the chest, and puffed back with equal force during expiration. Still of the same order and alliance of sounds is the cavernous, tersely described by Laennec as the sound produced by inspiration and expira- tion in an excavation formed in the substance of the lungs, whether it be from the softening of a tubercle, from gangrene, or from abscess. It re- sembles that made by breathing strongly into the two hands disposed so as to form a cavity. It requires a practised ear to distinguish between the cavernous sound and bronchial or tracheal respiration. A modification of the cavernous respiration is described by Laennec under the title of veiled puff. Very analogous to the cavernous is the amphoric resonance, or amphoric respiration. M. Louis describes it, as arising from air entering a large cavity through a narrow opening. I have now mentioned the chief simple sounds or murmurs which are either the vesicular or modifications of this latter ; and which are sup- posed to depend on a current of air impinging, with more or less force, on tubes (larynx, trachea and bronchia?), or their minute subdivisions into cells, or on the sides of morbid cavities, as of dilated bronchia?, pulmonary abscess, and softened tubercle (vomica). Next, I have to speak with equal brevity of the other division of sounds. Compound Sounds or Rallies (relies, rhonchi). These sounds may be said to supersede the respiratory murmurs : they are caused by the partial obstruction to the passage of air through the bronchial tubes, or to its introduction into their terminal vesicles, owing to a narrowing of these cavities, or its admixture with liquid of some kind. Of this class there are two primary qualities of sound—the humid or moist, and the dry rhon- chi. The last is merely a comparative term to establish a kind of con- trast with the rhonchi more evidently moist. Many divisions or varieties of these rhonchi have been detailed by different auscultators, which I shall not now repeat; but shall restrict myself to the following, as suffi- cient for practical purposes :—1. The mucous rhonchus or moist bronchial rhonchus or rattle, the large crepitating rale of Laennec. The death rattle, as it is called, conveys a good though exaggerated idea of this sound : it evidently depends on the passage of air through tubes con- taining a fluid which gives rise to a bubbling, compared to that produced by blowing through a pipe into soapy water. The sound of bubbling is generally interspersed with some whistling, chirping, or hissing notes. This mucous rhonchus is one of the signs, as summed up by Louis • COMPOUND RESPIRATORY SOUNDS. 29 " first of pulmonary catarrh ; it then exists on both sides, and progres- sively descends; secondly, of phthisis when the tubercle becomes soft; it then occurs at the apex of the lungs, under the clavicle ; thirdly, of gangrene ; fourthly, of dilatation of the bronchia ; fifthly, of abscess of the lung. It is generally circumscribed and confined to one side. When alone, therefore, it cannot form a pathognomonic sign." In unnatural enlargement of the bronchial tubes, the bubbling of air through them is of the coarsest kind ; it is quite gurgling, and if the liquid be scanty, has a hollow character entitling it to be called cavernous rhonchus. A roughness added to the ordinary respiratory murmur or more regu- lar but weaker sound of bubbling, constitutes the sub-mucous rhonchus of some writers. It may result from a slight degree of bronchitis, but acquires its chief importance by its being permanently present when bronchial inflammation is constantly kept up by the irritation of adjacent tubercles in an incipient state. Under the title of humid rhonchus with continuous bubbles, M. Fournet describes a morbid sound, which, he states, existed in twenty-three sub- jects, the only ones carefully examined, affected with sanguineous conges- tion of the lungs. 2. Crepitant rhonchus or moist crepitant rhonchus has been compared to the sound produced by salt when thrown on live coals, or by pressing a thin layer of healthy lung between the fingers ; or by dry parchment or silk stuff rubbed between the fingers ; also to the sound of tearing a piece of sarcenet, and hence, according to Chomel, who adduces this compa- rison, it is often called the sarcenet sound. Dr. Williams, with more approach to reality, compares the crepitation in question to the sound which can be produced by rubbing slowly and firmly between the finger and thumb a lock of hair near one's ear. Dr. Corrigan remarks, on such comparisons, that they are bad, as they lead us away from the manner of the production ofthe sound. This sound, called also humid vesicular, is exactly that of small bub- bles breaking through fluid, and, it is thus produced in the diseases in which it is heard—in pneumonia and oedema of the lung. Crepitant rhon- chus is chiefly, but not exclusively, met with in pneumonia, of which it is represented, however, as diagnostic. Besides in oedema it is heard in apoplexy of the lungs, and occasionally in pulmonary catarrh and bron- chitis. It is small, clear, and, most usually, it is accompanied by vesicu- lar murmur. M. Louis makes a remark of some importance on this rhonchus, viz., that it is heard over the whole chest of some healthy per- sons at the moment of a first forcible inspiration, after which it disappears. 3. Sub-crepitant rhonchus, or by some (Laennec and Chomel) called rhonchus redux, rale de retour, produces a sensation similar to that heard on applying the ear near the surface of a liquid slightly effervescing, or blowing with a pipe into soap-suds. It has been subdivided into the sub-crepitant, the liquid, and the continuous. Dr. Corrigan, on the other hand, does not believe sub-crepitant rhonchus to be a division available in practice or recognised by the ear; while M. Louis thinks that it can- not be mistaken. It is met with in pulmonary catarrh, or bronchitis in its most acute and intense form ; and in this case it is confined chiefly to the posterior and inferior part of the chest, or is heard in both sides at once : or if it extends to the upper it always begins below. At the summit of one or both lungs, it indicates local tubercular bronchitis, or tubercles in a state of softening. 30 PULMONARY AUSCULTATION. Cavernous Rhonchus—Gurgling.—Consists of a limited number of bub- bles of large size, distinctly projected, having a peculiarly hollow metallic sound, coexisting commonly with inspiration and expiration, but occasion- ally ceasing to be produced for a time—with or without cavernous respi- ration. It commonly arises from a cavity in the lung, or from a largely- dilated bronchial tube. M. Fournet mentions a pulmonary crumpling sound, resembling the new leather-creak of pericarditis, and conveying to the ear the impression ofthe crumpling of a tissue pressed against a hard resisting substance. It was detected by him in the first stage of phthisis, in one-eighth of the cases ; also in one case of encephaloid tumour of the mediastinum, and in another of non-tuberculous cavity of the summit ofthe lung. Of the dry rhonchi we have the sibilant and sonorous, included under the head of the dry bronchial. The sibilant resembles a slight and pro- longed whistle, as if through the teeth; and is either grave or acute, dull or clear : it is capable of masking the respiratory sound. The sibilant rhon- chus generally occurs in tubes narrowed by swelling of their mucous or sub-mucous coats; and hence, but in limited extent, is met with in pulmonary catarrh, or in the early stages of acute bronchitis ; and, also, in asthma or pulmonary emphysema. In typhoid affections it occurs in three-fifths of the cases, generally about the eighth day, and over the whole of the chest. The sonorous rhonchus is a grave, and sometimes an extremely loud sound ; at one time resembling snoring ; at another the sound of a bassoon ; and very frequently it is the cooing of a turtle-dove. It is most commonly met with at the beginning of pulmonary catarrh. We are very properly told by Dr. Williams that, as any of these rhon- chi may be produced in only one tube and yet make a great deal of noise, it is not to be supposed 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 announce disorder, which may be serious either from its permanency or its extent. II. Sounds furnished by the voice in speaking; or Auscultatory Vocal Phenomena. I now come to the second division, or auscultation of the voice. That a vibration is communicated to the parietes of the chest during the act of speaking is evident to another person whose hand is placed on this cavity at the time ; but still more so if the ear be applied through the intervention of the stethoscope. The phenomenon thus heard is called vocal resonance, and is modified according as the stetho- scope is applied over the larynx, trachea, or bronchia. It is then called natural laryngophony, tracheophony, and bronchophony. The voice at this time is transmitted from the larynx and trachea with a startling force and loudness. Natural bronchophony, which, though loud, is considerably less intense than the vocal resonance of the air tube before its bifurcation, is heard at the upper part of the sternum on the middle line, and with less force towards the edges of this bone ; behind, in the middle line, over the division of the trachea; and, on either side, between the spines of the scapula?. In proportion as the bronchial tubes ramify and are buried as it were, in the spongy pulmonary tissue, the sound originating in the vibrations of the glottis becomes deadened or dull; or it is merely an ob- AUSCULTATORY VOCAL PHENOMENA. 31 scure and diffused buzzing, a kind of vibration or fremitus, which may, as before remarked, be felt by the hand placed on the chest. As there is no absolute standard of vocal resonance by which to measure deviations, we cannot say what should be considered a sign of disease, on our applying the ear or stethoscope to any part of the chest. But as there is, generally, symmetry in the two sides, and as the resonance is equal, except under the clavicles and on each side the spine between the spines ofthe scapula, in which it is somewhat stronger on the right, any very notable difference between the two sides may be considered as morbid. If, for example, under one clavicle the voice resounds loudly, while it is scarcely heard under the other, we may be sure that there is some physical difference between the two sides which does not exist naturally. This leads us to inquire what are the circumstances which give rise to changes in the natural voice. 1. Morbid bronchophony occurs in the same morbid states of the lung or tube under which morbid bronchial respiration is evolved. The condi- tion for the more ready and complete transmission of sound in the tubes, whether by vibrations of air in breathing, or of the walls of the tubes in speech, are the same, viz.:—increased induration and solidification of the tissue interposed between the tubes and the thoracic parietes. The two kinds of signs are then associated, and whenever one is heard we are pretty sure to find the other. They are met with in red or grey hepatiza- tion of the lung, in pneumonia, in pleuritic effusions, and in indurations ofthe pulmonary tissue, as in tubercles and dilated bronchia. 2. (Egophony is another ofthe modifications of vocal resonance in cer- tain morbid states ofthe lungs. It sounds to the ear like the bleating of a goat, and hence the origin of this term, introduced by Laennec. The voice is rendered thus broken and tremulous by its transmission through a liquid effused between the pulmonary pleura and the costal pleura, and which is thrown by a vocal resonance ofthe lung into a state of irregular vibration. When most strongly marked, cegophony is distinctly metallic, jarring and muffled, is synchronous with the articulation of each word, or follows it immediately, like a shrill echo of natural resonance, conveying the idea of a distant origin. It does not appear to traverse the stethoscope, but rather to flutter tremulously about the applied end. CEgophony may be regarded as a favourable sign in pleurisy, as it indicates but a moderate degree of effusion; but we cannot regard it as pathognomonic of this state. It is heard, generally, on one side in the lower half of the sub-spinal scapular space, but may change its position on the different portions of the body. 3. Pectoriloquy—cavernous voice—is a still greater degree of vocal reso- nance, in which not only the voice but speech reaches the ear from a cavity formed in the lungs, as if the patient spoke directly in the ear of the auscultator. The cavity must be of some size, and communicate directly with the bronchia?. This takes place in phthisis, gangrene of the lung, and abscess, and in considerable dilatation of the bronchial tubes. Curgling is often heard at the same time with pectoriloquy, and adds to its diagnostic value. 4. .l/iiphoric Resonance or Metallic Tinkling designates that peculiarity of transmitted sound in speaking, which conveys the idea of its being produced in a hollow space of a large size, and it is hence called amphoric —like the humming produced by speaking across the mouth of a large pit- 32 PULMONARY AUSCULTATION. cher, three-fourths empty. It coincides usually with amphoric respiration. It may be produced in the cavity left by a large vomica or abscess, or by several of these coming together; but its more common seat is the sac of the pleura, into which air has entered through a fistulous opening in the lung. I must not conclude this division of our subject without apprising you, that the best auscultators ofthe day are far from attaching the same im- portance to these different vocal resonances, in a diagnostic point of view, that Laennec did, or from believing that they can be as readily distinguished as he supposed. III. Auscultatory Tussive Signs, or Resonance of the Cough.—In our endeavours to ascertain the sounds elicited by coughing, we pursue the same steps as in the case of the resonance of the voice in speaking ; and hence the divisions of the cough, in pulmonary disease, into bronchial, cavernous, and amphoric, corresponding, in fact, very much with broncho- phony, pectoriloquy, and amphoric respiration ; the former sounds being elicited by the act of coughing,—the latter by the voice. In a semeiolo- gical point of view, the sounds from coughing have less value than those of the voice, as these latter have less than those of respiration. Metallic Tinkling, already spoken of in connexion with amphoric resonance, is less commonly produced in respiration than as a phenomenon of vocal or tussive resonance. In some instances it is evolved only by forcible coughing. It is a name given to a quick, sharp, ringing sound, closely resembling that produced by gently striking a hollow metallic or glass vessel with a pin. I shall most probably have occasion to speak of the origin of this sound in a future lecture. Auscultation of the Larynx is thus described by MM. Barth and Roger:—" In the healthy condition of the larynx, the respiratory sound has a hollow and cavernous tone, the vocal resonance is at its maximum, and the cough gives the sensation of the rapid passage of air through a hollow space. In the pathological condition, the laryngeal respiratory murmur is harsher, or more rasping, as, for instance, in acute or chronic laryngitis, or else it is replaced by a whistling sound, as in spasm or oedema of the glottis, in stridulous laryngitis, in some cases of foreign bodies in, arid compression of, the trachea ; or by a sonorous tone, as in the case of laryngeal ulceration with thickened edges, and obstruction to the passage ofthe air ; or again, by a snoring sound, as in simple or stridulous laryngitis, ulcerations, laryngeal vegetations, fyc,—a sound which has frequently a metallic tone in croup. " In some circumstances, the ear perceives ^laryngealcavernous rale, as, for example, when the trachea and larynx are filled with mucus, this rale may be more circumscribed and confine itself to the presence of the mucus upon an ulceration, or around a foreign body arrested in the ventricles, &c. Finally, in some rare cases, we hear a tremulous ox vibrating sound, which announces the existence of croup with floating false membranes. There is another sign, that is met with in a great many diseases of the larynx, that may be established, it is true, by auscultation of the chest, but which ought to be mentioned here : it is the diminution, or complete obliteration of the vesicular murmur. This phenomenon accompanies every alteration which offers an evident obstacle to the introduction of air into the air pas- sages, whether it obstruct or narrow the diameter of the tubes (as swelling inflammation, vegetations, accidental products, foreign bodies, &c.) whe- COEXISTFVCE OF MORBID PHENOMENA OF RESPIRATION 33 ther it compresses them from without (cancerous tumours, cysts, aneu- risms, &c), or whether, finally, it produces more or less complete occlusion ofthe superior orifice ofthe air tube (as hypertrophy ofthe tonsils, polypi of the nasal fossa? falling upon the superior part ofthe larynx, &.c).—Br. Francis G. Smith''s Translation, pp. 48-50. IV. Adventitious or Friction Sound.— This sound is produced by the rub- bing together ofthe two opposing surfaces of the lamina? of the pleura, when the latter is in a morbid state from having lost its polished smooth- ness ; and hence the propriety of the title friction sound. It exhibits three varieties : viz., 1. The grazing sound. 2. Friction sound, properly so called. 3. Grating sound. These sounds are always audible in inspiration, but not so in expiration, unless they be strongly marked : thus the grating variety is not perceived in the latter movement, while the others manifest themselves in both. Under all circumstances, they appear first in, and disappear last from inspiration. It requires great attention to distinguish the rubbing sounds from similar ones arising from the movement of the clothes of the patient or the observer. Pleural friction sound consists either of a single, or, more commonly, of a series of jerking sounds, few in number, manifestly super- ficial in seat, and varying in harshness, tone and intensity, so that it may be divided into soft friction or rustling, and hard friction or rasping. It is audible over a variable, but usually limited, extent of surface ; per- sistent or intermittent; of variable but commonly more or less consider- able duration; almost always heard in inspiration, and more intensely- developed with that movement, but most frequently accompanying both inspiration and expiration. Friction sound is one of the first signs of pleu- risy ; but rapidly ceasing with effusion, to return often after absorption, and especially when false membrane is formed between the two pleural surfaces. It is met with in interlobular emphysema, according to Laen- nec ; and it occurs also sometimes in pleuro-pneumonia towards the de- cline of the disease, and when convalescence has set in. In illustration of some ofthe important associated phenomena of auscul- tation, I shall introduce the following table by M. Fournet, for which I am indebted more immediately to the British and Foreign Medical Review, vol. ix. :— Table, showing the mode of coexistence of the Morbid Phenomena of Respiration with Inspiration and Expiration. [The order in which the different phenomena are set down in each division, exhibits the degree to which they relatively acknowledge the law regulating them all.] A. Morbid Characters coexisting exclusively, or almost exclusively,-with Inspiration. 1. Humid rhonchus with continuous bub- bles. 2. Primary crepitant rhonchus of pneumo- nia. 3. Mucous rhonchus of third stage of pneu- monia. 4. Grazing pleuritic sound. 5. Pulmonary crumpling sound. 6. Dry crackling rhonchus. 7. Sub-cropitant rhonchus of oedema. VOL. II.—4 8. Sub-crepitant rhonchus of capillary bron- chitis. 9. Rhonchus crepitans redux of pneumo- nia. x.b. The first three sounds coexist exclusively with inspiration ; the others sometimes occur in expiration also, but exceptionally only. The frequency of these exceptions increases from .No. 4, down* wards. 34 PULMONARY AUSCULTATION. B. J forbid Characters Coexisting with both movements. Humid cavernous rhonchus Dry cavernous rhonchus. C Bronchial } Dry < Tracheal > rhonchi. C. &c* j Cavernous rhonchus. Grating pleuritic sound. Friction pleuritic sound. Augmentations of intensity. Diminutions of intensity. Augmentations of duration. Diminutions of duration. 11. Amphoric character. C Cavernous character- l*' 2 Veiled puff. 13. Bronchial character. 14. Metallic tinkling and echo.* 15. Blowing character. 16. Kinging character. 17. Clear ditto. 18. Mucous rhonchus. 19. Humid crackling ditto. 20. Dry, hard, rough, laborious character. 21. Humid character. C Morbid Characters coexisting chief y -with Inspiration. 1. Diminution of duration and intensity. 2. Complete cessation. 3. Humid character. 4. Dry character. 5. All varieties of friction sound. 6. Pulmonary crumpling sound. 7. Dry crackling rhonchus. 8. Sub-crepitant rhonchus of oedema. 9. Sub-crepitant ditto of capillary bronchitis. 10. Rhonchus crepitus redux. 11. Humid crackling rhonchus. 12. Bucco-pharyngeal rhonchi. 13. Cavernulous rhonchus. 14. Gurgling ditto. 15. Humid, bronchial, tracheal, laryngeal rhonchi. 16. Dry acute-toned bronchial, cavernous, tracheal, laryngeal rhonchi. D. Morbid Characters coexisting chiefly -with Expiration. 1. Augmentation of intensity and duration. 2. Metallic tinkling and echo. 3. Clear character. 4. Ringing ditto. 5. Blowing ditto. 6. Bronchial character. 7. Cavernous ditto. 8. Amphoric ditto. 9. Dry grave-toned bronchial, cavernous, tracheal, laryngeal rhonchi. E. Morbid Characters coexisting first -with Inspiration, and then extending to Expiration. 1. Pleuritic friction sounds. 2. Dry and humid crackling rhonchi. 3. Hard, rough, dry, laborious character. 4. Humid character. 5. Crepitant rhonchi, primary and redux. F. Morbid Characters coexisting first -with Expiration, and then extending to Inspiration. 1. Clear character. 2. Ringing ditto. 3. Blowing ditto. 4. Bronchial character. 5. Cavernous ditto. Sounds ofthe Heart and Vascular Murmurs have a diagnostic value in pulmonary auscultation, as when we find them propagated to a greater extent, or with more force in certain directions than in health, without the heart or the vessels being the seat of the disease. The positive in- tensity of the heart's sounds is unaltered, but its relative intensity, as discovered in different parts of the thoracic surface, is changed! In the latter case, we infer, if the cardiac sound be more intense than * In some cases of hydropneumothjprax with perforation, observes M. Fournet " the metallic tinkling of Laennec is not to be discovered ; but, instead, the amorphic character of the respiration seems to reverberate in a sort of vague diffused echo, which rinas like the voice under an archway ; this phenomenon may he called resonnance metallique ■ it often accompanies the voice and cough." The English reader will here recognise the precise description, almost the very words, of Dr. Williams, in reference to the pheno- menon of tinkling echo. " THEORIES OF AUSCULTATION. 35 common, that the lung or pleura has undergone some change, rendering them unusually good conductors of sound. Or there may be rarefaction in certain limits, so that the sounds of the heart's beats shall be less dis- tinctly heard than common. Theories of M. Beau and of Dr. Skoda on Auscultation.—1 have for- borne from introducing any conflicting theoretical views and explanations which assume a different basis from that laid down by Laennec and, gene- rally, by his contemporaries and immediate successors up to the present time. But, brief as is my present sketch, it ought to include, for your information, a notice of certain positions advanced by some other writers and observers, who claim for them, also, the enforcement of physical laws and of experimental observation. The chief of this class of auscultators are M. Beau, of Paris, and Dr. Skoda, of Vienna. M. Beau advanced his new thccry of the sounds heard in respiration in the Archives Generates de Medecine, in 1834, and in a series of papers in the same journal for 1840 he enlarged and enforced his views with additional illustrations and arguments. His cardinal proposition is, that the sounds heard during respiration are elicited by the same means as those formed by the voice in coughing, viz.:—primarily at the glottis and upper apertures by vibrations at these parts, and secondarily by the tra- cheo-bronchial tubes and ramifications receiving and transmitting these vibrations, which finally pass through the pulmonary parenchyma, and envelopes to the walls of the chest, and thence to the ear resting on thin last. The movements of the air in them has little to do in either case with the sounds heard externally. If, in common respiration, a person snores, to use a familiar example, the sound thus made at the nostrils, and more particularly at the velum palati and pharynx, resounds through the bronchia? and vesicles, and is heard by the ear applied to the chest. This fact, which I have myself noticed, seems to be not a little confirmatory of M. Beau's theory of resonance, as the noise made in the mouth and fauces at this time is not accompanied by any corresponding deviation from the usual respiratory movements, by which the air might be introduced into the bronchia? and vesicles with more force than ordinary. The chief sounds made resonant in the bronchia? are the glottic, according to M. Beau's explanation. Dr. Spittal, of Edinburgh, after having become cognisant of the views of M. Beau, advanced in 1834, instituted several experiments, which, together with accompanying reflections, he has recorded in the Edinb. Med. and Surg. Journ. (1839). Dr. Spittal's results are fully confirmatory of the theory of the French writer. M. Beau enumerates the orifices or openings of the respiratory pas- sages, capable of causing vibrations in the air which traverses them and of producing the superior sound, which afterwards becomes resonant and audible in its several varieties, according to the part ofthe laryngo-bron- chial tube and ramifications over which the ear is applied. These orifices are five in number, viz.—1. The lips ; 2. The nostrils ; 3. Isthmus of the pharynx; 4. Orifice of the glottis ; 5. Opening of the larynx. The orifice of primary, and indeed paramount importance, among all these, is the glottis; it is the glottic sound " reverberated in the air tubes and pulmo- nary vesicles that gives rise to all the various sounds of respiration de- scribed by auscultators. It is a double sound, at one moment inspiratory, at another expiratory." 36 PULMONARY AUSCULTATION. You will find a tolerably full synopsis of M. Beau's papers in my Intro- duction and Appendix to Dr. Stokes's Treatise on the Chest. In this same work I have also introduced, from the Edinb. Med. and Surg. Jour. (1841), an outline of Dr. Skoda's theory of auscultation. 1 ought to add, that MM. Barth and Roger (Practical Treatise on Auscultation—Trans- lated by Dr. Newbigger, with an Appendix by Dr. Lawson), deny the accuracy of M. Beau's opinions. I give you the conclusion of their argu- ment:— " In summing up this long discussion, which the elaborate exposition into which M. Beau has entered has in some degree rendered necessary, let us call to mind the chief propositions which invalidate his theory: 1. The guttural sound is heard the more distinctly the nearer we examine to the seat of its production, while the vesicular murmur is equally well heard in every point, where there is a sufficient mass of pulmonary tissue. 2. The guttural sound may be strong, and yet the vesicular murmur ab- sent ; and, on the other hand, the vesicular murmur may be pure, clear, and distinct, without the perceptible existence of any noise at the back of the mouth. 3. An observer, who has had a little practice, can recognise the production of the guttural sound, at a distance, while the respiratory murmur takes place immediately under his ear. 4. When a given point of the chest is explored, the two sounds may be distinguished from each other, although they exist simultaneously." Dr. Skoda explains the different degrees of strength ofthe voice in the chest, and perceptible to the ear applied to it by the law of consonance. When one body gives the same vibrations with another, or when it pro- duces the same note, or its vibrations form an aliquot part of the note, it is said to be consonant with this other body. The note of a Jew's-harp is scarcely perceptible when it is struck in the air, and it is heard much more distinctly when played in the mouth. Thus the air in the mouth must increase the sound of the Jew's-harp ; i. e., must consonate with it. It sometimes happens that the voice is heard more strongly at the tho- rax than at the larynx, which itself is sufficient to show that its strength is increased by means of consonance within the chest. As it is certain that the air in the pharynx, mouth, and nostrils, consonates with the sound formed in the larynx, there can be no doubt, Dr. Skoda thinks, that the air in the trachea and bronchia? may also be thrown into conso- nant vibrations with the sounds formed at the larynx. Hence it is the air in the chest and not the parenchyma of the lungs which consonates with the voice at the larynx, as the latter seems ill adapted for conso- nating, being neither stiff nor sufficiently dense. The strength of the consonance depends upon the size and form ofthe spaee in which the air is confined, and upon the properties of the walls which bound the space. It appears that the consonating sound of the inclosed air will be strono-er the more perfectly the walls reflect the sounds which spread through the air. For air to consolidate, it must be confined within a circumscribed space. A space surrounded by solid walls produces the greatest conso- nance, while in a linen tent the sound is but little increased. The deductions drawn from these physical principles will serve to ex- plain the consonance of the voice in the chest. The air in the trachea and bronchia? consonates with the voice as far as their walls resemble those of the larynx ; and an increase of consonance of the air in the rami- fying bronchia? ofthe lungs is procured either by their walls being carti- USE OF THE STETHOSCOPE. 37 laginous or becoming thicker, or by the surrounding tissue of the lungs becoming devoid of air. Provided, therefore, that there is no interruption of continuity between the air in the bronchia? and that in the larynx, the walls of the latter, thus thickened and firmer, reflect the sound more strongly than the membranous walls of the bronchia? and their vesical terminations. It does not follow, according to Dr. Skoda's views, that hepatised lung should transmit sound more readily, or indeed quite as readily, as the healthy parenchyma, provided the lining of the cavities including the bronchia? be sufficiently firm and resisting to cause the air to consonate in them. The vibrations in the walls of the larynx and the bronchia? are not, he thinks, transmitted along them from the glottis, in vocal move- ments ; but they are received from the air in its state of consonance and are in force and number proportionate to those of the air. They may afterwards spread through a layer of fluid or of muscle several inches thick, even to the parietes of the thorax ; and the sounds produced by consonance on the bronchia? will be perceptible at the walls of the chest. But while differing from the school of Laennec as to the mechanism of the transmission of vocal sounds through the chest, Dr. Skoda describes nearly as his immediate predecessors, and most of his contemporaries, have done, the morbid states of the respiratory organ which give rise to an increased resonance of the voice. The Austrian professor divides the varieties of respiratory sounds as follows—1. Vesicular respiration. 2. Bronchial. 3. Indeterminate. 4. Amphoric and metallic. The Rattles or rhonchi are divided by him into 1, the vesicular; 2, the consonant; 3, the crackling or dry crepitating with large bubbles ; 4, indeterminate ; 5, rattles with amphoric echo. I shall conclude by a few directions for the use of the stethoscope what I had proposed to say in auscultation proper. The best shape for a stetho- scope (from !tt»9oc, the breast, and , I examine), is that of a perfo- rated cylinder, hollowed at the chest end into a conical cavity, and the other end made flat, or slightly concave, to fit the ear ; in some cases, as when we want to explore small spots of the chest, to ascertain for exam- ple the extent of resonance, and whether it is produced in a small cavity, or merely transmitted by consolidated lung from several bronchial tubes distributed over some extent of surface, we use the instrument somewhat modified. Its conical cavity is filled up by a conical perforated plug, which re-converts the instrument into a simple perforated cylinder, and circumscribes its power. The stopper is also used when we want to shut out the sound of respiration in listening to the sound of the heart or arteries. The stethoscope serves—1. To conduct sound by its solid walls. 2. To conduct and concentrate sound by its closed column of air (resonance). 3. To transfer sounds from its column of air to its solid walls, or the con- verse, when circumstances impede their transmission by one of these ways. 4. To diminish this power of transfer, and contract the field of hearing when small spots are to be explored. Sometimes a flexible tube, like a common ear trumpet, is used for a stethoscope, and answers well, like that made of brass wire coiled and suit- ably covered, the invention of Dr. J. L. Ludlow. It has the advantage from its flexibility of being applied more conveniently, both for the pa- tient and the physician, than the straight, rigid tube of wood. 38 PULMONARY AUSCULTATION. The instrument should be applied in close contact with the chest, at one end, and with the ear at the other. Continued attention is required by beginners to prevent the least tilting of the trumpet end, that next the chest, by which air is interposed and the thoracic sound lost or greatly weakened. For the manner of conducting auscultation, we cannot give directions more clearly and succinctly than by using the language of M. Louis, on the occasion, as follows :— " The person to be examined should lie on his back, or sit, according as we wish to auscult the anterior or the posterior part of the chest; he must lean neither to the right nor the left; his shoulders must be in the same plane, and his symmetrical muscles in the same state of relaxation or tension as the position of the patient. " The contraction, tension, and relaxation ofthe muscles, have a marked influence on the results of auscultation, and when the corresponding points of the thorax are examined in comparison wTith each other, as we must always do if we want to draw rigorous inferences, we might imagine dif- ferences that did not exist, merely from the bad attitude of the patient. " The auscultator, too, must select a convenient position, as Laennec recommends, and take care that the respiratory sounds are not intercepted by thick clothes, and particularly that the patient does not retain any which might produce a fallacious sound, as, for instance, silk coverings. He must also find out which is his best ear, as experience shows that almost every observer has one ear finer than the other. All these precau- tions, which at first sight may seem over-punctilious, are absolutely neces- sary to prevent our falling into gross errors. " In opposition to Laennec, it is now allowed that the naked ear per- ceives sounds as well as when aided by the stethoscope ; and, indeed, it often happens that it distinguishes shades of sound which had escaped it when assisted by this instrument. The cases in which we ought to pre- fer mediate auscultation are very rare, and it is often necessary to have recourse to immediate auscultation to determine with clearness what would otherwise be obscure. " The patient and the observer being properly placed, auscultation, to be successfully practised, requires another condition, namely, the ear, if unaided,is to be exactly applied to the chest; if the stethoscope is used, the whole of its circumference is to be applied to the parietes of the tho- rax, so that if the patient is so wasted that the intercostal spaces leave a cavity under the stethoscope, it must be filled up by compresses placed upon the thorax." VARIETIES OF PERCUSSION. 39 LECTURE LXXXV. DR. BELL. Physical Diagnosis of Pulmonary Diseases (Continued).—Percussion—Defined— Avenbrugger its discoverer for diagnosis in thoracic diseases—Corvisart—Piorry— Two varieties, immediate and mediate—Mode of using immediate percussion—Divi- sions of mediate percussion—Plexirneler—Substitution for it of a finger or fingers —Chief percussing agents, a hammer and the fingers—Directions for mediate percus- sion— Percussion of the chest—Different regions in which it is practised—Postures of the patient and physician in percussing the different thoracic surfaces—What found on percussion—A verifying of different states ofthe lungs and pleural cavity—Diffe- rent sounds in different regions ofthe chest—Two chief divisions of sound on percus- sion of the chest, viz., increased sonorousness and diminished sonorousness or dulness— Auscultatory percussion—Autophonia—Snccussion—Inspection—Measurements—In- struments for—Two sides of the chest seldom quite symmetrical—Comparison—Value of comparison—Application of, to diseases of the chest—Sources of physical diagnosis —Improved diagnosis not always immediately productive of improved therapeutics. Percussion.—I shall continue a description ofthe methods of physical diag- nosis of diseases of the lungs, by some remarks on percussion. This term is applied to the act of striking the external surface of any of the great cavi- ties,but more particularly the chest,for purposes of diagnosis. M. Piorry de- fines it to be, a method of exploration, by which impulse, imparted to an or- gan or the walls of a cavity, gives rise to a sound and a degree of resistance fitted to enable us to judge of the physical state of the part to be explored. This is obviously a kind of auscultation ; the sounds listened to being artifi- cially made by the observer instead of being the result of vital actions in the interior of the organ. But percussion is something more than mere aus- cultation, since it impresses the sense of touch also; and hence every per- cussion gives rise to two distinct sensations, which the examiner or ope- rator ought to analyse. They are, the sensation of touch and that of hear- ing ; the former of which not being appreciated by the observers near, prevents them from distinguishing degrees of sound, of which he who per- cusses is readily sensible. We are indebted to Avenbrugger of Vienna for the discovery of per- cussion as a means of diagnosis ; but it was not until after the lapse of some years, and when Corvisart became the translator of the German work, and applied the method to detecting diseases of the heart, that it attracted any notice. At the present time we are indebted to M. Piorry more than to any other writer for the extension and precision of view and of practical detail in percussion. Favourable mention may, also, be made of M. Mailliot, his pupil and commentator, who, in his Traite Pratique de Percussion, has presented with adequate clearness the promi- nent particulars ofthe subject. There are two varieties of percussion ; direct or immediate, and mediate. Immediate percussion consists in striking directly with the fingers or hand on the skin over the part to be explored. Mediate percussion consists in striking the part by the intervention of another body. Avenbrugger and Corvisart practised direct percussion. The former used the four fingers of his right hand closely united on a level with each other ; the ball of the thumb being placed firmly against the articulation of the second pha- 40 PERCUSSION OF THE CHEST. lanx ofthe index finger, so as to support and give firmness to the fingers. The points ofthe fingers are then to be brought down perpendicularly on the surface with a sharp and quick stroke, which is found to produce a sound varying in properties with the condition of the subjacent parts. Avenbrugger recommended that the patient's chest should be covered with a thin dress, or that the operator should wear a glove, so as to pre- vent the sort of click resulting from the contact of the naked hand and skin. Corvisart struck the chest with his open hand, in order, as he alleged, to be able to appreciate the extent of the portion of the thorax which did not resound, and to determine more accurately the nature of the obstacle. Mediate percussion consists in striking the parts to be examined by the intervention of another body. Some, and they include the larger number of English and American physicians, make use of one or more fingers of the left hand resting on the chest, while they strike with those of the right. Others, and chiefly the French physicians, have recourse to some foreign body, usually of a solid nature, interposed between the chest and the percussing fingers, to receive the first impulse of the latter. The body interposed is called a pleximeter (from 7rhe%uc percussion, and i«im», a measure). Hence we have digital mediate percussion, and pleximetral mediate percussion. The pleximeter used by M. Piorry is a thin circular plate of ivory, about an inch and a half in diameter, provided with two prominences, slightly hollowed and filed on their outsides, to allow of their being held with the fingers and thus secure the better the application of the instru- ment on the skin of the part to be explored. Of the various modifications of this pleximeter and the new ones proposed from time to time, the left index finger and aflat piece of India rubber are to be preferred. The plexi- meter, of whatever nature it may be, should rest in close apposition with the surface, so as almost, to use the words of M. Piorry, to make one body with the part that it covers. For this reason it appears advisable to apply the palmar rather than the dorsal surface of the finger to the chest, when this takes the place of a regular pleximeter. There are varieties of percussing agents ; the chief ones are the fingers and some modification of a hammer. Preference should be given to the former, of which, generally, the index and median are the ones used. They should have their ends brought exactly to the same level, and be supported by the thumb with its'ball laid firmly upon the outer surface of the former, between the articulations of its second and third phalanx. The fingers employed in percussion should strike at the same moment, as if constituting one body, on the pleximeter or its digital substitute, and they should strike perpendicularly on the part examined. Care must be taken not to let the nails strike, as the noise which would thus be made must interfere with or drown the sound elicited from the organ beneath the body struck. All necklaces, breastpins, &c, should be removed from the patient, as their resistance is apt to interfere with the sounds proper to percussion. In proceeding to Percussion of the Chest, we should be aware of the different regions in which it is practised. Laennec and Piorry have divided the chest into twelve regions, on which examinations by percus- sion may be performed, with a view of ascertaining the physical con- ditions of the lungs. These are, 1. Sternal; 2. Supra-clavicular- 3. DIFFERENT REGIONS OF THE CHEST EXAMINED. 41 Clavicular; 4. Sub-clavicular; 5. Mammary; 6. Vertical; 7. Sub- scapular; 8. Supra-spinal; 9. Spinal; 10. Sub-spinal; 11. Sub-scapu- lar; 12. Axillary. 1. The sternal region is bounded by the limits of the sternum, which lie between the articulations with the clavicles and the cartilages of the ribs. 2. The clavicle and the cleido-mastoidean and trapezius muscles express the bounds of the supra-clavicular region. 3. The clavicular region will include all the portion of lung covered by the clavicles. 4. The sub-clavicular region is limited by the sternum, the anterior border ofthe axilla, the clavicle, and the fourth rib. 5. The mammary region begins at this point to terminate at the eighth rib. 6. The vertebral region will include the extent ofthe twelve dorsal vertebra?, and the ribs attached to them as far as the angles which they form. 7. The sub- scapular region will embrace the whole extent of the posterior portion of the thorax, comprised between the limits of the lung and the superior border of the scapula. 8, 9, 10. The limits of the supra-spinal, spinal, and sub-spinal regions are indicated with sufficient clearness by the rela- tions which these bear to the scapula, so as to render any farther descrip- tion unnecessary. 11. The whole space comprised between the vertebral column, the posterior border of the axilla, the inferior angle ofthe scapula, and the tenth, eleventh, and twelfth ribs, will constitute the sub-scapular region. 12. The axillary region extends from the top ofthe axilla to the eighth or ninth rib. The physician should be at his ease, whether sitting or standing, in order to make the exploration with more effect. The degree of force of percussion will be regulated by the thickness of the tissues interposed between the pleximeter and the lungs, and, also, the intention of the ex- aminer, as, for example, whether the means to ascertain the state of the superficial portion ofthe lungs, or their density at greater depths. Per- cussion should be practised in preference on the ribs, but not to a neglect ofthe intercostal spaces, if it is only for the purposes of comparison. In percussing the front part of the chest, if the patient be seated the physician should also sit; if the former be in bed, he should stand. The shoulders should be thrown back by elevating the arms, so as to protrude the chest, and give a relative degree of tension to the skin and muscles. Percussion of the chest, made with equal force on both sides, will give rise to the same degree of sound from the apex of the lungs to the fourth rib ; but below this latter different results may be expected, and a modi- fied process is to be adopted. The mamma?, particularly in the female, prevent a continuance of the percussion downwrards, and afterwards the heart on the left side and the liver lower down on the right give different qualities of sound. In examining the posterior part of the thorax, the patient should be directed to sit on a stool without a back, or on the outer angle of a chair, and with the head inclined forwards and arms crossed on the breast. Per- cussion is then to be made, by pressing with some degree of firmness either the pleximeter or the fingers ofthe left hand on the muscles covering the scapula and the vertebral sulci; and striking with various degrees of force, in different points down to the regions where the pulmonary tissue ends, behind the liver and spleen. For percussion on the sides of the thorax, the patient should lie on the side opposite that to be examined, with the arm raised, but not to such a 42 PERCUSSION OF THE CHEST. degree as to give tension to the pectoralis major, latissimus dorsi and teres major muscles ; and thereby prevent their separation and the application of the pleximeter or finger directly below the axilla. You may perhaps ask, before proceeding to practise it, what ought we to find in percussion of the chest ? The answer is ready. You will have vibrations giving rise to sounds, varying in intensity and clearness accord- ing as you strike over the lungs in health or in disease, that is, according as they are hollow and distended, or partially obstructed and compact; or, according as they are encroached on by solid organs, such as the heart or liver, or are covered with effused fluid. Considering the simplicity of the principle—the production of sonorous vibrations by percussion—and its application to common every-day use, as when we strike a wall with a hammer to ascertain what part is brick and what wood, or, suspecting fraud, to discover concealed cavities in walls, by the difference in the sound emitted according to the density ofthe body or part struck ; or in the familiar example of striking on an empty, a half-filled, and an entirely full cask—it is a matter of surprise that this principle was not earlier ap- plied to investigate the physical state ofthe different regions ofthe thora- cic cavity and the different states of the same region, so as to ascertain when the contained lung is healthy and when it is diseased. With this preliminary notice of the general nature of percussion, we are prepared to learn the difference of sounds in the different regions of the chest. The sound is clear above the clavicles, somewhat clearer behind these bones, and still more a little below them. The resonance is greatest over about the third rib; but becomes less distinct in the mammary region, and null in a great part of the precordial region. It disappears on a level with the seventh or eighth rib, to be replaced on the right by the dulness ofthe liver, and on the left by the sonorousness ofthe stomach. On each side, the chest sounds clearly over all the parts which corre- spond with the lungs. Behind, there is little sound above the scapula, less again on the supra and intra-spinal fossa? ; but towards the lower angle of the scapula the sound becomes clearer,—to be gradually succeeded by that of a less dis- tinct nature, until we have the complete dulness of the hepatic and splenic regions. On each side of the spine there is considerable resonance. Age and sex cause modifications in the sound ofthe chest on percussion. The lungs are at their maximum density in adult age, and minimum in old age ; and hence, while the chest of children sounds more clearly than that of adults, it is exceeded in this respect by that of old people. The greater fulness and extension of the mamma? in a well-formed female interferes with percussion of the anterior part of the chest; and hence this does not furnish quite so full data for diagnosis as in the case of an indi- vidual of the other sex. The individual differences are very great. In some persons whose chest is very muscular, there is a want of clearness; and in others, cushioned as it were in fat, dulness prevails. The diagnostic value ofthe two chief divisions of the states of sound ; that of increase and that of diminution or of dulness is easily inferred. We find that the first or increased sonorousness is met with in all cases in which the pulmonary tissue is lighter ; and the latter, on the contrary, whenever the density of the lung is increased. Examples of increased clearness of sound, on percussing the chest, are found, 1, in dilatation of the bronchia?, whatever may be the cause (chronic AVENBRUGGER'S APHORISMS — AUTOPHONIA. 43 mucous catarrh, pituitous catarrh, dry catarrh, &c); 2, in dilatation of the air cells or vesicles (the emphysema, properly so called, of Laennec); 3, in infiltration of air into the cellular tissue connecting the pulmonary vesi- cles (the emphysema of systematic writers); 4, in infiltration of air into the cellular tissue beneath the pleura (subpleural emphysema). To this enumeration we might add, as causes exaggerating the clear sound heard on striking the thoracic parietes, the excavations following phthisis, hepa- tization, gangrene, and pulmonary apoplexy. Diminished clearness of sound, approaching more or less to dulness, is met with in congestion, inflammation, gangrene, and oedema ofthe lungs, and in pulmonary apoplexy and tubercles ; it being understood that these diseases have not reached that stage in which cavities are formed in, and at the expense of, the parenchyma ofthe lungs. A few aphorisms of Avenbrugger, as we find them quoted by M. Mail- liot, may be quite appropriately introduced in this place. 1. So soon as a portion of the chest, usually sonorous, suddenly loses its natural sound in this respect, and gives out that as if striking on leather, disease is concealed in the part which emits this quality of sound. 2. If the chest, percussed on a spot, commonly sonorous, gives out the leather sound, we may be sure that disease is coextensive with the limits ofthe new sound. 3. If the chest, when struck on a particular region which is generally sonorous, emits the leather sound, the patient should be directed to make a full inspiration and to hold his breath. If, while the air is thus retained, the leathery sound be still heard, we augur a great depth of the disease in the cavity of the chest. 4. If the chest, on being percussed at its anterior part while the inspired air is retained, gives out a sound of striking on leather, then percuss the region behind and directly opposite ; and if it emits at this spot, which is usually sonorous, the leathery sound, we may infer that the disease per- vades the entire thorax. Modified auscultation, to consist of listening with the stethoscope applied to the chest while the latter is percussed, has been recommended. It is alleged that, by this means, the sound elicited by percussion is conveyed to the ear with a force and distinctness superior to that which occurs in the common method; but there is the inconvenience of loudness superseding the particular quality of sound really caused by the state of the parts be- neath. We have, it is true, the testimony of Drs. Cammann and Clark (J\"ew York Med. and Surg. Journ., vol. iv.) in its favour, who assure us that they were able, by the difference in the sound elicited, when the instrument was over the heart, on its margin, or external to this area, to measure that organ in all but its antero-posterior diameter, under most, perhaps all, circumstances of health and disease, with hardly less exact- ness than they would be able to do if the organ were exposed before them. Like success attended trials to define the outlines ofthe liver. But, after all, these are negative results, and do not prove the propriety of the method for detecting real and actual respiratory phenomena. Dr. Walshe, in his work already referred to (The Physical Diagnosis of Dis- eases ofthe Lungs), speaks in very disparaging terms of this modified auscultation. Autophonia is another modification of auscultation, which consists in the observer listening to his own voice while his ear is applied to the chest 44 INSPECTION—MEASUREMENT. of the patient. The voice is represented to vary in character with the state of the contained viscera. This mode, originating with iM. laupin, is represented by M. Hourraan to be a useful auxiliary in the investiga- tion of the pulmonary diseases of children. . -tit Succussion is the oldest practised fashion of auscultation, as it dates from Hippocrates. It detects the presence of air and fluid in a cavity, and hence is a useful aid to the diagnosis of pneumothorax, and of a tuberculous cavity in the lungs containing pus and air. It is performed by imparting a sudden and somewhat violent motion to the patient, as when he is jolted on horseback or suddenly gets up and sits down on a hard seat, or by another person shaking him, and then applying the ear sud- denly to the chest, a sound of fluctuation is heard, if there be the mixture of fluid and air as just described, in a cavity. Sometimes the slightest agitation of the body, as from coughing, sneezing, turning quickly, walk- ing up stairs, will elicit the sound. The formal method of practising suc- cussion consists, while the patient is seated on a chair or bed, to take him by the shoulders and shake him with some force ; the operator ceas- ing suddenly from the succussion and listening to the sound of fluctuation. Inspection is another means of physical diagnosis by which we detect a difference in the size ofthe two sides ofthe body, and particularly ofthe chest. WThat thus strikes the eye is more confirmed in a certain manner by measurement. * For the purpose of measuring the chest we may use the graduated tape coiled in a metallic box by a spiral spring. Dr. Stokes prefers a pair of broad steel callipers, the free extremities of which terminate each in a wooden ball. By either of these instruments we measure, first from the projection of a vertebra round the side of the thorax to a line marked with ink, to the middle of the sternum, and thence round on the other side to the vertebral spine whence we set out. In this way any differ- ence between the circumference ofthe two sides will be ascertained. In- equality in this respect is not, however, always a sign of disease, for, on the contrary, a symmetrical conformation ofthe chest is rare. According to the observations of M. Woillez the right and left segments were found equal in twenty-seven only of a hundred and thirty-three subjects. The right side was more expanded than the left in ninety-seven, and the left than the right in nine individuals. " The morbid conditions discovered by circular measurement are, in- crease or diminution of bulk of either side as compared with the other; and defective expansion during the act of inspiration. Deficiency of ex- pansion, confined as it usually is to one side of the chest, is best ascer- tained by comparing the width of the two sides at the end of expiration and of inspiration ; little or no difference will be found to exist in the for- mer, but a very marked excess on the sound side at the latter period, under the supposed conditions of deficient expansion." (Walshe,op. cit.) Measurement, by showing a retraction of the side following atrophy of the lung, is a most important part of diagnosis in the early stage of phthisis. In empyema, on the other hand, we detect a notable dilatation of the affected side. In connexion with the subject of physical diagnosis and as illustrative of the manner in which it is turned to the best account for practical purposes, the mode of investigating the thoracic diseases by comparison, so ably set forth by Dr. Stokes, is worthy of your careful study. I cannot do more SOURCES OF PHYSICAL DIAGNOSIS. 45 than indicate the chief traits here, but would recommend you to follow it out in its various bearings in the pages of this distinguished teacher's work (Treatise on Diseases of the Chest), already referred to at different times. The symmetrical conformation of the thorax favours greatly the study of the diseases of its contained viscera by comparison ; just as we judge of the extent of tumefaction or degree of deformity of a limb, by com- paring it with its fellow, in addition to a study of the direct symptoms of the disease. To take some of the examples adduced by Dr. Stokes:— Feebleness of respiration occurs in many diseases of the lungs, and in phthisis particularly we often meet with feeble vesicular murmur under one ofthe clavicles. Now, if we were to restrict our examination to this side, we might be led to error by this symptom, for extended auscultation on the other side might show that there is naturally in this person feeble respiration over the whole chest. An opposite state may occur, as in a case of a loud vesicular respiration approaching to puerile. This is com- mon when some other portion ofthe lung has been disorganised or other- wise suspended in its respiratory function ; but it may be universal, and it then ceases to have a special diagnostic value. To be available as a symptom, we must discover it in one portion of the lung coexisting with feebleness of respiration in another portion. So also in the phenomena of the voice. Greatly increased resonance would induce suspicion of solidified lung, if we did not, on examining the corresponding region on the other side, find that there also is bron- chophony presented, and that both lungs exhibited this phenomenon habit- ually in this case. It is only 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, that it becomes a symptom of decided value. " Independent of the importance," says Dr. Stokes, " of the principle of comparison, its practice, in all ca^es, 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 ofthe 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 ofthe right lung; his attendants had examined the upper part of the chest carefully, but had neglected the lower, and th*is the true nature of the disease had escaped them." I believe that I cannot conclude these remarks and directions respecting physical diagnosis in a more appropriate manner than by enumerating, after Dr. Stokes, its sources, viz. :— " 1st. Signs purely acoustic, including the results of percussion and of auscultation, mediate and immediate. It may be observed here, that of all the signs these are of the most universal application ; 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 ves- sels. 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 46 SOURCES OF PHYSICAL DIAGNOSIS. degree of chronicity. Under the first head we may reckon rapid liquid effusions into the pleura or pericardium, the result of inflammation, and recent pneumothorax, from fistula. Under the second, we have chronic liquid and aeriform effusions, hypertrophy and atrophy of the lung, both the result of chronic disease, and aneurismal or other organic tumours. " 3d. Signs referable 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 the 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 hepatization ofthe 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 respiration are otherwise impeded or altered. " 5th. Signs derived from the inspection of the thorax, with reference to the action ofthe heart and great vessels. " 6th. Signs derived from the existence of an external collateral circula- tion, as indicative of the existence of obstruction of the great internal venous trunks, such as the cava and innominata?. "7th. Signs derived from the observation of the displacement of the thoracic or abdominal viscera: of these, some may be appreciable by the senses of sight and touch merely, while others must be ascertained prin- cipally by that of hearing. The displacement ofthe heart (perceptible to the eye and touch), and the protrusion of the liver into the abdominal cavity, are examples of the first division ; while the displacements and compression of the lung, from liquid or aeriform effusions into the serous sacs, furnish examples ofthe second. "Now it is never to be forgotten, that although in these various classes we have a vast number of well-marked and essentially differing 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 impermeability; increase or diminution ofthe quantity of air; the existence of cavities of various sizes and with various commanications ; 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." If, after a survey of our whole position, and the bearings of physical diagnosis on therapeutics, you should ask whether the domain of the latter has been enlarged by a better diagnosis, and whether we have gained either a new remedy or a better plan of treatment generally in phthisis for example, I am unable to reply in a direct manner to the whole ques- tion. Physical diagnosis has not certainly revealed or suggested any new remedy or new plan of treatment generally. It has not advanced our therapeutical boundaries; but within the old limits it has given a better DISEASES OF THE RESPIRATORY APPARATUS. 47 insight into and a better appreciation of the value of remedies, and a better understanding of the time and the precise indications for their use, by indicating, as it were, the very spot or point of disease to be acted on, and the changes of tissue to be completed before recuperation of function can be brought about. LECTURE LXXXVI. DR. BELL. Diseases of the Respiratory Apparatus—Extensive operation nf the causes of these diseases and large number of persons exposed to them—Chief causes ; atmospherical vicissitudes and°neglect of hygiene—Community of causes affecting the several parts ofthe air-passagesfand community of organic function and morbid action ofthe mu- cous membrane lining these passages—Inferences from the study of the diseases of one part applicable to those of the other parts—Division of the diseases of respiration into three heads: those of the air-passages; of the parenchyma of the lungs; and of the pleura or serous envelope.—Coryza—Its synonyms—Divisions—Simple and ulcerative—Varieties of the simple; acute and chronic—Acute coryza—Anatomical characters—Symptoms—Local for the most part, sometimes general superadded—Ex- tension of inflammation to adjoining parts of the mucous system—Coryza in infants —its dangers —Consecutive coryza —Progress—Diagnosis — Prognosis—Causes— Treatment—Modifications in acute coryza.—Ozsna, thejulcerative species of coryza— Fetor not a distinctive feature—Anatomical characters—Symptoms—Progress—Diag- nosis—Distinction between ozaena and polypus—Inspection and exploration—Etiology —Cases—Treatment—Local and general. I now take up for investigation that large and important class of diseases depending on structural changes and derangements of function of the respiratory apparatus, or rather ofthe pulmonary organs, which constitute the greater and necessary part of this apparatus, the remaining portion of which is, you know, made up of the bony and muscular case. In the zones called temperate, which include the largest portion of the civilised world, the causes for the production of these diseases are continually at work, and the effects are told in a fearful mortality, the rate of which is hardly changed, except by the increase arising out of epidemic influences and aggravations. The people inhabiting the temperate or middle lati- tudes are exposed to great atmospherical vicissitudes, in which cold and moisture are predominant; and against which the majority of them are imperfectly protected, by proper habitation and clothing. Poverty pre- cludes the masses from the regular and methodical enjoyment of these means, and ip-uorance and inattention debar those in better circumstances from their judicious use and application. It is easy to see, when one looks around on the deplorable neglect of both public and private hygiene, how imperfect and scant are the resources of medicine. The former brings with it a train of constantly operating and wide-spread causes of disease, affecting the multitude ; the latter can only reach a few individuals. In prevention alone consists the safeguard ofthe many ; its agencies are evi- dent, and the conditions for their effectual operation easily traced. Pre- vention has strength and health, and the supports of both on its side ; cure, on the other hand, supposes, of necessity, prior infirmity and deterioration, and such rapidly changing conditions in the body to be acted on as to puzzle calculation, and often to defy the most patient, conscientious, and 48 DISEASES OF THE RESPIRATORY APPARATUS. learned efforts to solve the problem which it offers. But these are topics which involve too many considerations of both proof and postulate to allow of our even sketching them at this time,—and I shall pass on to an examination in detail, of the diseases ofthe organs of respiration, being the effects ofthe wide-spread cause, to which I, just now, adverted. Experience proves what general anatomy and physiology had, d, priori, indicated,—that the morbid agency of atmospherical vicissitudes is often manifested in quick succession, if not simultaneously, in all the air-pas- sages, from their beginning at the nostrils to the termination at the bron- chial cells. Rarely indeed is one portion seriously affected without the re- mainder suffering to some extent, either in its organic properties or func- tional exercise. Still, however, is each region, in virtue of the modification of mucous tissue with which it is lined, and of nervous supply for particular function, the seat of morbid changes which require separate consideration. The whole extent of the mucous membrane ofthe air-passages has one common stimulus, that of atmospheric air, evinces a community of func- tion in its secretion of mucus, and of morbid action in its exudation of plastic lymph or pseudo-membrane. Hence it is no strained inference to admit, that the lesions of structure and other deviations from the normal state, which we are able, with considerable accuracy, to measure in the uppermost division of the air-passages, represent very fairly those which occur in the lower and less accessible divisions ;—even if an improved system of diagnosis did not allow us to measure these lesions and devia- tions at their true value. Irritation and inflammation of the mucous mem- brane of the nasal fossa?, picture forth, in their leading phenomena of organic life, irritation and inflammation of the laryngeal mucous mem- brane,—as these last do of the tracheal and bronchial. A careful study of the phlogosis of one, cannot, on this account, fail to aid us very con- siderably in acquiring a knowledge of the others. But, although the chief functional activity of the respiratory apparatus is manifested in and through the mucous membrane ofthe air-passages; as, for example, the sense of smell in that of the nasal fossa?; vocalization in that of the larynx, the changes completing hematosis in that of the bronchia?, yet to these is superadded a large parenchymatous structure, in lung proper, and its investing membrane or pleura. A tolerably natural division of these diseases is deducible from this anatomical arrangement. Accordingly, I shall speak of the diseases of the air-passages first, then those of the parenchyma, and, lastly, those of the serous investment or pleura. Coryza.—I begin with a notice of inflammation ofthe mucous membrane investing the nasal fossa?. The name of coryza has been given from the earliest times down to the present, to this form of disease. Its syno- nyms are " cold in the head," " blenorrhinia," and " rhinitis." The last or rhinitis, with a show of philological precision, in its being derived from Ptv, nose, is as little applicable as the others ; for, why should rhi- nitis be appropriated to inflammation of the lining or mucous membrane of the nose, and not designate, as well, inflammation of the investing or cutaneous membrane ? Coryza has been divided into two kinds, the simple or benign and the ulcerative ;—and the first again into the acute and the chronic varieties. The anatomical characters of the inflamed nasal membrane, opportu- nities for the examination of which have only been furnished in very SYMPTOMS OF CORYZA. 49 young subjects, are, in the acute state, redness, injection and often a vio- let hue of the part, which is, also, somewhat swelled an.I thickened, and more easily torn than in health. Pseudo-membranous exudations have been noticed by Billard and others. In chronic coryza the nasal mem- brane has more density than before ; it is rough, rugous or with raamrai- lated elevations on its surface; and so thickened that the nasal canal may be not only greatly obstructed, but even entirely closed. It is of a pearl or sometimes slate colour. Symptoms.—Coryza is ushered in with a troublesome feeling of dryness and fulness of the nasal fossa?, a stuffing of the nose, together with pru- ritus, which provokes to frequent sneezing. To these soon succeeds a flow of transparent mucus or serum, of a saline taste, which reddens and scalds the skin at the lower side of the nostrils, and the upper lip. The inflammation extending to the frontal sinuses, gives rise to pain at the root ofthe nose, and along the supra-orbitar region, in fine, to frontal cephalgia, which is aggravated by the least motion of the body, and which is sometimes so annoying as to interfere with any exercise of the intellect. Less commonly the inflammation extends to the lachrymal pas- sages and the conjunctiva, which latter is injected, and there is accom- panying flow of tears and intolerance of light. In another direction the Eustachian tube and the inner ear may be affected, and there then ensue a sense of fulness, occasional pain in the ear, and diminished sense of hearing. Should the maxillary sinus be inflamed, the patient complains of pain in the corresponding cheek with some degree of tension of the jaw, and even aching ofthe teeth implanted in it. The sense of smell is rendered quite obtuse, and for a time even lost; and that of taste has, also, lost much of its delicacy. All the symptoms enumerated are some- times restricted entirely to one side, in which alone are felt the unplea- sant sensations, and from which alone flows the increased and morbid secretion. Although coryza, for the most part, manifests itself by local symptoms, yet, sometimes, it is accompanied by a febrile disturbance,—irregular chills, dry and hot skin, accelerated pulse, want of appetite and general languor. This state is more apt to show itself, if coryza be the precursor, as it often is, of bronchitis and pulmonary catarrh,—a continuation or extension this ofthe primary phlogosis, which, although not mentioned in the preceding description, is, by far, the most important. It is this com- plication which the ancient writers characterized by the term gravedo. Thus Celsus, nares claudit, vocem obtundit, tussim siccum movet. At the expiration of two or three days, the first symptoms abate ; the nasal secretion becomes more consistent, and of a white, then of an opaque yellowish, or greenish colour, which exhales a spermatic odour. In some instances it is quite fetid. The mucus thus formed is easily de- tached, dries rapidly, and is converted into crusts, which obstruct the pas- sage of air through the nasal passages, and give rise to a nasal sound in speaking, which sometimes is evident from the beginning of the disease, owing to the swelling of the mucous membrane. In infantile subjects coryza is a much more serious disease than it is in adults : as, owing to the narrowness, naturally, of the nasal passages, these last are more easily obstructed by thickened mucus ; and, hence, great difficulty, not to say impossibility, of breathing, when the child is at the breast. Between the calls of hunger, if they are yielded to, and VOL. n.—5 50 DISEASES OF THE RESPIRATORY APPARATUS. the danger of asphyxia, the little sufferer falls into a state of prostration and marasmus, unless means be taken to feed it with the spoon. In a child predisposed to spasm of the glottis or laryngismus stridulus, the impedi- ment to respiration from coryza, and when the little being is at the breast, will give rise to a paroxysm with convulsions. In consecutive coryza, after diphtheritic stomatitis and angina, the dis- charge from the nostrils consists of a fetid sero-sanguinolent matter, ac- companied by the expulsion of false membranes. The progress of coryza is rapid ; rarely does it extend beyond a week; or, if it is protracted, "it will generally be found that this is by successive renewals of the disease, rather than by uninterrupted prolongation of the original attack. Sometimes it assumes an evidently periodical type, and requires quinine for its removal. Chronic coryza, whether idiopathic or following the acute variety, sel- dom gives rise to pain, but rather a feeling of discomfort in the nose and of weight at the root of the organ. The secretion is always increased, and is of a thick consistence, opaque, greyish, yellowish or greenish, and inodorous. In some cases, however, the smell is insupportably fetid, even when there is no ulceration of the mucous surface. Persons affected with chronic coryza rarely have a clear voice, and they are seldom able to speak or sing long without their being much fatigued. The diagnosis of coryza is easy. In very young children, the suffoca- tion caused by sucking may proceed from some organic defect in the mouth, the tongue, or the nasal fossa?, as well as in the nipples of the mother; but in such cases, independently of the results obtained by direct inspection of the parts, the difficulty from such malformations must have existed from birth ; whereas if the difficulty depended on coryza, we have means of ascertaining that the child sucked freely before the attack of this disease. Chronic coryza may be mistaken for polypus of the nose ; but in the case ofthe latter, the stuffing ofthe nose is not constant, but only occurs in damp weather, and is not accompanied with a discharge. Besides, inspection of the nasal fossa? will generally lead to a discovery of the polypus. The prognosis of coryza presents no gravity, except in the case of a newly-born infant, or one at the breast. The causes of coryza must be frequently operative, as inflammation of the pituitary membrane takes place more readily than that of the other portions of the mucous system. Although the disease is common at all ages, it is most frequent in the period of childhood and among lymphatic subjects. It is sometimes epidemic after sudden changes of weather and at the beginning of cold seasons. Often it has been obviously due to residence in damp localities, to the suppression of perspiration ofthe feet, to being exposed bare-headed, the use of tobacco, &c. Treatment.—Acute coryza is, for the most part, left to run its course. If there be febrile excitation and headache, it is desirable that the patient should take an active cathartic, such as salts and the infusion of senna, or the compound powder of jalap ; and afterwards diluents, and pursue a restricted regimen, resort to warm pediluvia, and live in air of a me- dium temperature. For the troublesome and sometimes persistent frontal headache and sharp pain in the frontal sinuses, which are met with more particularly in seasons of epidemic catarrh, I know of no remedy so good SYMPTOMS OF OZjENA. 51 as the application of a few leeches just inside the nostrils, or to the first narrowing of the passage. I have myself found the greatest relief, and have at different times conferred the same benefit on my patients, by this means. A revulsion is sometimes exerted with good effect on the pha- rynx and fauces, by the use of stimulating lozenges, such as of oil of cubebs, slowly dissolved in the back part of the mouth. A speedy termi- nation has been put to the disease, by what is called the aborting treat- ment. It consists in touching as much of the nasal membrane as can be reached with a sponge dipped in a solution of nitrate of silver, of the strength often grains to the ounce. In the case of a newly-born infant suffering from coryza, and occlusion of the nares in consequence, it must suspend for a while its sucking, and be fed with its mother's milk administered by teaspoonfuls. Chronic coryza will demand a more sustained treatment, chiefly of an alterative kind, after premising some laxative medicines. With this view, the blue pill, compound syrup of sarsaparilla, and iodide of potassium, will be given to advantage. Stimulating fumigations, or inhalations through the nose of pungent vapours, are serviceable in some cases ; while topical applications, such as nitrate of silver, or mercurial preparations directly to the part, are preferred by some. A blister to the nucha has been found to answer a good purpose. Masticatory substances have also been pre- scribed. Ozjena.—The ulcerative species of coryza, on which I propose to offer a few remarks, is usually designated by the term ozcena. Some have thought that fetor of the nares and of the discharge from them constitutes a distinctive character of this disease ; but in this they are mistaken, for, in some cases of common coryza, and of polypoid tumours and excres- cences, the discharges are also fetid. Anatomical Characters. — The nasal fossa?, in ulcerative coryza, have their mucous lining thickened, swelled, mammilated, lacerable, and coated with a fetid pus. The membrane is also destroyed in many spots with ulcerations, which vary in their seat, number, extent and aspect: more commonly, according to Boyer, they are met with at the anterior portion of the septum, at the point of union of the bone and cartilage ; but they are also seen at the root of the nose, on the mucous membrane which covers the nasal bones and the vomer. In number they are few; there being often only one ulcer, and, at most, two or three, but they are of large size. Some are superficial, others deep and extend to the bone, which is cari- ous, and softened or necrosed. A puriform sanguinolent mucus and brown or blackish crust obstruct the nasal fossee, which exhale an extremely fetid odour. In more aggravated cases—happily of rare occurrence—the destruction of parts may extend to the loss of the bones of the nose, of the septum, the vomer; and finally of the nose itself, either in part or entirely. Symptoms.—The beginning of oza?na is gradual, and scarcely marked by any noticeable symptom ; or, at the most, more than would be met with in chronic coryza. The patient, after a while, has his nose habitu- ally stuffed ; he blows out a thick, yellowish, greenish and purulent mu- cus, in large quantity ; and experiences an uneasiness, but without pain, in the nasal fossa?. These latter are obstructed with adherent crusts or scabs, which most patients pick off with their finger-nails, and produce, in consequence, a bloody oozing mixed with the other secretion. By this 52 DISEASES OF THE RESPIRATORY APPARATUS. means, the irritation of the membrane is kept up and the cure retarded. In the more aggravated cases, the fluid which escapes from the nares is ichorous and fetid, and the air which traverses these passages during ex- piration is itself impregnated with this fetor,* which has been compared to different offensive and stinking bodies that need not be specified here. When the ulceration extends to the bones and cartilages of the nose, this oro-an is swelled and deformed, and assumes a violet-red colour: it exhi- bits, also, edema, on pressing the integuments with the finger ; and by this latter means we detect, also, crepitation. The progress of ulcerative coryza is always slow : although, at times, it undergoes exacerbations which give it the appearance of an acute disease. Having little tendency to get well spontaneously, oza?na is almost always tedious in its course and of indefinite duration. However much it may interfere with the comfort and social pleasures of the patient, it does not shorten life, and if death occurs to one thus afflicted, it is owing to com- plication of another disease. The diagnosis is not easily made between common chronic and ulcera- tive coryza ; and hence the necessity of a careful inspection of the parts, as recommended and practised by M. J. J. Cazenave, of Bordeaux. The patient being placed in a good light, opposite a window, and the head thrown back, so as to expose the cavity of the nasal passages as much as possible, the physician will introduce a probe curved at one end, in hook fashion, as far up the nasal fossa? as he can ; he will then gradually withdraw it, while making various movements of rotation so that the end of the hook part shall impinge against the pituitary membrane. If this latter be clear of ulcerations, the end of the probe will glide easily over it; but if, on the other hand, there should be solutions of continuity, the instrument will be caught in them and retained by the raised borders of the ulcers. This exploration should be made first and most carefully along the septum at the part near the root of the nose, as that on which ulceration most frequently occurs. The distinction between oza?na and polypi or other tumours and morbid growth is easily determined by careful inspection and exploration ; and that between the disease under notice and glanders is ascertained by a review of all the symptoms which, in the latter terrible disease, soon cease to be local, and when once they become general, assume unmistakable appearances. Something may be inferred from the amount and odour of the discharge as to whether the ulcer be simple and benign, or fetid and in a measure malignant. With the etiology of oza?na we are imperfectly acquainted : it is rare, except from traumatic cause in childhood ; and is met with chiefly in the period of youth and adult age. Sometimes it would seem to be heredi- tary. The predisposition apparently is laid in a lymphatic temperament and scrofulous diathesis; at least such are the constitutional characteris- tics of those who, under my own observation, have been sufferers from this disease. Of the two last whom I have been called upon to treat one a male, in advanced life, the other, a female, of middle age, both had small-pox in early life, and both were, for a term of years on the list of dyspeptics. In the case of the female, a single lady, the ulceration de- stroyed a portion of the cartilaginous septum, leaving quite a large opening between the nares. I mention these two cases of individuals whose cha- racters are well known to me as irreproachable in every particular in order to invalidate the too hasty assumption of some writers that 'the DIVISION OF DISEASES OF PULMONARY ORGANS. 53 disease is chiefly of syphilitic origin, especially where the bones and car- tilages are implicated. That oza?na has, however, such an origin, in certain cases, is undoubted. In others, it can be traced to the lesions left by the extirpation of polypi. Treatment.—This will consist of local applications and of constitutional remedies. The first are mainly detersive and stimulating, and sometimes astringent; the latter ought to vary with the condition of the patient, in respect to his labouring under other diseases, such as syphilis, scrofula, or anemia. If symptoms of nasal irritation be present, manifested by heat, tension, and the frequent formation of dry crusts or scabs, a few leeches to the inside of the nostrils in the manner already recommended for simple acute coryza, will be found serviceable, and constitute a good introduction to other remedies. For a while, simple emollient washes may be required, and revulsives by laxative medicines ; but after this, an alterative course, consisting of mercury, with sarsaparilla and diaphoretics, or of iodine, with the like adjuvants, should be adopted, according to the particular circumstances of the case. I have known salivation to remove oza?na at once ; but as this is a harsh and uncertain remedy, we should content ourselves with the use of blue mass and narcotics, followed by or alternating with tonics. Preferable to all is the use of iodine in the form of combination of the iodide of potassium, and, also, in union with iron, as in the iodide of iron. From both of these preparations I have derived the best effects ; they were the internal remedies chiefly relied on in the case ofthe lady before adverted to, which ended in entire removal of the disease. The solution of the iodide of mercury, and arsenic, or Donovan's solution, has been given with success ; so also has the solution of arsenic with potassa (Fowler's solution). Of the topical remedies, the list is a long one ; the chief are solutions ofthe chlorides of lime and of soda, ofthe acetate of lead, corrosive sub- limate, nitrate of silver, and alum, also, creosote, carried up the nasal fossa? by injection. Ointments of most of these substances have also been used to the same parts,—applied by means of a probe or ivory rod, to the end of which is fastened a small piece of sponge or lint. Mercurial fumigations have been practised : they ought to be associated with calomel, or blue mass, or a dilute solution of corrosive sublimate, inter- nally. The best detergent washes and correctors of fetor, are the solu- tions ofthe chlorides of lime and soda. LECTURE LXXXVII. DR. BELL. Laryngitis, or Cynanche Laryngea—Its varieties—Erythematic Laryngitis—General mildness ofthe disease and simplicity of its treatment—Catarrhal Laryngitis—Chiefly dangerous in infants—Its treatment—Acute Edematous or Sub-mucous Laryngitis—A most formidable disease—Its symptoms—Respiration 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 fre- quent occurrence—Treatment actively and speedily antiphlogistic—Venesection— General Washington'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 laryngoiomy—Mortality from acute laryngitis. I continue the investigation of the diseases of the pulmonary organs by speaking of the diseases of the larynx, both acute and chronic. These • 54 DISEASES of the RESPIRATORY apparatus. again, may be inflammatory or nervous ; and, if the former, may be accom- panied by an erythema or a tumefaction of the mucous membrane of the part, or by the secretion of mucus or of pus, or the formation of false mem- branes. Simple erythematic laryngitis is the mildest of all the forms^ of inflammations of this organ. Its causes are external and internal. Ihe former are sudden variations of temperature ; breathing air in 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 diseases 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 gastro-enteritis. It is sympathetic, as in measles, in which the same inflammatory congestion is present in the conjunctiva and bronchise. 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 loses its force, is changed in character, and hoarse. Deglutition is painful, and the cough is harassing by its frequency and dryness. After a while some mucus tinged with blood, aq,d more frequently 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 disinclined to speak, and dozes much. The treatment ofthe milder cases of this form of laryngitis is very sim- ple ; consisting in tepid mucilaginous drinks, and 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 opposite the os hyoideus to the lower end of 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 membrane, 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 atten- tion 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 a 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 adopted. Catarrhal laryngitis, little different from the preceding, is caused more directly by atmospherical changes, sometimes of an epidemic nature ACUTE EDEMATOUS OR SUB-MUCOUS LARYNGITIS. 55 and by 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 remedy is the more necessary in the catarrhal laryngitis of infants, who are unable to throw off the accu- mulated mucosities in the windpipe, and are in imminent danger of suffo- cation 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 intestinal canal. Calomel, therefore, with aloes or rhubarb, will be prefer- able to the saline purgatives, which often cause excessive watery discharges without their exerting a good effect on the laryngeal disease. The common cough mixtures are of very doubtful efficacy in laryngitis, since they con- tribute to increase the secretion of mucus without a corresponding augmentation of ability to throw it off. Free expectoration, by which the bronchia? are cleared, will not suffice for the laryngeal tube without addi- tional 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 continued and excessive secretion of mucus in the larynx. Acute Edematous or Sub-mucous Laryngitis.—A formidable variety of laryngitis is that called edematous, which should be regarded as an aggra- vated degree of the erythematic. Edematous ought not in propriety to designate this more violent stage of inflammation of the larynx—the effu- sion in the sub-mucous cellular tissue being only an effect ofthe inflam- mation. Acute laryngitis in this degree is one ofthe most alarming and intractable diseases 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 hiss- ing sounds, whilst the expiration is free ; pain and feeling of constriction at the larynx, greatly increased by pressure 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 involuntary hawking, as if to clear the passage by expecto- ration. In the aged the expectoration is often copious, and evidently from the larynx ; but it fails to give relief. 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 swallow- ing 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 a fluid recalling so vividly former sufferings. The patient complains of a feeling, as if of a foreign body in the larynx ; and a similar obstruction in the oesophagus. An examination of the fauces shows them, in most instances, to be inflamed, and very often, by pressing the tongue as much as possible downwards and forwards, the epiglottis can be seen erect, thickened, and of a deep- red colour. 56 DISEASES OF THE RESPIRATORY APPARATUS. With the increase of edema, laborious respiration, and an inadequate supply of air affect the appearance of the patient, as manifested in his pal- lid countenance, anxious expression, livid lips, protruding ^nd watery eyes ; pulse quick, feeble, and irregular ; surface ofthe body cold, lhe 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 become a convulsive 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 pa- tients 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. I have myself seen such. Contrasted with these are other cases in which the disease has lasted three or four weeks. The anatomical changes are inconsiderable ; sometimes only amounting to a redness ofthe mucous membrane of the larynx, which, in some in- stances, is also easily torn and thickened. In the latter case, there will be a diminished diameter ofthe laryngeal canal,—a result that may ensue, also, from serous or purulent infiltration in the sub-mucous cellular tissue. Finally, on occasions, we meet with inflammation and enlargement ofthe mucous follicles, or even superficial ulcerations ; and, more rarely, pus- tules analogous to those found in small-pox. When the disease has been restricted to the upper part of the larynx, the immediate cause of death is shown in the opening of the glottis being almost entirely closed by the thickeningand swellingof thearyteno-epiglottic mucous folds. Bayle, to whom we owe the most accurate account of edema ofthe glottis or super-glotteal laryngitis, has shown how these folds are so disposed that every impulse coming from the pharynx, such as the air inspired, turns them backwards into the opening of the glottis, which they obstruct in a greater or less degree, whilst every impulse coming from the trachea throws them outwards, and enlarges the opening. In other words, the glottis is blocked up during inspiration, and more or less open in expiration. In- cision of these folds exhibits a thickening and increased density of the cel- lular tissue, from which, with difficulty, the infiltrated serum is exhaled. If the inflammation has been rapid, plastic lymph is found instead of se- rum, at the rimce glottidis. The vocal cords are sometimes the seat of lesions. Frequently there are traces of inflammation of the pharynx and tonsils. Cruveilhier (Dictionnaire de Medecine et de Chirurgie Pratiques) makes a division of laryngitis into super-glotteal and sufr-glotteal. The former coincides more with that form just described, and depends on the anato- mical 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 exami- nation. 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 ACUTE EDEMATOUS OR SUB-MUCOUS LARYNGITIS. 57 the cricoid cartilage, which is sometimes 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 in- flamed. Hence, also, the disease is not so speedily fatal in the sub-glot- teal 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 edematous laryngitis. The causes of acute laryngitis are not very obvious. Sometimes they are atmospherical vicissitudes. At times the disease supervenes on con- valescence from fevers, and, again, on chronic laryngitis. It has been observed in connexion with erysipelas, and especially the epidemic variety. The more distinctly edematous cases are seldom primary. M. Valleix says that out of 37 cases there were only two of this kind. By some an edema of the glottis has been regarded as a different dis- ease from that now under consideration ; but without good cause. The term is misleading: it ought to be oedema rimse glottidis. The only dif- ference between this and the acute sub-mucous laryngitis just described, is in the extent to which the cellular tissue is inflamed. 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 children, or persons under the age of twenty. Authors describe, among the accompanying pheno- mena, in some cases, swelling of the integuments which surround the larynx, especially on the forepart 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 two and three years of age. Venesec- tion and purging seemed to have little effect in controlling the disease, which was obviously arrested, however, by leeches applied to the neck. Calomel was given at the same time ; and it seemed to be useful in completing the cure. Treatment.—But I am anticipating what is to be said on the treatment of acute edematous 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 edema and the consequent obstruction to respiration, which constitutes so much of the character as well as gives danger to the dis- ease. 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 edema ; 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 ful- filled 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. 5S DISEASES OF THE RESPIRATORY APPARATUS. On this main outline of practice I shall offer some remarks. The use ofthe 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 ofthe blood ; as when the face is flushed, and even turgid, and the 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 ofthe glottis by general bloodletting, which has the disadvantage at this time of weakening the action of the heart and of the respiratory muscles, 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 ofthe face and lips. If such a change take place, wTe shall be encouraged to let the blood flow until the main indication be fulfilled. Otherwise we promptly close the orifice, and prevent further loss ofthe 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 ofthe laryn- geal 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 disease, after copious vene- section 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 venesection had been used to procure a smaller quantity in the early part ofthe day. Tartar emetic was also freely ad- ministered, both as an emetic and counter-stimulus. Dr. Francis of New York, about nineteen 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 pre- carious 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 ofthe value of venesection, because the general appearance and the habits of the patient would not seem to bear such extreme 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 sounded as if she was 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 purga- tive enema and blister were prescribed. Next day she began to expec- torate yellow mucus, and could swallow fluids. On the 16th of 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 ACUTE EDEMATOUS OR SUB-MUCOUS LARYNGITIS. 59 to the difficulty of breathing, but yet it was so far from arresting the inflam- mation that death took place within twenty-four hours. The first accu- rately reported case of acute laryngitis, and one which will ever have deserved historical importance attached to it, was that which proved fatal to Washington. " The disease," says Drs. Craik and Dick, his physicians, " commenced with a violent ague, accompanied with some pain in the upper and forepart ofthe 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 respiration." 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 ap- plied to the part affected, two moderate doses of calomel were given, and an injection was administered, 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 consulting physicians, at half-past three in the afternoon, it was agreed, as there were 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 wrere frequently inhaled ; ten grains of calomel wTere 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 and imperfect, till half-after eleven, on Satur- day night, when, retaining the full possession of his intellect, he expired without a struggle." Harsh strictures were made, at the time, by English writers on the treat- ment 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 duly 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- pipe ; and afterwards recommended, in case suffocation should be immi- nent, 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, 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 rimao glottidis in their passage from the oesophagus into the mouth. But whilst we deprecate vomiting, we are not forbidden the use, in relatively large doses, of tartar emetic, which, 60 DISEASES OF THE RESPIRATORY APPARATUS. 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 ofthe disease. A very minute trac- tion 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 in- complete sedative operation, calomel, conjoined with minute doses of opium, should be given every hour, or at most every two hours. If want of confidence be felt in the tartar emetic alone, or fears entertained that it must necessarily vomit, the medicine may be advantageously combined with calomel and opium, and continued until relief be procured. After venesection and leeching, 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 with morphia or belladonna ointment. For the relief of this symptom, while we are removing its cause—inflammation—assafcetida mixture, with a few drops, in each dose, ofthe tincture of belladonna, will be of service. Gentle frictions with the belladonna tincture or liniment over the larynx and trachea will contribute to the same end. Derivatives, by the warm bath, warm pediluvia, saline diaphoretics and sinapisms, ought not to be omitted. Mr. Crampton and others recommend the application of leeches to the inflamed palate and tonsils : the objection is not in any danger of subse- quent 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 any time ; but in laryngitis must be productive of great distress. Remember- ing, also, the temporary tumefaction of the part to which leeches have been applied, we reasonably fear even a slight increase of this condition ofthe glottis, although it would be of short duration. Incisions or scari- fications of the edematous glottean borders, with a long and narrow bis- toury, covered with linen or muslin, to within two or three lines of the point, have been practised by Lisfranc; while Legroux recommends lace- ration of the membrane, to be performed with the end of the nail of the index finger, cut obliquely in each side for the purpose. The difficulties of either of these operations are manifest enough. In the more distinctly marked erysipelatous laryngitis, in which the serous effusion at the rima glottidis occurs so rapidly as of itself to en- danger life, less active but not less prompt measures are called for. The subjects of this variety of the disease are, for the most part, inmates of hospitals in which erysipelas prevails, and amongst such of them as are peculiarly liable to erysipelas, viz., the convalescent from continued fever, or from eruptive fevers, and those labouring under secondary syphilitic ulcers. Less call will exist here for the use of the lancet; and in its place we employ leeches, emetics, and bring on copious diaphoresis by the warm ACUTE EDEMATOUS OR SUB-MUCOUS LARYNGITIS. 61 and vapour bath. Mr. Busk, at a meeting ofthe Royal Medical and Chi- rurgical Society, at which Dr. Budd read a paper advocating the erysipe- latous character of edematous laryngitis, related two cases in proof of the success of a mode of treatment described by him. It consisted in making a great number of minute punctures on the back ofthe tongue, the uvula, and the pharynx, with a sharp-pointed bistoury. The operation was re- peated every half-hour for two or three hours ; it was productive of a great discharge of serum, and the relief was sudden and decided. The parts, after the puncture, should be gargled with warm water. On one point in the treatment of acute edematous laryngitis, there is unanimity of opinion. It is, to have recourse to laryngotomy so soon as symptoms of suffocation are exhibited, and the remedies 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 circum- stances ofthe patient, especially the condition ofthe circulating fluid, be such as to contraindicate bleeding, and to show that asphyxia is imminent, it may be improper to put off the operation for thirty minutes. If the complexion is good, if asphyxia is not threatened, the operation may be delayed for thirty days." Seldom, indeed, has the operation been per- formed soon enough to afford well-grounded expectations of relief; for, as Mr. Ryland justly observes (Diseases and Injuries of the Larynx and Irachea), 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 ofthe 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 respi- ration 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 insensible 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 in- cision 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 necessary to introduce a canula through the wound, and confine it there by bandages, as the irritation produced by it will cause strong expulsive efforts on the part ofthe 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 in them is lower in the neck, and 62 DISEASES OF THE RESPIRATORY APPARATUS. its dimensions larger, and consequently the crico-thyroid space more am- ple. The canula has been worn bv different persons for a length ol^ time without inconvenience ; the periods varying from six months to ntteen years. . . , , The mortality is great in acute laryngitis. Of twenty-eight cases col- lected 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 it supervenes gradually 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. Hydragogue cathartics and diuretics, among which digitalis must not be forgotten, and vesication of the forepart of the neck, will be the chief remedies. It is in the chronic form that we may anticipate most from laryngotomy. LECTURE LXXXVIII. DR. BELL. Laryngitis Membranacea—Croup—Anatomical peculiarity characteristic of the dis- ease; lymphatic exudation in,a membranous form in laryngeal inflammation—Phlo- gosis 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 ofthe breathing and the voice in croup—Dyspnoea evincing affection of the lungs at the same time—Causes—referable to locality, states of atmosphere, and age of the pa- tient—Seasons In which it prevails—Mortality from croup in New York, Philadel- phia, and Boston—Epidemic croup—A^e at which croup is most common—Propor- tion 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—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 appr aching collapse, perseverance in the use ot calomel and stimu- lating and anti-spasrnodic expectorants ; blisters, epithems, etc. Laryngitis Membranacea—Croup.—Croup has received a variety of names: Laryngitis Pseudo-m,embranosa, Cynanche Trachcdis, C. Laryn- gea, C. Stridula, Angina Palyposa, Suffocalio Stridula, Morbus Strangu- lators ; Bronchitis, by Young ; and Empresma Bronchilemmitis, by Good. The attempt to designate this disease by a symptom, whether of a sound in breathing, or of a sense of imminent suffocation, 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. Morbid [Anatomy.— The anatomical peculiarity which distinguishes croup from other varieties of laryngitis, is the production, primarily in the larynx, of a false membrane. This production is secreted from the mu- LARYNGITIS MEMBRANACEA—CROUP. 63 cous or lining membrane ofthe larynx ; it consists of albumen with a pro- portion 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. A microscopic examination shows it to be about a line thick and of a slight consistence : it is com- posed almost entirely of ordinary pus-globules, mixed with inflammation, corpuscles, and a species of cell double the size of.the pus-globule, but otherwise similar to it. "Regarding this false membrane or lymphatic exudation as a product of inflammation, we should naturally expect to see the surface from which it is given out evince this morbid state. Accord- ingly, 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 un- changed in these particulars. It is no forced supposition, however, that the inflammation may be so far relieved by this pseudo-membranous secre- tion that there would be diminished redness, which, as in many other cases of greatly increased vascularity during life, disappear entirely 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 symptoms of croup before this ter- mination. Even when we speak of this new product as the anatomi- cal character of 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 bronchise are soon implicated, and to such a degree as to be lined with this membranous exudation now con- tinuous with that of the larynx ; and the bronchise are filled with a tena- cious mucus. Evidences of inflammation 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 (Cyctopcedia of Practical Medi- cine), parts ofthe 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 dis- sections the lungs have a solid feel, do not recede when the thorax is opened, and cannot be compressed. Some have divided croup into varie- ties according to the extent of the region of the mucous surface affected ; hence we have laryngeal, laryngeo-tracheal and laryngeo-bronchial. We may not be able, nor is it very desirable for practical purposes, to desig- nate in advance these varieties; but it is exceedingly important that we should be fully aware of the coincidence of tracheitis and of bronchitis, and at times even of pneumonia with croup, or the laryngitis of children. For the most part, the first lesions are felt and seen in the mucous mem- brane of the fauces and larynx, and subsequently extend to the tracheo- bronchial portion. It has been affirmed as a general fact, that exudatory 64 DISEASES OF THE RESPIRATORY APPARATUS. inflammation appears, in the respiratory passages, to spread, invariably, from above downwards, never in the opposite direction ; so that when commencing in the bronchise, it can only descend to the pulmonary cells, never mount to the larynx. (Haase—final. Descrip. of the Organs of Circulation and Respiration.) If this be true we cannot admit the inverse course as indicated by Dr. Stokes, who supposes that the irritation may, at times, begin at the bronchial terminations, as manifested by cough, and then violently fix itself in the larynx. Dr. Stokes, in treating of the pri- mary inflammatory croup of children, lays down, as one of the most important considerations, the complication with inflammation in the remain- ing portions of the respiratory apparatus. 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 this 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 invariably found that the diagnosis was confirmed by dissection." We cannot doubt the cor- rectness of the opinion of a frequent conjunction of croup with bronchitis and pneumonia. In the few fatal cases of the disease, or at least of a pul- monary disease beginning with croup, which I have seen, this conjunction or complication was unequivocal ; the patient having recovered from the laryngitis, but sank under the pulmonary lesion. But it would be gene- ralising too much were we to say, that in the majority of cases of croup, in its first stage, and in its first attack, pneumonia existed either antece- dently 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 can- not be unmindful ofthe effects ofthe mechanical impediments to respiration by the encroachment on the calibre ofthe larynx and the almost occluded glottis. The breathing must be laboured and hurried, the blood is imper- fectly changed in the lungs ; there is effusion of serum in their paren- chyma, and accumulated mucus in the bronchial cells. The frequent complication of lobular pneumonia with croup has also been pointed out by MM. Rilliet and Barthez (op. cit., p. 1, p. 321). Laryngeal se%t of Croup.—I have already stated the seat of the inflam- mation of croup to be the mucous membrane which lines the air-passages, and in a more particular manner, the larynx and the trachea. The membra- nous 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 mem- brane 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 preparations then upon the table before him, nearly every one presents the false membrane also in LARYNGITIS MEMBRANACEA—CROUP. 65 the inner surface of the epiglottis. We must even go farther, and ad nit that, in a great many cases, especially those in which croup proper has been preceded by fever and anginose symptoms, 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 gene- ral. In twenty-six fatal cases of croup in the Children's Hospital at Paris, between 1S34 and 1839, there were but thirteen with inflammation other than of the air-passages ; in nine there was an accompanying mem- branous exudation ofthe tonsils, pharynx, and isthmus ofthe fauces. As many English writers, and most of our own, persist in calling croup tracheitis, or cynanche trachealis, and one ofthe former even takes credit to his countrymen for having established beyond doubt its treacheal 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 Traite Theorique et Pratique du Croup, d?apres les Principles de la Doctrines Physiologique, 2ine ed., Paris, 1824, quotes or refers to the fol- lowing writers respecting the seat of croup :—It is probable, says Vieus- seux, 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'Annecy, Leveque Lasource, Lechevrel, Latour, Valentin, Dejaer, Mer- cier, Carus, Regnaud de Lorrnes, have published cases in the Journal General de Medecine, 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 ofthe trachea. Boisseau (Diction. Abrege des Scien. Med.) says, the larynx is always affected in croup ; it is also the only part. The bronchise 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 (American Journal of the Medical Sciences, vol. iv.), has drawn an inference that the exu- dation begins lower down, as in the bronchial ramifications, and, a - cending to the trachea, ultimately reaches the larynx ; an opinion coinci- dent with that of Dr. Stokes, already detailed. In two fatal cases, the symptoms of which and the post-mortem appearances are described by Dr. Jacks,on, the membrane was continuous from the superior margin of the glottis down and into the bronchise, or the lung-'. It became thicker in its progress downwards. The mucous membrane of the larynx, tra- chea, and bronchise, beneath this lining, was highly injected with blood and inflamed ; presenting an appearance rather rougher than common. Blaud (JYouvelles Recherches sur la Laryngeo-Tracheite—Connue sous le nom de Croup) details twelve fatal cases, in all of which there was a membranous exudation lining the upper part ofthe air-passages ; and in almost every 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 the false membrane is stated to have extended from the trachea to the bronchise and their ramifications. In the case of a child three years vol. n.—6 66 DISEASES of the RESPIRATORY apparatus. old, which 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. Sometimes, even in primitive croup, the pharyn.v is partially lined with a membranous exudation, con- tinuous with that in the larynx. The character ofthe voice and breathing in croup, which arises from a spasmodic contraction of the constrictor muscles ofthe larynx, is further evidence of its laryngeal seat. The glottis can be voluntarily narrowed by some persons, so as to produce or imitate 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 oh 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 bass 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 ofthe glottis. We cannot understand, nor give any adequate explanation, of spas- modic 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 muscles 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, irritate the air-passages. Hoarseness or an equivalent condition of voice may be the fixed one in croup ; but the modifications depending 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 bronchise. A suspension of the more violent symptoms may take place, and the disease seem so far to be intermittent; but it is the spasm of the muscles, not the secretion ofthe exuded membrane and croup proper, which intermits. Inflamma- tion of the membrane, like any other of the phlegmasia?, is liable to exacerbation ; but this latter does not always correspond with 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 susceptibility of the nerves and muscles at this time. Death rarely results from the occlusion of the glottis, by the thickenino- 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. CAUSES OF LARYNGITIS MEMBRANACEA—CROUP. 67 But, although the characteristic symptoms of croup depend on organic lesion ofthe 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 dyspnoea gives a tolerably good measure of their presence and intensity. Hence, when we see the lips of a livid or violet colour, the face tumefied, the eyes promi- nent and shining, headache, somnolency, comatose stupor or convulsions, a peculiaVanxiety, hurried.breathing, and throwing the head back, we recog- nise symptoms of impeded pulmonary circulation and decarbonization 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 gene- rally appears, are in reference to locality, states of atmosphere, and age. As regards locality, we find that large bodies of water, running or stag- nant, fresh or salt, predispose to the disease. A damp and cold atmo- sphere has a similar tendency ; although we must consider cold as rela- tive. 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 suit- ably protected from these influences. The influence of locality in the production of croup is manifested 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 ofthe disease being worse on the banks of the river and lower part ofthe city than in the upper. It is comparatively rare among the children who live in the upper stories, or on the first stage. The children ofthe 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 fre- quently makes its attacks ; but the line of separation between exposure and immunity from croup is not always designated by the almanac. In New York the months exhibited mortality, during a period of sixteen years, in the following order: October, November, January, March, De- cember, February, April, May, September, July, August, and June. Croup is represented to be more frequent when epidemic catarrh or influ- enza prevails ; but the fact is only of occasional occurrence, for in some influenza seasons which I have witnessed I have not found soch a coinci- dence. In Boston, on the other hand, the disease would seem to increase at a faster rate than that ofthe 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 ; 15-9 and 21*3 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 Me- moire sur le Croup ou Angine Tracheale, relates that croup has been ob- served to be epidemic in different parts of France. Between 1772 and 1783 it occurred twenty times in Geneva ; from 1776 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 some of them at 68 DISEASES OF THE RESPIRATORY APPARATUS. least, were of secondary croup or angina diphtherite, already described. Valentin (Recherches Historique et Pratiques sur la Croup, Pans, 1^12,, 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 Stuttgard, 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, forty years 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, 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 returns 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 formerly in Ne"w 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, I 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. 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 pre- sented 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 be- tween six and seven ; 3 between seven and eight. From the period be- tween 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. Some will deny that it was 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 femalt-s, 63 died under a twelvemonth ; 25 between one and two years of age; and 43 between two and five years. The narrower o-bttis of a child than of an individual who has reached puberty is adduced as a probably 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 perceptible, whereas at puberty the aperture 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 bronchise at the same time enlarging and the voice undergoing a corresponding change. Respecting the relative liability ofthe two sexes, it would seem that this disease is much more frequent in males than females. Of 252 cases treated by Goelis, 144 were SYMPTOMS OF LARYNGITIS MEMBRANACEA —CROUP. 69 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 Philadelphia, on the other hand, for the same year, the proportion was reversed, the deaths of boys being 38, and of girls 45. The habit of body most liable to croup is fulness of cellular and adipose tissue, and a strumous diathesis. Symptoms.—The symptoms of croup are precursory, or those common to catarrh and other affections of the larynx and bronchise, and imminent or special. Among the first are hoarseness, cough, and modification ofthe 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 alarming 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 intensity and danger, without any prodrome. But a more careful inquiry would have satisfied the narrator that the child, said to be thus suddenly and unexpectedly attacked, had previously some of the symp- toms first mentioned, to which may be added, in certain cases, gastric de- rangement owing to the eating of some indigestible substance. Hoarse- ness has a signification in children more distinctive than in adults ; since it seldom precedes common catarrh 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 towards midnight, is often indicated, after a day of unusual exposure to the weather or get- ting the feet wet, by variable spirits, greater readiness than usual to laugh or to cry, a little flushing, and occasionally 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. Comparisons 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 swallowed 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 ad- vances. 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 symp- toms which indicate the complete establishment of the disease. The sen- sation of pain about the trachea is manifested in young children by a fre- quent application of the hand to the throat. The patient exhibits great 70 DISEASES OF THE RESPIRATORY APPARATUS. 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 epigastrium 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, per- haps, in the course of the following evening. But in general, unless the disease be treated with promptitude and judgment, the second stage, cha- racterized by a new order of symptoms, comes on the following day and terminates fatally. This second stage is called the purulent, the suppurative, or the suffo- cative. It may commence from the second to the seventh day, or, in the suddenly fatal, it may succeed the first stage in a few hours. This period is characterized by the absence of any remission, and the increased se- verity of all the symptoms, particularly the acceleration and diminished power of the pulse and of respiration. The cough, from being loud and sonorous, becomes husky and suffocating; it resembles the cough which attends tracheal phthisis, antl 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 di- lated ; the iris with less colour than natural : a symptom, this last, which attends the advanced stage of diseases of the lungs ; and mentioned 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 ofthe body is covered with a cold, viscid perspiration ; the feet and hands swelled. In this the second stage, or that of suppuration, the breathing may be often re- marked as most free in positions which are generally least favourable to easy breathing, as, for example, when the head is low and thrown back. There is seldom recovery from this stage last described. Sometimes tem- porary relief is obtained by the expectoration of a portion of the albumi- nous, 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 extended downwards, through the bronchise, 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 mo- ment ; 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 distress, seldom above twenty hours, he expires, sometimes with signs of convulsive suffocation, but as frequently with continued increase of the foregoing symptoms, exhaustion of the vital energies, and a state of lethargy. The stethoscope generally furnishes information in this period of the extension of disease to the larger bronchise. This extreme state of disease seldom lasts more than twenty-four hours: it corresponds with the stage of collapse of some writers. Duration.—Croup, when fatal, 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, ex'pec- MORTALITY OF LARYNGITIS MEMBRANACEA —CROUP. 71 torating 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, laryn- gitis membranacea. That the patient, relieved from the inflammation and its consequent morbid productions in the larynx, should suffer for many days, perhaps weeks, from the extension and persistence of a sub-acute disease of the bronchise and lungs, we can well understand. I have seen cases of this nature myself; and believe them to be of more ready occur- rence, and, I may add, more frequently mortal in children of a strumous habit. Mortality. — The mortality from croup has varied at different periods, and is rated very differently by writers in different coun'ries. M. Andral estimates the recoveries to the deaths to be barely 1 in 10 ; adding, 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 (Traile du Croup) has taken the pains to prepare a table exhibiting the results of the practice of fifty-eight writers who have published their experience 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 disease. In the spring of L760, 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 committed 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 medicine would, we might suppose, be brought to bear for the cure of disease in every form, the American student 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 Medecine, 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 the last 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, respectively, 187, 286, and 326. In the Children's Hospital, in 1340, 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 attri- buted 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 Montmatre, 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 72 DISEASES OF THE RESPIRATORY APPARATUS. ofthe proportionate mortality of croup in the United States ; but, adding my own experience 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, compared to the number attacked, are few. Varieties and Complications.—Before I speak ofthe 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 aggravation ofthe 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 tume- faction. 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 excretion of the substance is productive of much relief, which is increased after each discharge, unless the inflam- mation has extended down the ramification of the bronchise ; and then the respiration continues to be extremely difficult, and the disease assumes all the characters of an acute bronchitis, and frequently terminates unfa- vourably. 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 Traxhea/is Humida of Rush, and the Mucous Croup of some still more recent authors. I follow the specifica- tions of its character as laid down by Dr. Copland (op. cit.). It is not infrequent 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 hoarse- ness, and a suffocating, dry sonorous, or shrill cough, with a sibilous inspiration. The countenance 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 diffi- cult ; but a remission usually takes place in the morning. In the following evening there is a return of the croupal cough in a slighter depree. Sometimes the invasion is more gradual; the remissions but slio-ht 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 VARIETIES OF LARYNGITIS MEMBRANACEA— CROUP. 73 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, and milder in its character than the first, which 1 have described at length. Spasmodic Croup.—Thus far, there can be no doubt about the inflam- matory nature of croup, whether it be simply laryngeal, laryngeo-tracheal, or laryngeo-bronchial. The difference is simply in the degree and diffu- sion of inflammation along the mucous membrane ofthe 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 stridu- lus 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 temperament, 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 imperfect func- tion of the branch of the eighth pair of nerves which is distributed to the larynx, caused, as he supposes, by the pressure 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 a spasmodic closure of the glottis, but rather to an inability of this part to enlarge to its normal size, owing to the want of innervation from the diseased glandulce concatenates. 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 " prodigious rattling in the upper part ofthe asper 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 ofthe 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 de- fective power of the opening muscles, and may be either complete or partial. If complete, the child may be carried off by convulsions or by asphyxia without convulsions. More commonly, however, the glottis, becoming gradually, but partially open, air rushes through the still con- tracted aperture, producing the sonorous inspiration so characteristic of 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 obstructing glands, and in giving tone to nutrition, so as to prevent their becoming subse- quently diseased. But whilst admitting the propriety of this course, so 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, indi- 74 DISEASES OF THE RESPIRATORY APPARATUS. gestion, &c, for us to suppose that it could depend on a cause so deci- dedly and fixedly organic as that advanced by Dr. Ley. In reference to spasmodic croup, in general, there is no sufficient diag- nosis to enable us to distinguish it from common inflammatory croup. Cases of pure and unmixed spasmodic croup are rarely met with in prac- tice ; the intermediate states between it and the inflammatory variety being more constantly observed. It is worthy of notice, also, that, in the un- doubted inflammatory and membranous variety of croup, the obstruction of the larynx, or the laryngeo-tracheal canal, by new formations, is not sufficient to prevent the access of air to the lungs,—but that a great part ofthe phenomena and consequences ofthe disease are to be attributed to spasm of the larynx and trachea. This, however, it has been justly re- marked, 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 spasmodic croup un- connected 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 evidences of cerebral congestion. Dissec- tion has revealed, in some cases, albuminous concretions, sometimes ex- tensive, but more frequently consisting of small isolated patches in the larynx ; sometimes an adhesive glairy fluid, with vascular spots in the epiglottis and in the larynx. The congestion of the brain, particularly about its base and the medulla oblongata, and ofthe lungs, cavities of the heart and large vessels, which are also found, are most probably consecu- tive 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 removed by their expulsion, the title of spas- modic would seem to be applicable enough. In using it, I could wish that we had a terminology which would serve to designate croup thus occurring in children, and sometimes, though but very rarely, it is true, in adults, in which there is a temporary congestion of the mucous mem- brane ofthe 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 ofthe attack, its frequently gastric origin, and immediate removal, some- times by an emetic, sometimes by a common anti-spasmodic, or opium, or other narcotic, are farther points of resemblance between this nervous or spasmodic croup, and nervous or dry asthma. With both of these may- be associated not only congestion, but actual inflammation of the mucous membrane,—that of the larynx in croup, that of the bronchise in asthma,— and both with very slight modification of symptoms may require decided antiphlogistic remedies, antecedent to, and sometimes in place of those ofthe anti-spasmodic, opiate, and narcotic class just referred to. In our diagnosis it is very important that we should not confound pri- mary and idiopathic croup, either inflammatory or spasmodic with second- ary and symptomatic croup, in which the false membrane or puriform exudation is consecutive to an extension of that which lines the fauces and pharynx. The latter state is found in angina maligna, or diphtheriie VARIETIES OF LARYNGITIS MEMBRANACEA — CROUP. 75 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 repre- sented true croup, which, on this account, they have spoken of as not only epidemic but contagious. Such confusion in pathology must, of course, greatly obscure the treatment; and physicians, by an erroneous refine- ment, would be tempted to a practice in true croup that must be unfortu- nate and destructive, since it would recognise typhoid complications, which only exist with the membranous 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:— PH1MAUT CllOUr. SECONDARY CROUP. Jingina Maligna vel Membranacea.—Diph- therite. 1. The air-passages primarily engaged. 1. The laryngeal affection secondary to disease ofthe pharynx and mouth. 2. The fever symptomatic of the local dis- 2. The local disease arising in the course ea>e' of another affection, which u generally accom- panied hy fever. 3. The fever inflammatory. 3 The fever typhoid. 4. ISecessity for antiphlogistic treatment, 4. Incapable of bearing antiphlogistic treat- and the frequent success of such treatment. ment; necessity for the tonic, revulsive and stimulating modes. 5. I he disease spasmodic and in certain 5. The disease constantly epidemic and situations endemic, but never contagious. contagious 6. A disease principally of childhood. 6. Adults commonly affected. 7. I he exudation of lymph spreading to 7. The exudation spreading to the glottis the glottis, from below upwards. from above downwards. 8. The pharynx healthy. 8. The pharynx diseased. 9. Dysphagia either absent or very slight. 9. Dysphagia common and severe. 10 Catarrhal symptoms often precursory 10. Laryngeal symptoms supervening with- to the laryngeal. out lhe pre.eXJstence of catarrh 11. Complications with acute pulmonary 11. Complications with such changes iare. inflammation common. [Gastric complications common.] 12. Absence of any characteristic odour of 12. Breath often characteristically fetid. the breath. 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 the "aigument again, nor repeat the proofs of the downward extension of the lymphatic exudation from the glottis and larynx to the trachea, and thence to the bronchiae; but I will just add one familiarfact to the proofs already presented, viz., alterations of the voice, of course glotteal disorders, preceding the' other symptoms ofthe disease. The occurrence of secondary croup, or of angina membranacea, with extension to the air-passages, is frequent in times of real epidemic croup- of which proof is furnished in the late epidemic at Paris, before referred to. The prevalence of exanthematous diseases, and great tendency to mortification of tissues, particularly gangrenous tonsillitis, was also appa- rent 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 disease which manifested this property. In many instances of the malignant sore throat, the exudation thrown out rom the inflamed surface forms a pellicle coextensive with the spread of the morbid process from the fauces to the pharynx and air-passages. 76 DISEASES OF THE RESPIRATORY APPARATUS. In some cases, ulceration and slight apparent sloughing occur in the cen- tral parts and those first affected, whilst the surrounding surface »"« »e parts subsequently diseased, become covered by a soft and easily lacerated exudation. The complication with croup of various stages of angina or sore throat—malignant or epidemic—whether commencing m the pharynx, or in the fauces and extending to the pharynx, is not uncommon, tire- tonneau describes a remarkable epidemic affection of this nature, which he called scorbutic angina, or angina maligna. In eighteen cases ot which he gives the dissections, the air-passages were affected. In five, the dis- ease occurred in children, aged from eight months to seven years, and in all of them the exudation was first formed in the pharynx. In one case, it descended into the minute bronchise. The remaining thirteen cases proved 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 typhous fever, gastro-enteritis, chronic pleurisy, &c. In some cases, the morbid action originates in the tonsils, and extends to the ad- joining parts. In the croup epidemic in Buckinghamshire, in 1792, de- scribed by Rumsey, the croupal symptoms were stated to have been co- eval with inflammation of the tonsils, uvula and velum pendulum palati; and large films of a white substance were formed on 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 spas- modic 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 spasm, and to enable the system to throw oil' 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 physi- cian ascertains the antecedent and collateral circumstances, in regard par- ticularly 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 ipecacu- anha or antimonial wine, or the compound honey or syrup of squills, had been administered. If already nausen 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 solu- tion 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 accom- panying 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 repetition 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 TREATMENT OF LARYNGITIS MEMBRANACEA — CROUP- 77 be the toleration by the system of the medicine ; or, less equivocally ex- pressed, the longer will be the time before its ordinary effects are mani- fested. 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 ofthe medicine in full doses, it fails even to nauseate, recourse must be had, not toother enutics, but to means cal- culated both to abate the now evidently violent disease, and to renew the susceptibility of the system to tartar emetic. The remedy next in order, and the one indicated by the symptoms and our knowledge of the patho- logy ofthe 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 ofthe flow of blood in warm water. You frequently will be recommended to open the jugular vein, on account of its being super- ficial. The operation is simple, but not quite so easy as you might be led to suppose ; and the appearance of the thing is revolting to the mother and others present. But, as essentials 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 some- times 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 ofthe detrac- tion of blood, and evidences, in this case, of its having been carried to a suitable extent. Often, after venesection, free vomiting will be caused by the tartar emetic which had been given before the operation, without any such effect then resulting. The quantity of blood drawn will vary with the intensity of the symptoms and the habits ofthe patient. I often direct four ounces to be taken from the arm of a child between a year and two years old. 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 regu- lar bathing-tub is not at hand, to have a large wash-tub three parts filled with water of the temperature of 96°, in which the child should be im- mersed 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 recourse 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 appropriate remedies in quick suc- cession : so that immersion in the warm bath shall accompany the admin- istration 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 happens that a decided and salutary impression is not produced 78 DISEASES OF THE RESPIRATORY APPARATUS. by these three agents in the cure of croup. I have found vomiting and the warm bath adequate to produce a complete solution of the paroxysm in cases in which, but for the fatness ofthe children and consequent diffi- culty 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 administering minute doses of tartar emetic and a little sweet spirits of nitre, with a drop or two of laudanum each time. In a 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 ; but this recommendation need not be literally followed out. 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 ofthe symptoms, we direct leeches to the throat. I have treated successfully by leeches and an emetic a case of croup in a child six weeks old. If we are not called on until the suppu- rative 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 combining with tartar emetic calo- mel 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 operation 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 or the lancet, as well as in those which evince complications of bronchitis or of gastro-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 destroying its fibrin and colouring matter, and to produce a cachectic state of system utterly incom- patible with the existence of adhesive inflammation, we have additional indications for its use in croup. It may be given in doses of one to three grains, combined with 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. Afterwards, especially if the skin have lost its febrile heat and the excitement 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 ap- parent 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 to adapt other remedies, which may be employed at the same time, to the varying states ofthe general system. Thus, if there be a suf- fused blush ofthe face, turgid jugular vein, strongly throbbing carotids, with a heaving of the chest, we may venture, even though venesection has been freely used, to apply leeches in the manner advised already, and sinapisms to the extremities. Evidences of depression ofthe vital powers, in a paleness ofthe face, coldness ofthe skin, and smaller pulse, will on TREATMENT OF LARYNGITIS MEMBRANACEA — CROUP. 79 the other hand, require abstinence from the tartar emetic and recourse to the hot-bath, frictions ofthe surface, and warm infusion ofthe root ofthe polygala senega, with oxymel of squills and even the addition of a little carbonate of ammonia. During all this time, the calomel should 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 extremities, volatile or turpentine liniments and epithems to the chest, or by a blister between the shoulders. More stimulating expectorants, consisting 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 contribute 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 bron- chitis, is nearly the same as for this latter disease. Cups to the chest, or between the shoulders, succeeded by blisters ; and calomel with very mi- nute doses of opium, and tolerably free purging, are leading means of cure at this time. Having thus sketched the outlines of the treatment of croup ofthe 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 to 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 the attack. Febrile irritation and unusual fulness 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 medi- cine on the gastro-hepatic apparatus. It ought to be laid down as an in- variable 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 laryngeo-bronchial irritation, may often, in deli- cate subjects, be treated with anti-spasraodics, to which a little ipecacu- anha or squills has been added. I have relieved entirely an adult from an attack of croup by the extract of stramonium and blue mass given in pill; although during a prior one I deemed it necessary to bleed, leech, and vomit her freely, and afterwards to give calomel in large doses. Before speaking of local treatment in croup, and the probable utility of bronchotomy,—laryngotomy and tracheotomy,—let me bespeak youratten- tion to some remarks on the curative powers of tartar emetic and of calo- mel, and, likewise, of some other remedies in croup. The first two are not, I think, regarded in all their therapeutical bearings as they ought to be. But I shall postpone these subjects to another lecture. 80 DISEASE^ OF THE RESPIRATORY APPARATUS. LECTURE LXXX1X. DR. BELL. Therapeutical Action op Tartar Kmetic and of Calomel in Croup—Practitioners who have employed calomel—Venesection—its advocates—Leeching—Expectorants; those of the antiphlogistic kind to he first used—Tartar pmetie and opium ; '-alomel and opium—Squills—The alkalies—Polyuala senega ; its alleged powers and true value—Diaphoresis; is sometimes critical; when useful, 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 he con- founded with the hot bath—The arm-bath—Antispasmodics ; the best anti-spasmodics, venesection, tartar emetic, calomel, and the warm bath ; opium, and afterwards assa- foetida, camphor, &c.—Topical remedies; blisters—when and where to be applied— Stimulating liniments—Cauterization ofthe fauces and pharynx—Tracheotomy.—La- ryngismi's Stridulus ; not identical with spasmodic ctoup as often met with—De- scription 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 mi I'd—mixed, hygienic, and medical—Prevention. Not infrequently Ihe relief from an attack of croup will be as permanent as it was speedy, by means of vomiting and its accompanying effects ; and no other remedy after an emetic will be required for the solution of the paroxysm. I would lay stress on the words ' accompanying effects,' 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. With such persons the selection of an emetic is a matter of comparative indifference, provided they can cause their patients to vomit. But a very slight retrospect of the pathology of croup must convince us> that, from the outset, our remedies should be selected with reference to their power of abating morbid arterial and secretory action, not only in the larynx and trachea but in all the bronchial ramifications ; and, also, of causing sedation of the vessels of the lungs proper as well as those ofthe 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 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 relaxation : it will serve to eject mucosities and albuminous shreds and membranous exudations from the larynx and trachea; but there must have been'an antecedent state of diminished ex- citement and turgescence of the mucous membrane and its withdrawal from the adherent plastic lymph, before this latter can be readily detached 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 abdominal muscles into combined TREATMENT OF LARYNGITIS MEMBRANACEA — CROUP. 81 action, and give rise to vomiting: but their effect is confined merely to evacuating the contents of the organ; and if their do>e have been large, they cause continued straining efforts to vomit, with, at the same time, little or no increased secretion 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 cop- per, 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 notable extent, adherent false mem- brane, or that the mere scraping off of membrane and glairy mucus will give much relief to a croupy patient, the mucous tissue of whose larynx and trachea is inflamed, is too purely mechanical. Our object, then, being to abate and speedily remove the morbid ex- citement manifested by abnormal secretion, and the turgescence and in- jection of the mucous membrane of the air-passages, and particularly of the upper portion, we shall have recourse at once to the agent best calcu- lated to attain this end. Some writers recommend us to use, in the precursory or forming stage of croup, ipecacuanha 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 derived 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 syrup of squills, 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 pre- vented from maturing, or we acquire a measure of its violence and an index to a speedy 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 ofthe 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 the prostrating effects of the latter. Were our diagnosis so certain that we could ascertain positively the precise 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 passages, the safe practice seems to me to be that which shall prevent these probable and VOL. n.—7 82 DISEASES OF THE RESPIRATORY APPARATUS. often dangerous and fatal results, even though it be at the expense of momentary strength, and with the tax of temporary prostration. I Deheve, 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 necessitv 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 persistence in full doses of tartar emetic, after the violence ofthe 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 sinking 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. It wTill often be proper, if, after free emesis, there be much straining to vomit without corresponding discharge, to give a drop or two of laudanum to the little patient, and to allow it to sleep, for which it will be sufficiently prone, for a while. You must by this time be fully aware of the therapeutical basis on which I rest my use of tartar emetic in croup, as wTell as in so many other of the phlegmasia?. It is not merely as an emetic, but as a contra-stimulant or sedative, and opposed to inflammatory action irrespective of its procuring evacuations, that I habitually use this medicine. Its utility in this way is beginning to be perceived by some of the practitioners of Great Britain, one of whom, Dr. Wilson, 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 frequently renewed, the antimonial salt, in doses of one-fourth to one-third of a grain, at first every hour, until a decided impression was made, and afterwards every two hours, till the patient was considered 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 obviate 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 respecting 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 deserved reputation take such limited views of the effects of calomel in 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 revolutionising and alterative effects of mercurial preparations in general, unless the salivary glands are inflamed and incipient ptyalism caused, is rank empiricism, and has com- pletely 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 ofthe small intestines ; and, in a short time on the liver and pancreas, which, by means of their excretory ducts are TREATMENT OF LARYNGITIS MEMBRANACEA — CROUP. 83 placed in close and continuous relation with the intestinal mucous surface. Soon the large intestines are affected, and increased defecation is the conse- quence. 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 direc- tion and the genito-urinary and its secretory apparatus in another ; and is followed by increased expectoration and diuresis, together with an abate- ment of prior irritation which may have prevailed in one or other of these divisions. Calomel acts in a more especial manner on all portions ofthe mucous system, and through it on their glandular appendages; and hence its use is more immediately applicable to irritations and inflamma- tions 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 calomel unless and until ptyalism is produced. Under the influence of this error, immense quantities ofthe medicine are introduced into the stomach, with the effect often of a great depression of the vital powers, and particularly of the functions of the nervous system, cold skin, excessive inertia, &c. ; the pre- scribing physician all the while waiting for the action of the calomel. In this way the patient may be actually destroyed by mercury, without any suspicion being entertained of the fact by the expectants for salivation. Delafontaines, Inspector-General of Military Hospitals at Warsaw, speaks of calomel, as the first and the most efficacious of all the remedies employed in croup. He regards it, he says, as a specific, at least as cer- tain against croup as against syphilis. Albers and Olbers recommended and used calomel; sometimes alone, after venesection, sometimes alter- nating 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. Copious and fetid alvine discharges were followed in a surprising manner by a removal of the affections of the larynx. The use of calomel and enemata made up the chief treatment of Autenrieth, in croup. 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 dimi- nished the dose. Commonly evacuations upwards and downwards resulted. 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. Let me add, however, that two children were lost by the weak- ness which resulted from continuing the calomel after the symptoms of the croup had subsided. 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 rendering them more fluid, and thus diminished or prevented the secretion and ad- hesion of the membrane. On our chief remedy in croup, bloodletting, some remarks will appro- priately find a place at this time. Venesection was first recommended 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 S4 DISEASES OF THE RESPIRATORY APPARATUS. Geneva) recommends, in the case of a child three years old, that vene- section to the extent of six or eight ounces be practised, and then that leeches be applied to the neck, to be repeated 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 re- covered. Muller advocated and practised venesection. Dr. Dick, of Alexandria, 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 bloodletting, 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 experience leads me to believe that in the majority of cases of croup the lancet may be dis- pensed with, if tartar emetic be early used and persisted in, until an ade- quate impression is produced ; but if this remedy fails to arrest the pro- gress of the disease, and to remove the urgent symptoms, no time should be lost in having recourse to the lancet, or analogous means of sanguine- ous depletion. Arteriotomy 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, as in the case of venesection, the bleeding must 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 or twelve; Reil of Halle, ten to twelve ; and he allowed the blood to flow afterwards until fainting was induced. This, generally speaking, in the first stage of the disease, is the proper practice. It is that followed and re- commended 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 possible, and then to check any excess of bleeding by the application ofthe 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 repetition of sinister results, such as death itself, from the continued hemorrhage from leech-bites, the physician should give special injunction 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 recom- mend, we must bear in mind that one European is nearly equal to TREATMENT OF LARYNGITIS MEMBRANACEA — CROUP. 85 three American leeches. At Geneva (Switzerland), where croup is so common, one of the fundamental 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," con- tinues 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 vomiting or relief following, I directed leeches to the forepart of the neck, with the effect of almost immediate ease and speedy cure. My own belief was coincident with that ofthe 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 indications of croup, the procuring a solution of the inflammation of the mucous mem- brane of the air-passages, and a detachment of albuminous exudation which may have been formed on it, we cannot, as an inference, admit with equal readiness the propriety of giving expectorants, 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 secre- tion from the laryngeo-bronchial apparatus. 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 reduction. 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 lancet and purgatives. When direct repletion has been carried sufficiently far, we may substitute squills, in the form of syrup, for 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 at this time in the use of opium than of any other medicine, it will be well, whilst administering regularly the other articles 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 either to add a drop or two of laudanum in every second dose of the other medicines ; 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 pro- ducing a too great and alarming prostration of the system of our patient, are ammoniacum, senega, and the carbonates of the alkalies, to which 86 DISEASES OF THE RESPIRATORY APPARATUS. 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 excite- ment and phlogosis, in which some other medicines ofthe class would be improper. 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 alarming depression ; but much more good would be procured from its 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 two sons, 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. John Archer, few of us at this time will make objections. He recommends, in the first period ofthe. disease, venesection, mercurial purges and diaphoretics, chiefly tartar emetic. He has no reliance on blis- ters. 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, ac- cording 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 fer- vour 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 remedies, 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 enlisted more frequently in our service in the treatment ofthe 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 tar- tar emetic. Of this compound Dr. B. gives atablespoonful every quarter of an hour, in order to procure four or five ejections from the stomach ; and then a te'aspoonful every hour or two as an expectorant. Gradually, in proportion as the laryngeal and pulmonary oppression is relieved, the interval for giving the mixture may be increased. Among the means oc- casionally employed to promote expectoration is the inhalation of the va- pour of water, or.of vinegar and water. In one case, the child, a patient of Mr. Coigne, of Courbevoie, expectorated a membranous 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 a false membrane, and was cured. Diaphoresis is occasionally critical in croup. At least I have seen a patient, whom I kept for upwards of an hour in a warm bath, where I ad- ministered to it tartar emetic so as to excite vomiting, on its being after- TREATMENT OF LARYNGITIS MEMBRANACEA — CROUP. 87 wards 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 suf- fering from a little fever and cough, which were removed by a purgative. In a somewhat more advanced period ofthe disease, after venesection and analogous antiphlogistic remedies, the coming on of diaphoresis is accom- panied often by a relaxation of the laryngeal mucous membrane, 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 contra-stimulant or sedative, then expectorant, and finally diaphoretic. It is a great mistake to suppose, as is, however, so commonly taught, that its property of causing sweat is manifested by or bears any proportion what- ever to the nausea it produces. Never are the diaphoretic effects of this medicine so satisfactorily exhibited as when the patient makes no com- plaint 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 Cremona, that patients were cured by an abundant sweat towards the end of the disease. Dr. Wallenbourg informed Dr. Valentin, that in parts of Russia the Jewish women ran 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 cover them up carefully. Some, he adds, are cured by this means, and slight remedies in addition. One ofthe best aids to other remedies, and itself one of our best dia- phoretics, 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 well-informed physicians, of confounding the warm with the hot bath. You will read of objections to the former, which are only ap- plicable 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 ofthe temperature I have mentioned in my last lec- ture, 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 efficacy of arm-baths in croup. They are indicated, he thinks, at the commencement of the stage of exudation. He recommends that the arms of the patient be placed in a vessel sufficiently deep to admit them to a hand's breacfth above the elbow-joint, ami 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. 88 DISEASES OF THE RESPIRATORY APPARATUS. 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 bus- ter be applied to the throat. Antispasmodics.—Witnesses to the spasm of the glottis and larynx in croup, which often threatens suffocation and at any rate interferes with the full expansion of the lungs and circulation through them, you will be na- turally very desirous of removing it. With this view you may perhaps be induced to have recourse to anti-spasmodics. These medicines, in the common acceptation of the term in Materia Medica, are not, however, those on which you can rely in the early stage of croup. The best anti- spasmodics in the phlegmasia?, experience will soon prove to you, are venesection, tartar emetic, calomel, and the warm bath. After this opium is entitled to a preference, alone, or what is better, combined with the tartar emetic and calomel. In proportion as the inflammation subsides, recourse will be had to the recognised anti-spasmodics, such as assafcetida, castor oil,camphor, and, I may add, extract of conium,and at this time digi- talis, which sometimes serve very well to allay this irritability of the glotto- laryngeal muscles, by which they contract with spasmodic frequency 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 gives high praise to assafcetida, 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 ofthe disease. I would not go so far as Gregory and others, in recommending full doses of opium or laudanum after venesection and vomiting, in croup ; but I well know that after these operations, and when we are giving 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 recom- mended, we shall do more to mitigate and remove spasm and oppression than by any ofthe more common anti-spasmodics, at the same time that we carry out, undisturbed, 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 until a re- duction of phlogosis has been obtained by emetics, antimony, 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 reaction, 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 forepart 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 probably increased afflux to the mucous membrane ; 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 afterwards 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 best LARYNGISMUS STRIDULUS. 89 spots for the application of blisters in croup, are the nucha, on the upper part ofthe 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 complications, 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 blister- ing or other irritating ointments to the vesicated surface. M. Valleix recommends a magistral blister in acute laryngitis, which might be usefully applied in the proper stage of croup. It is made as follows :—Take of powdered cantharides and wheat flour, each equal parts, and of vinegar enough to make a soft paste, which is to be applied to the skin. Stimulating liniments, such as sweet oil and aqua ammonia, oil of tur- pentine 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. Ammoniacal cerate, made of simple cerate, ^j., mixed up with carbonate of ammonia, gj., has been applied every four hours in quantities of ^ij., on the forepart 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 flan- nel 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 cauterization ofthe 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 an^l cough. In primary and common croup, while we do not forget cauterization, we should be aware that it must not divert our attention from the more active and heroic measures which I have thought it my duty so fully and point- edly to recommend to you. Tracheotomy has been recommended as the last resource in croup. Apart from the reasons, t\ 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 exudation on its surface in the ad- vanced and last stage, from that in edematous laryngitis of adults, inde- pendently 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. Bretonneau and Trousseau, who have performed it ninety-eight times. Of 140 cases of croup in which it has been performed of late years by different French surgeons, 25 per cent, have terminated in recovery. M. Haine (Ann. de la Soc. de Med. d'Anvers) states that he has performed tracheotomy in croup in sixty cases, and eighteen times with success. Very different views of the subject of treatment of croup have been advanced by M. Guersent. This gentleman regards the surgical part as by far the most important, and alleges that the medical treatment is of very limited value, not acting directly on the disease, and being rarely crowned 90 DISEASES OF THE RESPIRATORY APPARATUS. with success. Surgical means are those, M. Guersent contends, on which we must chiefly depend. But he does not wish to be understood as mean- ing merely tracheotomy, but also local applications to the fauces, in speak- ing of surgical means. The local applications are liquid or solid : dilute muriatic acid and solution of alum, &c, but preferably strong solution of nitrate of silver, come under the first head ; and among the latter, pow- dered alum or nitrate of silver. I cannot give you any commentary on these strange opinions, as forcible as by repeating, after M. G., the outlines of a case in which the surgical means seem to have had a fair trial from the very outset of the disease, but with a most disastrous result. He was called, he tells us, to see a child who had, the preceding night, been sleep- less, restless, and slightly feverish ; there was no cough, nothing to call atten- tion to the pharynx. M. G. inspected the throat, however, as he made it a rule always to do, and perceived some white patches on the tonsils, which he immediately cauterized ; but, notwithstanding, croup of the severest kind set in, and tracheotomy had ultimately to be performed, but with- out success. Nothing is said of the medical treatment, and we are left to infer that M. Guersent, consistently with his opinion heretofore advanced, either made no trial of it, or rested his hopes mainly on his surgical means. Laryngismus Stridulus—Angina Stridulosa—False Croup—Thymic Asthma— Spasm of the Glottis. — I have already expressed my doubts whether laryngismus stridulus be properly identical with spasmodic croup. The latter mostly exhibits all the distinctly marked symptoms of the in- flammatory variety, with the addition of increased difficulty of 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 occasions, 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 in which laryngismus stridulus is manifested, is still more restricted than that of croup ; rarely exceeding three years from birth. Dr. Kerr (Ed. Med. and Sur. Journ., 1838) has known the symptoms of the latter to appear as early as eight days after birth. I have had the treatment of a case in which there is good reason for believing that the first attack was on the second day after birth, when life was almost extinct after symptoms of spasm and suffocation. Dr. Kerr 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 ofthe fact, that he has seen it in thinner habits, and in whom no scrofula could be suspected. Symptoms.—Laryngismus Stridulus is characterized 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 singultic 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 CAUSES OF LARYNGISMUS STRIDULUS. 91 to be perceived. In extreme cases the respiration stops entirely, and the face becomes quite livid ; the small inspiratory pipe then takes place, either in the beginning of the paroxysm or at its termination, it being quite suppressed by the strength of the attack. This symptom is pathogno- monic of the disease. 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 these are exhibited in the thumbs being turned into the palms, and the hands more or less clenched, and when opened by force immediately returning to 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 it is ushered in by them. Other parts ofthe 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 per- haps every case ofthe disease, the buttocks, even when well covered, are as cool as if newly washed. It is not correct to speak of the paroxysm being ushered in by fever, croupy cough, and sneezing, as often there are no such preludes and accompaniments. The disease has been confounded with spasmodic croup; but it differs from this latter in the following particulars. I give them as laid down by Mr. Meade (Lancet, p. 411, 1846): " 1. Spasm of the glottis is almost exclusively met with in young infants from the time of birth up to twelve or eighteen months of age. Spasmodic croup, on the contrary, is extremely rare in infants under a twelvemonth old. 2. In spasm of the glottis, there is neither coryza nor any febrile disturbance, while spasmo- dic laryngitis is always preceded and accompanied by some catarrhal symptoms and slight feverishness. 3. The first attack of spasm of the glottis may come on either in the night or day, and a child has been known to have more than twenty fits in the course of the same day ; spasmodic croup, however, always attacks for the first time at night; and the child will never have more than five or six paroxysms of difficult breathing during the whole attack. 4. In spasm of the glottis, there is no cough, and during each fit there are seldom more than one or two stridulous inspirations ; while in spasmodic croup there is always a hoarse cough, and the difficult and noisy breathing continues for some time. 5. In spasm ofthe glottis, convulsions generally come on after the disease has continued for some time, and also ' carpo-pedal contractions.' Con- vulsions are very rare, on the contrary, in spasmodic croup, and the con- traction of the limbs has never (that I am aware of) been observed. 6. Spasm of the glottis is almost always a chronic disease, while spasmo- dic croup is essentially acute." In chronic hydrocephalus, as remarked by Mr. Meade, infants, some- times, on being awakened from sleep, or when they have been crying, become suddenly stiff, blue in the face, remain for a minute without respiring, and then draw in their breath with a shrill noise. This is a real spasm of the larynx, and it only differs from the one which is the sub- 92 DISEASES OF THE RESPIRATORY APPARATUS. ject of notice at this time in its being a symptomatic in place of an idio- pathic disease. Causes.—Mental emotion, such as any vexation, is apt to bring on a paroxysm. Frequently the child is awakened out of sleep by one. A current of cold air will produce the same effect. Indigestion is a frequent exciting cause. In one case the use of milk invariably brought on an attack. In another, the irritating organic cause seemed to me to be in the rectum. Straining with some tenesmus would always bring on the disease. 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 occa- sioned wholly by the want of air, and are not infrequently 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 becomes sensible as soon as the fit is over. In general, when the disease is approaching a fatal termination, the epileptic fits be- come more numerous, and the child dies, apparently, rather from the effects of convulsions than from any affection of the glottis. Boys are repre- sented to be much more liable to the disease than girls. Dr. Kerr thinks that laryngismus stridulus is almost always a conse- quence 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 all diseases ofthe respiratory organs predispose to it,—such as catarrh, bronchitis, croup, measles ; but yet, in a case in which the attack was brought on by intestinal irritation, no spasm occurred during a violent and somewhat tedious attack of bronchitis. 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 appearances in the brain are similar to those pro- duced by convulsions unaccompanied with laryngismus (Dublin Journ. Med. Science, 1838). In a subject examined by Mr. Meade, the mucous membrane of the larynx, trachea and bronchia? were perfectly natural in appearance and structure. This disease, is obviously the same in its essential features as that de- scribed by Dr. Underwood, under the head of Inward Fits, and by Dr. Clarke as " A Peculiar Species of Convulsion in Children," whose account of it is introduced in a note by Dr. Hall, pp. 111-12, to the last (American) edition of Underwood. It also closely resembles, if it is not identical with, the thymic asthma, a detailed description and pathology of which are furnished by Dr. Montgomery (Dub/in Joum., 1836). °Mr. Hood had previously (Edinb. Med. and Surg. Journ., vol. iii., 1827) pointed out, after numerous dissections, the enlarged thymus gland as the cause of this disease. Taking into consideration all the phe- nomena, we must go farther in our explanation of its organic cause than Dr. Ley, who supposes a paralysis of the glottis to be induced by pressure of swelled glands on the recurrent nerves, and of Dr. Marsh who suggests that the seat of the disease may be at the orio-in of the pneumogastric nerve. The real cause is, a lesion which will give rise TREATMENT OF LARYNGISMUS STRIDULUS. 93 not only to the affection of the glottis, but also to the convulsions, and occasionally paralysis ofthe muscles ofthe limbs as well as those of degluti- tion. This must necessarily be in the cerebro-spinal axis, or more particu- larly at the medulla oblongata. It is sufficient for the production ofthe dis- ease, at least the glottic symptoms and convulsions, that irritation be trans- mitted from any organ to the base ofthe brain and to the medulla spinalis, to be by these reflected through the motor nerves on the muscles of the larynx, and of the voluntary muscles generally. The chief condition, therefore, or predisposition, consists in a morbid excitability, by which the brain and medulla spinalis respond too readily and violently to the irritation of any sensitive part,—whether cutaneous, gastro-pulmonary, or parenchy- matous. 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 come on from other causes. Mr. Simon (Physiol. Essay on the Thymus Gland) regards the enlargement of this body as the effect, and not the cause ofthe comatose breathing. Dr. Griffin (Dublin Journ. of Med. Science, 1838) thus sums up the essential facts connected with this disease, at the conclusion of an elabo- rate critical inquiry on the subject: " 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 terminates 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 convulsions, but have also the strumous disposition. 6. It is sometimes met with in connexion with an apoplectic or comatose state from the commencement, as in 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 breathlessness and crowing as indicative of it; and the children were as well, apparently, a few moments before death, as they were previous 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 ter- minated in death." This last conclusion will serve to indicate the charac- ter of the prognosis in laryngismus stridulus. Treatment.—That of the paroxysm would seem to be first in order from the nature and danger of the symptoms ; but the duration ofthe 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 mus- cles their full power; 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 adopted in inflammatory croup, or where there is any doubt in the diag- 94 DISEASES OF THE RESPIRATORY APPARATUS. nosis, will then be had recourse to, viz., an emetic and the warm bath. These failing, and life becoming rapidly or being, in fact, extinct, arti- ficial inflation of the lungs has been recommended, or laryngotomy practised, as the speediest method of accomplishing this purpose. When the attacks of crowing are severe and numerous, or the one attack is prolonged, the lower bowels should be emptied by an enema and some purgative medicine, such as calomel and rhubarb, or turpentine and cas- tor 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 irritation ofthe rectum by hardened feces higher up. Commonly the rule is a good one, to procure two stools daily for a child affected with laryngismus, or threat- ened 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 for allaying irritation or of procuring sleep, will generally fail. In illustration of the direct action on the larynx of mor- bid impressions or irritants in the stomach, I may state that I have car- ried off at once all the symptoms of spasmodic croup by an emetic, which discharged from the stomach an apple that had been eaten and very imper- fectly masticated a few hours before. Some of the German practitioners (Kopp, Kirsh, &c.) recommend a more active course, to diminish and prevent, as they allege, the recur- rence of all undue congestion and nervous excitement in the heart and lungs, by low diet, large and frequent bloodlettings (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 medi- cines, such as mercury, iodine, &c. I will not deny the utility of this course of treatment in some cases; but they must be comparatively rare, and can only occur in robust subjects. In a large majority of cases, the main indication of cure will consist in the methodical and persevering employment of the means calculated to give tone to the nervous system, after having allayed its morbid sensibility and removed the obvious causes of irritation. To meet this view, you will see that the bowels are kept regular, that the gums be frequently lanced, if they be at all inflamed or even swelled ; that narcotics, in combination with tonics, and espe- cially chalybeates, be administered at the same time, and, abo've all, that the patient procure pure air and light nutritive food. Convulsions occurring during the course of the disease will inquire 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 itself, but to remove the morbid condition of the parts, and notably the brain, irritation in which would endanger a return of the convulsion. 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. Relief has PROPHYLAXIS OF LARYNGISMUS STRIDULUS. 95 been procured by inhaling ether from a sponge saturated with this fluid. Attention 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 continued, 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 ctse will be, frequent changes of clothing; sponging the skin every morning with tepid, and after a while cold salt water, and careful rubbing it after- wards 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 in- creased. Prophylaxis.—A knowledge of the predisposing and exciting causes of laryngismus stridulus will guide us in the modification or abatement ofthe former and removal of the latter. Of these, cold has been already mentioned as the chief one. 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 transitions from a hot to a cold room, or damp entry, or the outer door. The upper garment should be of a wool- len 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, particularly 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 de- structive 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 obvi- ated if not entirely removed, is that of a strumous habit and scrofulous diathesis, sometimes associated with full and plump-bodied and well-com- plexioned 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 digestion is more or less impaired. To the restoration of this function by the alternate administration of aperients and mild tonics, and the use of plain nutritive food, the attention of the phy- sician 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 the scrofu- lous diathesis. With this particular view, the iodide of potassium and the iodide of iron will be usefully prescribed ; and an ointment of the former should be rubbed on the enlarged glands ofthe neck. The irritation from dentition will be diminished by occasional, and in- 96 DISEASES OF THE RESPIRATORY APPARATUS. deed in some cases of the present disease, by frequent cutting of the gum down to the tooth, so that the lancet shall grate on it. Disorders ofthe 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 medicines ; and it will be found that their removal will contri- bute not a little to the comfort ofthe patient. 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 Journul ofthe Medical Sciences. LECTURE XC. DR. BELL. Chronic Laryngitis—Its synonyms—Idiopathic and symptomatic—Morbid Jnalomy— Applicableness of the title, laryngeal phthisis.—Large proportion of ulcerations in the epiglottis, larynx, and trachea, in phthisical subjects—Symptoms .- sensations, voice, aphonia, cough, breathing—Different species of chronic laryngitis,—a know- ledge of, necessary for prognosis and treatment—Examination of the fauces and pharynx—To determine the state of the lungs: auscultation, percussion, and expecto- rated matter—Duration of the disease—Causes: age, sex, prior disease, vocal strain,— Peculiar exposure of clergymen,—atmospherical vicissitudes, habits—Complications. The disease which is the subject ofthe present lecture has been variously named. In addition to its technical designation of Chronic Laryngitis ; Laryngeal Phthisis ; Laryngitis with Secretion of Pus ; it has re- ' ceived the popular ones of Clergyman''s Sore Throat; Throat Consump- tion, &c. Chronic laryngitis may be the consequence of primary acute laryn- gitis 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 symp- tomatic is by far the most frequent variety. Morbid Anatomy.—The effects of chronic irritation of the larynx vary from a slight vascularity and thickening ofthe mucous membrane to changes so extensive as completely to alter and destroy the natural appearance of the canal. The successive changes in the laryngeal mucous membrane may be, redness ; thickening or diminished consistence ; softening, partial or gene- ral ; 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 shape, perfectly resemble 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 rimceglottidis in the adult than in the child, explains why the forma- tion of false membranes is so much less alarming in the former than the latter. Participating in these alterations, the mucous follicles may become chronic laryngitis. 97 enlarged and thickened, and secrete more abundantly than common. They are often raised into small rounded spots, of a dull white or yellow- ish colour, and then they have been erroneously called tubercles. Ulcera- tions are met with, which, according as they are above or below the vocal cords, will cause impaired voice or complete aphonia: they have been chiefly met with in the epiglottis, the aryteno-epiglottidean ligaments, the vocal cords, and the base ofthe ventricles ; and they may become so extensive as to give rise to fistulas. The number of ulcerations is gene- rally in the inverse ratio of their size. They often extend to other tis- sues, and when they do, the thyro-arytenoid ligaments are the chief sufferers. The sub-mucous cellular tissue may be thickened, and appear under the form of scirrhous cords, 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 hypertrophy. 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 cartilages 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 laryngitis, there has been found to coexist tubercles of the lungs. Sometimes 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 con- sumptive patients noted by Louis, the trachea was found to be ulcerated in thirty-one, the larynx in twenty-two, and the epiglottis in eighteen. In the whole of his researches up to the time of making this record, he met with only seven cases of ulceration of the bronchise. 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 Worces- ter) 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 ofthe mucous membrane of the larynx. It will be the more correct opinion to regard these ulcerations as symptomatic of tuberculous disease. Even though chronic laryngitis without complication should seldom be productive of consumption, the designation phthisis laryngea will still be applicable to those cases of tubercular pulmonary consumption in which the disease is aggravated, the symptoms in a degree characterized, and its march accelerated by the laryngeal affection. 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 VOL. n.—8 98 DISEASES OF THE RESPIRATORY APPARATUS. slight, and are only manifested towards the last stage, or occasionally at the onset ofthe disease. The uneasy sensations are chiefly confined to the larynx, and in it they are commonly in one spot only ; as at the upper and lateral part, for example, of thyroid cartilage. Sometimes there is a simple, pricking pain ; at the other times no complaint is made whatever, 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 organ. But by far the larger number of persons with chronic and sub-acute disease ofthe 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 re-assure him, I introduced once or twice a piece of sponge, tied on whalebone, into the upper part of the oesophagus. His real dis- ease, 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. Though not of an angelic nature, 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 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 were able to swallow, although the epiglottis was far from cover- ing the glotteal aperture ; and again deglutition was almost impossible, although the epiglottis was entire ; but the tongue was enormously tume-, fied, as was the epiglottis, which was erect and stiff at the same time. The 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 may be continual ; and at other times it 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. Immedi- ately before menstruation, as well as after venereal indulgences, the hoarse- ness becomes greater. Dividing the duration of the disease into three periods, it will be found that, during the first the hoarseness 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 suspected by the patient himself. When the larynx is diseased, the volume of the emitted sound is lessened ; and, in general the emission of air is proportioned to the intensity of the voice. Hence SYMPTOMS OF CHRONIC LARYNGITIS. 99 discordant and unequal intonation is avoided. But the voice becomes discordant and squeaking in those who attempt to give it the full develop- ment which it possessed before. This has been observed in several sing- ers 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 is an 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 advan- ces 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 known 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 can- not 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 most partially relieved by puriform mucus and sputa mixed with blood. Sometimes pure blood is expectora- ted ; at other times false membrane is expelled once daily for some months, and a more than usually copious discharge has been followed by convales- cence and restoration to health. Mixed with purulent or sanguinolent mucus, are occasionally seen the remains of carious cartilages of the larynx. The sputa, especially in the morning, on waking, are of a yellowish-white colour and sometimes in small lumps or pellets. In those affected with aphonia or stridulous hoarseness 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 symptom as hoarseness and the change in the volume of the voice. Some persons in whom there was 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 ofthe common diameter ofthe glottis. After the second stage ofthe 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 narrowness 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 oppres- sion is permanent. The patient cannot breathe in his bed, unless supported with pillows, and then the inspiration is habitually sibilant, and the expi- ration loud and prolonged. Paroxysms of true orthopnoea soon supervene, during which there are extreme anxiety and threatened suffocation ; and, generally, in fifteen or twenty days from this time the patient dies suffo- cated. These nocturnal 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 carbonate of potassa or liquor potassx, in a sufficient quantity of fluid, with sugar or syrup. Of this mixture, a single 100 DISEASES OF THE RESPIRATORY APPARATUS. dose at early bed-time will suffice to ward off the paroxysm. W hen there is anemia at the same time, a mild chalybeate in the morning more effectu- ally prevents a return ofthe nocturnal fit. When the ulcerations are situated at the superior orifice of the larynx, deglutition is impeded, giving rise to some uneasiness and cough ; but in cases in which the epiglottis is in part inflamed 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 im- mediately above, the thyroid cartilage. Still, as if to prevent positive conclusions respecting the effects of evident organic lesions, we learn, from Magendie, 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 ofthe cartilages, and by some it has been regarded as a pathognomonic sign of phthisis laryngea. But renewed experiments show that this occurs when the organ is perfectly sound. Expectoration in simple laryngeal phthisis does not furnish very positive signs. It is commonly purely mucus, transparent, and not very tenacious ; but when there is ulceration, the sputa, without 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. In the morning, on first awaking, the patient coughs up sputa of a yellowish-white colour and in little pellet-like masses, but without any particular characters. It is important to be aware of the different symptoms in the different species of chronic laryngitis or laryngeal phthisis. The progress of syphi- litic is not the same as that of simple laryngeal phthisis. The latter gene- rally 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, where an erythematous syphilitic affection is observed in the throat, the affection ofthe larynx will not be of an ulcerous nature ; on the contrary, where the pharynx and velum palati and nasal fossae 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 mem- brane is affected. Frequently, there are diseases of these parts and diges- tive 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 examination, 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 frequently 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 desirable since the larynx is seldom severely affected without this part participating in the disease. Sometimes, by getting the patients to utter loud cries during SYMPTOMS OF CHRONIC LARYNGITIS. 101 the inspection, the epiglottis, carried forward at each expiration, may be- come 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 ; and the trials made to ascertain by the introduction of the finger the state of the epiglottis and upper part of the larynx, must be regarded as hazardous, although the practice has been recommended with some emphasis in cases of s.uspected edematous laryngitis, in order to allow of our obtaining a satisfactory diagnosis. Believing the title of laryngeal phthisis to be sufficiently comprehensive, both to express consumption which may result from simple chronic laryn- gitis, 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 laryn- geal 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 com- plicated a tuberculous state of the lungs, which is, after a time, converted into true phthisis. In forming, therefore, our diagnosis and prognosis of diseases ofthe larynx, an examination ofthe state ofthe lungs can never be omitted. On this point, the advice of Dr. Stokes should be regularly and fully acted on.—(A Treatise on the Diagnosis and Treatment of Dis- eases of the Chest. Part I.) " The first step in the investigation will be to examine accurately into the history ofthe case ; and in particular to determine whether the laryn- geal 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 referable 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 ofthe disease, or that a syphilitic taint did really exist, we have a good proba- bility, 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 laryngeal character—particu- larly if it was at first dry, and afterwards followed by expectoration—if hectic has existed, although the expectoration continued mucous; if there have been hemoptysis, pain in the chest or shoulders; and lastly, if the patient was emaciated previously to the setting in of the laryngeal symp- toms—we may be almost certain that the 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 melan- choly certainty, even though, at the time, we can detect no certain phy- sical 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 expecto- ration, 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 constitute the phenomena of respira- tion, are greatly obscured or masked by the state ofthe larynx, when this part is the seat ofthe disease—a difficulty also mentioned by MM. Trous- seau and Belloc. Fortunately, percussion serves us here instead of aus- 102 DISEASES OF THE RESPIRATORY APPARATUS. cultation, and enables us to determine which lung, and of the diseased one which part is affected. " Under any circumstances," says Dr. Stokes, " the localised dulness points out that there is something more than laryn- geal disease ; and we know from experience that that something more is, in the great majority of cases, tuberclization of the lung." This present, the disease of the larynx runs its course with greater rapidity. Between laryngitis and tracheitis, either simpleas such or associated 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 edematous laryngitis), of which this is an accompaniment and a symptom, has been already described with requisite 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 connexions, and may be either inflammatory 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 considerably, and the system is weakened by dyspnoea, cough, prolonged abstinence, or maras- mus, 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 but 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 atmospherical 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 pro- cesses ; a prolonged mercurial course ; typhoid fevers, and debilitating causes in general; exanthemata ; foreign bodies in the larynx, occasion- ally give rise to it. Of the internal causes, unmeasured and protracted exercise ofthe voice is one ofthe 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. But even here, obvious as is the exciting cause, we find often 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. 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 forming an opinion, clergymen are most liable to it. In their case, then, our inves- tigation 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 serious and religious reflections ; 2, the bodily constitution and collegiate 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 responsibilities of the ministry. It will be found, I believe, on a review of the facts under CAUSES OF CHRONIC LARYNGITIS. 103 these 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 deficient exercise ; con- finement in illy-ventilated halls and dormitories; study beyond measure and at late hours in the night; anxiety of mind, both as respects his pre- paration for the solemn part which he is destined to perform, and his worldly success ; aud 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 inconsiderately zealous of his congregation, he is subjected, so soon as he accepts a call to a church. Preaching often on Sunday, and not seldom 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 laryn- geal disease in a person already feeble and unable to exercise any organ much without inducing phlogosis and its consequences. 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, to attend and officiate bareheaded at funerals, in the midst sometimes 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. Belonging to predisposition are general debility from deficient ex- ercise, depraved digestion and nutrition, excess in venereal indulgences, including masturbation and the depressing passions. The local predis- position 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 habitu- ally breathing such. Tobacco is a predisposing cause, both of general and local debility ; and a disturber of the functions of the lungs, stomach, larynx, and pharynx, by its 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 membrane, 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 ofthe organ. The use of tobacco may bring on all these derangements of func- tion. 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 complication 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 respectability have been ruined, and their lives abbre- 104 DISEASES OF THE RESPIRATORY APPARATUS. viated by such practices. Well have these privileged exempts been called the Devil's decoys—seducers ofthe thoughtless crowd to their un- doing. The use of ardent spirits is, particularly in conjunction with exposure 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 recorded 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 ; arid children, whose constitution is very ana- logous to that of women, participate in this immunity, attributable, also, and more especially to the relative infrequency of phthisis at this tender Complications.—Mention has been made already of irritation and phlo- gosis of the fauces and pharynx being associated with similar stages 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 sympathy, to the glottis and upper part ofthe larynx, and give rise to alteration in the voice, cough, expec- toration of purulent mucus, &c. A restoration ofthe healthy state ofthe stomach, if accomplished in an early period of the disease, will bring about a removal of the laryngeal symptoms. In small-pox, we have fre- quent instances of this extension of inflammation from the fauces and pharynx to the air-passages, and the consequent changes in the voice and respiration, 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 cele- brated singer, Mme. Mainville 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 XCI. DR. BELL. Treatment or Chronic Laryngitis—Rest of the vocal apparatus—antiphlogistic*— counter-irritants,—narcotics, mercurials, iodine, sarsaparilla, balsam of copatva blue mass and syrup of sarsaparilla, sulphurous waters—Topical remedies; inhalation of simple and stimulating vapours; caustic to the parts—The author's own experience- Attention to anginose complication—Syphilitic chronic laryngitis; mercurials sarsa- parilla; iodine—Tracheotomy, when proper—Change of climate—attention'to the digestive organs—Prophylaxis—Clergymen,—rules for their guidance—Uniform tem- perature of air—Jeffray's Respirator. The treatment of chronic laryngitis will vary with its stage and the pre- dominance of certain symptoms. In the first stage of the disease marked TREATMENT OF CHRONIC LARYNGITIS. 105 by slight hoarseness, a feeling of heat and dryness in the throat, and im- perfect expectoration or hawking 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 excitement, and if the hoarseness is increased, and accompanied by aphonia and the characteristic cough before described, more energetic and system- atized 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, speaking in a whisper is not attended with any evil, in the opinion of Drs. Trousseau and Belloc ; but even this in con- versation with a stranger, when an effort at a certain pitch is made, is sometimes more fatiguing to the patient than his speaking aloud. The indulgence of whispering is the more allowable, when we reflect on the extreme difficulty of keeping the patient silent for several months in suc- cession. First among the class of antiphlogistic remedies, applicable to the more decidedly inflammatory or incipient stage of the disease, is blood- letting. 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 method of drawing blood. If there is reason to believe that the disease has arisen from suppression ofthe menstrual or hemorrhoidal discharge, or is greatly aggravated by such suppression, leeches ought to be applied, in the for- mer case to the thighs or the vulva, and in the latter to the anus. Emol- lients internally may soothe irritation without exerting any material influ- ence over the disease ; but their external use, in the form 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- stimulating effects, in such doses, three or four times a-day, as the stomach will tolerate. In cases of sustained inflammation, the vinous tincture of colchicum may be combined with the 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. Scions 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 ammoniacal ointments rubbed, as in the former case, over the front and sides ofthe larynx and trachea, until an eruption is brought out by the former, and a rubefaction or slight vesication by the latter. The antimonial frictions should be continued even after the pus- 106 DISEASES OF THE RESPIRATORY APPARATUS. tules 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 obtained 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 frictions just specified have not been employed, a small piece of caustic potash, to be applied once a-week on either side ofthe larynx and trachea. In this way five or six cauterised spots are made to suppurate 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, he- morrhoids, &c. JVarcotics 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 adju- vant 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 reme- dies 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 ascer- tained by repeated prescription of this remedy in asthma complicated with laryngeal affection. A mercurial course, that is, the action of mercury on the mucous secre- tors and capillary system—but always short of ptyalism—even in cases not syphilitic, I have found to be of manifest and permanent benefit, particu- larly in persons of a sanguine temperament 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 me- dicine should be carefully abstained from. In these cases, a decoction of senega with nitre ; iodine—either a solution of the iodide of potassium three to five grains twice a-day, or Lugol's solution—iodine in water, in which the iodide has been previously dissolved, are applicable. In various chronic affections of the trachea and bronchial mucous membrane, as well 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 bronchiae also were affected. The symptoms—consisting of expecto- ration, more than a quart in twenty-four hours, and accompanied by hectic, night sweats and a rapid pulse—disappeared under a 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 pre- ferable 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! TREATMENT OF CHRONIC LARYNGITIS. 107 In the morning, if the bowels are not free, and the digestive apparatus is disordered, some mild saline, or rhubarb and magnesia, will be used. This latter difficulty obviated, and a regular and defined course deter- mined on, the blue mass and hyosciamus are to be administered every night, and the syrup of sarsaparilla in the morning. The doses 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 influenced by my own ex- perience, which in this particular entitles me to speak with some confi- dence. 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 insufficient for the cure of chronic laryngitis, as they are of ulcerations and puriform discharges of the throat, nose, eyes, vagina, rectum, &c. These means are laid down by MM. Trousseau and Belloc, as either emol- lient, 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 simple, or charged with emollient, balsamic, or aromatic substances. Sometimes the vapours were dry, as the smoke of tar, raisins, hyosciamus, 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. Scuda- more, 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 physicians lately, as it were a new thing; and it has been made an affair of newspaper prescription and popularity. If, which I doubt, any physi- cian 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, sulphurous acid, &c, with various, but not recorded results. All inhalation, of whatever nature, is, however, liable to the objection that the substance inhaled is not confined to the larynx, but comes in con- tact with the mucous membrane of the lungs, which it may irritate. It is im- possible, moreover, to limit its action, and hence the necessity of restricting ourselves to the employment of emollient, aromatic, balsamic, and narcotic 108 DISEASES OF THE RESPIRATORY APPARATUS. 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 glot- tis 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 bronchiae. Of these, some are irritating; others simply astringent. The former are, muriatic acid, solutions 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 harmless- ness, and its known efficacy in so many external ulcerations and other lesions of tissue. The strength of the solution will vary from a half-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 conveniently reaches the part affected. When it is desired to cauterise the pharynx, the base of the tongue, and the top ofthe larynx at the same time, 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 ofthe fauces, which gives rise to an effort of deglutition and a consequent elevation of the larynx, and at this moment the sponge is brought some- what forward, and from the entrance of the oesophagus 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 disa- greeable : 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 extremity with a very small opening, is attached. The syringe is filled three-fourths with air, and one-fourth with a solution of nitrate of silver. The canula is then introduced into the pos- terior 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 ofthe larynx and oesophagus. The patient is seized imme- diately 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 sewed 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 TREATMENT OF CHRONIC LARYNGITIS. 109 the solution as just now recommended. The patient is to be made, directly afterwards, to gargle his throat with water acidulated with muriatic acid, or salt water, which decomposes any ofthe 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 ofthe 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 ofthe 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 treatment of chronic laryngitis, that one must have practised these cauterizations, or seen them performed, to have an idea of their harmlessness and of the little pain which results. We are very much alarmed at a cautery, for it is exceed- ingly 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 glottidis 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, a good trans- lation of which has been made by Dr. Warder, of Cincinnati, 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. As discussions have been held in the medical and newspaper press on the subject of topical applications to the larynx in the treatment of chronic diseases of this organ, involving a question of priority of practice, which has been claimed by or for Dr. Horace Green of New York, I shall mention a few facts relating to my own reading and experience in the matter. Dr. Green's volume—A Treatise on Diseases of the Air-Passages, &c, appeared in 1846.—My first knowledge of the work of MM. Trousseau and Belloc was derived from an analytical review of it mine Edinburgh Medical and Sur- gical Journal for October, 1837. Taking this review as a basis, I wrote an article headed " Laryngeal Phthisis—Consumption ofthe Throat— Clergyman's Sore Throat," which was published in ray Eclectic Journal of Medicine for December, 1837. On that occasion the means of applying caustic solutions to the larynx were described according to the directions of Trousseau and Belloc, as given in the Edinburgh Journal and derived primarily from their work. It is very evident, therefore, that apart from the knowledge ofthe practice obtainable from the work itself of these gen- tlemen which was published in Paris in 1837, tolerably full publicity must have been secured to this knowledge in Great Britain through the Edin- burgh Journal and in the United States through the Eclectic Journal, before the expiration of the year 1837. The work itself was translated by Dr. War- der, of Cincinnati, and published in " Dunglison's American Library," in the year 1839. So much for the first announcement and subsequent diffu- sion of the process of the French writers. I have next to add a few words on the priority of the practice in this country according to the process re- commended. It would seem, as far as I can learn, that mine was the first published statement ofthe process recommended by Trousseau and Belloc having been carried into effect in the treatment of chronic laryngitis. It 110 DISEASES OF THE RESPIRATORY APPARATUS. was made not formally as a matter of boast but explanatory, in these words, which occur in Lecture XII. ofthe additions which I made to Dr. Stokes's Lectures on the practice of Physic, p. 668, and published in 1840. " I have used, as more convenient a piece of sponge sewed carefully to the end of a small-sized gum-elastic catheter with the rod in, and the end of which has the required curve given to it, so as to allow of a ready appli- cation to the opening of the larynx and borders ofthe epiglottis." My first trials of the practice were in 1839, and from that time to the present I have repeated it at intervals and always with benefit. As regards the extent to which the sponge moistened with caustic can be carried down into the larynx, this must be a matter of opinion. When the instrument, as we may call it, is used at all it is carried downwards and pressed on the glottis : some, with Dr. Green, may insist that it finds its way into the larynx, others, and the majority, believe that it stops at the rimae glottidis, and that the fluid alone which is squeezed out of the sponge passes this part. The difference of opinion by the former does not constitute any valid claim for discovery. Of the probable coexistence of angina pharyngea with chronic laryngitis I have already spoken. Again, I would remind you ofthe importance of being aware of this conjunction, and, of course, ofthe necessity of exam- ining 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 mani- fest itself either by a relaxed tissue, or by aphthous spots or granular ulce- rations. The portion ofthe membrane which in these cases more commonly requires to be treated in this way is that covering the tonsils and the arch of the palate. For this purpose, we should touch, two or three times a-wTeek, the part just mentioned with a pencil of nitrate of silver, or a so- lution ofthe 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 tirries its weight of sugar. The apothecary should be directed to pre- pare these powders on a porphyry slab, otherwise small crystalline asperi- ties remain, which act as irritants, and bring on repeated fits of coughing and the expulsion ofthe 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 ofthe 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 contact with the affected tissue. These inspirations will vary in number 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. TREATMENT OF CHRONIC LARYNGITIS. Ill When chronic laryngitis has a syphilitic origin, it will be removed by mercury, and, at times, under circumstances of the most discouraging nature, as where the patient had been reduced to the last degree of ema- ciation 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 aggravated all the symptoms. In these cir- cumstances, the ptisan of Feltz has brought about a rapid cicatrization of the ulcers.—(Cruveilhier, Diction, 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 ofthe mercurial salt in wrater, 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 sarsa- parilla. In the advanced stages of syphilis, in which the mucous membrane of the mouth and throat was the seat of extensive ulcerations, I have derived excellent results from the iodine preparations already mentioned, con- joined 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 pot relieved, ends in dissolution. I refer now to the immi- nent 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 sug- gestions 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 violence of attack, the absence of corresponding fever, and of tumefaction 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 tra- cheotomy 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-mixture, ammonia, valerian, ether, and opium— exhibited, aud repeated according to circumstances. Under this treat- ment, symptoms will rapidly subside, which, from their character and continuance, would seem to demand the knife ; and I would advise that, in all cases, previous to the performance of tracheotomy in chronic laryn- gitis, the question be carefully investigated, as to whether the urgent symptoms 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 appropriate treatment. We are not much attached to the doctrine of diseases being necessarily sepa- rate, but experience tells us that nothing is more common than to see spasm following organic disease, or organic disease occurring after a purely nervous lesion. " In cases showing this liability to spasm, the belladonna or other ano- dyne plaster may be usefully employed." Tracheotomy ought not to be performed except when the patient is 112 DISEASES OF THE RESPIRATORY APPARATUS. threatened with suffocation, and all the promptly available medicinal means have been had recourse to. These conditions having been com- plied with, and the operation performed, the physician is freed from the fear of seeing his patient die of asphyxia, and may proceed to treat the affection of the larynx in a suitable manner: when the organ is capable of performing its functions, the canula can be withdrawn, and the wound allowed to heal. Even should the disease be of such a nature that the passage of air through the natural canal is afterwards impossible, the canula may remain for an indefinite period, and the life of the patient be lengthened. A case is given by MM. Trousseau and Belloc, of an indi- vidual wearing such an instrument, made of silver, for ten years. They state their having performed tracheotomy seventy-eight times ; seventy- three for croup, and five for laryngeal phthisis, with, the loss in one in- stance only of life during the operation. They give a number of successful results from tracheotomy. A more permanent amelioration than from merely medicinal means in chronic laryngitis, is obtained by a change of climate. With this view, a residence for a year or more in warmer latitudes, or sometimes during the winter months only, is recommended to patients with chronic laryn- gitis as well as to those with chronic bronchitis. Where circumstances prevent their absenting themselves from home, an artificial climate may be procured 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 inflammation. 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 membrane 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 bron- chial affection, the liability ' to catch cold,' the ' spring cough,' the trou- blesome morning phlegm, &c, 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 treat- ment 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 diseases over which the stomach, in its different conditions, displays so great and, at times, extraordinary an influence, as to induce those who are not pa- tient 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. Prophylaxis. — The prophylaxis of chronic laryngitis should consist in an early attention, on the part of the professional student to all the agencies counteracting those which bring on the disease. These pre- PROPHYLAXIS OF CHRONIC LARYNGITTS. 113 ventive measures should be much exercise in the open air, a regular train- ing of the vocal apparatus by both methodical speech and even song, so as to accustom the voice to every variety of pitch and intonation ; and to husband its strength, if it be naturally weak, by acquiring the habit of distinct and expressive articulation and enunciation. By uniting the two kinds of gymnastic exercise—that of the muscles-of the body and limbs generally, and that ofthe muscles ofthe voice—the student will be both fitted to discharge his subsequent 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 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 retain distinctness and power within this range. Deviation from healthy digestion, and particularly if associated with uneasiness in any part of the throat, should be early attended 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 cauteriza- tion in the manner already described. Among the hardening measures is the use of the tepid bath, or sponging the surface of the body, and par- ticularly the surface of the chest, daily, with cold salt and water. The throat should be well gargled, 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 exerts a compression on the neck, or invites more blood to the part. Many ofthe 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 diseases ofthe vocal apparatus. x\s any sudden change of temperature of the air which is inhaled is prejudicial to the invalid suffering under chronic laryngitis, he is recom- mended, when about to pass out from a warm room into the external air, to place a silk handkerchief or some kind of network before his mouth and nostrils. There has lately been made in England an apparatus called " Jeffray's Respirator," which is preferable to a handkerchief or any simi- lar contrivance. It consists 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; in doing so, he inhales an air, which, by the time it has reached his mouth, and certainly his larynx, is of a suitably elevated temperature. I am acquainted with the case of a lady, who, whilst suf- fering 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 husband's suggestion. Transition from a cold to a hot air is even still more injurious than the one from hot to cold ; and hence the respirator should be kent on for a while after coming in from the outer air. VOL. n.—9 114 DISEASES OF THE RESPIRATORY APPARATUS. LECTURE XCII. DR. BELL. Bronchitis—Its complications with other diseases—Catarrh, a prelude to more serious djsease—Importance of early attention to it—Outlines of the treatment of catarrh— The dry rneth-d cf Dr. Williams—Bronchitis.—its divisions—Asthenic variety—The kind showing itself in young children, or capillary bronchitis—Duration of acute bron- chitis—Symptoms,—appearance of the sputa—Physical signs — Percussion, indi- rectly useful—Touch, "iving a sense of vibration—Auscultation—Modifications of sound, produced by inflamed and obstructed bronchiae—Morbid Anatomy—Causes. 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, not Naphtha Hast- ings, has since contributed largely to fix attention on the disease, and to introduce it formally under the title of bronchitis, by which some writers used to designate croup. By Sydenham and Cullen it has been de- scribed under the name of Peripneumonia JVotha. 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 irri- tating gases or poisons ; or as an occasional and always alarming compli- cation in remittent and typhous fevers ; in the exanthemata generally, and more especially in measles and small-pox ; also in gout and rheumatism, and in hooping-cough, asthma, pneumonia, phthisis pulmonalis, pleurisy, and carditis. Being in sympathetic relation with all the membranes 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. Bronchitis frequently occurs in an epide- mic form, under the popular title, 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 on the breast, is a mild form of bronchitis. All ages are subject to this disease, which may even be congenital. 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 derangement is frequent; more so, probably, than the union of pneumonia or of pleurisy with dis- order ofthe liver, designated as bilious pleurisy or pneumonia. 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 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 bronchiae, there is a tickling cough, with an expectoration of mixed serum and mucus. At this stage the isorder sometimes ceases, and the individual is said to have soon got TREATMENT OF CATARRH. 115 over his cold. But, under other circumstances, there is not simply an irritation ofthe mucous membrane and glands of the bronchise, but a posi- tive inflammation of these parts, and a train of associated symptoms which indicate great distress in the respiratory apparatus, as they do real danger to the life ofthe patient. Sometimes the affection ofthe bronchia? shows itself without any prior irritation 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 diseases. A few remarks on catarrh, or a common cold in the breast, as it is familiarly called, will properly precede a notice of bronchitis in its more aggravated 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 ofthe 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 diseases of greater complexity and mortality than these latter. The common complications of a cold, viz., toothache, earache, headache, weak and watery eyes, sore throat, rheu- matic pains, indigestion, and renal disorders, are quite numerous and dis- agreeable enough to entitle it to a very respectful notice, and much more considerate treatment than it usually receives. If to these annoyances we add the danger from bronchitis and pneumonia, which often follow 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, whicff, however mild in its incep- tion, is directly or indirectly productive 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 submitting at once and with a good grace to the adoption of suitable measures for his relief. These will be, quiet in an air of equable and rather warm tempe- rature, abstinence from animal food and all 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, according either to the prior experience ofthe 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 ple- thoric, he should take salts. After evacuation procured by this means, if the cough harass and be aggravated by a thin serous secretion from the trachea and bronchiae, an opium pill of one to two grains, or twenty to forty drops of laudanum, or Dover's powder in five-grain doses, repeated two or three times at intervals of four hours, or laudanum with antimonial wine will come in appropriately enough, and not infrequently relieve all 116 DISEASES OF THE RESPIRATORY APPARATUS. 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 harts- horn 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 continue after the above remedies have been used, recourse is generally had to various for- mulas of cough mixtures, the active basis of which is either ipecacuanha or antimony, and less frequently squills, wTith opium in some form or ano- ther. My own experience 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 gastric complication, and opium if the skin be cool or the temperature of the surface unequal, and the cough be accompanied with thin expectoration, come on in fits, and be readily excited through the nervous system alone. I can add, with great confidence also, my own testimony, in confirmation ofthe 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, carbonate of potassa and laudanum in suitable proportions, mixed with simple syrup and water, make a cough mixture, to which, especially in the cases of catarrh of children, 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 substituted for tbe 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 linctus or lozenges, and I would add, than the syrups of squills commonly in use, and which, however 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 to keep up their influence on the secretion from the bronchiae, as well as to their immediate impression on the glottis and the throat, cough medicines should be taken frequently ; and during the interval 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 a 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 secre- tions both 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 person! Having observed, on being attacked with one of the colds, to which in SYMPTOMS OF BRONCHITIS. 117 early life he had been so subject, that taking a quantity of tea or any other liquid, although very comfortable at the time, was invariablyr fol- lowed 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 agree- able surprise, not only did I escape these occasional aggravations of the complaint, but the stuffing and discharge began to show evident signs of abatement, and the handkerchief was in less continual requisition. I per- severed for twenty-four hours more, and my cold was gone ; there being only now and then a little gelatinous opaque mucus collected in the nos- trils and throat, without any stuffing or irritation, just as it takes place at the end of a cold. What was of still more consequence, no cough fol- lowed ; 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 (some fifteen 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 ofthe mass of circulating fluids, and a diminution ofthe 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. 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 lying warm in bed, or by commencing with a purga- tive, or by any other dry means of increasing the natural secretions. 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 inflammation 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 lungs is in- flamed. Something, also, will depend on the intensity of the phlogosis, even on an equal surface. Like all the phlegmasia*, bronchitis exhibits an acute and a chronic form. The first again is appropriately divided into the sthenic and the asthenic varieties. Dr. Stokes treats of it under the head of acute primary and acute secondary bronchitis, a division which I shall adopt on the present occasion. Symptoms.—In acute sthenic bronchitis, inflammatory symptoms are evident from the commencement. After the preliminary stage of simple coryza and catarrh, with headache and want of appetite, already men- tioned, or, sometimes, without any notification of this kind, the patient suffers from pain and feeling of tightness across the sternum, dry hard cough without expectoration, or with the discharge in this way of gluti- nous 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 somewhat laboured breathing and dyspnoea, and sometimes a dull pain at the sternum on coughing ; tongue white with red borders ; pulse 118 DISEASES OF THE RESPIRATORY APPARATUS. quick and full, and at times hard ; pain in the forehead, back and limbs; constipation, and scanty, high-coloured urine. As the disease advances, the rough 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. 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 bronchiae, as felt under the sternum, and in what is called sore- ness or 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 gene- rally sleepless and disturbed. The common posture is on the back ; but it is often changed. If there be no relief by expectoration or perspira- tion, or by prompt remedial measures, bronchitis shows a change of cha- racter. Feelings of great depression 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, in place of being often flushed, becomes anxious and pallid, or partially livid, according to the quantity of blood in the system ; and pulmonary conges- tion becomes evident by a slightly diminished resonance on percussion in the postero-inferior regions of the chest. Ttie secretions are scanty and vitiated ; the tongue is loaded with a brown fur; the thirst is intense. Cerebral and abdominal congestions may also occur, and dropsical swell- ings are no infrequent results. 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 ofthe worst form of bron- chitis is, the rapidity with which the collapse and the symptoms of ex- treme prostration and debility succeed to high fever, and well-marked local excitement. The whole course of these fatal cases is sometimes wonderfully rapid, death ensuing within two days from the commence- ment of the attack. They are commonly confounded with pneumonic in- flammation, and are scarcely to be distinguished from it during life but by the physical signs. The severest form of bronchitis is, however, more formidable and rapid in its course than pneumonia itself. The asthenic form of bronchitis bears more analogy to broncho-pneumonia just described than to simple acute or sthenic bronchitis. One of its earliest and characteristic symptoms is oppression of breathing, and a peculiar wheezing with spasmodic cough. 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 severe as to prevent the patient from lying down, and accom- panied by extinction ofthe voice. The expectoration, at first scanty, be- comes 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 ex- cesses. 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. CAPILLARY BRONCHITIS. 119 When bronchitis supervenes on pneumonia (vesicular bronchitis), the smaller divisions of the bronchiae are the parts inflamed. Bronchial catarrh will sometimes give rise to all the symptoms of suffocating catarrh, which are regarded as the result of an infiltration of serosity in the pulmo- nary tissue. In simple lobular pneumonia, the two elements, the bron- chial and the parenchymatous, are equal and manifested nearly at the same time. In some cases the cough has a decidedly croupy character, although the breathing, which is hurried, is not at all stridulous during the intervals. This state is often associated with slow and laboured den- tition. Sometimes the bronchial secretions approach nearly to the membranous form. The frequency of its occurrence, and the mortality produced by it, require a somewhat detailed notice of the bronchitis of children. It has been carefully studied of late years by different French physicians; but more especially by M. Fauvel, of Paris, and MM. Mahat, Bonamy, Marce, and Malherbe, physicians to the Hotel Dieu Hospital at Nantes, the latter of whom have given an excellent description of its epidemic visita- tions in the years 1840 and 1841. M. Fauvel has designated the disease by the title of capillary bronchitis, which we may regard as equivalent to general inflammation of the minute bronchial tubes and their vesical ter- minations. It is well described by M. Valleix (Guide de Medecin Prac- ticien, fyc, Tome i.): but I shall follow, just now, the description by M. Grisolle, derived from the sources indicated above. Capillary bronchitis follows, almost always, a common bronchitis; and it is quite unusual for the inflammation to attack at once the smaller bron- chiae, and to be announced by violent symptoms. When once formed, capillary bronchitis manifests itself by great oppression ; the breathing, accompanied often by a hissing, is performed with great difficulty and by the convulsive and simultaneous contraction of all the respiratory muscles. The number of respirations in a minute is extraordinarily great; being, in cases, as many as sixty to eighty even in this time. The cough is trou- blesome by its frequency and paroxysmal nature, and painful by the tearing feeling it induces behind the sternum. After repeated efforts, the patient ejects some glairy and frothy mucus, mixed with white and vis- cous sputa, which are sometimes tinged with blood. In other cases there is expectoration of yellowish mucus without bubbles, which is not pro- ductive of any relief. Percussion gives a clear sound ; and, at times, even manifests an unusual sonorousness, arising out of the emphysema caused by the bronchitis. Auscultation reveals sibilant and mucous rhonchi, but the sibilant rattle is sharper and finer than usual, and is blended with the mucous; and the respiratory murmur often cannot be heard. With so much disturbance of the respiratory functions, the speech is brief and abrupt; the pulse, always frequent in the disease, acquires an astonishing frequency at times, ranging from 120 to 160 beats in a minute. The skin is hot and dry, or bathed in sweat. The whole appearance of the patient indicates suffering and anxiety. He is seated in bed, resting on his elbows, and with head inclined forward ; the face is pale, features altered, and the skin of a mottled appearance ; the lips and cheeks, for the most part, of a violet hue. At the end of some days of violent struggle, such as that now depicted, the system manifests exhaustion ; and the breathing, in consequence, is 120 DISEASES OF THE RESPIRATORY APPARATUS. less frequent, but not less laborious and painful ; the expectoration is light; the sub-crepitant rhonchus is less evident ; and mucus accumu- lates in the air-passages to such a degree as to cause a gurgling noise or the rattles. The blue tint of the face becomes deeper; and shows itself in the hands and feet, and sometimes in spots on the body generally ; the pulse fails to impart any resistance under pressure, while its frequency is augmented and its regularity lost. The patient becomes more and more exhausted, falls into somnolency, and gradually sinks into death ; preserv- ing, however, to the last, all his mental faculties. When, on the other hand, capillary bronchitis tends towards recovery, there are diminished frequency of respiration and beats of the pulse ; the rhonchi are less loud, more diffused, and more numerous, indicating a more permeable state of the lung; the skin loses gradually its blue colour; and convalescence has at length begun. The disease may, even after the subsidence of the more alarming symptoms, exhibit the appear- ance of simple bronchitis. • Capillary bronchitis seldom terminates in less than five days, or goes beyond ten, or at the most, fifteen days. Conva- lescence is tedious, and the disease is liable to relapse. 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. It then terminates in resolution or in chronic bronchitis. The appearance of the sputum, if not the chief characteristic of acute bronchitis, as some regard it, is unquestionably of such importance as to require our early and continued attention to its successive changes. Bronchial like pulmonary mucus, in a healthy state, separates into clear and gelatinous, or else into grey or yellowish flocculi, which remain sus- pended in water for some time ; but ultimately sink to the bottom. In the early stage of bronchitis the secretion from the bronchiae 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 from one vessel to another, it flows in one mass of extreme tenacity,—drawing out sometimes like melted glass ; and the degree of viscosity is a tole- rably accurate measure ofthe degree ofthe 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. These become, as the diseaseadvances,more opaque, more abundant, and tenacious ; and at the period when the inflammatory fever ceases, and is either succeeded by an apyrexial state, or by a hectic, we observe a remarkable change in their character. They are thick, and have considerable consistence ; or they 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 ofthe appearancesand other characters of expectorated matterin bronchitis, 1 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 raucous 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 secre- tions ; 5, serous secretions. In very young children the expectoration is either entirely wanting, or is very slight. MORBID ANATOMY OF BRONCHITIS. 121 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 furnishes no direct sign in the present case ; the sound on striking the chest being almost always of a natural clearness. A temporary loss of this clearness may ensue from an excessive secretion of fluid in the bronchial tubes, or more permanent when tubercles are present at the same time. 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 tho- rax. This sensation can be detected both during inspiration and expira- tion, 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 in the upper portions ofthe lung: it is not met with in simple pleurisy or pneumonia. In pleu- risy, however, a sensation of rubbing 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 direc- tions through an adhesive fluid. By auscultation we discover in the early stage of acute bronchitis, that the natural sound of respiration is replaced at times by the puerile, but the most marked change consists in the formation of the sibilant rhonchus or wheezing and whistling sounds. They occasionally present a graver tone like the prolonged note of a violencello, or the cooing of a dove ; and they indicate that some of the larger bronchiae are the seat of phlogosis. As the disease advances and the inflammation of the bronchial membrane is moderated by the secretion of fluid which is at first glairy and mixed with bubbles of air, we hear a mucous or sub-crepitant rhonchus, chiefly per- ceptible at the root of the bronchiae over the base of one or other lung. In capillary bronchitis the sibilant rhonchus is acute and small, and is mixed up with the sub-crepitant rhonchus. The respiratory sounds, weak or for a time suppressed in the tissue corresponding to the affected tubes, are exaggerated in the adjoining ones. The diagnosis in acute bronchitis is easy enough, if attention be paid to the sonorousness ofthe chest on percussion, and the rhonchi, at first dry, then humid, together with the character ofthe cough and expectoration. The prognosis of this disease depends on the part and extent ofthe bronchial inflammation. The result in capillary bronchitis is always doubt- ful, as the disease carries off about a sixth part of the adults and seven- eighths of the children who become its subjects. The same remark applies to pseudo-membranous bronchitis. Simple inflammation of the larger bronchiae, on the other hand, is comparatively a mild disease, which termi- nates favourably, except in some cases among old persons and children. Morbid Anatomy.—More frequently the morbid changes in the bronchise have been found in the bodies of those who have died of other diseases, during the attack of which they had suffered at the same time from bron- chitis. 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 ofthe trachea and the first divisions of the bronchiae ; but in the terminations of the latter, which are rather serous than mucous, this appearance is less seldom met with. If the inflammation has been more intense, the redness extends to a greater number of tubes, and more 122 DISEASES OF THE RESPIRATORY APPARATUS. so in the smaller ramifications. Often, says M. Andral, the redness is exactly limited to the bronchiae 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 bronchiae towards the small ones; at other times the reverse is met with. Often the redness presents itself in patches, or zones, constituting, as it were, so many cir- cumscribed inflammations, between which the mucous membrane is white and healthy—a state of parts similar to that which is so frequently found in the intestines. On opening the thorax the lungs do not in general col- lapse, the escape of air being prevented by the obstructions ofthe bronchiae. These in most instances contain a quantity of frothy liquid, of the quality of the matter expectorated before death. Not infrequently it is mixed with bloody serum ; but as this is not perceived in the matter expectorated it is probably an exudation from the distended bloodvessels at the moment after death. Purulent matter mixed with mucus is, also, sometimes ob- served, and mostly in very acute cases which have proved fatal within four or five days. The mucous membrane of the bronchial tubes is soft and granular. Frequently the changes do not extend beyond the larger ramifications, but at times they are only seen on the minute terminations, and then the bron- chitis is said to be capillary. In these cases, on incising the smaller bronchiae they are found filled with a thick muco-purulent matter, divested of air-bubbles, which fills up the second and third divisions as far as the capillary ramifications. Obstruction of the smaller bronchiae, when it is general, causes necessarily a dilatation of the vesicles (emphysema vesi- cularis), a lesion which explains why it is, that the lungs, in place of collap- sing when the thorax is opened, tend on the contrary to expand beyond their customary limits. Almost always there are spots of interlobular pneu- monia, a complication more generally met with in children than in adults. The dilated vesicles contain analogous matters to those found in the bron- chiae, but they show themselves more in the shape of whitish or yellowish granulations, which we must take care not to confound with tubercular granulations, resembling these latter as they do in figure and size. The bronchial mucous membranes, in common with all the divisions of this tis- sue in the air-passages, are sometimes lined with false membrane in the form of white elastic cylinders. These are most apt to occur in the smaller bronchial tubes. The membranaceous bronchitis often accompanies capil- lary bronchitis, and is most common in children. In adults a few scattered branches of small diameter are alone found clogged with white plastic co- agula down to the still more diminutive twigs, whilst the remainder con- tain merely the usual fluid, catarrhal secretion. The blood in acute bronchitis exhibits decided indications of hyperino- sis. " The buffy coat is scarcely ever absent, the serum is clear,'and the clot firm and consistent. The fibrin and fat are always more or less increased, and the haeraato-globulin diminished." The disproportion be- tween the ratio of fibrin and that ofthe corpuscles, in the increase ofthe former and diminution of the latter, is not so great in this disease as in pneumonia and rheumatism. Causes.—Bronchitis follows sudden exposure to cold and moisture and the more readily if the application be partial, as by a current of air or'cold TREATMENT OF ACUTE BRONCHITIS. 123 and wet feet; and the body have been previously over-heated. The disease is, therefore, one which chiefly makes its appearance in the winter half of the year; and, on occasions, it assumes an epidemic character, without our being able, always, to refer this to atmospherical extremes or very marked pe- culiarities'of weather. Habits of excessive repletion would seem, in some cases, to predispose to acute bronchial inflammation, as they un- doubtedly do to bronchial congestion. Of the liability to bronchitis in the exanthemata, I shall take occasion to speak under the head of secondary acute bronchitis. The predisposition is increased by prior attacks ofthe disease. Men are subject to it in much larger numbers than women. LECTURE XCIII. DR. BELL. Treatment or Acute Bronchitis—Venesection not to be pushed far—Purgatives— Emetics, of doubtful value in acute bronchitis—Tartar emetic, as a counter-stimu- lant—Rules for its use—Immediate effects various—Case—The warm bath—pedilu- vium—Blisters and other counter-irritants to the chest—Calomel in bronchitis com- plicated with abdominal disease; to which are added opium and ipecacuanha—Second stage of bronchitis, with symptoms of debility—Stimulating expectorants useful ; car- bonate of ammonia, wine whey, senega, acetate of ammonia—Calomel and a few cups, with stimulants, for congestion of a part of the lunsj—Diaphoresis without diaphore- tics— 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—Outlines of treatment—Complications of acute bron- chitis— Bronchitis with remittent fever, in the typhoid stage—Cooling remedies useful—Depletion and stimulation sometimes necessary at one time—Inhalation of watery vapour—Chancre of posture—Quinia and laudanum, for excessive bronchial secretion—Dr. Graves's practice—Sugar of lead. The advantage of the physical signs of bronchitis, is to inform us with certainty of the first coining on of an inflammatory affection of this cha- racter. When, with the febrile state before described, whether the func- tional disorder be permanent or not, we find extensive rhonchi in every part ofthe 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 such depletory measures as are admissible in the individual case. These will consist of bloodletting, by venesection, or by cupping or leech- ing, 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 deranged in the man- ner 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 disease 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 pro- ducing of syncope. His aim must be to bring down the inflammation to 124 DISEASES OF THE RESPIRATORY APPARATUS. the secreting point, for expectoration, but not to sink the excitement and depress the strength of the body below this point. There is good reason to believe, also, that bronchitis will run its course for a definite period, and therefore, as that for active depletion is likely to be of short#duration, we should be careful to employ with reserve remedies calculated to reduce the patient's strength. But, on the other hand, we ought not to be deterred from venesection or even its repetition by the symptoms of weak- ness—the sinking as it is called of the patient, which are the effects of incipient asphyxia, owing to the retarded and in part limited circulation of blood. 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 preferable to leeching. In severe cases, the patient should be cupped over the part which auscul- tation 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 sca- pulae. 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 practitioner. 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, or increase of dyspnoea not caused by over-secretion—a point this ascertained by auscultation. Next to the remedy just mentioned, a free evacuation of the bowels will often give the greatest relief. There is no disease of the thoracic con- tents in which free and early purging is so beneficial as in bronchitis. I have been most sensible of this fact in the epidemic form of the disease, or in influenza, in which, be it said, also, there is frequently a complica- tion 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, particularly in chil- dren, 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 contra-stimulant or sedative doses is entitled to a pre- ference. This remedy will either follow bloodletting as an adjuvant, or take its place in cases in which, although the dyspnoea and fever be con- siderable, we are afraid from 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 admin- istered every hour until a decided abatement of the symptoms follows. M. Girard of Marseilles recommends strongly, after considerable experi- ence of its efficacy, a succession of emetics of the antimonial salt. This simple prescription is preferable greatly to common expectorant mixtures, which often only irritate and tease the stomach, and just serve to increase the secretion, but without either adequately abating or modifying the in- flamed 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 ex- TREATMENT OF BRONCHITIS. 125 penditure 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 own experience, which has been considerable with this remedy in thoracic affections, ever since my visit to Italy more than thirty years ago, and acquaintance with the then new Italian medical doctrine of counter-stimulus. Even now, after so much has been written on the subject, I may refer you to my paper, one of the first in order of time, on Counter-stimulus, in Dr. Chapman's Medical and Physical Jour- nal, vol. iii. 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 peiiod 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 has occurred in a debilitated constitu- tion, where the pulse 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- ccecal 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 comparatively little influence on the pulmonary disease, and too often increase the gas- tric symptoms. Laennec recommends an aromatic and opiate to be combined with the antimony, as in the following solution :— B. Tart, antim., gr. vj. Aq. cinnam., ^vj. Tinct. opii acet,, gtt. xij. M. Of this solution half an ounce, a tablespoonful, 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 combination with cream of tartar, either in the form of powder or solution 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 medicine in question with camphor-mixture, and a little laudanum. The immediate effects ofthe antimonial practice are various. In a few cases, particularly where the stomach had been foul, free vomiting is pro- duced, 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 by the system of 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 then chiefly when the patient moves. In evidence of the tolerance by the system of full and repeated doses of tartar emetic, I would refer to the case of a person labouring under bronchitis complicated with pneumonia, which was attended by the late 126 DISEASES OF THE RESPIRATORY APPARATUS. Dr. Otto of this city and myself about ten years ago. The patient be- came 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 adapted to the stage, which was the second one of the disease, we prescribed tartar emetic dissolved in some simple drink, slightly sweet- ened. The dose ofthe 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 reducing the dose of tartar emetic, and with the best effects ; the delirium was removed, the expectoration became loose and free, the matter being thick and opaque, and the pulse was abated of its great fre- quency. 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 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. Stimula- ting remedies, which, even in the second stage of this disease, have only increased the indirect debility caused by continued and unchecked excite- ment, will now kindly restore the feeble powers of life and re-animate 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 con- fined to the lower limbs, or the lower portion of the body at most. 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 respira- tory distress, with the diffused rhonchus still continuing, counter-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 preferred by some prac- titioners, 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 piece of coarse flannel ; or the skin may be still farther excited by apply- ing a warm hand wetted with camphorated spirits, or by the short appli- cation of a mustard poultice. The tartar emetic should then be immedi- ately 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 inflammation in as short a time as that required for the rising of a blister, with far less irritation to the sys- tem, 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 pro- duced by it, in the capillary injection and inflammation, and in the effu- sion of serum on the cutis, is more complete than that caused by tartar emetic ; and the subsequent pain is, judging from my own feelings, cer- TREATMENT OF BRONCHITIS. 127 tainly less than that from the latter. A blister should not be allowed to remain on a child for more than three or four hours, or until its action has been distinctly felt by the patient. It is then to be 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, or gauze muslin. An emollient poultice, applied after the vene- section is induced, I have often found to be of great service. In the cases in which disease of the abdominal viscera is complicated with bronchitis, and in subjects not robust and easily depressed by reme- dies, and in whom there is more evidence of congestion than of excite- ment of the circulation, calomel combined with ipecacuanha will be pre- ferred to the tartar emetic. I have, every now and then, seen ipecacuanha, in small doses particularly, to have rather an irritating effect than other- wise in inflammatory affections, and certainly, except in coughs of gastric origin, it has no beneficial one that I have witnessed. Hence, if the com- bination 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 a remedy of the greatest efficacy, when 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 bron- chitis, and bring it to a satisfactory termination. But if it fails 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 evi- dently 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 de- pressing the general system. For this reason, in asthenic bronchitis, as a general rule, ipecacuanha is preferable to tartar emetic for a vomit. It is now that the class of expectorants, which in the first stage would have been for the most part mischievous, may be advantageously enlisted in the treatment; those of the stimulating class being preferred. At this time, also, the alkalies may be had recourse to, united with some stimu- lant. Carbonate of ammonia, assafoetida-mixture, answer admirably, and enable the child or the old person to throw off the mucus with compara- tive ease. Aiding to the same end, a teaspoonful of wine whey now and then for a child, and in proportionately large doses for an adult, should be tried ; its continuance to be regulated, of course, by the pulse and the state of 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 ofthe polygala senega, with the addition ofthe liquor ammonia? acetatis, or the carbonate of am- monia. If, apart from the symptoms of general debility and difficult ex- pectoration, we find evidence of congestion or inflammatory engorgement 128 DISEASES OF THE RESPIRATORY APPARATUS. of a portion of a lung, the use of calomel in minute doses may still be con- tinued, 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 charac- ter 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 semicupium 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 diaphoretics, 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 sedative and diuretic, and all of which have been recommended in the disease under notice, especially with a view to prevent effusion. Without pretending to specify the precise time when they ought to be had recourse to, we can very well infer, fro n 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 derivation through the kidneys. When given with a view to their anti- phlogistic operation, tartar emetic is combined with one or other of them. 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 conse- quence 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 reco- vered from. Secondary or Symptomatic Acute Bronchitis. — Our treatment of various diseases will be readily modified by the extent to which bronchitis is associated with them, either as a primary symptom or one of secondary occurrence. In measles, the chief danger, both in the first or acute stage, as well as after the disappearance of the eruption, 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 of eruptive fevers generally, of asthenia with inflammation, which will prevent our carrying out, in all its 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 ofthe general system, and even administer camphor and ammonia in alternation with calomel and ipecacuanha, and apply revul- sives to the skin. These in scarlatina will be the warm and hot bath sinapisms to the extremities, friction of the chest and limbs with cam- phorated and terebinthinate liniments. Vesication is not safe in this ex- anthema. Bronchitis is a frequent secondary occurrence in small-pox. During the epidemic visitation of this disease in L823 and 1824 I often found my patients, more especially those in the hospital, sink under bron- chitis and pleuro-pneumony after the eruptive febrile stage had been gone BRONCHITIS WITH REMITTENT FEVER. 129 through, and the desquamation of the skin nearly completed. In some instances the bronchial disease was coeval with the pustular eruption, which appeared on the trachea and its ramifications at the same time with that on the skin ; in others there was reason to believe that the inflamma- tion of the bronchia? was secondary, and consequent on the morbid im- pression 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, ac- companied 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 pro- cess, 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 decoction 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 alternation with the remedies last mentioned. As a general rule, emetics are useful in those cases of bronchitis, com- plicated with scarlet fever, measles, and small-pox, in which a state ana- logous 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. Complications of Acute Bronchitis.—It is quite common for remittent fever, especially the autumnal, to be ushered in with, among other symp- toms, a slight bronchitis, which, as the fever advances, may either disap- pear, or, a no unusual thing, be augmented, and thus complicate not a little this disease. In addition to the other phenomena of fever, we find the patient exhibits lividity of countenance, cough, hurried breathing, and expectoration. If, at the beginning, under the impression that, as we have to deal with both inflammatory irritation, perhaps positive inflamma- tion 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, 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 bron- chial 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 ascer- tain 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 febrile symptoms in some instances predominate in the respiratory, in others in the digestive system ; and we can, not unfre- quently, observe a remarkable alternation of this predominance between the thoracic and the abdominal viscera. More commonly, if there be VOL. II.—10 J 130 DISEASES OF THE RESPIRATORY APPARATUS. disease ofthe respiratory mucous surface, there is an associated disease of • that of the gastrointestinal: the reverse does not prevail with the same frequency. But as it is not my intention here to discuss the pathology and treatment of remittent fever, except in connexion with bronchitis, I shall pass on to another and more advanced stage of the fever, in which it has assumed a typhoid form. We are now pr%etty 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 extended to the bronchia?, so as obviously to interfere with the regularity 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 juncture, 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 carbonated 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 intes- tines furnish a full share, but which I do not now enumerate, have fol- lowed or been originally associated with 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 auscultation. The brain, the pulmonary apparatus, and the abdominal viscera, are now all suffering, perhaps more or less phlogosed ; but the organ, the partially suspended function of which is most prejudicial, is the lungs. It is now no longer a question, however, whether venesec- tion is to be practised or not. This might have been debated during the first stage. AH that is left for us is, to discuss the propriety of local de- pletion. 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 of a violet 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 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 assafcetida 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, while we deplete to relieve the con- gestive lung, nutritive and diffusible stimulants are called for to keep up the general strength, unless we are prohibited from using them by exces- sive tenderness of the stomach, morbid heat of the epio-astrium 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 indications is to apply a few leeches over the epigastrium. WTiilst we attend to the state ofthe 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 ofthe patient. I have known TREATMENT OF SECONDARY ACUTE BRONCHITIS. 13] 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 intro- duction 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 them, and the consequent imperfect hematosis, would all seem to indicate the advantage ofthe freest supply of air to the lungs, at the very time that we envelop the skin in warm clothing. Dr. Armstrong was fully impressed with, perhaps even somewhat exag- gerated, the dangers from the bronchitis in 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 exclude 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 Treat- ment of Diseases), which are called typhous, typhoid, putrid, low, or ma- lignant 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, largely diluted of course, the effect would probably be useful towards a solution of this varnish and adherent mucus ; and produce a not ill-timed excitement ofthe bronchial vessels so as to enable them to throw out a modified and more fluid secretion. Change of posture is desirable in this variety of secondary bronchitis, 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 predo- minance of disease in either lung will be an indication of the necessity of his lying or being turned on the side of the one opposite to that affected. In the very last stage of this bronchitis with typhoid fever, when hope is on the point of forsaking us, the patient lying on his back nearly insen- sible, 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 inter- vals, if a renewal ofthe symptoms calls for it. Dr. Graves has recommended a new, and, in his hands, successful means of arresting the excessive bronchial secretion, the continuance of which to this extent is always harassing to the patient, and often hazards his life. This gentleman proposed the employment 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 re- quires that we should give his own ideas as to the discernment to be exer- cised 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 them- 132 DISEASES OF THE RESPIRATORY APPARATUS. selves, that we can hope for its removal. In such cases, we must try everything that experience has proved to be even occasionally useful, and must carefully 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 qui- nine and laudanum possesses, as appears from the cases I have detailed, very great powers, and for that very reason must be used with circumspec- tion ; for if exhibited at an improper period of the disease, or in cases where expectoration is at all scanty and difficult, it may produce danger- ous consequences." Sugar of lead has been given under these circumstances of disease with a very happy effect. LECTURE XCIV. DR. BELL. Chronic Bronchitis—Description of—Expectorated matter—pus with hectic fever— Difficulty of diagnosis of chronic bronchitis with purulent expectoration—Morbid Ana- tomy—Ulcerations of bronchise 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 digitalis—Iodide of potassium—Tonics with the balsams—Compound syrup of sarsaparilla with iodine or iodide of iron— Counter-irritants to the chest—Inhalation of various vapours—Modification of treat- ment in co-nplic .ted chronic bronchitis—Visits to mineral springs—Change of air and climate—Prevention' of chronic bronchitis. Chronic Bronchitis.— It has been well said, and the remark is one of great practical value, that chronic bronchitis is not separated by any dis- tinct line from the acute form ofthe disease. The two pass by insensible gradations into each other, and are often conjoined, for, although acute bronchitis frequently exists alone, chronic bronchitis is rarely free from occasional admixture of acute inflammation supervening on it, in conse- quence of the exposure of the invalid who is labouring under the for- mer 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 time, of its original character. So long as the expectorated matter remains glairy and v^cid, uniting in mass and without opacity, the inflammation is acute. Towards the termination of an attack of this kind the sputa become opaque and expectorated in distinct masses, which, although consistent, are not very adhesive or glutinous. Sometimes, instead of being dimin- ished 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 ofthe chronic kind. Morbid Anatomy.—When the inflammation has been chronic the bron- CHRONIC BRONCHITIS. 133 chial 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, apriori, have said, that there would be cases in which the mucous membrane ofthe air-pas- sages was white through its whole extent. Both Bayle and Andral, how- ever, 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 white 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 inflammation did not exist, because the membrane is thus found white. Analogous appear- ances 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 mu- cous membrane, though traversed with numerous ulcerations, often pre- sents a remarkable paleness, either in the very place where these ulcera- tions exist, or in their intervals. More than once, in individuals whose urine was for a long time purulent, the mucous membrane of the calyces and pelvis of the kidney has been found very white. In these different affections 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 indications. The bronchial membrane is seldom softened in bronchitis ; but it is often thickened, so as to cause an occlusion of some ofthe minute or ter- minal branches. Ulcerations of the bronchia? are rare. The frequency of ulcerations de- creases from above downwards in the different portions of the mucous membrane ofthe air-passages. Thus, in chronic laryngitis they are com- mon enough. It is not rare to find a part of the chorda? vocales stripped of mucous membrane, and the thyro-arytenoid muscles and the cartilages ex- posed to a greater or less extent, in persons who, affected 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 inflammation ofthe lower parts of the mucous membrane of the air-passages. 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. Symptoms.—Chronic bronchitis in its slightest form manifests itself only by habitual cough and expectoration, which are increased by certain changes of weather, and generally 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 acccorapanied with dysp- noea, occasional pain behind the sternum and about the pra?cordia, a feeling of heat and weight in the chest, and some febrile symptoms, espe- cially towards evening, palpitation, and disorder of the digestive func- tions. The cough varies in its character, being sometimes slight, at others recurring frequently in fits or catches, and is worse, especially at night: expectoration copious. Sometimes the respiration is not disturbed, un- 134 DISEASES OF THE RESPIRATORY APPARATUS. less exercise be used : in other cases, the dyspnoea comes on in paroxysms, resembling asthma. This is more particularly the case when the mucous membrane is thickened, or the bronchia? obstructed by mucus. 1 he fit comes on suddenly and goes off equally suddenly. To this description it may be added, that even with considerable ema- ciation 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 thorax is sonorous as in health ; auscultation reveals rhonchi similar to those in acute bronchitis, but with a greater predominance of the moist than in the latter. 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-greyish nr greenish hue, from, as Laennec thinks, an admixture of the pulmonary matter; and in this state it cannot be distinguished from the expectora- tion of phthisis. In some cases it is real pus, and presents all the varie- ties 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 approaching the gangrenous fetor. After a period, this bad smell disappears, but it may return perhaps seve- ral times in the course of the year. WThen the secretion is obviously of pus, there are not unfrequently a quick pulse and signs of hectic, and a tendency ofthe disease to a fatal termination, with night sweats, emacia- tion, diarrhoea, and all the common symptoms of pulmonary consumption. The following case, related by M. Andral (Clinique Medicate), is an exam- ple of this variety of chronic bronchitis, in which also the tracheo-bron- chial mucous membrane was white. A locksmith, twenty-seven years of age, entered La Charite Hospital during the month of December, 1821. For the two years preceding, this man had 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 re- sounded equally well in all parts; some mucous rale was heard in dif- ferent 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 presented nothing remarkable. What diagnosis, continues M. Andral, could be given here? Auscul- tation informed us, to be sure, that there was no tubercular cavity ; but the aggregate of the other symptoms seemed to announce, that numerous tubercles, beginning to soften, existed in the luno-s. The marasmus and debility increasing, and diarrhoea also supervening:, together with disturbance of the intellect, the patient died in a half-coma- tose 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 turbid seium. Pulmo- DIFFICULTY OF DIAGNOSIS IN CHRONIC BRONCHITIS. 135 nary 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 appreciable alteration ; white fibrinous con- cretions distended the right cavities of the heart. The digestive canal, opened to its entire extent, 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 symptomsof phthisis, although the lungs were sound, but we had 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 ofthe patient's condition before death. This case serves also to apprise us ofthe difficulty of distinguishing a simple chronic bronchitis from a tubercular degeneres- cence of the lungs. What, 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 conclusion : that so long as the existence of tubercles shall not be ascertained 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 mem- brane 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 ofthe evil. Much stress is sometimes laid, but without reason, on the large quantity of expectorated matter in a doubtful disease of the pulmonary 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 mucous secretion is at first less, with more watery dis- charge ; 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 having 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 produ- cing death by asphyxia in an individual affected with pneumonia and chronic bronchitis. Auscultation, although it cannot apprise us positively of the exact con- dition ofthe bronchia? in all their morbid changes, is still a valuable ad- junct towards our obtaining a correct diagnosis in chronic as it was shown to be in acute bronchitis. The respiration and cough are heard with various rhonchi—mucous, sonorous, sibilant, 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 continuance of the copious and puriform respiration, on lis- tening, day after day, we still find no signs of a cavity, no cavernous rhonchus, or pectoriloquy. But the assertion, that there is no permanent 136 DISEASES OF THE RESPIRATORY APPARATUS. absence of respiration 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 principal branches of the upper lobe of the right iung ; and almost entire absence of the respi- ratory 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 ofthe bronchial tubes and ofthe lungs. Etiology.—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 after their inception. The habitual inhalation of dust or fine metallic particles, detached in various processes in the arts, is a cause of a distinct variety of chronic bronchkis. Stone-cutters, needle-pointers, they who powder and sift the materials for making china, and leather-dressers, are particularly liable to the dis- ease. 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 in- creased, and is accompanied by severe cough and a copious expectora- tion, sometimes mixed with pus and blood. Not unfrequently the cough brings on a profuse hemoptysis. At this time the constitution generally suffers much,—the pulse becomes 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 repeating, these symptoms are relieved by remedies, and a total abandonment of the unhealthy occupation, they become worse ; the expectoration 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 secon- dary bronchitis, occurs after hooping-cough, measles, small-pox, or some cutaneous eruption. Farther examples ofthe occurrence of secondary bronchitis are furnished in the irritation ofthe lung supervening on abdominal disease, and par- ticularly on irritation of the stomach, constituting what is often called sym- pathetic 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 expectoration will be proportionate to the degree of bronchial irrita- tion, sometimes it is wanting, at other times present; but the excretion may be suspended by means calculated to relieve gastritis, and this sus- pension is favourable to the patient. This secondary or stomachic cough is no new discovery ; it is associated with either acute or chronic disease ofthe gastro-intestinal mucous surface ; being in the first case marked by more violence, and more likely from the existence of fever to become complicated with pulmonary inflammation. In reference to an accurate discrimination of this kind of cases from primary chronic bronchitis we may say that when there is a want of proportion between the physical s'ip-ns and functional derangement, we are led at once to the correct principle of DIAGNOSIS OF CHRONIC BRONCHITIS. 137 diagnosis. This is laid down by Dr. Stokes to be—That when distressing pectoral 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 irritation. If a pa- tient 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 mo- ment in a complication of maladies, which is, I know, of frequent occur- rence, and the treatment of which is subject to fluctuations 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 in- tended 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. WThether 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 enlight- ened, we shall succeed in readily curing protracted gastric cough, which had proved intractable to general depletion on the one hand, and various stimulating expectorants on the other, simply by a removal of the gastritis. For this purpose, 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, several years ago, a case of this kind occurring in a young girl about seven years of age, in which the pulmonary symptoms with remittent fever were well marked : but the state of the abdomen, the appearance of the tongue, and the commemorative 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 remission from day to day ofthe bronchial irritation. There are other varieties of chronic bronchitis, also of a secondary na- ture, 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 mucous membrane is sometimes violently affected, and that this bronchitis is cured by the same class of remedies which are adapted to and successful in the original disease. I cannot concur in all the ideas conveyed by the expression, " that the 138 DISEASES OF THE RESPIRATORY APPARATUS. 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 ofthe gout, is not, to my mind, evidence ofthe specific or arthritic character of the former. A more enlarged view and experience of the operation 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 evidence that the former was also a modification of gout. This kind of argument was at one time com- mon ; 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 in which no suspicion of gout could be entertained. These remarks are not meant to apply to another variety of chronic bronchitis, or that consequent upon syphilitic irritation. Syphilis, unlike gout, attacks, in its successive stages, a certain order of parts, viz., the mucous membranes, skin, fibrous membranes, and bones. That in its progress the respiratory mucous membranes and the digestive ones should suffer, is not incompatible with our existing knowledge of its organic seats. The upper parts ofthe digestive canal, or the palate, tonsils, and pharynx, are commonly enough assailed by secondary syphilis, as is the larynx or upper part of the air-passages. Participation of the bronchia? in this mo- dification 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 seldom seeing bad and pro- tracted 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 analo- gous to the bronchial irritations ofthe exanthemata, of which he has seen a few interesting examples; whilst in the second, there is a chronic irri- tation which, when combined with the syphilitic hectic and with perios- tosis ofthe 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 duration of which has not been determined, the patient falls into a feverish 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 altogether sub- sides, or becomes singularly lessened. Dr. Byrne, physician to the Lock Hospital in Dublin, is quoted by Dr. S. as corroborating 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 liche- nous 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; TREATMENT OF CHRONIC BRONCHITIS. 139 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 suffered from general febrile symptoms. These phenomena subsided after bleeding and mild diaphoretics, which had the effect of restoring the cutaneous eruption. The more chronic form of syphilitic bronchitis with which pneumonia 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 affecting the lungs as well as other parts. A cautious use of mercury in such cases will improve the patient, whose 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 this mercurial course, remembering, as we must, how prejudicial 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 bron- chitis, 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 ofthe symptoms. If these latter indicate that acute has supervened on chronic bronchitis, 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, unless 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 con- gestion. When called for, it is best done by leeches under the clavicles, or cups between the shoulders. In case of doubt, I consider 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, ofthe congestion, and the susceptibility to the other remedies is thus more completely awakened. These are, in the first place, purgatives, and then antimony or mercury with opium, ac- cording to the degree of excitement. Chronic bronchitis is so often asso- ciated, at least in our climate, with gastro-hepatic derangement, and a torpid or irregular state of the large bowels, that purging may well pre- cede the alterative and tonic course with which, in conjunction with counter-irritants, the treatment is usually completed. An emetic in per- sons of a lymphatic temperament, and whose tongue is white and loaded, 140 DISEASES OF THE RESPIRATORY APPARATUS. is sometimes serviceable. Calomel and jalap, or calomel followed by the compound powder of jalap ; pills of the compound extract of colocynth 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 thrice a-day, according to the trouble which the cough gives—attention being paid to keep the bowels open, and to suspend the prescription 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 the peculiar liability to the sialagogue 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 morning, will exert a salutary effect in removing the cough, and giving the secre- tion a healthy character. I am aware that slight ptyalism has been strongly recommended in chronic bronchitis-; but my own practice, as here indicated, which I have pursued for the last twenty-five years, is, I think, preferable. I know no remedy equal to the blue pill, given as an alterative. Where the disease is more paroxysmal, the fits of coughing being'vio- lent, and febrile irritation manifesting 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 symp- toms, and a feeling of tightness of the chest and difficult expectoration. Camphor will form a convenient and appropriate medium for the adminis- tration 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 digi- talis, in a dose of five 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 effects on the bronchia?, to relieve these indirectly by keeping the bowels in a soluble state. After the regulation of the digestive system, our atten- tion should be directed to the renal secretion, which is at all times not a little influenced by the function ofthe 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 morn- ino-, and both repeated for some days, to have a very good effect. Where we anticipate a salutary operation through thvi kidneys, the iodide of po- tassium will be serviceable, and should the more readily be enlisted in the trealment, if the habit ofthe body ofthe patient.be strumous, and he exhibit any evidence of tubercular predisposition, which would indispose us from prescribing mercury. If, in despite of these remedies, the disease still persists, with an ab- sence of all the remains of acute disease or of febrile irritation, and exhi- bits a purely chronic character, with profuse perspiration, cool skin, soft and rather feeble pulse, and a moist or slightly loaded tongue, the treat- TREATMENT OF CHRONIC BRONCHITIS. 141 ment should be changed to one of a tonic kind, and the use of the bal- sams. Calumba and cascarilla, with nitric acid or sulphate of quinia, sar- saparilla, 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 vascular excitement. Other practi- tioners and writers of authority and 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 spirits of nitre and occasionally I add the carbonate of soda, or the carbonate of potassa. From my own experience, I would recommend, as when I spoke of their use in chronic laryngitis, the farther addition of compound syrup of sarsaparilla and a moderate portion, say five grains, of iodide of potas- sium. In purely asthenic cases, in which there is a languor of the func- tions of digestion 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 conjunc- tion with the remedies already indicated. It may happen, in fact, that, owing to a weakness of stomach and intolerance of almost any kind of in- ternal medicine, or to the peculiar circumstances in regard to the occupa- tion of the patient, or tender age as in children, our main reliance must be on external remedies, or counter-irritation, to the skin. To carry this out successfully, we may direct friction of the chest with a liniment, contain- ing with oil various proportions of tartar emetic, tincture of cantharides, the essential oils, ammonia, acetic acid, or a diluted mineral acid, accord- ing to the degree of effect desired. This combination will represent the liniments which quack physicians and medical quacks laud in books and newspapers 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 sprinkledgover 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 inflammatory irritation, it may be occasionally worth while to have recourse to the inhalation of balsamic and stimulating vapours, in cases particularly of a phlegmatic habit, and in which the bronchial discharge is considerable. Gases, and substances of a more decidedly irritating nature, are better diffused with watery va- pour through the air of an apartment, or small closet even used for the purpose. In this way iodine and also chlorine might be used with bene- fit; a few grains of the former, or a solution of the chloride of soda or of lime being placed on 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 bron- chitis has come on, will of course modify our treatment; as where it has a syphilitic origin, or appears in a gouty diathesis, or is associated with chronic gastritis. Of this conjunction, I have already spoken in such a 142 DISEASES OF THE RESPIRATORY APPARATUS. way as to indicate the appropriate remedies. 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 pa- tient is scrofulous, and the predisposition to pulmonary tubercles obvious, iodine, and sarsaparilla, and the narcotics, should take the place of mer- cury. The simple bitters and quinia, or some chalybeate, will advanta- geously complete the remedial course, part of which should consist ofthe tepid and warm bath, according to the degree of excitement prevailing at the time; and if the reaction be considerable the cold shower-bath. Regimen.—The diet in chronic bronchitis will be regulated very much by the state ofthe stomach. If this organ is 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 ha- bitually good. There are instances in which a moderate repast of solid food has allayed the cough, which has been aggravated by an empty sto- mach. 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 pectoml affections, is not equally well adapted to all. There are some whose stomachs are so constituted that they cannot, without much inconvenience, indicated by weight ofthe 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, ofthe animal kind. They obey the doctor's injunction, to take milk at breakfast afid at dinner ; but they do not understand him to mean for t breakfast and for 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. 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 may often be thus traced. 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 the latter be a light supper. There are some persons so constituted that the common functional excitement of digestion will affect the 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 digestion demand 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 ofthe disease to the termination of the chronic, and during convalescence, this is one ofthe prime indications of cure and health. If TREATMENT OF CHRONIC BRONCHITIS. 143 the bowels are tardy in their peristaltic action in this latter period, we en- deavour to quicken and give tone to them by the combination of purga- tives and bitters ; one of the best and most convenient of which is aloes and quinia ; or extract of gentian and rhubarb. Ripe and dried fruit 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 disorders. To the one before us it is well adapted, particularly in patients who labour under a slight febrile excitement or an irritability which precludes either tonics or stimulating food. The more protracted and obstinate cases of bronchial inflammation will often be either entirely cured or materially relieved by the use of certain mineral waters—a selection ofthe kind of which will denend vprv mur-h on the complications 01 me ureases or oiner orgams wim Uiose or me oron- chia?. If the skin has been long affected, and the irritation has disap- peared, or the 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 aci- dity and irritation ofthe stomach being the accompaniments, the water of the Sweet Spring will suffice. Cough, with febrile excitement, evening paroxysms and a greatly accelerated pulse, have been often completely and speedily removed by a course of the waters of the Salt Sulphur. Drinking one or other of these waters, the use ofthe tepid or warm-bath, and inhaling the pure mountain air ofthe region of Virginia in which they are situated, have restored many invaluls in the advanced stages of bron- chitis, 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 bronchial affections, this kind of air is most serviceable ; and to breathe it habitually invalids resort, as a winter residence, to Pisa anil Rome in Italy ; or to Norfolk, Savannah, and Augusta, in our own country. Those patients who are annoyed by copious expectoration, and whose system is rather torpid than otherwise, will be told to give Naples and Nice, in the old world, and parts of Florida, in the new, the prefer- ence. 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 sedu- lously avoided. With this view, as well with that of procuring 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 bronchitis or incipient phthisis pulmonalis, in apartments warmed by heated air conducted through flues. It is easy, 144 DISEASES OF THE RESPIRATORY APPARATUS. by having large vessels of water in the hot air-chamber, to preserve the requisite moisture of the air which is sent up afrer being heated by the furnace below, into the rooms above. An additional provision for allow- ing of the escape of the air from the upper part ofthe room is desirable for the invalid. 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 inva- lid, would be precluded from the advantage and enjoyment of exercise in the open air during the winter months ; only in the case ofthe latter this should be taken with a nicer selection of sunny days and noontide hours, and when a 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 sud- den 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 ofthe cutaneous function, by which, in one person, bronchitis, in another rheumatism, is brought on, is greatly dimi- nished by sea-bathing. The precautions and the associated circumstances to be attended to in visiting the sea-shore with this view have been de- tailed 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 per- spiration. On this account, flannel or Merino jackets and drawers should be worn in winter, and domestic muslin or cotton flannel in sum- mer. There are many individuals whose liability to fluxions of the bron- chia? or bowels, or to rheumatism, is such that they cannot at any season dispense with flannel. In all cases, the inner garment ought to 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, when we see the fashion of the dress of these little beings, we cannot but deplore the exceeding blindness of parents to consequences, and the too general indif- ference of physicians to the physiological law respecting the evolution of animal heat. They who have less ability to create animal heat, and whose bodies in consequence are less able than adults to resist the morbid im- pressions 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 transi- tions 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 arm-pits, is acted on by cold and by cold and NARROWING OF THE BRONCHIA. 145 moisture, and we find a cause, the chief cause, of so many attacks of croup and bronchitis. We need hardly inquire for the often additional ones of cold and damp feet and chill by detention in the open air, without active locomotion. LECTURE XCV. DR. BELL. Effects of Bronchitis.—Narrowing ofthe Bronchiae—Causes—Symptoms—Obliteration of the Bronchia—Dilatation of the Bronchia;—Organic changes in the tubes and air- cells—Thickening, the first change—Duration and Progress—Symptoms—Difficulty of inspiration—Obliteration of the bronchise with shrunken pulmonary tissue—Dilatation of the bronchiae may occur very early in life—Prior diseases—Symptoms analogous often to those of phthisis pulmonalis—Diagnosis between these two diseases—Its great difficulty—Causes—Treatment,—nearly the same as for chronic bronchitis— Ulcers ofthe Bronchial.—Dilatation of the Air-cells—Pulmonary or Vesicular Emphysema—Dilatation and ruptur" of the air-cells—Symptoms equivocal—Disease often begins in early life,—Constitutes a variety of asthma.—Influenza—Epidemic Catarrh—Epidemic Bronchitis—Closely resembles common bronchitis—Exhibits the same features, complications, and alterations—Seasons for its appearance—Is met with at all seasons—Its reputed terrestrial origin—Supposed to depend on a particular poison—Objections to this view—Treatment—Regulated by the same principles and consisting ofthe same remedies as common bronchitis ofthe season. There are other changes in the bronchial tubes resulting from inflammation than those which occur in the mucous membrane. These are attended with opposite symptoms in different cases. As chiefly referable to chronic inflammation ofthe bronchia?, they might have 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 ofthe air-cells. 5. Atrophy ofthe lung. I shall not follow the author in the details under these specifications which you will find in his Treatise, but content myself with a brief sum- mary from various sources. Narrowing of the Bronchia.—The channel of the air-passages may be diminished by tumours pressing on them, such as goitre, aneurisms of the aorta, and enlarged or tuberculated bronchial glands. The most sim- ple change of structure ofthe bronchial tubes is a mere thickening ofthe mucous and the sub-mucous membranes, which generally in some degree accompanies acute inflammation. This is accomplished by an increased secretion 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 cellular and parenchymatous tissue, it is after a while ab- sorbed. But it is otherwise when the inflammation recurs frequently, or vol. n.— 11 146 DISEASES OF THE RESPIRATORY APPARATUS. 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 development 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 alihough not often serious in itself, yet it may so abridge the sphere of the function of respiration as to make its increased exertion on bodily exer- cise a matter of difficulty and disorder, and to render it illy able to bear any other attacks of disease, to which the lungs can in general adapt themselves by supplementary 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 ofthe function. Symptoms.—The chief symptom of hypertrophy of the longitudinal fibres, and of increased rigidity ofthe tubes generally, is difficulty of inspiration, which is short, quick, and performed with an effort, especially on making any exertion; whilst the expiration is comparatively easy; but both acts are often accompanied by wheezing sounds, compared to those made by broken-winded horses, when the trachea is implicated. These depend on irregularities in the calibre of some ofthe tubes, and frequently on partial congestions or inflammation, from which tubes thus diseased are rarely free. The vesicular murmur is impaired, and the expansion ofthe whole chest is perceptibly limited. These symptoms resemble those of spasmodic asthma, except that they are permanent, and are not removed ap the latter may be for an instant on respiration after holding the breath. As the bron- chial tubes cannot be narrowed without the sound caused by the entrance of air into them being also changed, there results a peculiar rhonchus or rat- tle, on auscultation, which, in consequence of its seat and nature, is called by M. Andral the dry bronchial rattle or rale, the two principal varieties of which were denominated by Laennec sibilant and sonorous. Thisra/e is evidently owing to the air in its way to the pulmonary vesicles, traver- sing tubes which are narrower 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 rales or rhonchi already mentioned. Sometimes they are only heard during expiration. When the obstruction is only on one side or ramification of a large bronchia, the dulness of sound in respiration is confined to that side. There is usually diminished clearness of sound on percussion. In reference to obliteration of the bronchite, the following considerations merit notice. If we follow the bronchial ramifications from their origin to RYMPT0MS OF DILATATION OF THE BRONCHIA. 147 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 terminations. In the larger tubes we find a vascular mucous membrane endowed with villosities and glands, but, as we advance into the substance of the lung, this tissue gradually loses its original cha- racters, until, at its ultimate point, if it be not completely serous mem- brane, it closely approaches to it in appearance and function. It has been remarked by M. Reynaud, that we may expect to see the plastic inflam- mation 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 ex- isted, beyond which the tube was converted into a solid fibrous cord, fur- nishing 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, however, the air-cells were fre- quently found dilated, while in ether instances the tissue was dense and impermeable. Obliteration of the bronchia? has been met with as either a chronic, or an acute affection. As a chronic disease it will be frequently found in connex- ion with tubercle. It is, continues Dr. Stokes, an interesting fact, that it occurs much more frequently in the upper than in the inferior portions of the lun hydrocyanic is oneP of thos^ doubtful articles on which we can never place reliance for anything like neVroTsten"6 ^^ °f ^ " «* **«. and in the ^ulsfve Ofthe anti-spasmodics, so called, assafcetida in American practice has ntr^rlXtthe ? " «*? I "^ » the f°rm ^~ Uic child aid Itewnfi .mer /te' m d°Se Var>'inS with the age of ri™*fow?££l Cf°mP amt' fr°T ten dr°^S t0 half a drachm, withcara^ra&t^ nd ^0f ^ a^ie's to iTt *"*' ^ " little laudanum is added. *' t0 Wh,ch' 0n oc™sions, a 174 DISEASES OF THE RESPIRATORY APPARATUS. There is yet one other remedy of admitted power that has been prescribed with notabfe benefit in the disease before us. I now refer to the arsenite of potassa (Fowler's solution), which, as an anti-spasmodic and exerting a powerful influence on the nervous system, may readily be supposed to be actively remedial in the simple spasmodic form of hooping-cough. I have seen it very speedily control cases of considerable severity and of long standing, beginning in adose of two drops twice a-day, gradually increased to four drops. A safer remedy, although analogous in some important par- ticulars in its operation, is the sulphate of quinia, from which I have also derived good effects in the more advanced stage of the disease. In this second or apyretic period of hooping-cough tincture of cantharides has been highly lauded by Dr. Graves (A System of Clinical Medicine). He cites the prior experience, in its favour, of Dr. Thomas Beattyand that of the father of this gentleman, when used according to the following formula :— f&. Tinct. Cinchin. Comp. §v. ------CanthariHis, ------Opii Oamphorat. aa. 3ss. M. Ft. Mistnra. One drachm of this may be taken in linseed tea or barley-water three times a-day ; and in persons above five or six years of age, the dose may be daily increased one-third, until half an ounce is taken three times in the day. Tincture of cantharides used in this way produces its good effects, as we learn from the Dublin gentlemen just named, without giving rise to pulmonary irritation. Revulsives in the shape of counter-irritants to the skin, and applied more particularly to the nucha and along the dorsal spine and also to the chest, have from time immemorial been much used. Of these it will be sufficient to designate oil of turpentine with certain adjuvants ; also tincture or juice of garlic, tincture of assafcetida, croton oil, &c. Assiduous friction alone along the spine, two or three times a-day and persevered in for a consid- erable period each time, will be of good service. Warm pediluvia and the warm bath are serviceable in the earlier periods of the disease ; the tepid and shower-bath in some of the more protracted, but yet simple cases. Change of air is recognised among the chief agents of an hygienic nature, as a means of giving speedy and after a little while entire relief to patients who had been brought to a very low state, and in whom supervened emaciation and night sweats, by the duration and violence of the disease. Vaccination has been spoken of in very decided terms as an efficient means of moderating the violence of pertussis. Of its value in this way I know little from personal experience, and in looking to others for counsel I find the evidences of too contradictory a nature to allow of my reaching a positive conclusion. During the paroxysm itself, some minute but not unimportant matters of detail should be enjoined on the patient or attendant of the little invalid. It ought never to be left alone ; and on the coming on of a fit it should be made to sit up and allowed a firm support, particularly for its head, which should rest on the hand of the person who has charge of it at the moment. Mucus collected in the back part of the mouth and pharynx should be detached and brought out by the finger or a feather. With the same view the patient should be induced to take a few mouthfuls of tepid or even cold drink. Where the paroxysm has been violent and unduly SUMMER CATARRH, ETC. 175 prolonged, a compress dipped in cold water and applied to the lower part ofthe sternum has displayed a tranquillising operation. Summer Catarrh — Summer Bronchitis — Hay Asthma — Hay Fever.—A troublesome bronchitis attacks some persons uniformly in summer, and owing to the accidental circumstances of individual suscep- tibility to being strongly impressed by vegetable odours and exposure to emanation from hay, the disease has been supposed to be the product of such exposure, and hence has been called hay fever or hay asthma. But even were we sure that this vegetable effluvium is not a coincidence merely with the coming on of the disease from other causes, we could still only receive it as an occasional cause. Persons living entirely in the city without exposure to any such effluvium are affected in a similar manner. The peculiarity of this disease consists more in the season at which it makes its attack, and the marked annual periodicity of its visits, even to a particular day in the month,—with some in June, with others in Au- gust,—than in any symptom or order of symptoms varying from those of catarrh or bronchitis. It exhibits in different subjects all the varieties of these latter. Sometimes it spends its force on the mucous membranes of the eyes and nose, giving rise to all the unpleasant symptoms of coryza ; then, again, it exhibits itself, as in the case of a youthful patient of mine, in the form of catarrhal ophthalmia ; but more commonly it settles on the tracheo-bronchial mucous membrane, causing the phenomena of bron- chitis with greater or less oppression in breathing, and at times almost simulating asthma. But in no one of its modes of manifestation can it excite suspicion either of any specific cause or of peculiar organic seat or symptomatology. One diagnostic feature has been assumed for it by some patients and their physicians; in the fact, as they believe, that it will run its course despite of any mode of treatment or attempt at prevention, except in this latter case entire change of air by travelling be procured. But even this is not always effectual prophylaxis. The marvel here, as respects per- sistence of definite duration, is not greater, however, than we often meet with in cases of common bronchitis when it attacks certain persons, who will tell you that it is no use for them to take any medicine—their cold will run its course. The fact I believe to be very problematical in either common winter and vernal or in summer bronchitis. But, be this as it may, the inference that the disease should be allowed 1o go on through its entire period without recourse to therapeutical means is erroneous, and leads to mischievous results. All the precautions required in a case of common acute bronchitis to prevent remoter bad consequences, such as chronic bronchitis, dilated bronchia?, development of tubercular disease, are equally demanded in the affection now under notice. In some cases venesection will be re- quired to relieve bronchial and associated pulmonary congestion, — fol- lowed by tartrate of antimony and opium. In others cups to the chest, or leeches to the trachea or under the clavicles, and calomel, will answer the same purpose. Those oppressed with tenacious mucus will be relieved by an emetic, and afterwards the use of alkalies with hyosciamus and ipecacuanha. To the aged and the constitutionally feeble we give early, after appropriate evacuation, whether by bloodletting or by purging, tonics, alternating or combined with some of the stimulating gums. 176 DISEASES OF THE RESPIRATORY APPARATUS. They who may object to a course of medicine, as they term it, will still receive benefit by some revulsives to the skin, such as croton oil or tartar emetic. Considering the strictly periodical returns of summer bronchitis, it would be well worth while to excite cutaneous irritation by these means, and to keep it up two or three weeks, before the usual time for the coming on ofthe disease. The use of some ofthe narcotic extracts with sulphate of quinia or a preparation of iron during this period, by also contributing to the same end, would be worth a trial, and, consistently with this view ofthe case, would be a change of regimen so as to produce a modification of the customary functional actions. LECTURE XCVII1. DR. BELL. Hemoptysis—May be called bloody secretion—Is idiopathic or secondary ; the last variety most common—Active and passive—Structural changes—Causes,—age, inhe- rited predisposition, certain employments, atmospheric exposures, plethora, compres- sion of the chest—Tubercular diathesis and disease the most frequent cause—Next to this diseases of the heart—Hemoptysis often vicarious—Apoplectic congestion of the lungs, an effect from a common cause—Explanation of its origin—Symptoms— Quantity of blood discharged, variable—The physical signs few—Progress—Diagnosis, not easy—Prognosis—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 deple- tion is practised—Leeches to remote parts,—vulva or anus—Active purging—Pecu- liarities sometimes following the use of leeches—Sugar of lead—Tartar emetic—Blue mass with laxatives—Astringents—Narcotics and chalybeates. Hemoptysis (from *ip*. blood, and vtvet, to spit)—Broncho-Hemorrhage— Pneumo-Hemorrhage—Spitting of Blood.—The term hemoptysis is applied to a discharge of blood, or a hemorrhage from any part of the mucous mem- brane of the air-passages—larynx, trachea, and bronchia?; although, for the most part, the last, or the bronchial mucous membrane, is the seat of the disease. Appropriately does the consideration of hemoptysis, which is, for the most part, bronchial hemorrhage, follow that of bronchitis and bronchial congestion ; the former being in truth but a modification of the latter; the discharge of blood giving the relief from the inflammatory congestion ofthe 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 trans- cended, 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 lon- gevity. The second variety, associated as it often is with tubercles ofthe 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 tubercles into the bronchia? is often accompanied with a slight hemorrhage, from the rupture of small vessels, CAUSES OF HEMOPTYSIS. 177 which soon stops spontaneously. But, on the other hand, a rupture of a bloodvessel traversing a tuberculous 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 current 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. Another division, into active and passive, is not without its use, if we understand by those terms the states of the system generally rather than of the affected organ. The local irrftation giving rise to hemoptysis may be associated with a sthenic diathesis and plethora, and in this sense the disease will be active ; or it may be con- nected with asthenia, and even anemia, and so far passive.- The structural changes produced by, or rather associated with, and fol- lowing 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 membrane 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 injec- tion in some points. We may, as M. Andral suggests, 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 hemoptysis dependent on pulmonary apoplexy or pulmonary hemorrhage ; that is to say, when bronchial hemorrhage has succeeded 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 equally as in the greatest degree of hepa- tization. The extent of lesion is both small and circumscribed; the pul- monary tissue around being quite sound and crepitant, and having 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 ofthe natural texture of the part, except the bronchial tubes and the larger bloodvessels. In hepatized lung after pneumonia, on the other hand, we can perceive, says Laennec, who draws the contrasted picture which I am now copying, the dark pulmonary spots, the bloodvessels, and the fine cellular intersec- tions; all of which give to this morbid state the aspect of certain kinds of granite. M. Andral's description ofthe 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 ofthe 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 engorged with serosity. In a majority of cases, the exhalation of blood takes place in one lunc alone. b The causes of hemoptysis are numerous and diversified. The period VOL. ii.—13 r 178 DISEASES OF THE RESPIRATORY APPARATUS. of life which predisposes to it are of youth and adult age, or from 15 and 20 to 30 and 35 years of age. In some rare instances, this disease has been noticed in infants at the age of three months (Dr. Morris—Transact. Col- lege of Physicians, Philadelphia). As regards sex, women are more liable than men, in the proportion, according to Louis, of three to two: their liability is greatest in the period between 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 themselves threatened with consumption, are in most dangerfrom hemopty- sis. This is increased by certain employments, such as of a tailor or shoe- maker, which require the body to be much and long bent forward. Sudden variations of temperature, and particularly change to a dry, cold air, are enumerated among the causes of spitting of blood, which is, on this ac- count, more frequent in spring and autumn than at other seasons. 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 wind, is a too frequent cause of hemoptysis, and should be care- fully 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 ascend- ing high mountains, to the great muscular effort and excessively hurried respiration in consequence, than to the rarefied atmosphere. Hemoptysis has supervened on protracted mercurial treatment, the use of iodine, the inhalation of irritating gases ; also after strong moral emo- tions, excessive venereal indulgences, and prolonged wakefulness. It may be caused by general or local plethora ; the latter induced by ardent spirits, loud and protracted speech, the suppression of an habitual hemor- rhage, 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 corseting, 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, religious or profane. It is doubtless owing to this cause that, as M. Andral thinks, consumption is so frequently met with in the other sex. M. Louis, it is true, does not join in this latter"opinion. M. Andral gives the following statement, as the result of his own ob- servations, in regard to the relative frequency of the several modes of connexion between hemoptysis and consumption. Ofthe 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 unequivocal symptoms. In the remaining two-sixths, the hemoptysis preceded the other symptoms of tubercular disease, and seemed to mark the period of its commencement. By this comparative statement you will see how very frequently hemop- tysis occurs as one of the symptoms connected with tubercular 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 Andral found it. Among eighty-seven instances of consumption, there were fifty-seven, or four in every six, in which hemoptysis had been present. Next to tubercular disorganization of the lungs, the most frequent source STATE OF THE LUNGS IN HEMOPTYSIS. 179 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 attend- ing 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 ofthe heart which we could suppose likely, u priori, to cause pulmonary congestions, and thereby hemoptysis, would be in- creased strength and thickening of their muscular parietes—hypertrophy ; a morbid condition which is comparatively rare on that side ofthe heart, and which, perhaps, would not suffice for the production of hemoptysis, even if it did not 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 portce; and to prevent the lungs from receiving their due proportion of blood. But any material obstruction existing in the left auricle or ventricle will im- pede the return of the blood from the lungs, lead to their accumulation in those organs, give rise to mechanical congestion, and so dispose strongly to pulmonary hemorrhage. Hemoptysis is often vicarious of the menses, and recurs under such cir- cumstances 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. Pul- monary congestion and the hemorrhage under consideration are notunfre- 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 (op. cit.) are quite appropriate:— "In truth, the morbid condition ofthe 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 appear- ances which they leave behind them in the organ affected, are yet, essen- tially, 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 consequence 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 mate- rially from those which you will find expressed in the works of almost every writer on pulmonary apoplexy. The opinions I entertain 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 medi- cal friends. It is a matter of satisfaction to me to find that they are es- teemed 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 Dis- ease. Laennec speaks ofthe pulmonary apoplexy, as if it were the cause of the hemoptysis. But this is surely a very incorrect view of the matter. 180 DISEASES OF THE RESPIRATORY APPARATUS. The partial engorgement and the hemoptysis, are not mutually connected with each other as cause and effect, but they are concurrent effects of the same cause; of that cause which gives rise to the extravasation or exhala- tion 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 con- trary direction,into the ultimate divisionsof the bronchi,soas to filland 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 san- guine effusion takes place in the uliimate air-cells; and he applies to this form of disease the term pneumo-hemorrhage, to distinguish it from ordi- nary hemoptysis, which he calls broncho-hemorrhage; and this I believe to be the true pathology of the uncircumscribed 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 pulmonary 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 portions 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, so as to preclude any subsequent admission of air." " The principal symptom attending the formation of these masses is he- moptysis; and the principal, though not the only cause, is disease of the heart. The hemorrhage is often severe and copious in the first, or circum- scribed form; sometimes slight and scanty, but commonly slow, oozing, and persistent, in the second or uncircumscribed form. The heart disease is in its left chambers, and very often consists in contraction ofthe mitral orifice. No example of pulmonary apoplexy, or of pulmonary hemorrhage, even apparently dependent upon hypertrophy of the right side of the heart, has ever fallen under my notice." By Dr. Graves (op. cit.) another view of hemoptysis is taken, deduced from known anatomical and physiological peculiarities of circulation and sanguineous supply in the lungs. He points out the fact ofthe bronchial mucous membrane receiving its supply of blood from the bronchial arteries, and the pulmonary vesicles from the pulmonary artery ; and, also, of the want of direct communication between these two sets of arteries. An in- direct one, it is true, is established by a system of capillary vessels, but this does not prevent the separate phenomena being manifested by the bron- chial arteries on the one part, and the divisions of the pulmonary artery on the other, in the case of hemoptysis. Thus the hemorrhage from the bronchial mucous membrane and consequently from the bronchial arteries, although it may be copious, yet when it is accompanied by cough, heat, and constriction of the chest and fever, it is generally scanty and is seldom dangerous. The blood of this variety of hemoptysis is florid and arterial. The hemorrhage from the branches of the pulmonary artery is attended by different phenomena: the blood escapes from them in two directions into air-cells and into the cellular tissue which connects them. That portion which gets into the air-cells will also get into the bronchial tubes, and may be spit up, while that portion which gets into the intervesicular cellular tissue has no such exit: there it must remain and become coagulated and SYMPTOMS OF HEMOPTYSIS. 181 solidified. To the union of these two last states, viz., spitting of blood and effusion into the cellular tissue, the term pulmonary apoplexy has been applied. In this variety or effusion from the pulmonary arterial branches into the cavities of the air-cells and outside their cavity into the cellular tis- sue, the blood is black or dark, and if coagulated some time in the air- cells and bronchial tubes, it will become coagulated and be spit up in clots. Many ofthe worst cases of spitting of blood are attended with this symptom ; and hence a difficulty in establishing a diagnosis and in receiv- ing as correct one of the current signs of hemoptysis, viz , that the blood spit up is florid and frothy. The blood effused into the cellular tissue of the lungs soon loses its serum by absorption, while its crassamentum, retaining its colouring mat- ter, is solidified. One beneficial effect of this process is to arrest the fur- ther effusion of blood, which it does by the pressure of the coagulum on the bleeding air-cells, and thus, by preventing the passage of the blood from the pulmonary artery to the pulmonary vein, it stops the circulation entirely, in the diseased part. Among the curiosities of this disease may be mentioned its originating sometimes from strong sensations; such as the impression of music, above all, on phthisical patients. M. Andral relates the case of a young man 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 hemop- tysis whenever he ate honey, and another again after having eaten aspa- ragus. In very nervous subjects the disease has been brought on by strong odours. In the symptoms of hemoptysis 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 men- tion 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 sur- face ofthe body are cold, and irregular chills are experienced in the back and loins; the countenance is changed, the face becoming alternately 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 vi- brating: pain and uneasiness in the limbs are complained of. The labo- rious breathing is augmented, and the patient feels a kind of bubbling caused by the passage of air during the movements of inspiration and ex- piration, and at the bifurcation ofthe 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 bronchial cells, in which case it is dark, and towards the end of the attack clotted. Sometimes the quantity and rapidity ofthe discharge are such that one would describe it as a vomiting of blood. After it has ceased the patient commonly experiences relief, especially from the oppression, palpitations, and headache. This absence of disease may be either temporary or per- 182 DISEASES OF THE RESPIRATORY APPARATUS. manent. Often, at the expiration of a not well-defined period, the same symptoms of congestion, already enumerated, are manifested, and are fol- lowed by fresh hemorrhage. In some cases, this kind of paroxysm has returned five or six times in the course ofthe day ; its intensity diminish- ing, however, at each repetition. The quantity of blood discharged is very variable ; 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 perfectly sonorous, and auscultation only shows a mucous rattle or rhonchus with unequal bubbles, usually larger than those of catarrh, and formed, one may sup- pose, of more liquid materials. The rattle is more or less evident accord- ing to the quantity of blood effused. 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 pulmo- nary apoplexy, auscultation makes us acquainted with the true diagnosis. In this case the stethoscope, according to Laennec, furnishes us with two principal signs, viz., 1, the absence of the sound over a small, circum- scribed 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 it is frequently wanting in its latter stages. When these signs, and the fact is of great importance, coexist with pulmonary hemorrhage, we may be assured that the origin of the discharge is in the pulmonary substance, and not in the bronchia? simply. If the induration of pulmonary tissue is ex- cessive, 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 except peri- pneumony ; and even then only in cases in which the spitting 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 apoplexy 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 re-produced 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 regu- larly 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 pneumonia and hemoptysis, if the latter be dependent on pulmonary apoplexy. In pneu- monia the sputa are distinct, and, as it were, fused, which is not the case PROGNOSIS AND TREATMENT OF HEMOPTYSIS. 183 in the other disease. In nasal hemorrhage 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? : there are no signs of thoracic disease, and inspection ofthe throat will generally show some dark clots adherent to the pharynx. If we look at the nares, also, we shall see, generally, traces of blood ; and if the patient be made to blow his nose, clots will appear similar to those brought up from the mouth. In some cases, again, there is a slight hemorrhage from the vessels of the pharynx, which, calling the bronchia? into sympathetic irritation, may be as- sociated with cough, and mixed with the expectorated matter thus brought up, thereby imposing on the physician as if it were a true hemoptysis. This latter is usually represented as readily distinguishable from hematemesis, by the cough, dyspnoea, vermilion colour of the blood, and its mixture with bubbles of air, when the discharge is from the bronchia?; while in hemorrhage from the stomach there is nausea, oppression at the epigas- trium, 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 that there is bronchial hemorrhage, 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 both 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 sometimes 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 ascer- tained, 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 treatment of hemoptysis resolves itself into, 1, the means of arrest- ing the discharge ; and 2, those of preventing its return. It consists in diminishing the sanguineous congestion of the lungs, and in relieving the opprcs^on of these organs, and consequently the turgescence ofthe bron- chial mucous membrane, by revulsive action on 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. The very first measures enforced must be absolute silence and rest in a semi-recumbent posture, and to avoid as much as possible coughing. 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 184 DISEASES OF THE RESPIRATORY APPARATUS. of the older writers and chance passages in English books, will be sur- prised to learn that the author just named expresses himself in the follow- ing 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 characterize 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 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 im- pression 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 posi- tion, determined by a knowledge of the premises. In incipient hemop- tysis, 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 repeated occurrence. We ought, also, to be aware, that a simple idiopa- thic bronchial hemorrhage will sometimes be of itself sufficient to relieve the congestion, which may have been but temporary, ofthe mucous mem- brane ; and that if the discharge do not cease spontaneously, it is readily stopped by means of an easy application to be hereafter mentioned. When, on the other hand, we are led to believe, from the habit and general ap- pearance 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 bloodletting, says Laennec, of 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 fort- night. 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 venesection falls short of the loss of blood sustained from pulmonary hemorrhage, in young and robust subjects, even in the course of a few mkiutes ; while the debilitating effect of the hemorrhage is infinitely greater than the loss of blood produced by the lancet. (Forbes's Translation.) This advice does not asluredly 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 employment of other auxiliary but not unimportant measures. The position of the pa- tient 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 TREATMENT OF HEMOPTYSIS. 185 even the chest sponged with cold water and vinegar. The remedies at this time, taken internally, may be of a simple and readily obtainable kind ; such as vinegar, or common table salt, or mouthfuls of cold and even iced water. My theory of the effects of this refrigerating or sedative practice is, that the diminished excitement produced on the capillaries and exha- lents ofthe skin, and the gastric mucous membrane, is participated in by those ofthe bronchial mucous, which, in consequence, refuse to give pas- sage 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, strengthened by general plethora, and perhaps hypertrophy of one ofthe great cavities of the heart. The occurrence of a reaction is not so much an argument, however, against these sedative or refrigerant agents, adjuvants to blood- letting, 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 he- morrhages, is to remove the cause ; as it may be supposed to depend either on increased raolimen, 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 ofthe 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 pre- sented, from the beginning, to the mind of the physician who has taken charge of a case of hemoptysis, and who maybe debating with himself, or with a medical friend, the propriety of trying substitutes for venesection, in order to arrest the hemorrhage. The quantity of blood, and the exal- tation of vital phenomena, consequent on or associated with its greater afflux at this time to the lungs, must be diminished. The means are de- pletion and derivation. Venesection in the arm or in the foot carries out both of these objects, but more particularly depletion and unloading ofthe vascular system. After this, derivation is easier; and when the hemor- rhage originates in the suppression 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 import- ance 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 con- gestion 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 benefit received in phlegmasia and congestions ofthe former by a pouring out of fluids from the latter. If it were necessary to enforce this view by collateral aid I might refer you to the observations of writers who, like Stoll, have noticed the connexion between bilious disorders and hemop- tysis in certain seasons; and the interesting fact, that free purging gave prompt relief to the latter complication. 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 186 DISEASES OF THE RESPIRATORY APPARATUS. 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 bloodletting ; leeches chiefly, if not only, under the circumstances stated, viz., of suppressed hemorrhoids or menses. Obviously proper as these 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 period 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 ob- servation ofthe French writer just quoted, to have a like effect on hemop- tysis ; and cases of this kind are clearly those in which purgatives should have a trial. On this remark, Doctor, now Sir James Clark, has the fol- lowing comment:—" The fact is not generally known, though it is one of great practical importance. In a plethoric person threatened with apoplexy ofthe brain or hemoptysis, the application of leeches may, and, I believe, frequently does, cause the very occurrence of the disease it was intended to prevent. I have more than once seen slight hemoptysis follow the ap- plication 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 appli- cation of the leeches, requiring general bloodletting, &c. A very small bleeding may, as Laennec observes, produce the same effect; but inde- pendently ofthe quantity of blood abstracted, there is a sympathetic effect produced on the extreme vessels by the action ofthe leeches, or the con- sequent 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 con- gestion 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 rhu- barb 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 discharges and consequent diminution of the bulk of the con- tained blood ofthe vascular system following their operation. Hemoptysis with febrile reaction may at once be treated, after venesec- tion, or where the hemorrhage is but slight and its returns have been fre- quent, without this preliminary, by sugar of lead. This medicine has ac- quired great and in many cases deserved reputation in nearly all the forms of hemorrhage, particularly when administered in conjunction with opium, as in the following formula:— R. Plumb, sub-acetat., gr. xij. Pulv. opii, gr. j. Sacch. albi, 3ss. M. ft. pulv. vj. TREATMENT OF HEMOPTYSIS. 187 Take a powder 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 ofthe 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 injurious to the animal economy. My own experience enables me to speak with considerable confidence 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 themselves. But whether you choose to adopt my explanation or not, you may be assured ofthe 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 ofthe case and the toleration ofthe medicine by the stomach, without vomiting being brought on. Even if nausea and retching should ensue, the state of arterial seda- tion which precedes will prevent any injurious effect, or any increase of hemorrhage, which, without such prior depression, would be readily brought on by vomiting. 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 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 times asked for a renewal of it, when its use had been temporarily sus- pended. When hemoptysis assumes a chronic character, and you have symptoms of bronchial congestion, with small but frequent discharges of blood, and associated disorder of digestion, you will find the use of the blue pill in doses of three to five grains, joined to a grain of ipecacuanha, once or twice a-day, and, if necessary to procure a full alvine discharge, rhubarb and magnesia, or a small dose of salts on the following day, a good plan of treatment ;%to be continued until the tongue is clean and the bleeding cither arrested or reduced to a very small quantity at prolonged periods. Sometimes a pill, composed of ipecacuanha and soap, taken two or three times a-day, for some days, will suffice under these circumstances. If anemia be present, or the patient much reduced by the hemorrhage and the vascular excitement be inconsiderable, small doses of the oil of tur- pentine, 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, that the hemorrhage becomes passive. In these, astringents have been prescribed, such as alum, pure tannin, galls, or rha- tany in moderate doses. By some of the French writers, rhatany in the form of extract is preferred to all the articles of the astringent class. It is 188 DISEASES OF THE RESPIRATORY APPARATUS. given in much larger doses than we are accustomed to prescribe it, as, for example, a drachm, two drachms, and even three drachms—4, 8 or 12 grammes (Grisolle). In cases of incipient tubercle, the administration of narcotics and some preparation of iron should be tried, under the hope of postponing for a time, at any rate, the development of symptoms of phthisis. With this view, also, even more than merely to prevent the recurrence of hemorrhage, a permanent discharge from the inside ofthe 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 horse- back, and alternately with that on foot; the tepid and after a while, if the reaction be sufficient, the cold bath, by momentary immersion or by shower; frictions, and great attention to preserving the feet warm and dry. In a case which came under my care nearly twenty-five years ago, I directed cloths dipped in cold water to be applied to and wrapped round the chest, with the effect of speedily arresting the hemorrhage. The pa- tient himself was much pleased with the remedy. He eventually, as I learned, sank under phthisis pulmonalis. Late hours and nocturnal excess of any kind must be avoided by the invalid, who'is fearful of a return of hemoptysis. LECTURE XCIX. DR. BELL. Pneumonia—Transition slight from vesical bronchitis to pneumonia—Definition— Varieties—Syniptoms—Chief diagnostic marks of pneumonia—Stages of Pneumonia— Measured by auscultation—Minute crepitation in the first stage—Condition of the lungs in the first stage, or that of engorgement—Microscopical characters—Second stage, or that of hepatization—State of the lungs in—Microscopical characters— Changes of position of individual lobes—Third stage, or that of suppuration—Products of deposit in the pulmonary cells—Change of respiratory sounds in the second stage of pneumonia—Morbid anatomy—Appearances of the lungs in the three stages of pneumonia—Inflamed bronchiae with pneumonia—Appearances in catarrhal pneumo- nia,—in hypostatic or senile pneumonia,—in circumscribed pneumonia—Gangrene of the lungs—Local symptoms resumed—Percussion—Cough—Appearance of the sputa—'I'heir microscopical characters—Different states of the expectoration—Colour of the sputa—Dyspnoea—Pain — Decubitus—General symptoms—Febrile phenomena —frequent pulse and respiration, and disordered digestion—State of the skin—Pun- gent heat of the surface—Urine—Disorder of the liver,—jaundice—Delirium, when occurring—The blood in pneumonia,—exhibits the characters of hyperinosis. Pneumonia—Peripneumony—Pneumonitis—Pulmomtis—Inflammation of the parenchymatous structure of the lungs.— The passage from the bron- chial tubes, and more especially their vesical terminations, to the adjoining tissue external to them or the pulmonary parenchyma, is indeed slight; and, as Dr. Stokes aptly remarks, he who would call pneumonia a bron- chitis of the terminal tubes would be hardly guilty of a misnomer. In fact, between vesicular bronchitis and pneumonia, which is believed by the best pathologists to consist in inflammation of the pulmonary vesicles, the difference is but nominal. Even if we suppose different parts to be VARIETIES AND SYMPTOMS OF PNEUMONIA. 189 affected in the two diseases, how slight is the line of demarcation between the terminations ofthe bronchia? and the pulmonary cells. The surface is continuous in both, and in its properties is nearly identical. Rokitansky (Manual of Morbid Anatomy) thinks that pneumonia, having its seat in the air-ceils, might be denominated parenchymatous croup. A comprehensive definition of pneumonia is given by Dr. Williams (Cyclopaedia 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 expectoration; at flrst the crepitant rhonchus, afterwards bronchial respiration and bronchophony, with dulness of sound on percussion in some part of the thorax. He adds : pathologically, pneu- monia consists essentially in an inflammation ofthe parenchyma ofthe lung, occasionally 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 pathognomonic character. The chief recognised varieties of pneumonia are the vesicular, the lobu- lar, and the lobar, according as patches of vesicles alone, or those of an entire lobule, or an entire lobe or all the lobes of a lung, are the seat of inflammation. Inflammation attacking the vesicles, the parenchyma remaining intact, is vesicular pneumonia. But in what does this differ from vesicular bron- chitis ? 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 inflam- mation, constituting lobar inflammation. Lobular pneumonia is most com- mon in children. Rokitansky makes four varieties of pneumonia ; viz., croupal (ordinary or plastic pneumonia), typhous, catarrhal, and interstitial; dependent to some extent on the peculiarities in the state of the blood. Catarrhal pneumonia, rarely seen in adults, is quite common in children : it is always lobular, always has a bronchitis of the tubes belonging to the diseased portion ofthe Jung associated with it, and is a frequent concomitant ofthe various diseases of childhood, especially of hooping-cough and suffocative catarrh. Its especial seat is in the superficial lobules, many of which are often affected, and which become bluish-red, dense, and moderately firm. The interstitial pneumonia is that usually described as chronic,—some- times it occurs spontaneously, and spreads from one lobule to another. It is most frequent at the apices of the lungs. More commonly it is a conse- cutive affection. There are also hypostatic or senile pneumonia, typhoid pneumonia, and bilious pneumonia. Symptoms.—The symptoms of pneumonia are local or general:—1. Those furnished by the lungs. 2. Those by the other organs or organic tissues sympathetically and secondarily disordered with the pulmonary. 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 received diagnostic marks of pneumonia. They are: 1, the crepitating sound transmitted when the ear is applied to the chest, or rather to that 190 DISEASES OF THE RESPIRATORY APPARATUS. part in which is contained the diseased lung ; 2, the rust colour of the sputa ; 3, the peculiar pungent heat ofthe skin. I shall begin with what the auscultatory phenomena of pneumonia offer to us, and connect these with a description of the several stages of the disease. Stages of Pneumonia.—The division made by Laennec of pneumonia into three stages, has been generally adopted by succeeding pathologists. They are, 1, of engorgement or congestion (engouement); 2, hepatization and red hepatization or red softening; 3, suppuration or grey hepatization, or grey softening. I shall describe these several stages in connexion with the phenomena which they elicit by auscultation. Auscultation, either by applying the ear to the chest, or by the inter- vention of a stethoscope, enables us to reach generally an accurate diag- nosis 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 the fine crepitation, as some others term it. 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 observers (Drs. Gerhard and Rufz), this crepitation is said to be wanting in children between five and ten years old suffering from pneumonia: by others (MM. Rilliet and Barthez), it has been distinctly heard. With the exception of three cases, it has always been blended with bronchial respiration, in the experience of these last-mentioned writers. The crepitating rhonchus or the minute crepitation, is characteristic of the first degree of pneumonia, or that of turgescence and engorgement,— the second of Dr. Stokes, who believes intense respiratory murmur in the affected part and fever to be indicative ofthe (his) first stage, and the pre- cursor of crepitation. In the^rs^ stage the pulmonary vessels are so much distended that the whole tissue is of different shades of red, and the pul- monary cells, ordinarily filled with air, become, for the most part, con- tracted and more solid than before. The blood contained within the capillaries has, also, undergone a change, both in its physical and other qualities. The stasis of the blood in the capillaries is attended with a solution of the colouring matter of the blood-corpuscles, and its blending with the serous portions of the blood. The walls of these little vessels are now so far changed as to admit of an exosmosis of their contents, and the tenacious, rust-coloured, and semi-transparent sputa form in the pul- monary vesicles, and in the minutest bronchial tubes. Viewed under the microscope these latter display within an amorphous, or slightly granu- lated mass, a tolerable quantity of blood discs, a proof that at the outset of inflammatory stagnation, the smallest vessels undergo partial rupture. This first stage is designated by the term sanguineous infiltration, (engoue- ment).—Hasse, op. cit. The minute crepitant sound of the first stage of pneumonia may undergo two kinds of change: either it is replaced by the respiratory murmur, indi- cating a termination of the disease by resolution, or it is lost entirely, no sound at all being perceived; the morbid phenomena are increased and the lung becomes hepatized. This is the second stage of Laennec: it is often reached very rapidly, or after two or three days' disease, more especially in young and vigorous persons, otherwise prone to plastic exudation. In STAGES OF PNEUMONIA. 191 rarer instances the first stage is of longer duration, lasting for ten days or upwards, and then passing, if there be any tendency to the formation of heterologous products, into a chronic state, or proceeding promptly to the third and commonly fatal stage. Hepatized 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 hepatized 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 hepatized 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-grey ; if mixed with the black pulmonary matter, a granite-like aspect. 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 ofthe lung at this time is sometimes 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 limited portions of the pulmonary lobes, and then it is called lobular pneumonia. In the stage of hepatization or red softening, gorged capillaries have thrown out their soft contents (decoloured blood, serum, and fibrin) into all the interspaces ; and the tissues have lost their distinctive characters, and become uniformly macerated. The decomposed blood within the pul- monary cells is now transformed into a coagulated mass (plastic lymph) of slight consistence. Viewed under the microscope the exudation of genuine pneumonia reveals a distinctly granulated condition. The effused sub- stances display a number of blood discs, imbedded in a nearly amorphous, slightly granulated or striated mass. When some time elapses before the coagulation of the effused substances takes place, nuclei, which are mixed with the elementary granules, have become sheathed in spherical cells— exudation cells. The amorpho-granular mass, after coagulation, is made up chiefly of exudation cells and pus-globules. In this stage of pneumonia, granule-cells appear to form in very small number, and often not at all. The change in position of the individual lobes, in the stage of hepa- tization, is important in aiding us to trace the progress of pneumonia by percussion and auscultation. The inferior, which is the lobe the most frequently affected, is enlarged posteriorly ; its apex being elevated to above the third rib, whilst in front it is apparently of the breadth of a couple of fingers only. The middle lobe and the superior half of the upper lobe occupy almost the whole anterior surface of the thorax, whilst the inferior and half of the superior lobes cover, in equal proportions, its lateral surface. The third stage of Laennec, to which inflammation brings the lungs, is that of suppuration or grey 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 suppuration is generally diffused in the form of purulent infiltration; but it is very rare to find it assume the cha- racter of a distinct abscess. This last is an uncommon termination of pneumonia. In several hundred dissections of persons dead of this dis- ease, 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 192 DISEASES OF THE RESPIRATORY APPARATUS. 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. Phle- bitic deposits of pus and sometimes tubercular vomica? and cavities, may have been taken for genuine abscesses ofthe lung. Suppuration begins at one or several points of a hepatized portion of lung, nay, each individual air-cell must be considered as a separate sphere of suppuration, so that the coagulated fibrin partly liquefies, partly changes into free exudation and pus-corpuscles. The suppuration, for the most part, spreads very rapidly, without, however, time being allowed for its taking up so much room as the fibrinous exudation, death commonly ensuing shortly after the commencement of the third stage. The dirty- grey appearance of the suppurating portion of lung arises from the admix- ture ofthe purulent fluid with black pigment. In the course ofthe third stage, the circulation through the diseased portion of the lung appears to have been almost wholly interrupted ; at least the smaller twigs of the pulmonary artery, and sometimes, also, ofthe pulmonary veins, are found filled with clotted blood, or with fibrinous concretions. (Hasse.) In this stage it is evident that the sero-sanguineous effusion poured into the pulmonary cells, and there coagulated, is converted into a mixed fluid, holding suspended a number of real pus-globules, whereby the utmost degree of softening is communicated to the tissues. The deposition of lymph which constitutes hepatization of the lung com- pletes the obstruction ofthe 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, con- fined 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 hepatization 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 tubal respiration, owing to its resemblance to the sound which would be produced by blowing into a tube close to the ear of a listener. It is a variety of bronchial respiration. The voice is modi- fied at the same time in a peculiar manner, in its passage through the lungs and parietes of the chest, on 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 hepatized lung and a pleuritic effusion ; for the latter when considerable generally abolishes completely the vocal vibration. Often we hear in the same patient and at the same time different 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. Sometimes 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 'MORBID ANATOMY OF PNEUMONIA. 193 the morbid changes in the lung through the stages of engorgement to hepatization. "Can it," says Dr. Watson, "trace it any farther? I believe not, with any certainty." But, at last, h'e adds,—the structure of the lung breaks down, and a portion of it is expectorated, and finds its way into the vacant spot, and gives rise to large gurgling crepitation. Among the local symptoms should be noticed a diminution in the motion of the affected side, in proportion as the air fails to get admittance into the inflamed lung, grey softening or purulent infiltration. Morbid Anatomy of Pneumonia.—Many of the details under this head have been anticipated in my remarks on the different stages ofthe disease, and the anatomical characters of each. These I shall not repeat. Inci- sion ofthe substance of the inflamed lung in the first stage of pneumonia is followed by the escape of a somewhat frothy and reddish serum ; the cut surface itself is deeply red and the pulmonary tissue of the inflamed part is more friable and is easily torn with the point of the finger. In the second stage or degree the pulmonary tissue ceases to crepitate, is quite imper- vious, so heavy as to sink in water, is of a deep-red colour externally and when cut into presents a like hue or more generally a mottled or marbled appearance. The fluid which escapes after the incision is red, without bubbles of air, and less in quantity than that in the first stage. The chief anatomical character at this time is furnished by an inspection of the cut surfaces of the inflamed lung, which are studded with red hard granula- tions, rounded and somewhat flattened, and which are, in fact, pulmonary vesicles transformed into solid bodies by the thickening of their sides and filling up of the cavities. This granulated arrangement is still more evi- dent when the lung is torn. Sometimes it is absent in the case of the pneumonia of newly born infants and in old persons. The morbid alte- ration is not confined to the pulmonary vesicles,—it prevails equally in the intervesicular cellular tissue. Taking into consideration the increased hardness ofthe lung at this time, it has been proposed to designate the second stage or degree of pneumonia by the term red induration ; M. An- dral, likewise, from a review of some of the peculiarities of pulmonary tissue such as its greater readiness of laceration, thinks that red softening (ramoUissement rouge) is an applicable title. In the third stage of pneumonia the lung presents at first the size, hard- ness, and imperviousness which it had in hepatization, but when complete the grey or straw colour replaces the red, at first in disseminated spots and afterwards through the entire organ. When abscesses do form by the union of several centres of suppuration they rarely communicate with the bron- chia?. Their seat is mostly under the pleura. One stage is invariably developed out of another. Thus hepatization always begins at the centre of a patch in the first stage of inflammation, and spreads on every side towards the margin ; meanwhile a sound neigh- bouring patch becomes involved in the first degree, and so on. Purulent infiltration, in like manner, always commences at the centre of a hepatized portion. The duration of the respective stages is indefinite ; the third stage may, however, be attained within five or six days (Hasse). Both lungs may be inflamed at the same time, and this (double pneu- monia) is quite common in old persons, and children under six years of age. But the right, in persons of all ages, is, M. Grisolle assures us, more frequently attacked than the left, in the proportion of 11 to 5. The dif- ference is explicable, he thinks, by the difference in volume and capacity VOL. n.—14 194 DISEASES OF THE RESPIRATORY APPARATUS. of the two lungs. Pneumonia of the inferior lobe is more frequent than that of the upper lobe, in the proportion of 4 to 3. The disease is repre- sented to spread, in its course, from below upwards, from behind forwards, and from right to left ; but in these respects there will be differences ac- cording to the form of the disease. Still farther, we learn that, when both lungs are affected with pneumonia, the inferior lobe of the right lung is mostly found hepatized, and partially infiltrated with pus, and the upper lobes, and likewise the inferior lobe of the left lung, in the first stage of the disease. 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. Sometimes 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, by an injection of varying distinctness, in albuminous concretions, slightly serous, purulent, or bloody effusions. Pleuritic effusion is seldom extensive when pneumonia coexists with the pleurisy. Rokitansky thus describes the post-mortem appearances after catarrhal pneumonia : " It is always lobular, always has a bronchitis of the tubes belonging to the diseased portion of the lung associated with it, and is a frequent accident ofthe various catarrhal diseases of childhood, especially of hooping-cough and catarrhus svff'ocativus. Its especial seat is in the superficial lobules, many of which are often affected, and which become bluish-red, dense, and moderately firm. The walls of the air-cells are swollen even to the closure of their cavities, which, when the swelling is less, contain a watery, mucous, and slightly frothy secretion. There is no trace of a granular texture discernible. The pulmonary substance around the diseased lobules being, for the most part, emphysematous, they appear (when they are situated at the surface) depressed somewhat below the level and are distinguished by their dark colour." Gradually, during the disease, the colour changes to a brown-red and eventually to a yellow- brown. The texture of the lung, from being at first saturated with a turbid reddish fluid, ultimately assumes the aspect of a pale, yellowish-brown puri- form one. When a large proportion of pulmonary lobe becomes thus dis- organised, which is, however, rare, it is found shrivelled, lax, moist, of a yellow-brown hue, and wholly devoid of air, resembling a wet rag. This kind of catarrhal pneumonia appears peculiarly calculated, as Hasse ob- serves, to produce obliteration of the pulmonary texture, with permanent exclusion of air therefrom, and consequent general dilatation of the seve- ral branches ofthe bronchia? implicated. In hypostatic pneumonia which affects aged persons, the morbid changes are spread over the posterior surface of all the lobes, penetrating thence to the depths ofthe lung. The most deeply-situated portions of the lung are here the most intensely inflamed, being found generally in the second, less frequently and only partially in the third grade or stage. In other cases the pulmonary tissue is chiefly affected about the roots of the bron- chia? and bloodvessels. In this senile pneumonia the bronchial mucous membrane is always much reddened, and the air-passages, from the trachea to the minutest bronchial ramifications, filled with a turbid, tena- LOCAL SYMPTOMS OF PNEUMONIA. 195 cious mucus. The pleura is frequently implicated in this variety of pneu- monia. Hypostatic pneumonia must not be confounded with that state of the lungs met with in the persons who die of typhous fever. The pulmonary- tissue in this latter case is, likewise, of increased gravity, little permea- ble, and mostly softened ; but careful comparison shows that these changes are the result of stagnation of, for the most part, diseased blood. The lung is not so much distended as it is collapsed: and stained of a blue- black, by imbibition of its fluid blood ; and although the stain cannot be removed by careful washing, yet the substance of the lung may be, in a great measure, restored to its natural state, and the tissue will fail to exhibit any inflammatory product. This stagnation of blood is always equally diffused along the posterior surface of the lung, whilst the anterior half is generally observed to be bloodless and dry,—but otherwise per- fectly sound. There is a circumscribed pneumonia, virtually lobular, also consequent upon great surgical operations. It is distinguished by circular patches of a spherical shape, isolated in the centre of a sound lung, and of the size of a walnut. They have the appearances of abscesses, but do not contain fluid matter; their consistence, in fact, being greater than that of portions of lung in the third degree of inflammation. The adjoining tissue of the lung is in a state of red or grey hepatization, but beyond this it is per- fectly healthy, only somewhat moister than usual. Sometimes these puru- lent deposits are deep-seated, but more frequently seem to be superficial, and near the pleura. Gangrene is an unusual result of pulmonary inflammation ; being nearly as uncommon as the formation of an abscess. It seems, however, as re- marked by Dr. Williams, to arise pretty generally from the influence of those noxious gases which directly destroy the vitality ofthe tissue ofthe 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. I now resume a more particular consideration of the local symptoms. Percussion does not show any change in the sonorousness of the chest, in the first stage of pneumonia ; and it is until the second or third day that a dull sound is evident. As the disease disappears the natural sound of the chest is restored. Percussion cannot be practised when the walls of the thorax are painful or covered with a vesicated surface, or where there is deformity of the chest. In 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 ofthe lower part ofthe thorax. Cough is present in a very large majority of cases of pneumonia ; but it exhibits no peculiarity, nor are its violence 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 become 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 den- sity augments as the disease advances ; they become viscous, tenacious, 196 DISEASES OF THE RESPIRATORY APPARATUS. 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 new diagnostic feature of the sputa in pneumonia has been announced by M. Remak. It is, the appearance of fine fibrinous threads of the form and diameter of the extreme bronchial ramifications. In order to see them distinctly the sputa are to be poured into and well washed with water. Under the microscope they are seen to consist of very«delicate fibres laid lengthwise and inclosing cell-like bodies resembling those of pus. These fibrous concretions mostly make their appearance from the third to the seventh day of the disease, but are never seen, according to the author's observation, in the last stage or that of purulent infiltration. These concre- tions, considering their coincident appearance with the crepitant rhonchus, that is to say in the first stage, indicate in M. Remak's opinion a decidedly favourable result to the case. These observations have been confirmed by Schonlein. It is important for you to know that pneumonia of a fatal kind may go through its course without either cough or the expulsion of any sputa whatever, or even pain. This latent form, as it has been called, is mainly met with in lobular pneumonia, which, we may add, is confined almost entirely to infantile subjects. There are cases, again, in which the sputa at the beginning ofthe pneumonia may be bloody, but in which they soon cease to appear at all during the whole course of the disease up to the period of entire resolution. With the entire absence of expectoration there must also be an absence of crepitus and of course of the crepitus redux which Laennec and others speak of as indicating the resolution of hepatized lung. A termination of the disease in resolution is indicated by a less height- ened 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 cha- racters, and exhibit those of the catarrhal state, yet auscultation still ap- prises us of a crepitation or crepitating rhonchus (rale) of more or less duration. A suppression of the expectoration may occur from an exasperation of the disease ; and also from an excessive viscosity of the sputa, or from the weakness ofthe 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 complicated with pneumonia, by purgatives given early in the disease, by excessive bloodletting or its unseasonable repetition ; and by all 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 greyish, inodorous, and in a measure purulent; even in the red hepatization they may preserve the same characters ; and, finally, they may lose their vis- GENERAL SYMPTOMS OF PNEUMONIA. 197 cosity, 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 expectoration of a greenish matter, which yields after a while a dirty-grey, 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 characterized by distinct expectoration: some of them slight, some grave, running their course to a happy or fatal termination ; and yet the sputa merely resem- ble those of a simple bronchitis. In intercurrent or secondary pneu-. monia particularly, we must not be surprised at the absence of expecto- ration. 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 usually 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, com- plains 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 imperfect resolution ofthe disease, or to the weakness ofthe patient. Pain, according to Andral, is never felt in pneumonia, unless there be pleuritis coexisting; but Laennec asserts that simple inflammation of the lung has given rise to pain ; a fact which he had an opportunity of ascer- taining 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 lie on the affected side: the posture is generally on the back. Of the other tissues inflamed in conjunction with the pulmonary, in pneumonia, the pleura is by far the most frequent; pleuritis presenting itself in 33 out of 35 cases. It is less frequent among old persons and children. The bronchial glands are also in a morbid state, being swelled, red and softened in pneumonia. Fibrinous concretions in the cavities of the heart are also quite common. Softening of the gastro-intestinal mu- cous membrane occurs in a fourth part of pneumonitic cases. General Symptoms.—Among these, the most constant is disordered cir- culation, 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 intense febrile disturbance supervenes, even although expectoration and auscultation should not furnish any character- istic signs of pneumonia. A chill is the customary prelude or announce- ment ofthe 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 ofthe respiratory move- ments ; and when this correspondence is destroyed by the pulse becoming 198 DISEASES OF THE RESPIRATORY APPARATUS. slow, and yet the respiration 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 disap- peared, there are probably some remains of phlogosis. If intermittent, we are to attribute it to some disease of the heart. The belief entertained by the old writers, and still accredited by some of the moderns, that the fever precedes the pneumonia as its cause, is not correct. The febrile suffusion of the cheeks is sometimes more manifest on one side, that, as we read, 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 somewhat 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 converted into a copious sweat. This last symptom, generally described 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 favoura- ble symptoms, indicating an abatement ofthe inflammation, it ought to be regarded with mistrust. If the skin has remained 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 language 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 conclusive in a diagnostic point of view is a pungent heat of the surface ; by this symp- tom alone the first stage of pneumonia may in most instances be readily recognised ; by this symptom alone pneumonia has been repeatedly pro- nounced 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 varied may be the tissues involved in the inflammatory process, provided this symptom be present, pneumonia may be confidently pronounced to form a part in nineteen cases out of twenty, and perhaps in a larger pro- portion. A similar pungent heat ofthe surface is now and then observed in certain forms of renal dropsy ; more frequently in continued fever, espe- cially in children ; and still more commonly in the eruptive fevers of the exanthemata and erysipelas; 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, pp. 241-2. The urine is of a deep-red during pneumonia, and deposits a lateritious sediment at its decline. It must be subject, of course, to considerable variations, dependent upon the extent of the disease and the degree of inflammation. When this is severe, the urine is very dark, of high spe- cific gravity, and frequently sedimentary, especially at critical periods during the fever. An appreciable amount of albumen is by no means GENERAL SYMPTOMS OF PNEUMONIA. 199 rare. The urine, for the most part, remains acid during the whole period of inflammation, and Becquerel found the same to be the case during the period of convalescence also. The mucus is increased during the febrile period. Andral's observations show that while in some cases the sedi- ments are for the most part spontaneous, and composed of amorphous uric acid, in others, and they the majority, the urine remained clear during the whole course of the disease ; and in a third class, again, the urine was alternately clear and turbid or sedimentary. Simon, from whom I now quote, mentions the occurrence, in a case of pneumonia in Schonlein's wards, and in two cases of peripneumony, of deposits of ammoniaco- magnesian phosphate ; he also tells us that precipitate induced by the addition of acids to the urine gradually crystallized and showed uric acid, and hence that the turbidity and precipitate were caused by the decompo- sition of a urate. In one case the urine emitted an odour of hydrosul- phate of ammonia, and deposited a sediment of uric acid during the dis- ease. In pneumonia it may be said that, in general, the urea is a little diminished, the uric acid is increased, the salts are diminished, and the extractive matters, especially the alcohol extract, are increased. Accord- ing to Schonlein, the crisis in pneumonia shows itself in the urine by the secretion becoming sedimentary ; after ten or twelve hours, a crystal- line micaceous deposit forms, above which the urine becomes clear. But among the glandular organs, there is no one, the functions of which are so disordered in this disease 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 dif- ferently 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 pa- tient exhales what has been called a bilious odour, and he is tormented with cephalalgia in the lower part of the forehead, head, or back of the eyes. In fine he has complete jaundice. There is not, often, much disorder of the nervous system in pneumonia. When delirium occurs, we should regard it as the result of cerebral com- plication 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, how- ever, 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 blood in pneumonia exhibits the characters of hyperinosis more decidedly in pneumonia than in most other inflammatory diseases ; it also retains its heat for a longer period. The clot is rather below the ordinary size, is very consistent and does not break down for a considerable time. It admits of being sliced, and the sections retain their consistence for some time. Its surface is covered with a buffy coat, and is more or less cupped. The serum is of a pale-yellow colour. The quantity of solid constituents is usually less than in healthy blood. Simon tells us that the maximum of fibrin in his analyses was 9*15, which is the largest quantity he ever discovered in inflamed blood. The minimum was 3-4, and the mean of four analyses was 6-0. Andral and Gavarret found the maximum of fibrin to be 10-5 ; the minimum 4 ; and the means to fluctuate between 7 and 8. 200 DISEASES OF THE RESPIRATORY APPARATUS. They never met with more than 10-5 of fibrin in the whole course of their analyses. The maximum of ha?mato-globulin was, in Simon's experiments, 78, and the minimum 36, which is very far below the amount in healthy blood. Heller observes that he has often been able to detect biliphcein in the blood of patients with bilious pneumonia where there have been no other indications of a disordered state of the hepatic functions. LECTURE C. DR. BELL. Pneumonia (Continued)—Symptoms of Infantile Pneumonia—Difficulty of diagnosis in this disease__It always follows capillary bronchitis—Is catarrhal pneumonia—Peculiari- ties of respiration in the young patient—Physical signs—Bronchial respiration the most important— Expectoration — Percussion — Anatomical characters—Symptoms and diseases precursory of pneumonia—Commonly the disease attacks suddenly—Is preceded sometimes by intermittent fever and cholera, measles, rheumatism and gout __follows surgical operations—Progress of sthenic pneumonia—Sudden sinking- Case__Prognosis and Termination—(Critical evacuations and critical days—Age modi- fies results—The old and young most apt to sink under pneumonia—Part of the lung most liable to inflammation—Which side most affected—Complication with other dis- eases increases danger—Causes—External and internal—Climates and countries in which pneumonia prevails 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—Inter- nal causes—Liability of the disease to return in the same person—Tuberculous phthi- sis—nge—Young children most liable—Sex:—.Men much more liable than women— Treatment—Great mortality in pneumonia—Contradictory reports of different modes of treatment. Symptoms of Infantile Pneumonia.—The importance but yet difficulty of diagnosis of pulmonary inflammation in children and the frequency ofthe disease, will justify my making some additional remarks on this topic. Acceleration of the pulse and of respiration are important symptoms in the disease, and influence not a little our prognosis. They may, when there is no complication of other acute diseases, be taken as a measure of the intensity and extent of the inflammation. Infantile pneumonia is re- presented by M. Grisolle to be always consecutive to capillary bronchitis; and hence it may be regarded as catarrhal pneumonia. The catarrhal period varies from several days to as many weeks—after this the symp- toms are all at once exasperated and the disease sets in with violence. At the outset ofthe disease there are some peculiarities in the mode of respiration, and, if the child be still fed from the breast, of sucking, men- tioned by Dr. West (Memoir on Infantile Pneumonia—Brit, and For. Med. Rev.), which will aid us in forming a correct, and, what is of great importance, an early diagnosis. If, while a healthy infant is sleeping, the mouth be gently opened, it will be observed that the tongue is applied to the roof of the mouth, and that respiration is carried on through the nares. So soon, however, as the lungs become affected, even when no other symptom exists than general febrile disturbance, and perhaps the vomiting above alluded to, the infant will be seen no longer to breathe solely through his nose, but to lie with his mouth partly open, and drawing in air through it. This imparts to the tongue its preternatural dryness, and GENERAL SYMPTOMS OF PNEUMONIA. 201 the same inability to respire comfortably through the nares causes the child to suck by starts. The infant seizes the breast eagerly, sucks for a moment with greediness, then suddenly drops the nipple, and, in many instances, begins to cry. As the disease advances, these peculiarities in the mode of sucking and respiration often become more striking, but it is at the onset ofthe disease that it is of especial importance to notice them, since they afford most valuable indications of its real nature. As respects the physical signs of infantile pneumonia, it may be said that the mucous rhonchus is heard in most cases in which catarrh has preceded the symptoms of pneumonia proper ; but, Dr. West thinks, it should be looked on as one of the least important of the physical signs of this dis- ease, since it was present in thirteen only of fifty-one children under five years of age. It is of importance, however, in the young subject, as the immediate precursor of bronchial respiration ; while in the adult there is no such connexion. " The sub-crepitant rhonchus is a sign of far greater importance than the mucous rhonchus, whether we regard the frequency of its occurrence or the consequences which follow it. It was heard in forty-two out of fifty-one cases ; in thirty-one of which it either had not been preceded by mucous rhonchus, or if it had, that had ceased before the patients came (says Dr. West) under my notice." The observation made by M. Guenard is confirmed by Rilliet and Barthez ; viz., that these sounds readily disappear if the little patients are kept seated for a short time ; and that their greatest distinctness is when the child is raised from the bed. Bronchial respiration, of all the modifications of the respiratory sound, deserves, in the opinion of Rilliet and Barthez, the most particular atten- tion. It was present in two-thirds of their cases, and when its existence was not ascertained, either the disease was very slight, or it had become impossible to practice auscultation during the last few days of the life of the patient. Frequently, the bronchial character was only observed during expiration, the inspiration remaining perfectly natural, or manifesting a slight rhonchus. This may be regarded as indicative of lobular pneumonia, the most frequent form of the disease in children. In those from two to five years old, the bronchial respiration was, in a certain number of cases, preceded by rhonchi of different kinds. In children of a more advanced age, it was ushered in by an obscurity of the respiratory sound, and in this class, more than in the other, it was the first symptom established. In children from two to five years, it always existed on the posterior part ofthe thorax, and, most commonly, near the vertebral column; although, as Dr. West, who makes a similar observation, adds, it is not by any means invariably confined to this situation. The expectoration consists of tenacious and whitish sputa. Death comes on with great agony and often with symptoms of slow asphyxia. Percussion is of much less value than auscultation in investigating the presence and characters of infantile pneumonia. Dr. West describes a difference between the upper and lower part of the chest as appreciable long before bronchial respiration becomes audible; when bronchial respi- ration exists, dulness on percussion can always be detected, and even if it should be necessary to percuss with the utmost gentleness, so as scarcely to elicit a distinct sound, the finger is yet sensible of the presence of solid lung beneath. The anatomical characters of infantile, which is also lobulated pneu- 202 DISEASES OF THE RESPIRATORY APPARATUS. monia, consists of patches of hepatization disseminated through one or both lungs. The precursory symptoms and diseases on the invasion of pneumonia are various. Sometimes the patient has felt, for a few days preceding, dis- comfort, fatigue, anorexia, disinclination to motion without either ausculta- tion or percussion indicating pneumonia. Occasionally, a day, or two or three days before the attack, a slight fever, like that which precedes va- riola, scarlatina, measles, &c, accompanies the preceding symptoms. This is the inflammatory fever which, in the opinion of some writers, al- ways precedes the local malady. In some cases all the organs are threat- ened in succession with disease: to-day, the patient complains of gastric symptoms ; to-morrow, of a tendency to cerebral congestion; subsequently, to rheumatic pains, until, finally, the pneumonia discloses itself. M. An- dral has seen pulmonary inflammation preceded by two paroxysms of in- termittent fever, and during the cold stage of the third a slight cough su- pervene, pain appear, the sputa of a characteristic nature ; and, in fine, all the symptoms of pneumonia evinced. Sometimes pneumonia succeeds bronchitis; the inflammation, 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. This union is most common in children, especially when lobular pneumonia is present. Tubercle is a frequent complication. 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 not say unfrequently, in fever, the pulmonary inflammation is not revealed by any symptdm, and its pre- sence 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 cho- lera, to mention the congested lung in many fatal cases of that disease. This state was most evident in the stage of reaction. Disease of the large intestine is mentioned by MM. Barthez and Rilliet, as a most frequent complication; as is, also, gangrene ofthe mouth. In subjects worn down 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 of the catarrhal form, especially if the eruption is repressed or disappears suddenly; but in this case the symptoms are com- monly urgent and sufficiently characteristic. Pneumonia is sometimes pro- duced in gouty and rheumatic subjects, and this may occur either vicari- ously, so that the limbs are relieved, or conjointly with these affections. P. Frank has remarked that, in rheumatic subjects, pneumonia sometimes terminates without any expectoration, and with a copious discharge of clear urine, amounting to twelve pounds and upwards. This curious fact is another evidence of the connexion which subsists between rheumatic and gouty affections and a diseased state of the fluids ofthe body. Inflammation of the lungs sometimes succeeds to and complicates acute GENERAL SYMPTOMS OF PNEUMONIA. 203 rheumatism. The fact is distinctly stated by Dr. Latham (Lectures on Subjects connected with Clinical Medicine, pp. 86-7, Am. Edit.). Of 136 cases of acute rheumatism, inflammation of the lungs was found in 24 ; or in the proportion of 1 in 5^. Of 90 cases of rheumatism in which the heart was inflamed, the lungs were inflamed in 19 ; here the proportion is more than one in five. The danger from pneumonia in rheumatism exists chiefly when inflammation ofthe heart, or rather when endocarditis or pericarditis is conjoined. Several surgical writers have noticed the occurrence of pneumonia after amputation and other great surgical operations, and likewise after exten- sive wounds; and it has been supposed that this disease is frequently the cause of death in these cases. Of this form I have previously spoken. I well remember to have heard Dupuytren frequently speak, in his clinical lectures at the Hotel-Dieu, of this always troublesome and not seldom fatal sequence of amputations, particularly in scrofulous subjects; and so im- pressed was he with the necessity of some preventive measures, that he uni- formly directed a blister to be applied, and a discharge established, com- monly on the chest or the inside of the arm, before he removed the dis- eased limb. M. Erichson (Med. Gaz., 1841), by -whom this subject has been examined in detail, regards pneumonia thus occurring as in close affinity with typhoid pneumonia. The progress of sthenic pneumonia is well and tersely described by An- dral (op. cit.). From the first to the second day ofthe disease, pain, chill, impeded respiration, cough without expectoration, crepitating rhonchus, resonance of the chest, and fever, are the observable phenomena, and those which constitute the first period of the disease. From the second to the third day the expectoration is distinctive, by its becoming viscous and variously coloured. The crepitating rhonchus (crepitation) is more evident, the resonance of the chest is weaker on the side in which the pneumonia exists ; the pain is less acute than at the beginning, but the dyspnoea is increased ; the patient lies on his back ; the fever is violent, skin dry, sometimes moist. If resolution be not effected in the first stage of the disease, or that of engorgement, and the symptoms be more intense, the second stage is reached ; and then the laborious breathing is increased, the speech is tremulous, the tenacity ofthe 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 convalescence. If the pneumonia reaches the third stage, the expectoration in the larger number of cases is watery and brown, and more or less like plum-juice. Commonly, also, the face becomes 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 hepatiza- tion 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 symp- toms of pneumonia, and when the patient is congratulating himself, and praising his physician for the removal of his disease and the prospect of a 204 DISEASES OF THE RESPIRATORY APPARATUS. speedy restoration to health, things take a most unexpected turn. The pulse becomes slow and wTeak, the skin cool, then cold ; sweat oozes from every pore, but to increase the coldness and weakness. If the pa- tient 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 allowTed his patient light nutri- ment, now makes it more stimulating, by substituting animal broths for sago, arrow-root, or 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 occur- rence. It was in the case of a patient of my 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, decu- bitus 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 sinking 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 interesting by the estimable character of the man who was its subject, I was attracted by the heading of a paper in the Edinb. 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 ofthe symptoms of typhoid pleurisy or pneumonia. Mine had nothing of that character at its onset; but, on the contrary, exhibited all the symp- toms of well-marked acute inflammation. 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. Prognosis and Termination.—The prognosis in pneumonia is always serious, although physicians are not agreed as to the proportionate mor- tality ; 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 to a crisis by spontaneous evacuation. A very 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. PROGNOSIS OF PNEUMONIA. 205 Thus, in simple pneumonia the viscidity and rusty tinge of the sputa are in exact proportion to the intensity ofthe inflammation, and their increase in quantity and diminution, or tenacity and colour, are the common at- tendants on resolution. Dirty or watery-brown sputa and those contain- ing pus import great danger, inasmuch as they indicate the probable supervention ofthe third stage, and a gangrenous odour generally implies a state of great peril. The sudden suppression of expectoration is gene- rally an unfavourable sign ; for although the disease may be resolved without any increase of the expectoration, yet this has always a favour- able 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, sickness of stomach, and tender- ness of the epigastrium. A moderately perspirable skin is the most favourable state ; profuse perspirations, as I have already stated, some- times 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 ofthe inflam- mation, a fatal result may be anticipated. Delirium is generally con- sidered 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 ex- acerbations; but in hysterical females it is of less importance. Equally fearful is a comatose or lethargic state, as it shows that the functional dis- order has greatly encroached on the strength required for the necessary treatment. Ofthe 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 pneumonia a perspiration that can be called critical, without, at the same time, a deposit in the urine. A copious ex- pectoration of a critical character does not occur so often as is described by Sydenham 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, eleven on the fourteenth, and nine on the twentieth days. The recoveries 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 in- flammation continues for a much longer period in the first stage ; after some weeks' duration presenting only some hepatized 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 remark- able tendency to pneumonia in old and debilitated subjects to pass rapidly to the state of purulent infiltration,—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. 206 DISEASES OF THE RESPIRATORY APPARATUS. A strong constitution and youth have sufficed to triumph over this sinister state of things. The extent of the inflammation modifies greatly the prog- nosis. Thus a double pneumonia affecting both lungs at once is frequently fatal, even in the first stage; and whenever the whole of one lung is in- volved there is much danger of an unfavourable issue. The part ofthe 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 ofthe upper or lower portion of the lung. Andral's statistics on this point are in favour of the predo- minance ofthe latter. Of 88 cases of pneumonia, in 47 the inflamraation was of the inferior 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. Dr. Hughes, in 101 cases, states, as a result of his inquiries, the inflammation to have attacked the base alone in 62; the entire lung in 12; the posterior part alone in 8; the apex in 5; the centre alone in 3. The parts were not mentioned in 2, and various parts in one or both lungs, without specification, in 9. MM. Val- leix and Vernois assign, in 139 examples, pneumonia of base and summit, 44; base alone, 44; summit alone, 20; disseminated lobular pneumonia, 31. From the combined observations of Andral, Chomel, and Lombard, 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 disease 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 gentleman, it will be found that the double pneumonia is more frequent than appears from the above statement. It commonly hap- pens 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 detec- tion. Confirmatory of this opinion I place before you the following table:— Right Lung. Left Lung. Both Lungs. Unascertained. Andral (210 cases) 121 58 25 6 Chomel (59) 28 15 16 Valleix and Vernois (128) 17 0 111 Berg (335) 201 134 West (37) 37 Hughes (101) 52 29 19 1 " (145) 43 40 60 2 Total (1015) 462 276 268 9 The complication of other diseases with pneumonia increases the dan- ger ; as in the case of fevers and the exanthemata, and the more formi- dable is the inflammation in these cases because it is often latent. Pneu- monia 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 preg- nancy 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. CAUSES OF PNEUMONIA. 207 Causes.—The causes of pneumonia may be considered under the two heads,—of those external, and those connected with the individual him- self. The first include climate, season, and atmospherical 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 diseases in general. Of the Ionian Islands, Corfu is said to suffer most from this disease. The gradual substitution of pulmonary for hepa- tic disease is shown in the English troops returning from India losing the latter and becoming subject to the former. In Italy pneumonia is quite common. 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 fourth. 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 differ- ence 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 diseases, but in a more especial manner in consumption. I shall point out more formally, hereafter, this fallacy, when treating of the etiology of phthisis pulmonalis. At Nice, Genoa, Pisa, and Florence, the disease prevails greatly, and cuts off many ofthe inhabitants. The neighbourhood of Naples, or around Mount Ve- suvius, is remarkable for this occurrence. Hence it may be called truly endemic, especially by those who attribute it to the noxious exhalation which prevails there. To more recognised climatic influences should we attribute the endemic character of pneumonia in northern Europe gene- rally, 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. Recent statistical returns in England show, that the greater mortality from pneumonia in persons under 15 years of age takes place in December. 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 predisposition by which certain indi- viduals 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 atmos- pherical influences, in'the manner just described, should count largely in our inquiries into the causation of pneumonia. The epidemic occurrence ofthe disease is clearly proved, although even here, again, we shall be at 208 DISEASES OF THE RESPIRATORY APPARATUS. a loss to account for the fact in any known and appreciable limitations and combinations of states ofthe atmosphere. The influence of particular employments, in which those engaged are much exposed to cold and humidity, ha? been greatly overrated, as we learn from Thackrah, among others. Regularity in other respects, and particularly avoidance of alcoholic stimulation, renders exposures of this nature, and even sudden transitions from high to low temperature, com- paratively innocuous. That there are internal causes, a special but not a priori recognisable 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. Dezoten fifteen times. Perhaps the chief predisposing cause, at any rate the one depending on recognised peculiarity of organi- zation, is tubercles of the lungs. How many are the cases of tuberculous consumption in which pneumonia is developed. 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 pneu- monia, 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 dothinenteritis, 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 inflammation of some other organ singularly predisposes some individuals to pneumonia. One ofthe most severe cases ofthe 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 etiology 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 fro.m pneumonia which is chiefly latent. The age between one and five years from birth is declared by MM. Barthez and Rilliet to be a predisposing cause of pneumonia. Secondary acute pneumonia is much more frequent at this age. Sex displays a modifying influence, in the greater readiness of men to contract pneumonia. Out of ninety-seven cases which occurred in the wards of La Charite, 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. MM. Rilliet and Barthez tell us that of 245 cases of pneumonia, 95 were of girls and 150 boys. Treatment.—If inferences were to be drawn respecting the treatment of pneumonia from the proportionate number of fatal cases, we should be greatly at a loss to determine on which side the advantage lies ; both owing to the fluctuation at different times in the same place, and the dif- ferent results published by two sets of writers of the same cases. The great success of M. Laennec, under the tartar-emetic treatment, in his only TREATMENT OF PNEUMONIA. 209 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. Bouil- laud, 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 were 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 90 cures, which is a mortality of 1 in 8^. M. Lacaze of Mont- geron, near Paris, has published, in the Journal Hebdomadaire (1834), a statement of the treatment of 42 cases of pneumonia treated by large bleed- ings, which shows only one death out ofthe entire number. In the ques- tion of mortality and of treatment, you must, however, always remember 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, over-work, or excesses of various kinds, and the deteriorating influence of the air of a hospital, are all adverse 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 treatment in inflammatory diseases. The inability of their patients in the hospital to bear free depletion, ought not to be received as evidence of its inapplica- bleness to patients of even a similar age and temperament 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 venesection in pneumonia. It is difficult to explain the results furnished by M. Louis's tables, with respect to bloodletting 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 pneumo- nia ; and as we know that the lancet has comparatively little efficacy in the latter form, we must conclude, without impugning the method or ac- curacy of M. Louis, that its value in sthenic pneumonia is greater than what appears from these calculations. In addition, it may be observed, that no mention is made of local bleed- ings 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 certainly 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 genera] bleeding is to remove or modify the constitutional symptoms. 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. But I reserve for the next lecture a methodical view of the treatment of pneumonia in its varieties and stages. VOL. n.—15 210 DISEASES OF THE RESPIRATORY APPARATUS. LECTURE CI. DR. BELL. Treatment of Pneumonia—Superiority of venesection over all other remedies—Extent of its use and frequency of repetition—Not to be deterred by the fear of interfering with critical evacuations—Circumstances which modify bloodletting—Original strength of constitution ; complication of pneumonia with other diseases—Bloodletting in the pneu- monia of infants—Purgatives—Tartar emetic—Laennec's and Louis's advocacy of— Mode and rule for using it in infantile subjects—Calomel — Revulsives and counter- irritants—Drinks. The treatment of pneumonia will differ according as we have to do with the simple primary or secondary, and the mixed or typhoid pneumonia. It is to the first that my remarks will chiefly apply just now. As respects venesec- tion, too cautiously advised by Dr. Stokes, although I would not go so 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 pneumonia, he would be contented to dispense with all other aids than those of the lancet and water gruel, 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 sometimes invoked against bloodletting in pneumonia, 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 cannot be intro- duced to contradict the experience of both ancients and moderns in favour of free, or we might, as Dr. Watson properly does, say prodigal bloodlet- ting. The abstraction of blood is productive of immediate and direct re- lief to the suffering organs, which are now able to resume, in degree, their functions at once. To be most effective, venesection ought to be prac- tised at the first invasion of the disease; an advantage which may be readily procured 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 in cases of pleuritic stitch, ought, as this judicious practitioner recommends, to be considered as adjuvants, but not a principal remedy nor as substitutes for the lancet. If we can bleed early, within the first twelve or twenty-four hours of the attack, and produce a decided impression just short of syncope 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 can- not hope for much from it, and when hepatization has begun it will be in- jurious. How often should the bleeding be repeated ? Dr. Stokes tells us (Treatise, &c.) not more than twice; M. Andral says from three to five times ; 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 TREATMENT OF PNEUMONIA. 211 would induce me to press the use of the lancet without stint, where there is pleurisy associated with pneumonia, until the pain is removed 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, of previously good constitution and rather full habit, was directed by me to be bled, and she was bled, but not to the extent which I wished. I prescribed a repetition ofthe opera- tion on the morning following the first venesection, but the quantity fell far short of the exigency of the case. In the afternoon (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 this remedy by a fear of its interfering 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 ofthe disease. After expectoration is freely es- tablished, 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 neces- sity, not of precaution; nor is it one of cumulation, an increase merely of remedial impression for the removal of the disease. Bloodletting cannot be as efficacious in the hepatization of pneumonia as it is in the primary stage of engorgement; but still it often produces excellent effects; even, as M. Andral assures us, after the grey hepatization in the suppurative stage. Not that we bleed in this case for the removal or absorption ofthe pus, but to relieve other parts of the lung in which hepatization still pre- vails. 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 phlegmasia?, often rises and acquires volume after bleeding. Copious sweat has been regarded by some as a cause for our withholding the use of the lancet; but I have already told you that often a warm sweat ac- companies some of the worst and fatal cases ; and hence, that it is not critical, nor can its suppression be attended with deleterious effects, 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 ofthe 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 pneumonia you will not see any buff on the blood. Returning from this digression, let me conclude my remarks on the circumstances requiring and modifying bloodletting in pneumonia. When delirium is present in the disease, and proceeds from meningitis, we find additional reason for the use ofthe lancet, followed, if necessary, by cups or leeches to the temples. In intemperate subjects local depletion from the head will suffice, followed by tartar emetic and opium, in old per- sons 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 de- pression caused by loss of blood. But this is a mistake, if assumed as a 212 DISEASES OF THE RESPIRATORY APPARATUS. 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 anemic orscrofulous habit, and weakened by excesses of any kind,—in the same disease. I ordered to be both bled and cupped a female eighty years of age, and of a thin habit, and apparently fragile constitution, who had pleuro-pneumonia during the last winter (1843-4). She recovered entirely, and lived four years afterwards. In the complication of pneumonia with eruptive fevers, some physicians are afraid to draw blood,—imposed upon by the small, frequent pulse, and predominance of nervous symptoms, great weakness, and apparent prostration. This is often the critical epoch, when blood- letting 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 external warmth and frictions. A similar remark applies to the supervention ot 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 predomi- nates over inflamraation, and we cannot hope to free the lungs by full bleedings ; but we may greatly relieve them, and simplify the diagnosis by small ones either from the arm, or preferably by cups to the chest,— on the sides, under the clavicle, and between the shoulders. The pre- sence of the menstrual flux has been supposed to contra-indicate bloodlet- ting in pneumonia ; but without reason, if the symntoms are violent, and the case is of such a nature that it would otherwise call at once for vene- section. In the pneumonia of children we have at first difficulty in establishing 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 adapting our views of practice, in reference to their peculiar constitution. Bloodlet- ting is required in primary infantile pneumonia, but not to the extent nor wTith the same freedom of repetition as in the case of adults. If it does not materially shorten the disease, it abates the febrile movement and diminishes the local malady and the probability of complications. Could we, with Dr. Gerhard (Am. Jour, of Med. Sciences, vol. xv.), in his valu- able paper on the pneumonia of children, suppose that this disease, in subjects from two to five years of age, approaches more to sanguineous con- gestion 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 characterize an inflammatory affection ? 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 ab- straction of blood. Nutritive life is active in them ; and there is great mobility both of the circulatory and nervous systems ; but their powers of reaction are not great. We are restrained, also, by another consideration TREATMENT OF PNEUMONIA. 213 in the disease before us. It is seldom idiopathic ; but results from other diseases and ailments, among which, as I have already told you, bron- chitis is one of the principal. Thus gradual in its approach and compli- cated with other diseases, the pneumonia of children is not of that open kind that would justify large and repeated bloodletting. The experi- ence of MM. Rilliet and Barthez and the recorded testimony of other writers adduced by them, are unfavourable to the remedy, which, as they allege, under these circumstances, 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 ofthe chest, or between the shoulders, than from venesection ; 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. Although bloodletting is the chief it must not be regarded as the sole available remedy in pneumonia. In the beginning of the disease and towards its decline tolerably active purgatives, into the composition of which calomel enters, are administered with good effect. In fixed hepa- tization we cannot promise ourselves much service from them. But next to bloodletting in pneumonia comes tartar emetic. My own experience, and I have used this medicine freely for the last twenty-five years, is coin- cident with that of Dr. Stokes and the French School. I would quote on this particular point, in terms of decided approbation, the language of Laennec, who says : " As soon as I recognise the existence of the pneu- monia, if the patient is in a state to bear venesection, I direct from eight to sixteen ounces of blood to be taken from the arm. I very rarely repeat the bleeding except in the case of patients affected with disease of the heart, or threatened with apoplexy, or some other internal congestion. More than once I have even effected very rapid cures of intense peripneu- raony without bleeding at all; but in common I do not think it right to deprive myself of a means so powerful as venesection, except in cachectic or debilitated subjects. I regard bloodletting as a means of allaying for a time the Violence-of inflammatory action and giving time for the tartar emetic to act." M. Lepelletier, among the numerous pathological facts contained in his volume, gives, from various sources, the details of twenty-four cases of pneumonia successfully treated by venesection and tartarized antimony conjointly, and of twelve failures by the same method ; of thirteen fortunate ones by tartar emetic, and of two fatal when the same means were used. (Brit, and For. Rev., vol. i.) We generally begin, says Dr. Stokes, 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. He has never gone beyond this dose ; but it must be remembered that the most careful attention was always paid to local treatment. For the reduction ofthe ordinary inflammations ofthe lung in Ireland, continues Dr. S., returns show that it is seldom necessary to administer 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, he has often continued the exhibition of the remedy to the amount of fifty grains, and in one case, where an acute double pneu- monia was superadded to a chronic bronchitis, one hundred and seventy grains were used in the quantity of twelve grains daily. The patient's 214 DISEASES OF THE RESPIRATORY APPARATUS. 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 produced vomiting, and in some purging; but the effects generally subsided, after the first twenty-four hours. With re- spect to the interval of tolerance, he has constantly verified the statements of Laennec; and there is hardly a more interesting circumstance in medi- cine than to see a patient take from eight to twelve grains ofthe 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 treat- ment, 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. Believing that adequate justice is not done to the antimonial practice by our medical brethren generally in the United States, many of whom are pleased to reject what they call theory, on the strength of some a priori reasoning of a hypothetical nature of their own, I give insertion here to the opinions of M. Louis on the subject. This gentleman's skep- ticism on the remedial value of modes of practice the most esteemed by others is well known, as, for instance, on the efficacy of bloodletting in pneumonia ; and henr^e more will be thought of his favourable view of the utility of tartar emetic in full doses in this disease. " To sixteen of the individuals who recovered, tartar emetic was admin- istered, during a period of from four to seven days, in quantities progres- sively increasing from six to twelve grains in six ounces of the distilled water of the flowers of the linden-tree (eau distille de tilleul), sweetened with half an ounce or an ounce of syrup of poppies, and the patients took these quantities in six or eight doses. Their disease lasted, on an average, eighteen days—three days longer than that of the individuals not subjected to this treatment: so that it would appear at the first glance, that the emetic tartar had a pernicious effect on the course of the disease, instead of having accelerated its fortunate termination. " But this influence was pernicious in appearance only. The emetic tartar was administered, after several bleedings had been performed, on the eighth day of the affection on an average, because the disease continued acquiring greater and greater intensity ; and in cases not bled for the first time till the fifth day, as a mean term : whilst it had been performed on the third day in the cases in which this medicine was not employed. That is to say, it was given under the most unfavourable circumstances, and in severe cases, which explains the long duration of the disease in those who took it. Let us add, and it is necessary to insist on the importance of this fact, that the patients, for whom the emetic tartar was prescribed, were older than those who did not take it, in the proportion, on an average, of forty-five years to thirty-one : an enormous difference, which shows that not only had the medicine no pernicious effect on the duration ofthe dis- ease ; but that in some cases it must have accelerated its course and pre- vented a fatal termination. " The last proposition appears, moreover, to be confirmed by the changes TREATMENT OF PNEUMONIA. 215 which almost immediately followed the exhibition of the emetic tartar. From the day following that of its first employment, fifteen of the seventeen persons who took it found themselves a little better, or much better, having then perceptibly more strength, an improved physiognomy, and the respi- ration less restrained. Besides, thirteen of them, whose chest emitted a sound more or less completely dull over a certain space, when the emetic tartar was first administered, showed from the following day a perceptible improvement in this respect; percussion of the thorax being already more sonorous ; and these various ameliorations were permanent, and made ad- ditional progress daily. " The increase of strength from the day next ensuing, or that in which the medicine was administered, is the more remarkable, as its action was accompanied with frequent purging and vomiting. In sixteen cases out of seventeen, the alvine evacuations were very numerous, ranging from eight to fifteen on the first day, one-half less frequent on the second, and on the third and fourth, not more so than in the ordinary state. The vomi- tings were less numerous, and of a shorter duration, than the alvine dis- charges : they did not continue beyond the first day, and were absent altogether in five instances. " Three ofthe patients who died took the emetic tartar, and did not experience any improvement on the day following that of its administra- tion. One alone of these had not the evacuations mentioned. " Thus of twenty cases in which the emetic tartar was employed under unfavourable circumstances, three only were fatal ; which cannot leave a doubt, as it appears to me, of the utility of this medicine, in large doses, in the treatment of pneumonia ; and so much the more as these three indi- viduals were all aged, being sixty or seventy years old." Laennec has been severely censured for his statement, that the gastro- enteritis of fever does not contra-indicate the use ofthe tartar emetic. 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 reduci- ble 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 contradictions to the use of this, as of all other medicines, ought to be founded on experience alone. It is now proved, that the ex- istence of typhous fever does not contra-indicate the use of tartar emetic, but that, on the contrary, its exhibition may be followed by the happiest effects ; the gastro-enteritis of Broussais, then, does not contra-indicate the use of this remedy. The rule to guide us in the antimonial practice is thus described by Dr. Stokes:—The success of the antimonial treatment depends on or is favoured by, the inflammatory character ofthe 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 ofthe 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 cannot be used with boldness, and where stimu- lants are required, the exhibition of the tartar emetic, in full doses, is very 216 DISEASES OF THE RESPIRATORY APPARATUS. hazardous. The mercurial treatment is to be preferred from its greater safety, and, in this disease, more than equal efficacy. It is while the crepitating rale is heard more distinctly, and before a complete solidification has taken place, that the remedy answers best. Indeed, in the advanced stages ofthe disease, and where the object is to remove hepatization, the antimonial is inferior to the mercurial practice ; but the mere occurrence of hepatization does not contra-indicate the use of the antimony, if it be in the early stage of the disease, and while the crepi- tating rale is advancing in other portions of the lung. In those cases in which the remedy has been borne well, it is not advi- sable to omit its use suddenly. A severe relapse has followed this prac- tice ; but by diminishing the dose at the rate of a grain or two daily, these effects can be avoided. In those cases in which the tartar emetic is not borne, or its use seems inadmissible, we may generally have recourse to mercury. Respecting the value ofthe tartar-emetic treatment in the pneumonia of children, my own experience coincides with the conclusions of MM. Rilliet and Barthez, 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 gastrointestinal accidents give little cause of fear; and finally, that this medicament ap- pears to act more directly upon the pulse and respiration than upon the hepatization itself." This remedy is likewise of service in secondary pneu- monia. From a grain to a grain and a half may be taken in the twenty- four hours. But a remark made by the French writers just named, 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, whatever may have been the treatment employed. As a prompt abater of inflammation calomel is inferior to tartar emetic, but where congestion is complicated with phlogosis, and especially where secretion from a mucous membrane is suspended by an inflammatory con- dition of the latter, calomel is entitled to a preference. This medicine acts on the gastro-hepatic and gastro-intestinal apparatus, which are liable to be implicated in pneumonia, and in this way, by revulsion, relieves the oppressed lungs, at the same time that it facilitates abundant secretion of sputa and thus unloads the turgid and congested air-cells. Calomel con- tributes, also, to a more natural action of the skin, which becomes softer and cooler under its use. We may advantageously combine with it nitrate of potassa, and, taking care not to offend the stomach, minute doses of tartar emetic. My own usage is, after an adequately full venesection, to administer a mercurial purge of calomel and jalap, or ten grains of calomel followed, after four or five hours, by half an ounce of sulphate of magne- sia and a drachm of the wine of colchicum seeds. I then, if the lancet is not again called for, but the pneumonia persists, direct calomel in a dose of two grains every two hours, to be continued for forty-eight hours, either alone or in combination with nitre and tartar emetic. But in thus pre- scribing calomel, I do not desire to see those proofs of extreme constitu- tional operation which end in ptyalism, short of which its best therapeutical effects may, in a vast majority of cases, be obtained. Counter-irritants in the shape of sinapisms to the extremities and hot pediluvia, are generally and usefully prescribed. As revulsives, leeches TREATMENT OF PNEUMONIA. 217 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 in pre- ference to their application to the chest. Blisters, a favourite 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 ofthe disease they are not to be relied on; and they irritate, often exces- sively, 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 ofthe disease. In children we must trust more to counter-ir- ritation than in adults; and hence, in cases of pneumonia attacking the former class of subjects, we direct stimulating liniments rubbed on the skin, irritation of the lower extremities by liniments or sinapisms, the 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 pneu- monia, as calculated to injure both by filling the bloodvessels and by in- ducing dyspnoea, owing to distention ofthe stomach. LECTURE CII. DR. BELL, a Treatment of Pneumonia (Concluded)—Opium and other narcotics—Depression to be met by stimulants and mild tonics—Treatment of complications—Bilious pneumonia —Tartar emetic in their case—Regimen and drinks in pneumonia—Convalescence— Cautions requisite in—Typhoid Pneumonia—Its epidemic prevalence—Predisposing causes—Symptoms—Treatment—Depletion less used, and stimulants more freely—Com- plications to be attended to—Chronic Pneumonia—Physical signs of—Caution atrainst much depletion in—Edema of the Lungs—A secondary disease—Symptoms and treat- ment. I spokk of opium as a medicine which might be usefully given on the ac- cession of pneumonia, and especially and mainly after a large bleeding. This period over, we ought to be very sparing in the use of this medicine, which may increase the pulmonary congestion, both by its effects on the circulation and by dangerously weakening the innervation on the respira- tory muscles, and also by its operation 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 symp- toms and wakefulness,—Dover's powder, in doses of three grains every two or three hours, will be of much service. When calomel is adminis- tered, this fashion of opiate may be usefully combined with it, even in an earlier period ofthe disease; and, as already pointed out, the addition of a few drops of laudanum to the tartar-emetic solution is both admissible and proper. You will find no contradiction between these admissions in favour of the occasional use of opium, and the general prohibition pre- cedingly 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 ipecacuanha, serves both as an ad- juvant and corrigent, and aids the operation of these medicines without any inconvenient exhibition of its own more distinctive and peculiar powers. 218 DISEASES OF THE RESPIRATORY APPARATUS. In cases of doubt, less objection applies to other narcotics, such as hyos- ciamus; and as a narcotic diuretic which directly soothes, and indirectly relieves also, by a revulsion on the kidneys, digitalis is entitled to consi- deration. 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 a former lecture. This requires mild tonics and even stimulants. Of the latter I prefer, as prompter in its operation, and less hurtful subsequently, carbonate of am- monia, to which small doses of Dover's powder and wine whey are pro- perly added. In the cases in which we are forbidden to repeat venesec- tion, but 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 expectoration and urine are scanty, small doses of oil of turpentine. Possi- bly under these circumstances a trial might be made of tincture of cantha- rides, as recommended in sthenic pneumonia, by Dr. Mendim, who regards the medicine, oddly enough it would seem to us, as counter-stimulant. In the second, verging on the third stage, the iodide of potassium has been used with manifestly good effects by Dr. Upshur. (Medical Exami- ner.) He directs it in doses of five grains every two hours, in two ounces of infusion of hops. Dr. U. believes it to be particularly indicated; 1. In the pneumonia of anemic persons, in which the disease is characterized by typhoid symptoms in its early stages. 2. In cases in which inflammatory action, high at the commencement, has been much reduced by antiphlogis- tic treatment and the suppurative stage is just beginning. 3. In cases which are superinduced on long-continued intermittents, that have left the blood much impoverished. 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, ealumba 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 of the liver 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, nor of 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-pneu- monia, or pleurisy alone, preference should be given to calomel over tartar emetic, after the lancet has been used. We give calomel, at first to act on the bowels, aiding its operation in this way by saline purgatives, and after- wards as a direct antiphlogistic; a sedative, in fact, but not as a sialagogue. The regimen in ordinary pneumonia ought to be strictly antiphlogistic throughout; and hence a restriction to simple drinks, demulcent and di- luent. Warm drinks are those generally recommended; but unless there be some gastric complication forbidding their use, cold ones are not inad- missible. If the counter-stimulant plan be adopted, the patient should not be allowed to drink much liquid until toleration of the tartar emetic is es- tablished. An exception to the antiphlogistic course in pneumonia is sometimes met with, in the cases of old and intemperate persons, to whom, in some TREATMENT OF PNEUMONIA. 219 instances, wine and even spirits have been allowed. The safer practice will be to give volatile alkali (carbonate of ammonia) 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 ofthe room should be attended to, in connexion with the other parts of the treatment of pneumonia. Hot air and currents of cold air are alike 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 occasionally allowing the patient to breathe cold air, admitted by 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 ofthe 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, in- cluding that of talking, is injurious, and must, except for the necessary acts of defecation, &c, be prohibited. Convalescence.—Remembering the tendency to tuberculous disease 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 edema of the lungs, as it is termed by M. Andral, which follows inflammation. 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; tor, as we learn from the same high authority just named, dyspnoea and the cre- pitating rhonchus, to which this form of the disease gives rise, are not suf- ficient to enlighten us. We are apt to be misled both during the progress of pneumonia and of many other phlegmasia?, by a persistent fulness and tension, or at least vibration ofthe pulse, which is due to hypertrophy, or sometimes tempo- rary irritation of the left ventricle. A persistence in bloodletting and ana- logous 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 or thrice 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 exigencies ofthe case, should there be any remains of pul- monic congestion. The means for preventing a relapse are the same as those which are prophylactic against pneumonia. They will consist in a careful protection ofthe skin by suitably warm and, what is best for this purpose, flannel and merino inner garments: 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 220 DISEASES OF THE RESPIRATORY APPARATUS. 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 excuse is gross ignorance, to subject their infants and other children to similar exposures. Typhoid Pneumonia.— I have now to offer a few remarks on a very important modification of pneumonia, the typhoid. Epidemically prevailing under the names of typhoid pleurisy, bastard peripneumony, putrid pneumonia, &c, its ravages are great, and even when occur- ring sporadically, or as an intercurrent, it is not less to be dreaded. In the United States during the last war with Great Britain, and for two successive winters after the peace, or from 1813-14 to that of 16- 17, this disease prevailed very extensively, in fact from Canada to Geor- gia. To me this form of pneumonia possesses a peculiar interest from its epidemic prevalence in Virginia, when I was a student of medicine, and also, from the circumstance of my early introduction to clinical me- dicine taking place, by my services being enlisted for the relief of many of the numerous sufferers from the disease. The general predisposing causes were, atmospherical extremes and vicissitudes, especially prolonged cold and moisture; the occasionally predisposing ones were defective food, mental anxiety, or derangements and feebleness of the nervous system, by the prolonged or suddenly increased use of ardent spirits. The aged and the intemperate, and those much exposed to hardships, were the chief suf- ferers; although, in other instances, disease, rapidly followed by death,came on in young subjects of different habits and constitutions. The most speedily fatal and least manageable complication was that with angina. Endemically,typhoid pneumonia is met with in low marshy districts, during the later winter months; cold and moisture seeming to give rise to pulmo- nary congestion at this season, with the same readiness that heat and mois- ture did, during the antecedent autumn, to congestions of the spleen. Ac- cording to the class of subjects, we may expect, in those countries, and with some slight modifications of temperature, to see bilious pneumonia and typhoid pneumonia. In towns and situations in which a large num- ber of people are congregated, with but limited opportunity of inhaling air, while they are still exposed to its inclemencies, and on whom imper- fect alimentation and the use of ardent spirits also exert their effects, we see pneumonia more manifestly of a typhoid character, with gastrointes- tinal complications, and attacking subjects of different ages thus circum- stanced. By whatever name we may designate the disease, we cannot help being struck with the general sameness of the causes assigned by different wri- ters, and on reflection, with the mode in which these causes operate, by enfeebling the nervous and capillary systems and inviting congestions, the precise location of which will depend on prior weakness and present atmo- spherical conditions. If we admit the share which the nervous system, thus deteriorated, performs in the special etiology ofthe disease, we must go a step farther, and see in its morbid condition a cause for depravation of the blood, and the introduction of a new element in the pathology of typhoid pneumonia. It was in reference to the probable part performed by the blood in the production of this disease that I have elsewhere made the remark that its history yet remains to be written. It may be that the TYPHOID PNEUMONIA. 221 same causes which tend to derange thp functions of the nervous system act also on the composition and quality of the blood, and that the two stand in the relation of common effects rather than in that of cause and effect. Be this as it may, we cannot overlook the state of the blood, in studying the pathology, or in laying down the indications of cure, of typhoid pneu- monia. Connecting the observations left us by Huxham, ofthe peculiar appearance and change of the blood in the disease, with the remarks of M. Andral (Essai de Hematologic Pathologique) on the defibrinization of this fluid in cas.-s of pyrexia in which there is such a tendency to sangui- neous congestions, we know enough to authorize a belief that in typhoid pneumonia the blood has undergone a change of this nature, analogous to that in scurvy and in splenic congestions. We cannot say, as Dr. Stokes justly remarks, that there is any specific typhoid pneumonia ; but we find that, under a variety of depressing cir- cumstances, conditions of the lungs more or less analogous may be in- duced, presenting the characters of the disease as given by various authors. Among these he refers to Huxham on Fevers ; Stoll, De Peri- pneumonia Vera; also Burserius, who has described an erysipelatous pneu- monia. In the writings of Good, Williams, Mackintosh, and Andral, the disease is noticed. Louis merely alludes to the occurrence of hepatiza- tion in typhous fever, in Recherches sur la Gastro-Entente. In the ear- liest editions of the Histoire des Phlegmasies, the statements of Broussais, written before he had formed his theory of fever, may be studied with great advantage. 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 ofthe disease ; of these, the nervous peripneumony seems most like the disease met with here. This disease is seen more frequently in hospital than private practice— a fact strongly illustrative of its connexion with the low state of the sys- tem. Dr. Stokes has observed it in the following cases :— 1st. As a complication with enteritis, or gastro-enteritis. 2d. Complication with true typhus. 3d. Occufring in cases of bad erysipelas. 4th. Supervening in cases ofthe 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 origi- nal nature, yet, with respect to the pneumonia, they have a certain agree- ment ; for the affection is more or less latent, presents similar physical signs, requires that the antiphlogistic treatment should be employed with extreme caution, and in many cases that the free and early use of stimu- lants should be resorted to. Of the cases above noticed, those complica- ting typhous fever are most frequently observed. The terminations of typhoid pneumonia are various: it may rapidly produce a fatal hepatization ; 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 physician is the extreme slowness of its resolution, as compared with sthenic pneu- monia. Months may elapse before the respiratory murmur is restored, and in many cases this is never completely re-established. The fact, that contraction of the chest has been only met with in these cases, shows the 222 DISEASES OF THE RESPIRATORY APPARATUS. slowness with which the disease is removed. For farther details on the pathology of typhoid pneumonia, I refer you to Dr. Stokes's Treatise on Diseases of the Chest. I should give you an imperfect view of typhoid pneumonia if I were to restrict myself to the notices of the disease by European writers alone. Of its epidemic prevalence in the United States I have already spoken. I might have added, that its appearance during the periods indicated gave rise to a number of essays on the subject, the majority of which were writ- ten in haste and in a spirit of preconceived pathology and therapeutical indi- cation, nor were they illustrated with the requisite detail of cases or of post- mortem examinations. But apart from its epidemic visitations, typhoid pneumonia would seem to exhibit an almost endemic character in particu- lar portions of our country, and which in addition, also, to its frequent sporadic recurrence invest it with decided interest in the eyes of the American practitioner. Dr. S. H. Dickson, occupying a different field, and witness to the occur- rence ofthe disease under different circumstances from what English wri- ters have described, is entitled to be heard with no little consideration in this matter. This gentleman, who, until recently, was Professor of the Institutes and Practice of Medicine in the Medical College of South Ca- rolina, and who is now Professor ofthe Theory and Practice of Medicine in the University of the City of New York, holds different views from those generally entertained on the pathology of typhoid pneumonia. He classes it among the idiopathic fevers, with a remark of " the disease so widely prevailing at times over the North American continent—its eastern poition especially." Its being modified by circumstances, is described in the following terms: " Thus, while it scarcely differed from ordinary catarrhal fever in some situations, in others it appeared little more than a violent inflammatory congestion of the lungs—like the lung fever of the eastern states ; and in others still, the chief symptom was a pulmonary congestion, little or not at all inflammatory, resembling what has sometimes received the denomination of pulmonary apoplexy. In some districts it was ushered in by a chill, long-protracted, extremely distressing, and, indeed, in many cases fatal, whence it received its common title of cold plague. At its commencement, so many of the cases presented a cutane- ous eruption, or the occurrence of petechia?, that the vulgar called it a spotted fever,and the learned a pestilential typhus, or, as I have said above, a return ofthe old febris petechialis. It is strange to find how soon in its progress it lost that feature, even in the very localities where it had been most marked." (Essays on Pathology and Therapeutics, being the substance of the Course of lectures delivered by Samuel Henry Dickson, M.D. fyc.) The disease continues to show itself sporadically, Dr. Dickson observes, where it has once found footing. " We scarcely pass a winter without meet- ing with instances of it, especially among our blacks." Regarding its etiology, the author just cited justly remarks that it has certainly some relation to the sensible qualities of the atmosphere—as its dampness and coldness, and that the disease occurs most obviously in those peculiarly exposed to these agents, especially if the exposure be pro- tracted. Children seem to enjoy a special exemption. Females are less liable than males. To the atmospherical causes predisposing to the disease may be added damp and illy-ventilated dwellings, insufficient food or clothing; labour beyond the strength and continued fatigue. An important TREATMENT OF TYPHOID PNEUMONIA. 223 form of typhoid pneumonia is that which occurs in delirium tremens from excess of stimulants. " The disease, as we learn from Dr. Stokes, com- monly attacks the left lung, particularly in its lower portion, and yet it is constantly overlooked. The coexistence of gastritis and of a low peri- carditis with the disease ofthe lung has been recorded." The symptoms are those common to pneumonia, with the addition of great dejection of the spirits, and from the beginnings in many cases, a degree of delirium which sinks gradually, as the patient grows worse, into the low muttering characteristic of typhus. As the disease advances the typhous symptoms become aggravated. The next most common form of typhoid pneumonia, described by Dr. Dickson, resembles much, in its onset, the bilious pleurisy of the southern portion of our country, indicated by " great gastric oppression, frequently with retchinprand vomitinp-of foul mucous and bilioussecretions. Thecoun- tenance is flushed, the eye red and watery, there is aching ofthe head, back and limbs; the pulse is full, but unduly soft and compressible,soon becoming feeble and losing its volume. This stage of vascular excitement is short ; muscular prostration soon supervenes, and the circumstances of the patient become very similar to those described in the first instance." A " peculiar pulmonary congestion" has constituted the principal symptom, in " several impressive examples of this disease." But of all complications of typhoid pneumonia, the most alarming and fatal, as I well remember, were the an- ginose ones. Popular apprehension in this respect corresponded too closely with their fatal result. Auscultation apprises us ofthe crepitant rhonchus, or if the disease is far advanced, bronchial respiration and bronchophony. In some cases, however, there is no abnormal sound. The disease is sometimes ushered in with sudden increase of prostration and an anxious expression of face and appearance of emaciation. The substances effused in the lungs are but little plastic and of a dirty-grey colour as if mixed wTith decomposed blood. The brain, as we learn from Dr. Dickson (op. cit.) is usually more or less altered in appearance, its vessels filled with dark blood, and effu- sions of serum, of coagulable lymph, and even of purulent-looking fluid, are occasionally found upon the surface of the membranes, in the ventri- cles, and even, it is said, within the cerebral substance. The blood is, as in typhus, of a particularly blackish hue. Treatment of Secondary including Typhoid Pneumonia.— Dr. Stokes enumerates the principal points of difference between the treatment of the typhoid and that of primary sthenic pneumonia. They are— " 1st. That general bloodletting is to be used with extreme caution. " 2d. That the mercurial is in general to be substituted for the antimo- nial 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 pneu- monia, close attention must be paid to the abdominal viscera. "6th. That stimulants are to be used with greater boldness and at an earlier period." A still more extended view of the subject may advantageously be taken, by our regarding all secondary or intercurrent pneumonias as associated with states ofthe system in which debility predominates, owing to the ex- haustion by the other and primary disease or the habits of life which either 224 DISEASES OF THE RESPIRATORY APPARATUS. predisposed to or excited them into activity. Hence we may expect to find pneumonia occurring in the progress of small-pox, measles, scarlet fever, hooping-cou^h, remittent and typhoid fevers, and sometimes also in cachectic and enfeebled habits of body, under all of which circumstances the treatment must be modified by these complications. But, and herein is a source of danger, we must not content ourselves with merely regard- ing pneumonia, in such cases, as a symptom or condition of organ depen- dent on the primary disease and removable by the means employed for it. We have to deal not the less with pneumonia, although its febrile associa- tions are different from the usual ones, and the sensibility of the patient so small that the several stages are gone through with hardly any notice from general symptoms. We are not the less required to direct remedies especially for the removal of the morbid condition of the lung, although we must not draw blood with the same freedom, nor give tartar emetic as liberally, nor restrict our patient to the antiphlogistic regimen, as we do in simple sthenic or primary pneumonia. I am afraid that some practition- ers persuade themselves, that the stimulating medicines administered for the removal of debility and to quicken the action of the sluggish heart and inert brain, will carry off at the same time the inflammation of the lung. This kind of medication will do no such thing. All that we can hope for from it and the exhibition of some nutritive stimulants at the same time, is to sustain the powers of life generally, and thus give an opportunity for the inflammation to go through its several stages, with the prospect, often indeed a faint one, that absorption may be sufficiently active to remove the deposited blood in the parenchyma, or the expectoration vigorous enough to allow the patient to throw up the pus that may have been formed. In this kind of pneumonia, then, we must have recourse to the compound practice, which, although it may be adverse to the simplicity of systematic medicine, is really required by the exigencies of the case. It was that certainly attended, I distinctly remember, with the largest measure of suc- cess in the epidemic typhoid pneumonia, during its prevalence in northern Virginia. It consists, after an emetic, in the administration of diffusible stimulants, at the same time with that of the remedies more particularly adapted to pneumonia. Thus, while we direct volatile alkali, camphorated julep, wine w-hey, brandy and water, oil of turpentine, sago with wine whey, &c, we may often usefully draw a few ounces of blood from the chest by cups or leeches, give minute doses of tartar emetic with opium, or its weaker substitute ipecacuanha similarly combined ; or the indica- tions forbidding the antimony, we have recourse to calomel, at first in such doses as to act on the bowels, and afterwards as a counter-stimulant, and sedative alterative. Infusions of polygala senega and of sanguinaria Canadensis are useful remedies. Convalescence from this disease is slow, and requires the administration of mild tonics such as infusion of bark or sulphate of quinia, and great attention to the rules of hygiene. More freely than in sthenic pneumonia shall we have recourse to revul- sion to the skin—to counter-irritants, and among these blisters are entitled to a favourable consideration : they should be used earlier than in the sthe- nic or simple variety. Also, to soothe the pain and oppression, fomenta- tions and bags of hot salt to the chest. Great attention is required at this time, to the posture of the patient, which should be semi-recumbent, alter- nating with entire pronation ; or if this cannot be done, he should change ATELECTASIS. 225 from back to side, and from one side to another. In some cases of second- ary pneumonia with very hurried pulse and but slow respiration, I have employed small doses of digitalis with advantage. Cold skin, on the other hand, is benefited by oil of turpentine mixed with some mucilage. The ethereal oil of turpentine has been recommended by Dr. Huss of Stockholm, in the following formula:—K. iEther ol. terebinth., jss. ; ovor. vitell., j. ; mucilag. ^ij. ; aqua?, ^j. Ft. emulsio. Dose, a tea- spoonful every hour. Opium in full doses often gives signal relief in those cases in which the nervous system is much implicated. Atelectasis.—I revert to the subject of infantile pneumonia in order to introduce, by some additional remarks on it, a consideration of the fmtal condition ofthe lungs after birth, and to point out a probable source of error in writers on inflammation of the lungs in children. It has been already stated, that the chief characteristic feature of infantile pneu- monia is its first showing itself in a single lobule, or if in several they are separate from each other: after a longer period of duration ofthe inflam- mation, the contiguous lobules, in groups as it were, are affected. Lobular pneumonia for the most part appears on both sides of the chest at the same time, and begins at the lower lobe. The lungs are heavier than common, and do not crepitate. Their surface exhibits, at the diseased parts, a granite-red hue, arising from a number of reddish patches. Each patch represents a lobule varying in the extent of congestion, and corresponding with a partial induration of the pulmonary tissue. To the hand grasping these deep knots or nodes, the sensation is that of tuberculous granulations. The engorged lobules are prominent, of varying size, have a smooth ap- pearance, and considerable density; no longer crepitate: they are infil- trated with a reddish sanies, are impermeable to air, and sink in wrater. In their interior they exhibit a roseate colour, studded with red spots. The impermeability that exists during life may, however, M. Bouchut asserts, be removed in the dead body by insufflation, by which the ob- structed cells are distended, resume a roseate hue, and elasticity, with crepitus characteristic of the organ in its healthy state. In true hepatiza- tion of the lung, this change by insufflation cannot be supposed to take place. The very inception, almost, of lobular pneumonia, is evinced by small, red, miliary points, somewhat hard like ecchymoses, in the midst of which is a small point of a darker hue than the rest. These ecchy- moses are so many vesicular pneumonias, by which the congestion of the entire lobe begins. Lobular, by extension, is often converted into lobar pneumonia. Tu- bercular pneumonia is as common in children as simple pneumonia ; and makes its appearance without premonition, or at least in children appa- rently in good health. The tubercles in these cases act as irritants, and induce inflammation of the lungs, which is the fatal disease. Infantile pneumonia is sometimes complicated with pleurisy, and often with bron- chitis. Vesicular or catarrhal pneumonia beginning in catarrh occurs con- jointly with both the lobar and lobular forms ofthe disease. Emphysema is an extremely frequent accompaniment. In a small number of cases only is the brain affected. In the greater number of cases of lobular pneumonia death occurs before the inflamed lobules have passed into the stage of grey hepatization, or the lobular pneumonia becomes general,and the third stage consequently presents no peculiarity. On occasions, however, the inflamed lobules either become infiltrated with pus, and present, on a small scale, VOL. n.—16 226 DISEASES OF THE RESPIRATORY APPARATUS. the same appearance as is seen on a large one in ordinary grey hepati- zation ; or each lobule becomes the seat of a small distinct abscess, with numbers of which the lung seems riddled. The prognosis in .infantile pneumonia is unfavourable. Were we to receive the report of MM. Valleix and Vernois, we should almost abandon all hope of recovery. These writers indicate 127 deaths in 128 cases. M. Bouchut's experience, in the Necker hospital, was somewhat more encouraging ; since out of 55 children attacked with the disease, the re- coveries were 22, and the deaths 33. Among children of a somewhat more advanced age, or from two to fifteen years old, the deaths in the Children's hospital (Hopital des Enfans) were 48 out of 61 cases. Atelectasis (from arsx*?, imperfect, and onuw, I draw out), or atelectasis pulmonum as it was called by Jcirg, consists in an imperfect expansion of the lungs by the first inspirations after birth ; that is in a permanence of the foetal state, in the lung ofthe newly-born infant. The disease does not depend on any original defect of formation in the respiratory organs, but upon restricted functional development at the time of birth. An entire lung, or even an entire lobe, is seldom found in a state of atelectasis—but for the most part only single and scattered lobes. The inferior lobes of both lungs, and the posterior half of the remaining ones, generally are in a particular manner liable to retain the foetal condition. The patches of a brown or violet colour on the surface of the lungs, in intensity proportionate to the want of expansion, always exhibit a deep depression, the superincumbent pleura remaining perfectly smooth and polished. A lobe in this condition, so far from being enlarged, as in common, is, on the contrary, of smaller dimensions than the others, and almost as collapsed as in the foetus; being, in general, deeply imbedded within the thorax, and drawn towards the entrance of the bronchia? and bloodvessels. The general aspect may be likened to dimples created by emphysema in adult lungs. Crepitation is not produced either by inci- sion or pressure, unless where a few air-cells here and there happen to have become expanded. The same delicate reddish froth is never found here as in the healthy parts of the lung, but merely a small quantity of serous, slightly sanguineous fluid. The cut surface appears smooth — uniform — without a vestige of granular elevations. The whole of the diseased structure is not softened, but rather of a hard character : still with- out the tenacity ofthe healthy parts. When a piece is cut off and placed in water it sinks to the bottom of the vessel. It is possible to dilate arti- ficially or by insufflation the undeveloped parts, if death takes place a day or two after birth. Where, however, the little patients have survived for weeks or months, this inflation seldom succeeds, or only imperfectly. At this juncture, the unexpanded pulmonary cells are for the most part adherent; a remarkable fact, seeing how long the lungs continue unex- panded in the foetus, without adhesion ever taking place. In infants who had died of atelectasis, E. Jorg invariably found the foramen ovale of the heart unclosed ; a fact confirmed by Hasse, whose description of the disease I now adopt. The brain was in a congested state. When death followed shortly after birth, the body had the ap- pearance of being generally well developed, but was extensively ecchy- mosed ; the hands and toes were clenched ; and there was foam in front of the nostrils and of the closed mouth. When, however, the disease had lasted some time, the body was wasted and the skin loose and ATELECTASIS. 227 wrinkled. Inflammation of one part of the lung may be contiguous to another part, atelectatic ; a different state of things from that described by Jorg, who believed that both the affected or collapsed and the adja- cent parts are found inflamed, when the disease had been of some dura- tion. If we compare the description of the affected lung in infantile pneumo- nia, the chief features of which I derive from M. Bouchut (Manuel Pra- tique des Maladies des Nouveaux-Nes et Des Enfans a la Mamelle), writh that of atelectasis so carefully given by Hasse, and dwell a little on the account of this latter by Jorg, we can see the difficulty of diagnosis ofthe two diseases, and understand how they would seem to run into each other and be confounded together. Thus, if many of the French and some of the German writers have mistaken atelectasis for infantile pneumonia, Jorg himself and others have described as phenomena ofthe former what were really incident to the latter. Hasse himself, in describing what he believes to be marked differences and contrasts between the two diseases, indicates, as distinctive of one, certain appearances that some of his con- temporaries regard in quite another light. Thus, he says that atelectasis usually affects both lungs,—pneumonia is for the most part confined to one. Bouchut asserts that lobular pneumonia almost always attacks both lungs. In inflammation, the diseased portions are preternaturally distended, whilst in atelectasis they are collapsed, and inferior even to the healthy texture in volume. But here, again, is a difficulty: Dr. West says, that in both diseases the dark portions of the lung are depressed beneath the general level; but in atelectasis the depression is real and owing to the dark por- tions never having been expanded by the entrance of air: in lobular pneumonia it is apparent only, being produced by the emphysematous distention of the surrounding tissues. In inflammation, Hasse observes, the pulmonary texture is softened, in atelectasis it is hard, and the cut surface is not granular but smooth. Now we have seen that a certain degree of hardness under pressure was mentioned as one of the changes induced by inflammation. Then again, as regards seat: both diseases most affect the lower portion of the lung. Shall wre attach any import- ance to the alleged difference of colour in the two diseases? " In atelec- tasis the colouring of the diseased portions of lung always approaches more to a violet, their exterior appearing smooth and glistening so as to contrast with the dull, brown-red surface of inflammation." It must, however, be remembered, that Bouchut speaks of the smooth appearance of the inflamed lobule, while he designates the colour to be of a granite- red, and West describes it as mottled, portions of deep red being inter- spersed with others having a natural aspect. Here, in colour at least, there would seem to be contrasted appearances—a ground of diagnosis. Infiltra- tion of the inflamed lobules with a reddish sanies would seem to be another point of distinction. Where no complication exists, the anatomical charac- ters of a first or third stage of pneumonia are not discoverable either on or near the diseased patch : in short, we have nothing like pneumonia except the solid, non-crepitant mass, which has been confounded with the second stage of that disease, namely, with red hepatization. A portion of incised lung retaining its foetal condition, allows a little thin, dark, apparently natu- ral blood to escape upon pressure. In the first degree of pneumonia a tolera- ble quantity of turbid, bloody fluid, mingled with fibrin, and with a few minute air-vesicles, — in red hepatization, a tenacious dirty-brown red- 228 DISEASES OF THE RESPIRATORY APPARATUS. dish,—in grey hepatization, a large proportion of greyish-yellow purulent fluid may be expressed. Finally, and this is an important consideration, the secondary phenomena attendant upon pneumonia, as inflammation of the pleura and ofthe bronchial mucous membranes, softening ofthe bron- chial glands, fibrinous concretions within the heart's cavities, &c, are wanting in atelectasis. Hasse concludes his summary with this not encouraging remark : But the peculiar characters of this foetal condition of the lung are only thus marked during the first few weeks after birth ; subsequently when, as already stated, ulterior changes take place, it be- comes extremely difficult to form an exact diagnosis from mere cadaveric inspection. The embarrassment is greater the younger the child. It is chiefly with infants under a twelvemonth, that there can be a question of atelectasis, as has been justly remarked by Dr. Gerhard. Hasse closes his critical remarks with the following inferences: New- born infants are prone to an organic affection of the lungs, altogether dis- tinct from pneumonia, and dependent upon imperfect inspiration after birth, by many pathologists confounded with pneumonia, and by Rilliet and Barthez designated as carnification. The greater number of cases of pulmonary disease occurring at the earliest period of infantile life, and set down as pneumonia, may be looked upon as cases of atelectasis. The last assertion is, however, to be taken with some reserve ; inasmuch as, in. vast lying-in or foundling hospitals, pneumonia is apt to become epi- demic with new-born infants, and, under these circumstances, to attain a numerical preponderance over atelectasis. Although cadaveric phenomena may fail to furnish us with an exact diagnosis, the vital ones or symptoms will not fail us in the same way. Febrile disturbance, and this of a paroxysmal character, with headache, florid redness ofthe tongue and lips, thirst, sudden stopping in the midst of eating, coming on where previous good health had existed, point to a state of things in connexion with symptoms of pulmonary disease, which cannot be referred to a congenital obstruction merely in some point or points ofthe lung, such as atelectasis. Chronic Pneumonia.—It may sometimes happen that acute pneumonia stops short after the effusion of lymph or stage of red hepatization, and the diseased portion of the lung, after partial absorption, assumes a dense and indurated character, and a colour varying from a dingy red to brown, buff, and sometimes grey, the " induration gris" of Andral. This mor- bid change of texture is almost always in circumscribed spots. A slow inflammation of the lung, accompanying tubercular formations, to which the epithet chronic may be applied, is the most frequent form of the dis- ease. Other heterologous substances, such as medullary fungus, in par- ticular, enter into the same reciprocity of action with the inflammatory product as tubercles. Most of the consolidation of lung met with in phthisis is of this nature. Dr. Gerhard (op. cit.) represents acute pneu- monia to have a tendency to become chronic in young children. The symptoms of chronic are similar to acute pneumonia, but of reduced intensity. The sarae may be said of the physical signs, which are those of circumscribed consolidation with, of course, obstruction ofthe pulmo- nary vesicles of the part. The diseased portions of lung may remain unchanged for a length of time, producing only some impediment to respiratory function and a slight paroxysmal fever. But in other cases they become the means and cen- SYMPTOMS AND TREATMENT OF EDEMA OF THE LUNGS. 229 tres of fresh inflammation, or they may become the seats of ulceration, and phthisis terminating in death. The treatment will be modified by the stage and duration of prior dis- ease, and the constitutional diathesis of the individual. General blood- letting is not called for, and will, mostly, be mischievous ; but it is differ- ent, in some cases, with a local detraction of blood by cups or leeches over the diseased lung, which contributes to check progressive inflammation and to stimulate the absorbents to remove the lymphatic exudation,— a result quickened by counter-irritants, calomel, or blue mass with narcotics, and the iodide of potassium with the syrup and infusion of sarsaparilla. A regulated regimen and moderate exercise in a pure and mild air are of course to be enjoined. Edema of the Lungs—Pulmonary Edema.—A few words will suffice for a notice of effusion into the pulmonary tissue, which, although it have its seat there, is, like all hydropic formations, merely symptomatic of other and often remote organic disease, commonly obstruction to the circulation. Pulmonary edema results from organic diseases of the heart, lungs, or liver; it occurs also in eruptive fevers, especially scarlet fever and meas- les, and in consequence of renal disease, as I have had occasion to men- tion in its proper place. It shows itself in the aged, in those enfeebled by prior causes, and in the convalescent. The symptoms are both remote or displayed in other organs, and direct or evinced in derangement of pulmonary function. The former are the direct product ofthe organic causes, and of course various; the latter are cough, difficult breathing, and thin mucous or serous expectoration. With these we generally find also edema of the limbs. On percussion, the chest emits a dull sound, or one less clear than natural. The vesi- cular murmur is also indistinct, and particularly at the posterior part of the chest. The physical signs are, indeed, closely analogous to those in the first stage of pneumonia ; but there is an absence ofthe characteristic symptoms of these latter, such as fever and even rust expectoration, and the disease does not advance to other stages. The treatment will depend of course on the organ affected and the dura- tion of its disease, the degree of phlogosis, &c. If the heart be the seat, the remedies will be varied according to the part affected : sometimes direct depletion, sometimes tonics and diuretics doing most good. When edema of the lungs follows scarlet fever or measles we are generally con- tent with the employment of hydragogue cathartics and diuretics ; of the former the compound powder of jalap or scammony with cream of tartar, and ofthe latter digitalis alternating with solution of cream of tartar, calo- mel and squills. When the oppression is considerable, and complaint made of pain in any part ofthe chest, the application of a few leeches, or in their stead, of cups, will both relieve and predispose to a more satis- factory operation of the purgatives and diuretics. Cutaneous revulsives are also called for. If the patient be bed-ridden, his posture ought to be frequently changed, in order to prevent passive congestion and increase of the edema. 230 DISEASES OF THE RESPIRATORY APPARATUS. LECTURE CIII. DR. BELL. Phthisis Pulmonalis—Difference between phthisis and the phlegmasia? of the respi- ratory apparatus—Universality and continued prevalence of phthisis—Fearful mor- tality from the disease—Appearance of tuberculous lungs—Tubercle, its distinguish- ing anatomical trait.—Natural History of Tubercle—Its Origin and Growth—De- rived from ihe blood—Deposited in the pulmonary cells and parenchyma—Envelopes the tissues, which preserve their normal character—Tubercles take the form of the tissues in which they are imbedded—They do not grow, in the physiological sense— Different appearances of pulmonary tubercles—Grey and yellow—Grey tubercles the most common—Miliary granulations the supposed primary form of tubercle—Changes in grey tubercle from slight causes—Appearance and characters of yellow tubercle— Frequent coexistence of the grey and yellow varieties—Grey semi-transparent granu- lations—Originate at an advanced period of phthisis—Grey semi-transparent matter does not always appear under the form of granulations—Mode of distribution of tuber- cle in thf limns—Miliary tubercles,—aggregated tubercles,— tuberrculous infiltration- Structure and Elementary Composition of Tubercle—Resemblance between the genera- tion <>f tubercle and the formation of normal tissue—Dr. Wright's description—Vo- gel's additional remarks—Constant elements of tubercle,—molecular granules, adhe- sive hyaline mass, and peculiar tubercle-cells—Chemical composition—Seats of Tuber- cle—-Upper lobes of the lungs most affected—Stages of or Changes in Tubercle—Of crudity, of softening or elimination and of ulceration or cavity—Maturation preceding softening—Vomica—Successive changes of tubercle described. Phthisis Pulmonalis—Pulmonary Tubercle, or Tubercular Phthisis. —Phthisis Pulmonalis, or Pulmonary Consumption, is now almost every- where among medical men understood to designate a disease caused by the presence and development of tubercles in the lungs, and of tubercles alone. This proposition, distinctly affirmed by Laennec, has been con- firmed by MM. Andral and Louis. Hitherto you have had presented for your notice those diseases of the respiratory apparatus which are preceded by hyperemia, and consist in phlogosis, with an increase, in the case of inflammation of the air-passages, of its natural secretion, mucus, and if this morbid process be not speedily checked, of the effusion of plastic lymph. The plasma or formative mat- ter of the blood, that is to say, the blood independently of its corpuscles or colouring part, furnishes this exudation mainly by its fibrinous portion, which in its coagulation assumes a stratified arrangement, and gives rise to the formation of false membranes. But this change implies organiza- tion and the production of distinct and regularly formed cells. Another formation from the fibrinous fluid of the hlood plasma, when the inflam- mation has reached and somewhat transcended the degree of exudation of coagulable lymph, is pus, which is, also, regularly organised, in its cor- puscles being for the most part of a cellular nature, with a nucleus, cell- wall and contents. The successive changes in the pulmonary tissue or organ, beginning with hyperemia and ending in suppuration, or in milder cases in resolution, are local, and other and distant organs are only af- fected by sympathetic irritation : there is nothing formed incompatible with the subsequent discharge of function ; for the fluid products are either discharged externally, or are absorbed, or acquire organization, and, as in the case of false membranes, assimilate themselves to the tissues out of which PULMONARY CONSUMPTION. 231 they were originally formed. How often do we not find that false mem- branes have been formed on the pleura, and after having become adherent to this membrane, and in a degree identified wTith it, have remained for a series of years without any notable inconvenience to the individual in whom the change had taken place. Very different from all this is the state of things in Phthisis Pulmonalis, the disease of the lungs on which I am now about to address you. In it the bloodvessels do indeed throw off a portion of their contents, it may be, also, that this, to a certain extent, is fibrinous ; and it is deposited, like the mucus and exuded lymph and the pus, on the air-cells and mu- cous membrane, &c, or at times in the cellular tissue external to this. But the process, although it may be the product of a slight hyperemia, is not clearly so ; nor is it the product of a still higher degree of vascular and nervous excitement, constituting inflammation. The separation of the blood, at this time, is properly designated by the term infiltration, the lowest degree of functional action and secretive deposit. The matters thus separated are mainly albuminous, or, at best, of degraded fibrin. At first, their appearance is that of disseminated minute points or seeds; but, after a period, they coalesce into masses of an indeterminate and amorpho-granular character, which, at the most, have a very imperfect cellular structure. Their development is by deposit, accretion, and, finally, softening: the final product, an indeterminate granular detritus, which remains a foreign body incapable of being assimilated to the tissues or organs with which it is in contact, or of being removed by absorption, or thrown off with any of the normal secretions. There has been no true plasma or formative fluid: but a pseudo-plasma merely, with scarcely more vital activity than the mother liquid of a solution from which crys- talline deposits are formed, in accordance with chemical laws. Neither have there been transmutations of the normal tissues ; but, rather, new formations, which penetrate amongst the previously existing histological elements ofthe body. Unlike the phlegmasia? which are local, pseudo-plasmata arise in va rious and remote parts of the body, as well as in those contiguous to the first products, either simultaneously with these or subsequently. The common termination of these deposits is by softening, which, although it bears some analogy to suppuration and ulceration, is not, by any means, an identical process: it is not productive of true pus except in as far as this latter is furnished by the contiguous organised tissues which have been inflamed by the presence ofthe deposited matters, or in the attempt of these latter to escape through the normal tissues. The successive de- posits and softenings, with the accompanying destruction and ulceration of adjoining normal tissue, generally end in death. In some rare cases, indeed, as we shall afterwards see, the deposit, instead of softening, be- comes converted into an earthy or cretaceous mass, and forms a concretion which, no longer receiving fresh deposits, is surrounded and isolated by an organised investment, and ceases to give farther trouble. In the class of pseudo-plasmata slightly or not all organised, are tuber- cle, scrofulous deposits, and typhous deposits. Of these, tubercles are the most frequent and the most important variety of the class. We under- stand by the term tubercle, a pathological production presenting itself in different parts of the body, in consequence of a peculiar predisposition or raorbid diathesis called tuberculosis. But of the many different organs in which tubercle is met with, the pulmonary are in a pre-eminent degree 232 DISEASES OF THE RESPIRATORY APPARATUS. its chosen seat and home. It is to this manifestation, or to pulmonary tuberculosis, that the following observations are meant, with few excep- tions, to apply :— The prevailing term, Phthisis (from a>6« Bronchial . . 70 ... 1* Mesenteric . . 102 ... 23 = \ Meso-caecal and ) ,, ,.,., , c 4l tl ,, ,, nT , > " a little Jess frequently than the mesenteric. Meso-colon ) n J Lumbar . . .60 ... 5 = JT Axillary . . ... 1 The cellular tissue sometimes exhibits tubercles. The peritoneum in a fifth part of the cases has a serous effusion, and occasionally false mem- branes, pus, and adhesions. Ascites is only met with when there is com- plication of heart disease with phthisis. Chronic peritonitis, when not arising from organic disease of some of the abdominal organs or from traumatic causes, is almost always of a tuberculous character. The liver is morbidly affected by what is called fatty transformation, which reaches the entire subslance ofthe organ. M. Louis has met with this in 40 cases out of 120, or one in every three. The figure ofthe 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 ileum. Its consistence 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 * There is a typographical error in the original, either in the number of cases or the proportional frequency; the context renders it much the more probable if not actually certain that it is in the former, we therefore give the latter. It is to be observed, with respect to the state of the bronchial glands (and, indeed, the circumstance must inva- riably be borne in mind throughout this article), that the researches of M. Louis refer to the'disease as it exists in subjects aged upwards of 15—younger individuals beinor excluded from the hospitals in which he observed. Tuberculization of the bronchial glands is in infancy more frequent even than that of the lungs.—Ed. Brit, and For. Med. Rev. CAUSES OF PHTHISIS PULMONALIS. 247 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, hyda- tids, cysts, &c. In general, the bile in subjects in whom this fatty trans- formation ofthe liver has taken place is of a dark colour and pitchy con- sistence. 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. Tuberculous matter has been secreted in the mucous surface of the vesicula? seminales and vasa deferentia, but in phthisical subjects alone. 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 se- creted milk which contained an unusual quantity of this salt. The peri- toneum is frequently observed to be the seat of serous effusions in phthisis, and also, but in less degree, of tubercle. False membranes and tubercles were found at the same time. Analogous changes are met with in chro- nic pleurisy. In a majority of cases some anatomical changes in the brain and its meninges have been discovered in those dead of phthisis; but the only morbid ones observed exclusively in these parts, in the subjects of this disease, are hydatids and tubercles. The last are met with on the upper, never the under surface of the arachnoid, and in the substance of the brain, particularly in children. The pia mater is found in many cases to be red, thickened, and injected. The blood in phthisis exhibits the ordinary characters of inflammatory blood ; but, in this respect, there are differences during the successive stages of the disease. MM. Andral and Gavarret observe, that whatever be the stage at which the blood is analysed, the fibrin seems always on the increase, and the corpuscles on the decrease ; these changes being greatest as the tubercles begin to soften, and greatest in the formation of vomica?. The fibrin, in this last case, rises to 5-5 and sometimes to 5-9 ; but never attains the height observed in pneumonia. In the very last stage, however, as the blood becomes impoverished, the fibrin diminishes in much the same ratio with the other solid constituents, and sometimes falls under the healthy standard of 2 to 2*5. Generally speaking, it seems that the amount of fibrin attains its maximum about the period when the febrile symptoms are regularly established. LECTURE CV. DR. BELL. Cavses of Piithisib Pulmonalis—External Causes—Climate—Difference of mortality in different countries—Consumption, a common disease in the Mediterranean climates, —also in the West Indies, and in the islands ofthe Indian Ocean—Consumption varies in its rates of mortality in different periods—Cold and moisture—They act chiefly by impeding the cutaneous functions—Experiments and observations by M. Four- cault—Close and impure air a common cause—Deleterious influence of confinement in close and impure air—Effects of dust given out in certain trades—Deficient or im- proper food—Habits of intemperance dispose to phthisis—Internal causes of con- sumption—A rises gradually to 8. duration S First Phasis. A few small tubercles scatter- ed through the lung. Skcond Piiasis. Infiltration of crude tuliercles in groups. quality, clear, ringing. L Commencing bronchophony in rare cases. f Pulmonary crumpling sound. Dry crackling rhonchus. Sonorous, sibilant, rhonchi (symptomatic of bronchitis). Inspiration—intensity = 12, 1-i. duration = 9, 8. quality, clear, ringing. Expiration, intensity? _ ,„ J i .• J- — o, 10. "S duration 3 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. 278 DISEASES OF THE RESPIRATORY APPARATUS. f Humid crackling rhonchus. Third Phasis Sonorous sibilant rhonchi, as before. (or of transition Pulmonary crumpling sound disappears. from first to se- Inspiration — intensity = 15, 18. cond stage). duration = 7, 6, 5. quality, blowing, or slightly bronchial. Expiration, intensity) , duration S ' "j quality, bronchial. Strong bronchophony, or imperfect pectoriloquy. Sound more obscure, or even dull. Commencing J Vocal and tussive fremitus much diminished. softening. Diminution of partial movements of ribs corresponding to indurated mass. Transverse retraction of corresponding part ofthe chest. l^ Sub-clavicular flattening. The normal intensity and duration of the inspiratory sound being re- presented by 10, the extreme degrees of increase and decrease mark 20 and 0; between the maximum point of elevation and that of total cessa- tion, 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 circumjacent healthy tissue ; in a word, it announces the general fact, that a part of the lung supplies, by increased action, the func- tional 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 modification, which, in the great majority of cases, affects both the intensity and duration of the sound, is apparent from the fact, that there is scarcely an organic disease of the larynx, trachea, bronchiae, 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 con- dition constitutes, according to M. Fournet, its normal rhythm.. In cases of sharp pleurodynia, he states, this rhythm changes ; the murmur be- comes abrupt, jerking, and divides into several successive and unequal parts. In incipient pleurisy, in the dry stage, a similar state is, however, observed; so that this observation throws no new7 light on the diagnosis of these two complaints. During the alteration of inspiratory rhythm the expiratory remains unchanged ; a fact easily intelligible. The expiratory murmur is subject to much greater increase in point of intensity and duration than the inspiratory: if we credit M. Fournet, the maximum increase in these respects may be represented by the number 20, that already employed to designate the corresponding condition ofthe 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, expi- ration 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 ofthe 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 DIAGNOSIS OF PHTHISIS PULMONALIS. 279 times a higher proportion to the inspiratory 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.—(Brit, and For. Med. Rev.) Augmented expiration may either coexist with a proportional increase in the inspiratory murmur, or the healthy ratio ofthe two phenomena may be destroyed by an accompanying fall in the inspiration. The former condition occurs in puerile or supplementary respiration ; the latter in the early stage of phthisis, and in emphysema : these are indeed the only affections in which the disproportion exists to a very large amount, and hence its special value in their diagnosis. The resonance of the voice also undergoes modifications by the presence of a certain number of tubercles in the parenchyma of the lung. The alteration, at first slight, gradually increases in such a manner that, after the lapse of a period of variable length, actual bronchophony may be detected. The vocal resonance varies, however, on the two sides of the upper part of the chest, just as we find the character of the respiratory murmur to vary in these regions. Mensuration ofthe chest, though not noticed by M. Louis, ought to be included amongst our aids to diagnosis, derived from physical signs. A tuberculous lung becomes atrophied and shrunken and the chest corre- spondingly contracted, with a consequent diminution of its antero-posterior diameter at the summit, and diminution of the transverse diameter, espe- cially opposite the upper part of the axillary regions. In the earlier stage there is no visible alteration, except a flattening or slight hollowing under the clavicle. The qualifying remark of M. Piorry is worthy of notice on this occasion. He thinks, that the diminished circumference ofthe thoracic cavity is owing more to an atrophy of the pectoral and scapular muscles than to a real curtailment of the capacity of the chest at this part. There are materials for diagnosis furnished indirectly which are far from being unimportant. Thus, double pleurisy denotes, almost with certainty, the existence of tuberculous disease. Ofthe same signification are ulcerations of the larynx ; for, setting aside cases of syphilis, they are almost exclusively observed in tuberculous subjects. As tubercles are developed simultaneously in a multitude of organs, and as after the age of fifteen they are not formed in any organ without their existing in the lungs, it follows that the moment special symptoms of their presence in an organ are met with, we may infer the existence of pulmonary tubercles. Thus, when we see chronic peritonitis or tuberculous meningitis in any subject, we are sure that the lungs are suffering from tubercles. Pro- tracted diarrhoea, as from six to ten months or more, accompanied with emaciation, and persisting in spite of abstinence, opiates, and blue mass, and blisters to the abdomen, is almost peculiar to phthisical subjects. 1 da gnosis of the Second Period.—The lesions in *the second period of phthisis are of a more serious character and greater extent than the first, and in consequence more easily recognisable. We meet with pains and hemoptysis in both periods: but the sputa, more or less thick and yel- lowish at the close ofthe first period, become greenish and striated with whitish lines at the beginning of the second. The sound of the chest becomes gradually less clear under the clavicles, or one only of them, 280 DISEASES OF THE RESPIRATORY APPARATUS. until it lapses into absolute dulness. Not unfrequently the extent of dulness includes the whole upper lobe. It is now that we see a marked depression or sinking in of the clavicular region of the chest, and dimi- nution both of the antero-posterior diameter and of the circumference. Changes in the phenomena of respiration are going on at the same time. This is not only rough, harsh, and prolonged in expiration, but it becomes bronchial or perfectly tracheal under the clavicles where the percussion sound is dull. It is, also, commonly accompanied by crepitant rhonchus, composed of large bubbles, more or less moist. The resonance of the voice is much louder than during the first period ; the bronchophony strong and sometimes very noisy, so much so as to be disagreeable ; and pectoriloquy accompanied by respiration becomes audible. Independently of tracheal or cavernous respiration, which exists opposite tuberculous cavities( vomica?), that modification of respiration, known under the name of amphoric, together with metallic tinkling, may also be pretty frequently detected. In children under five years of age, these signs are not met with ; but in their stead are those of a merely bronchial character; viz., tubu- lar respiration, mucous rhonchus, bronchophony, and dulness on per- cussion. Prognosis.—The question of the prognosis of phthisis soon receives a melancholy answer. This disease almost invariably terminates fatally, after a space of time varying from a few weeks to several years. By some enlightened physicians phthisis is declared to be incurable. Dr. Chapman, in his published lecture on Phthisis Pulmonalis (op. cit), in which he had just before been speaking of the alleged curative powers of mercury, declares:—" Never have I had the good fortune to witness a single cure of this form of disease or to know of one well authenticated, though in private practice, and that of the public institutions I have attended, mercury was employed by myself or others in several hundred cases." It may still be not without instruction if I place before you a brief outline of the prominent reasoning and observations to show the curableness of phthisis. Laennec states, as the result of personal observation, that cicatrization or healing of a tubercle has taken place. M. Andral declares 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 emp- tied of pus, its walls are lined by a cellulo-vascular membrane. After a while this cavity disappears, and we meet with nothing but a simple cel- lulo-fibrous line at which abut abruptly large bronchiae; or, there maybe a larger mass of cellulo-fibrous or of calcareous or cartilaginous structure at which abut the bronchiae. This is commonly the appearance of things at the apex of the lung, 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 pulmo- nalis, have been cured, and afterwards died of some other disease. Dr. Carswell believes in' the curableness 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, CURABLENESS OF PHTHISIS PULMONALIS. 281 in scrofula, which are evidently often arrested, and the patient is left for a term of years in tolerable health. He has seen children who had tabes mesenterica entirely 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 mesenteric glands. Dr. Williams mentions the healing, by contraction in size, of tuberculous cavities ; but he adds, that they are 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 adjoining vesicles are gene- rally dilated to fill up the space. The cretaceous matter is probably secre- ted by the fibrous false membrane (which lined the cavity of the tubercle); but it may have been originally 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 dis- ease, and of the restorative efforts of the parts to oppose farther degenera- tion. Dr. Stokes describes phthisis to be curable. MM. Barthez and Rilliet make a similar assertion. Dr. S. G. Morton, in his valuable " Illustra- tions of Pulmonary Consumption," distinctly expresses his conviction, not merely of the cicatrization of open tubercles but of their entire removal by absorption. But the most extended investigation of the subject is that by M. Rogee (Sur la Curabilite de la Phthisie Pulmonaire, fyc). His obser- vations were made in a careful post-mortem examination of more than two hundred subjects. Of this number there were a hundred old women, up- wards of sixty years of age. M. Rogee noticed more particularly two kinds of lesions 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 hun- dred ; their situation corresponding precisely with that of tubercles as com- monly seen in the lungs, viz., at the summit of the lung thirty-nine times; equally distributed through the lung six times; in several parts ofthe 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 \ ery frequently when there were concretions in the lung 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 hazel-nut; and, again, often as small as a millet-seed. They were found in distinctly tuberculous lungs as well as those otherwise healthy. M. Rogee does not hesitate to regard these cretaceous and calcareous concretions as the result of the transformation of tubercles; in fact of tuber- 282 DISEASES OF THE RESPIRATORY APPARATUS. cles which were healed. An additional argument in favour of his opinion is adduced by him, in the fact of concretions 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-cartila- ginous cicatrices. 4. Cellular cicatrices. He details cases of persons at a 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 cicatrized; a third less advanced containing tuberculous matter, which had passed into the cretaceous form. In the left lung there was a calcareous concre- tion. In two other cases of women, each seventy-four years of age at the time of death, cicatrized excavations were found, which had no communi- cation with the bronchiae. The whole paper of M. Rogee, which is pub- lished in three consecutive numbers of the Archives Generates de Medi- cine, 1839, merits an attentive perusal. He certainly must obtain credit for establishing the position with which he set out, that pulmonary con- 'sumption is curable. More recently still, M. Boudet has added his experience and observa- tions to those of M. Rogee, in confirmation ofthe curableness of phthisis. M. Boudet (Recherches sur la Guerison Naturelle ou Spontanee de la Phthisie Pufmonaire) indicates five modes of cure, brought about by cor- responding changes in pulmonary tubercle ; viz., 1, sequestration, by becoming completely encysted ; 2, induration, of which there are three varieties; 3, transformation into black pulmonary matter ; 4, absorption; 5, elimination. M. Boudet tells us, that he has examined successively and without selection, the respiratory apparatus of 197 persons, whose ages ranged from two to sixty-three years, and who died in the hospitals of Paris of different diseases, including some individuals who were cut off by acci- dent and wounds in the midst of full health. Of these he found in 45 cases, at ages ranging from 2 to 15 years, 33 tuberculous ; and of 135 from 15 to 63 years he detected tuberculosis either of the lungs or bron- chial glands in 116. These facts, which, as the author truly remarks, would seem to be almost incredible, are explained by the readiness with which these morbid products cease to be incompatible with health, owing to certain changes in their intimate structure. Not only have the transformations of tubercle been noted by M. Bou- det on the dead body, but they have also occurred within his knowledge in the living subject. In less than a year he collected 14 cases, of which 6 were softened tubercle or undoubted excavations. In all ages and in every stage of the disease, cures, for the most part indeed spontaneous, have been brought about. Dr. H. Bennett (Edinb. Med. and Surg. Journ., 1845) gives the result of his observations in 73 subjects which he examined, from which it appears that he found cicatrices in 28. That the concretions and cicatrices in the lungs of the subjects exa- mined by MM. Rogee and Boudet, and Dr. Bennett, are really proofs of an arrest of tubercular deposits and of subsequent sanitary change, would seem to be established by the following considerations adduced by Dr. Bennett:— "1. A form of indurated and circumscribed tubercle is frequently met PROGNOSIS OF PHTHISIS PULMONALIS. 283 with, gritty to the touch, which, when dried, closely resembles cretaceous concretions. " 2. The concretions are found exactly in the same site as tubercle ; they are most common in the apex, in both lungs. " 3. When a lung is the seat of tubercular infiltration throughout— recent tubercle occupying the anterior portion, and older tubercle, and perhaps caverns, the superior—the cretaceous and calcareous concretions will be found at the apex. " 4. A comparison of the opposite lungs will frequently show, that, whilst on one side there is firm encysted tubercle, partly transformed into cretaceous matter, on the other the transformation is perfect. " 5. The puckerings found without these concretions exactly resemble those on which the latter exist. Moreover, whilst puckerings with grey induration may be found in the apex of one lung, a puckering surround- ing a concretion may be found in the apex ofthe other. " 6. The seat of cicatrices admits of the same exceptions as the seat of tubercles. In one case the author found the puckerings in the inferior lobe only ; he has only met with three cases in which the lower lobe was densely infiltrated with tubercle, the superior being only slightly affected." Hasse, who exhibits due caution in admitting novelties of fact or of opi- nion, begins his observations on this topic by this remark : " Having duly considered tubercle in its destructive character, we shall next inquire into the circumstances under which it is rendered inert, and its ravages repaired by the healing process, even at an advanced period of the dis- ease." The possibility of tubercles, while in a crude state, being re- moved by absorption is still a matter of doubt. M. Andral and Dr. Cars- well are on the affirmative side. The cure of pulmonary tubercle, whe- ther in the crude or softened state, is more particularly due to shrivel- ling and calcareous formation. Tubercular cavities heal precisely in the same manner, whether debarred from the air-passages, or connected with several larger bronchial canals. Cavities cicatrize in various ways. They may disappear altogether, or contract only to a limited extent. In the first case they fill with a cellulo-fibrous substance. In the second the cavity is not obliterated, but remains open, simply losing the characters of the original disease. With the advance of the curative process, the lung and adjoining portions of the bronchial tubes undergo material changes. The whole ofthe apex, if not the entire upper lobe ofthe lung, is shrivelled and obliterated, and at the same time the collective bron- chial tubes, up to their very end, degenerate into white, thread-like rami- fications. The involved parenchyma of the lung is now converted into an almost cartilaginous'mass, impervious to air, very scantily supplied with blood-vessels, and presenting, when cut, a smooth glistening sur: face. A very remarkable fact is the extraordinary deposition of black pigment into the lungs, during the healing process. In older persons, continues Hasse, this melanotic accumulation is so constant and so con- siderable, that one m,ight now and then entertain a doubt whether it be the cause of, or the sequel to the cure of phthisis. But, more of this presently. Such are the differences, in states apparently similar, in the rapidity of progress and duration of phthisis, that the prognosis to determine even the probable period of its termination in death is a very difficult thing. Sometimes the patient rallies from a condition apparently hopeless, ac- quires strength and even gains flesh ; and congratulates his physician on 284 DISEASES OF THE RESPIRATORY APPARATUS. the success of his treatment. A few months more, however, and the scene is changed. All the bad symptoras return with aggravation, diar- rhoea sets in, and death soon closes the scene and terminates the false hopes of the patient and friends, while it rebukes the vanity, if he had given it any license, of the successful physician. LECTURE CVIII. DR. BELL. Treatment of Phthisis Pulmonalis—Discouraging view of the subject—Systematic divisionsof treatment, into prophylactic, palliative, and curative—Prophylactic treat- ment—To be begun early in life—Attention paid to the health of the mother, or the nurse who may replace her—The child to take abundant nutriment, and moderate but not violent exercise in the open air—The warm, and then the tepid bath—Cheerful emotions encouraged, but yet suitable restraint practised—Moderate exercise of the intellect—Watchfulness at the epoch of puberty—Various exercises, including gym- nastics ; tepid or cool bath; skin protected by flannel ; food nourishing ; milk, eggs, and meat,—For weak appetite, bitter infusions, and for anemia, preparations of iron— Health still delicate, travel is beneficial—Attention to ventilation in the sleeping apartment—Tone to be imparted to all the organs, and equability of functions pre- served—Palliative treatment—Complication of phlegmasiae of the thoracic organs and disorder of the digestive apparatus to be removed—Antiphlogistics succeeded by tonics —Different ideas of palliative and curative treatment—The practitioner to make his choice—Circumstances determining him—Different forms of phthisis—Localized bron- chitic variety; its treatment—Hemoptysis; its treatment—Pneumonia; its treatment— Recuperative measures—Depletion not always necessary—Diarrhoea, remedies in— Perspiration and night sweats—Additional hygienic measures—Exercise on horseback; travel ; change of scene—Benefits from change of climate overrated—Climate of East Florida—Alleged efficacy of residence in marshy countries disproved—Summary of curative treatment—Reported remedies against tubercle—Counter-irritation—Condi- tions for its use—Opening of a tuberculous cavity by perforation of the walls of the thorax. To the subject of the treatment of phthisis, the intelligent physician, whose knowledge of the disease rests on a pathological basis, will approach with a feeling of depression and discouragement. Even though he should admit that phthisis is curable, yet he cannot say that it is so under any known course either of hygiene or of therapeutics, much less by the administra- tion or use of any one article ; nor can he imitate the means, whatever they may have been, by which the fatal result has been warded off in some cases, and tuberculization arrested by the conversion of vomicae into calcareous deposit. • The systematic division of the treatment is into the prophylactic, the palliative, and the curative. Of the two first alone we can speak in terms of any confidence. Prophylactic Treatment.—This to be of avail ought to be begun in early life, even from infancy, when, owing to the disease of the parent and the lymphatic temperament of the child, there exist well-grounded fears of the development in it of tubercles. The health of the mother during the period of lactation, or if she is unable to perform this duty, the health of the nurse, is a matter of the greatest importance. Abundant nutriment easy of digestion, but to the avoidance of excessive repletion, daily ex- posure to the outer air when the weather is not damp, wet, or very in- PROPHYLACTIC TREATMENT OF PHTHISIS PULMONALIS. 285 clement, and regular bathing, first in warm and afterwards in tepid water, should be the outlines of hygiene for the infant. When old enough to take exercise freely itself, the child should be encouraged to indulge in active sports, if possible out of doors, but not to exert an undue strain on any organ, by excessive running, jumping, or lifting weights beyond its strength. With advance of years, mental occupation should keep pace with, but in no instance exclude or materially interfere with a full share of bodily exercise. The cheerful emotions should be encouraged, and the depressing ones sedulously prevented, and when they come on, speedily dispelled. Let not this advice, however, be construed into indulgence in appetite for every kind of food, or in caprice or passion, or into a with- holding of wholesome restraints on these propensities. Restraining coun- sel and firm rule, far from interfering with the cheerfulness and pleasures of a child, are found to be signally conducive to a prolonged enjoyment of them, by nurturing a proper and healthful frame of mind. Parental vanity ought not to prompt the sometimes precocious intellect of the child to prolonged exercise of its faculties and sedentary life in con- sequence, by which hematosis and nutrition are retarded and on occasions perverted, and a greater probability is afforded for the development of scro- fulous diathesis and subsequently tubercular formations in the brain and lungs. The period of puberty approaching, the greatest watchfulness should be exerted, but not exhibited, to prevent excitement, which grows out of the new organic developments, from taking a hurtful direction by the acquirement of bad habits and especially solitary vices, which throw the system open to various derangements of health and disorders of a serious, sometimes of an alarming nature, in which we must include phthisis. Variety of exercise, by alternate walking and riding on horseback, or in a vehicle of any description, and moderate gymnastics, frictions of the skin, and the use of tepid or cool bath, as personal experience may indi- cate, are now to be regularly and systematically practised. The skin is to be protected from vicissitudes of temperature by a flannel or merino jacket with long sleeves, and drawers of a lighter texture and material, to be changed always at night, and for the most part to be left off during this time and a gauze jacket substituted for the thicker flannel. Abundant and wholesome food, in which a fair proportion of animal matters enters, including milk and eggs, should be allowed ; and occasional languor of the digestive function remedied by the watery infusion of simple bitters ; or, if there be paleness and anemia, of one of the milder preparations of iron. If early delicacy of frame and constitution continue after puberty, travel and change of climate will be attended with more beneficial consequences than at a later period, when phthisis has been developed or made marked progress. Both during the period of infancy and in the subsequent period of early life, the sleeping room should be, if possible, of commodious size, well ventilated, and with, especially in winter, a southern exposure. Of late more than formerly, since the increasing use of furnaces and flues to warm houses, open chimney-places are no longer made, or if made are closed up, so that persons inhabiting a room of this kind during the day, or sleeping in it at night, are deprived ofthe requisite means for ventilation, and for the escape of the impure air generated by respiration and cuta- 286 DISEASES OF THE RESPIRATORY APPARATUS. neous exhalation, &c. If this difficulty be obviated, I regard the intro- duction of warm and sufficiently moist air, into all parts of a house, as decidedly sanitary, and a no unimportant part of prophylaxis, as it is of palliative cure, by its diminishing the risk of contracting catarrhs and phlegmasia? of the thoracic viscera, and by rendering them more readily amenable to remedies and less liable to return. In fine, remembering the greater tendency to, we dare not say uniform occurrence of tuberculous formation in consequence of a disordered con- dition and distribution ofthe blood, it should be our constant endeavour, by prophylaxis, to impart such a degree of tone to all the organs, and such a rhythmical exercise of the functions, but without stretching them to the highest manifestation of vigour, as shall be most likely to conduce to the elaboration of food into good blood, and then the equable distribu- tion of this blood to all the tissues, so as to insure a healthy deposit of its fibrin and other elements for the formation and growth of these tissues, and the organs into the construction of which in various degrees they enter. Palliative Treatment.—Our knowledge ofthe complications of tubercles, and the circumstances accompanying their increase and growth, are suffi- cient to teach us that they often prove sources of irritation, and develop inflamraation, as pneumonia, for example, and that they often follow, on the other hand, the occurrence of this and other forms of thoracic inflam- mation. In either case, the sufferings and danger of the patient are in- creased by the occurrence and persistence of these phlegmasia?, whether it be pneumonia, bronchitis, pleurisy, or hemoptysis; and hence the ne- cessity for our having recourse to measures, which, although they do not reach the tubercles themselves, will contribute to remove the complica- tions, and allow of the organs to perform, with but little comparative difficulty, their appropriate function for a longer period than if treatment had not been adopted. Disorder of the digestive functions, sometimes constituting gastro-ente- ritis, sometimes associated with altered states of the mucous membrane, including ulcerations, constitutes additional complications, and requires correction and abatement, without which the life of the patient is abbre- viated in a degree that the pulmonary tuberculization alone would not have caused. I will first state, in a few words, in what the palliative treatment of phthisis consists, and then offer some explanations and commentaries, in addition, for the better understanding of the subject. The occurrence of partial inflammation, pleuro-pneumonia, or bronchitis, is to be met by small bleeding, preferably by means of leeches or cups ; the digestive ap- paratus to be kept in a normal state by plain nutritive food, occasional lax- atives, with vegetable bitters ; and in lymphatic constitutions, iodine, or the milder preparations of iron : cough will be obviated by small doses of opium, or preferably, in reference to the nervous and digestive systems, by hyosciamus, stramonium, or belladonna; and in cases of dry cough with heat of the chest, by the inhalation of watery vapour, in which some- times narcotic substances may be usefully suspended. Counter-irritants may be used where congestion or pain with slight phlogosis is present. The concurrent opinion of nearly all those who have most earnestly and carefully directed their attention to the subject, is in favour of anti- phlogistic remedies, with a view to remove the local inflammation and abate the number and violence of the constitutional sympathetic actions, PALLIATIVE TREATMENT OF PHTHISIS PULMONALIS. 287 such as fever. Nor is this view of treatment abandoned even now that the deterioration and depravation of function growing out of enfeebling causes is admitted and in a measure understood. But this knowledge is so far usefully applied, that while we adopt measures to restrain and remove promptly the accidentally associated inflammation of the part of the pulmonary apparatus which may happen to be phlogosed, we are still especially mindful to have recourse, as soon after as possible, and even in some cases of very feeble constitutions, simultaneously, to means both hygienical and therapeutical, calculated to supply blood and to invigorate the general system. It may be, when inflammation shows itself early in the disease and is promptly combated and removed, and, afterwards, judiciously devised sedative remedies are used, while the hygienic treatment already described under the head of prophylaxis is persevered in, that tubercular growrth will be arrested, and phthisis remain in a quiescent or latent state for a length of time, or for a considerable period of a man's life. Hence the measures which are proper for palliation are those to be used, but with somewhat more freedom, in the curative treatment. By some writers, Dr. Stokes, for example, assuming that tubercles actually exist, but without complications except those of thoracic inflammation, the treatment is de- scribed as curative ; while the palliative is understood to apply to the means adopted for abating the violence of the hectic fever, the cough, expectoration, diarrhoea, and it may be hemoptysis, without any hopes of arresting the disease, but merely of diminishing the sufferings of the patient. They who deny the curableness of phthisis will regard all the alleged cases of Dr. Stokes and others as merely instances of suspended disease, and will of course deny the propriety of the term curative at all to its treatment. Without adopting this extreme view, I am still disposed to give, as I have already intimated, a large interpretation to the term pal- liative, in the disease now before us, and to apply it to all parts of the treatment ofthe phlegmasiae, or to other forms of disease ofthe lungs and other organs, ensuing on or associated with pulmonary tubercles—restrict- ing the term curative to that treatment which modifies by removing or even diminishing the number and development of these tubercles them- selves. This, I believe, is the light in which the question is viewed by M. Louis in his Researches. With this understanding ofthe use ofthe terms palliative and curative, you will be prepared to receive with profit the following observations by Dr. Stokes, which are preceded by a running commentary in proof of the connexion between inflammation on the one side and tubercle on the other. On being called, says Dr. S., to a case of phthisis, the practitioner has to satisfy himself respecting— 1st. The absence of the strumous diathesis, or an hereditary disposi- tion. 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 symp- toms. 3d. The want of proportion between the extent of disease as indicated by physical signs, and the duration of symptoms. If the extent be slight, although symptoms have existed.for months, it shows a power of resist- ance in the economy. 4th. The calmness of the pulse. 288 DISEASES OF THE RESPIRATORY APPARATUS. 5th. The absence, or slight degree of emaciation or hectic. 6th. The healthy state of the digestive system. In all the extremely chronic cases, the digestive system continues healthy. 7th. The fact ofthe disease having distinctly supervened on a pneumo- nia or bronchitis. 8th. The occurrence of free expectoration from the first period of the cough. An important character, as showing an early attempt to relieve the irritation by secretion. 9th. The healthy state of the larynx. Most important. The combi- nation of even a small quantity of pulmonary tubercle, in laryngeal dis- ease, is always fatal. 10th. The disease, as shown by physical signs, being confined to one lung, and to a small portion of that lung. 11th. The absence ofthe signs of cavities. This requires explanation. We know that recovery happens after the formation of cavities, but in most cases their existence implies that of tubercle in great quantity, occu- pying 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 ofthe lung is obliterated, and indicating a quiescent state of the other portions. 13th. The absence ofthe 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 con- stitutional or not. Incipient curable phthisis is declared by Dr. Stokes to be met with in one of four forms, which may be designated as the Localized Bron- chitic, the Trachea], the Hemoptysical, and the Pneumonic varieties. I shall give you his advice in his own language as to the management of the first. " Localized 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 generally 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 exertion on the part ofthe 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 nature 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 substances, and light vegetables. " Leeches are to be applied in small numbers, alternately, to the sub- clavicular and axillary regions of the affected side. This depletion is to be repeatedly performed, the cupping-glass being occasionally used over the bites. Under this treatment Xherdle will be commonly removed, the PALLIATIVE TREATMENT OF PHTHISIS PULMONALIS. 289 vesicular murmur increased in strength, and the dulness diminished, and all this with corresponding relief to the symptoms. We are now to com- mence 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 all cases be covered with silver paper. A blister is to be applied about every three days. This counter-irritation is to be 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 ointments. During this treatment the cough is to be allayed by mild sedatives. The following is the formula which Dr. Stokes employs at this stage :—R. Mucilaginis Arab, vel Tragacanth. £iij. ; Syrup. Limon. ^ss. ; Aq. purse, ^iiss. ; Aq. Lauro-Cerasi, £ss.—jj.; Acetatis Morphia?, gr. j. This can be perma- nently 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 ofthe vapour of water impregnated with narcotic extract. From twelve to fifteen grains of the extract of cicuta may be employed, at each time of the inhalation. In mild weather exercise on horseback 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 consump- tion. 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. Incipient tracheal irritation, regarded by Dr. Stokes as a distinct form of curable phthisis, can hardly serve to designate a state of things requiring separate consideration under the present general head. As far as the trachea alone is implicated, the disease does indeed require, as he judi- ciously remarks, an active and decided treatment, which will be successful just in proportion as the tracheal disorder is unconnected with tubercle. I need not enlarge on the course to be pursued under either supposition, after the fulness of detail in which I was led when treating of chronic laryngitis, the affinity of tracheitis to which was stated on that occasion. Entire rest of the vocal apparatus, leeches to the windpipe, inhalation of simple vapour, demulcents, narcotic sedatives, and counter-irritants over the trachea, or between the shoulders, constitute the main outlines of treat- ment. The mercurial treatment in the sense in which it is recommended by Dr. Stokes, viz., to affect the gums gently but decidedly,,is of much more doubtful efficacy. In the early stage, tartar emetic with sulphate of morphia, in solution and mixed with sugar, and in the more chronic, the blue mass with some narcotic extract, will be employed. The first combination, I direct as follows :— li. Tart. Antimonii, gr. j. Mist. Camphor. §ij. Sulphat. Morphia?, gr. ss. Syrup Simplex, ^ss. Dose.—A teaspoonful at intervals of three or four hours, according to the irritation of the cough. When the attack of phthisis in its first stage is ushered in with hemop- vol. 11.—20 290 DISEASES OF THE RESPIRATORY APPARATUS. tysis, we have recourse to treatment already indicated in its chief outlines and details in my lectures on hemoptysis or bronchial hemorrhage. I had then, however, forgotten that Dr. Cheyne was partial in that disease to tartar emetic, a remedy of which, from personal experience, I spoke with considerable confidence. It may be that, in some lymphatic and feeble subjects, the discharge of blood by hemorrhage from the lungs gives of itself the desired relief to the previously congested organs, and reduces the system without the call for any further loss of blood by artificial means. If the hemoptysis ceases spon- taneously, and there is no great complaint of heat and oppression in the chest, we may content ourselves with enjoining entire rest and silence, cool and acidulated drinks, warm pediluvia, and sinapisms to the lower extremities, with a mild laxative, or laxative enemata. In more violent cases in which life is threatened by the great loss of blood, and venesec- tion has been practised without avail, or the subject is scrofulous and weak, cold may be applied directly to the chest. I have in some cases had recourse repeatedly to this remedy by means of a sheet half wrung out of cold water and applied round the thorax ; and with manifest relief and comfort to the patient. Ice has sometimes been applied to the chest with similar intention and effect. Emetics, on the strength of the reports of their success by M. Rufz in Martinique, are recommended as worthy of trial by M. Louis. If vomiting were to be brought on by the use of tartar emetic in moderate doses at short intervals, so as to insure decided and general relaxation, I see little risk from the remedy, and I have known it to be advantageous. But if vomiting be suddenly induced by a single dose of tartar emetic, or, still more, by other emetics which stimulate the stomach more than they depress the general system, bad effects, caused by the violent straining and imperfect attempt to vomit, will follow, and in some instances, as in that referred to by Dr. Stokes, death itself. Pneumonia supervening on tubercle, the pneumonic variety of Dr. Stokes, demands a treatment nearly identical with that resorted to when the disease is primary, as regards the remedies used, but not the extent to which they are carried. Thus, when the inflammation involves the lung to any extent, or the stage of phthisis and remaining vigour of constitution of the patient justify it, venesection should be employed, and even repeated if the circumstances originally calling for its use still continue. In the more advanced period of phthisis, it will generally be sufficient to draw blood from the surface over the affected spot, by cups or leeches, and follow their application by counter-irritants of blisters or tartar-emetic ointment. I have found it necessary even in the advanced stage of phthisis, when cavities were formed, both to bleed from the arm and to apply cups to the chest. In one case, that of a medical student from North Carolina, this treatment certainly saved his life at the time (the spring season), and gave opportunity for him to rally so that he was enabled to return home and take exercise on horseback. He sank, however, as I afterwards learned, under the original tuberculous disease, some time in the latter part of the summer. In all intercurrent irritation and inflammation of the mucous membrane and parenchyma in phthisis, including, of course, bronchitis, pneumonia, and hemoptysis, Dr. Stokes and other leading practitioners of the Dublin School, recommend, in decided terms, the free use of mercury, so that it shall give rise to ptyalism. The practice has long been common, quite PALLIATIVE TREATMENT OF PHTHISIS PULMONALIS. 291 too common in the United States, where a salutary dread now happily re- places in the minds of many physicians the confidence once entertained of the remedial powers of mercury in phthisis. If mercury is to be of service, it must be in what are rather vaguely called scrofulous inflammations ofthe pulmonary organs, in which direct depletion fails us, and which, if not checked, soon end in or rapidly de- velop tuberculization. In simple anemia, with scrofula or tubercle, where nutrition is defective, and mere irritation exists with really feeble functional action, the use of mercury ought to be deprecated in the most decided manner. You will find in the London Medical Gazette, 1840, a sensible though somewhat prolix communication from Dr. Munk, setting forth the indications for the mercurial practice in phthisis, and the modifications and subsequent measures of treatment required to give it adequate effect. Among the means of palliation, and, by the more sanguine, of cure, in phthisis, issues have been highly extolled and not a little used. Dr. Stokes lays great stress on this remedy, as indispensable in many cases ; while M. Louis, on the other hand, has seen no benefit from their use. My own experience would lead me to coincide in opinion with the latter. Moxa repeatedly used under the clavicle has also been praised. I now recur to that part of the advice for the treatment of a phthisical patient, in which, concurrently with or very soon after the employment of antiphlogistics and revulsives for the removal of intercurrent affections or of complications in phthisis, recourse is had to those measures calculated to furnish blood and keep nutrition up to a point of average activity ; for, be it remembered, that it is not a plethoric state of the system and exces- sive quantity of blood that give rise to the disorders calling for depletion and reduction, but a wrong direction, an afflux of blood to a particular part, consequent often upon the local irritation of tubercle. Our aim, therefore, must be to establish the equilibrium as soon and with as little expenditure of strength as possible. Contributing to this end will be the use of opiates, or if these disagree, other narcotics alternating with simple bitters, which latter of themselves display a sedative much more than a stimulating operation. We shall not unfrequently find that carefully en- veloping the patient in warm clothes, after hot pediluvia, and giving him a Dover's powder and some warm diluent, or if there be cough, mucila- ginous drink, surprisingly abate and even remove violent stitches of the side and incipient pneumoniae or bronchitic attacks ; the renewal of which will be prevented by the judicious use of tonic but not stimulating reme- dies. In pleuritic stitches, which often are transferred from one point of the chest to another, we must rely on moderate counter-irritation or revul- sion, by fomentation, simple plasters to the chest, and opiates rather than bloodletting, which, if at all tried, ought to be by the application of a few leeches over the pained part. The food in phthisis should consist of nutrimental substances, in a rela- tively small compass or quantity, and even in reasonable variety ; that is, of change from day to day commensurate with the digestive powers, more than with cravings of appetite of the invalid. When diarrhoea sets in more simplicity of diet is demanded, and even though we may not admit that the change in the mucous membrane of the stomach and bowels con- stitutes gastro-enteritis, yet will the alimentary canal be for the most part readily and injuriously affected by commixture of food and highly season- ed or very nutritious articles, and soothed by those of a simpler and 292 DISEASES OF THE RESPIRATORY APPARATUS. blander nature. By curtailing the quantity of bread and milk taken by a patient in the morning, and withholding for a few days the animal food taken at dinner, and substituting in its stead rice and sago, and rice-water and gum-water for drink, and giving as the only medicines a few grains of magnesia and a fraction of a grain of ipecacuanha at intervals, I suc- ceeded in reducing the number of discharges in the twenty-four hours from ten or twelve to two or three: and this was in a case in which dis- section revealed immense patches of tubercular ulceration of the end of the small, and beginning of the large intestines. In some cases of diarrhoea, I have found the patient to derive ease for a time from sugar of lead with a little opium; in others lime-water and lau- danum have afforded most relief. All the remedies recommended for diar- rhoea may be tried in succession, and each may suspend the symptoms for a few hours or a day or two, but no one exerts any notably controlling power over the disease, or materially retards its progress to a fatal termi- nation. The irritative or symptomatic fever with extreme frequency of the pulse in phthisis has been attempted to be combated by particular remedies, among which digitalis ranks foremost. It seems to have been forgotten that the morbidly excited heart is here but a symptom, an effect of diseased lungs: wre may produce a temporary sedation ofthe nervous system and diminish its sensibility to the pulmonary irritation, but we do so by partial poison- ing, when we give digitalis and analogous remedies. I have derived more benefit from minute doses of tartar emetic, or from ipecacuanha wine with carbonate of potassa. Perspiration and night sweats, so enfeebling to the patient, and sometimes more distressing to him than even diarrhoea, are, like this latter, occasion- ally mitigated in their extremes, and even partially suspended ; but seldom by any remedies directed against them as a mere symptom. All external excitement by undue heat or covering, and all are undue that are not re- quired by the feelings of the patient, should be withheld. Cool and slightly acidulous drinks are to be directed, and of these latter the one longest and most extensively used is the aromatic sulphuric acid, or elixir of vitriol, largely diluted with water, to which some patients like the addition of sugar. Cold sage tea, extolled by some for its wonderful anti-diaphoretic powers in these cases, has, within my own experience, failed much oftener than it has proved serviceable. Better is the cold infusion of bark. Sponging the skin with vinegar and water, and a strong solution of alum in water, has also been used with temporary advantage. In addition to the hygienic measures already described, and in connex- ion with a proper diet in phthisis, we may allow the patient carbonated waters, such as the Seltzer; and the condimental addition of vinegar and oil to simple and tasteless articles of food. As part of the hygienic course, moderate exercise in the open air, and preferably on horseback, if it can be obtained, should be taken by the phthisical patient whenever the weather is not inclement. If adequate in- ducement could be offered so as agreeably to excite his attention, travel to some extent will be productive of no little benefit in incipient phthisis, provided there be no complication of pulmonary phlogosis nor much irri- tative fever. Change of scene with moderate and sustained exercise, are the chief causes of the relief which is attributed so generally to change of climate when this is made. WTith our now better knowledge of the effects PALLIATIVE TREATMENT OF PHTHISIS PULMONALIS. 293 of climate and locality, and of the fact that in nearly all the regions of the earth phthisis is met with, and in warm climates to a very great extent, we can hardly promise our patients any very decided benefit in distinctly formed phthisis, certainly little or no hopes of cure, by send- ing them to other and distant lands. That certain states of bronchial irritation and chronic phlogosis, exceedingly harassing to the patient and by their persistence calculated to develop into destructive activity nascent tubercles, will be relieved greatly by change of air, we are not allowed to doubt; but even in such cases it is easier to state the pro- position in general terms than to specify the precise conditions of atmos- phere and climate which are to give it a practical value. For many preg- nant suggestions on this topic, I must refer you to the two works of Sir James Clark on Climate and on Pulmonary Consumption. Good hints will be found also in the more elaborate and statistical production of Dr. Forry on the Climate of the United States and its Endemic Influences, to which reference has been made by me in former lectures. 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 be- come in a sort endeared to him by the very hardships which, as one of the campaigners in the Indian war, he necessarily encountered. He describes the peninsula of Florida as " possessing an insular temperature 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," 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 ap- plied 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 good opinion now entertained in favour of the countries bordering on the Mediterranean would be dispelled. The reputation ofthe 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 advocate the 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 on 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 feelings 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 ex- ercise can be taken daily; and who has not seen, by a persistence in this plan, invalids apparently in the last stage of decline battle it out for many months, sometimes years, 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 re- 294 DISEASES OF THE RESPIRATORY APPARATUS. side in a house in which equable temperature and moisture were kept up during the winter and spring months, with adequate ventilation, with the privilege of sallying out for a short walk, or preferably still, a ride on horse- back, whenever a genial sunshine and a southern air would allow of exit from the house. These, with the comforts of home, the prompt use of re- medies for removing inflammation or any complication of the disease by one's own physician, and the solace of friends, will give the invalid advan- tages which neither Nice, nor Pisa, nor Rome, nor St. Augustine, nor Cuba, can procure for him. Connected alike with prophylaxis and the cure of phthisis, is the ques- tion, renewed lately in France by discussions in the Royal Academy and in journals, as to how far the air of marshy countries affords protection from this disease ; or, in the present fashion of formalising,—How far is there antagonism between consumption and intermittent fever? That there is no special novelty in the idea, must be evident to those who re- member, or who have read of the sanguine hopes once entertained of the cure of the consumptive by a residence in marshy regions. I have, myself, as far back as 1825, when combating the notion of intermittent fever being caused by the imaginary agency of malaria, spoken of the contrasted localities of this fever and of phthisis. " In the same county of Lincoln, in England, the inhabitants of the fens are sufferers from in- termittent fevers ; those of the wolds or hills are obnoxious to catarrhs, pleurisies, and phthisis. If an exchange be made of habitation in these two cases, there will be an exchange of diseases." The very conflicting testimony on this subject must prevent our making any immediate conclusion ; or ought I not rather to say, that the adverse testimony of many physicians both in France and Italy, resident and practising in paludal regions, the inhabitants of which are continually subject to periodical fevers, and yet suffer from phthisis, is sufficient to destroy the value of the opinion of any decidedly prophylactic virtue in marsh air, and to nullify the general proposition or law that M. Boudin has attempted to establish. Cayenne, proverbially subject to periodical fevers ofthe worst grade, as might readily be anticipated from the nature of its soil, which is mainly alluvial, and its incumbent atmosphere, has also phthisis among its diseases. The negroes especially, as we learn from Campet (Traite des Maladies des Pays Chauds), fall victims to it in large numbers. How frequently, also, are we able to trace in different parts of our own country in which intermittent and remittent fevers are endemic, tubercles developed or brought into activity by the visceral diseases, congestive and inflammatory, associated with these fevers. Dr. Dickson (of the New York City University) tells us : "I have personally witnessed several melancholy instances of this kind." After all that we have hitherto learned of pulmonary tubercle and of the attempts made to modify, by either moderating or arresting its de- velopment, are we prepared to speak of curative treatment of the disease ? It would be presumptuous to do so at present, and I shall dismiss the investigation by a summary notice of the measures and means which san- guine hopes have ventured to designate as curative of phthisis. In doing so, I shall repeat the language used in another place (Notes in Stokes's Treatise), and to a certain extent some of the ideas advanced in a prece- ding part of this lecture. The elements of disease, as well stated by Dr. Williams (Principles of CURATIVE TREATMENT OF PHTHISIS PULMONALIS. 295 Medicine, p. 329), chiefly to be kept in view in the treatment of phthisis, are : " 1, the disordered condition of the blood, and its causes ; 2, the dis- ordered distribution of the blood, and its causes; 3, the presence of the de- posit, and its effects and changes." In our efforts to correct or remove the first of these morbid elements, small progress will be made unless ade- quate materials, in the shape of wholesome aliment and pure air, are sup- plied to regenerate healthy blood ; in fact, suitable pains taken to procure for the invalid healthy digestion and improved respiration. Attention to the state of these functions with a view to hematosis, implies necessarily a careful superintendence of all the other organic functions, and especially of secretion and excretion—from the skin, kidneys, &c, and an equable warmth and active vitality ofthe external surface, maintained by suitable clothing, bathing, and friction. These last act hygienically in the same way as counter-irritants do therapeutically. Whatever good effects are derivable from a change of climate to the phthisical patient, depend on the aid which it gives to nutrition, including, of course, hematosis, more than on any directly sanative, or, as some ima- gine, balsamic influence of the air on the lungs. This truth is beginning to be better understood, now when it is discovered, that warm southern climates are never beneficial unless digestion and healthy nutrition are maintained ; and hence, also, we can now understand the seeming para- dox, that some phthisical patients are benefited by a change from a warm to a cool, even although it be a somewhat inclement, climate. The general health is often better in the latter, and the patient's chances of longer life increased, provided local hyperemia, congestions, and inflam- mations of the lungs be guarded against. To these the patient is more liable in cold climates ; but, as it has seemed to me, he is, on the other hand, more exposed to tuberculous disease and irritation of the bowels, and consequent impediment to nutrition, in warm climates. When we speak of the latter we mean those in which not only the average tempera- ture of the year is considerable, but also the temperature of the winter months, as in the West Indies, is relatively high. In atonic states ofthe system, and where the appetite is inconsiderable, digestion slow, and nutri- tion imperfect, I would recommend residence, even during the winter months, in northern latitudes to that in southern and warm ones,—pro- vided that all due attention be paid to the clothing of the patient, and a uniform temperature of the air in-doors through a suite of apartments, if not the whole house, be kept up'. Precautions of this nature will not be found incompatible with permission to exercise on foot or in a carriage, whenever the weather is not very inclement. In this opinion I am strengthened by the observation of cases, the treatment of which, I have directed in accordance with it. Of the different remedies which are believed to act on the blood and prevent new deposits, and to promote the absorption of those already made, preparations of iodine have, in late years, enjoyed the most vogue. The mildest and best is the iodide of potassium, which, as a good altera- tive, favourable to nutrition and improving the appetite, will be found to amend the general health, even, and unhappily this occurs in the largest number of cases, when it fails to remove the tuberculous deposit. It should be combined with the compound syrup and the decoction of sarsapa- rilla, or a simple vegetable bitter. More benefit will be derived from its moderate use when largely diluted with water and continued without inter- 296 DISEASES OF THE RESPIRATORY APPARATUS. ruption, than when it is given in full doses at certain intervals, as twice or three times a-day, with a risk of its offending the stomach, or producing its peculiar disorder of iodism. From at, priori reasoning, and even a due share of favourable attesta- tions of its power in scrofulous diseases, the iodide of iron has been used with a view both to promote the absorption of tubercle and to prevent its farther deposit. As a useful tonic in debilitated states of the digestive system and of the body generally, this medicine may be used in many cases of phthisis with advantage ; but if we believe in its possession of curative powers we shall be disappointed. M. Louis, who, in the last edition of his work on consumption, passes in review the latest recom- mended remedies, gives his experience of this article (the proto-iodide of iron). He employed it in upwards of sixty cases, occurring either in his hospital or private practice, and, " to his astonishment, in not a single case did he observe any amelioration which could be attributed to the new agent." Still, on the faith of M. Duparquier's positive assertions of its efficacy, M. Louis thinks that it would be worth while to make a far- ther trial of the medicine. Common salt has been subjected, by M. Louis, to the same test, that of experimental trials, and has proved to be without any value. In no single case did he observe any appreciable effect produced on the state of the functions. Some patients could not go on with the chloride for more than a few days, the greater number took it for a month or upwards. Carbonate of potassa, rather a favourite medicine with Laennec, has been used and praised by some of his successors for its resolvent proper- ties in tubercle ; but more on the grounds of analogy than from direct evidence in its favour. M. Louis might have attached some importance, however, to a recommendation from such sources, even though he did not think it worth while to try this article on the faith of M. Pascal's praises. Dr. Cless, of Stuttgard, lauds sal ammoniac in large doses ; and M. Hirzog, of Posen, is equally confident of the powers of chloride of lime. But the truth is, as well observed by the British and Foreign Medical Re- view, and we introduce the remark as applicable to many physicians both in Great Britain and the United States, a great number of the Germans are in the happiest of all possible conditions for " curing phthisis" readily— in perfect ignorance of the principles of physical diagnosis they trust to the local and general symptoms for their guidance, and their acquaintance even with these is superficial and routine-like,—how often chronic bron- chitis, simple chronic induration, chronic pleurisy, &c, must be confounded with phthisis under such circumstances, is sufficiently obvious. Cod-liver oil has been employed by many practitioners with, as they inform us, clearly beneficial results ; among others by Dr. Thompson, one of the physicians of the Hospital for Consumption and Diseases of the Chest, at Brompton (England). When benefit was derived, it was, he informs us, generally to be observed within a fortnight. The emetic treatment, once so highly praised and so often practised, but which fell properly enough into disuse, has been again revived with fresh laudations by Dr. Hughes. He gives a preference to the sulphate of zinc or of ipecacuanha in doses of twelve grains, or a combination of six grains of ipecacuanha and two grains of sulphate of copper. As a general rule, the earlier the stage and the more chronic the character of the disease the greater has been the benefit derived from their operation. CURATIVE TREATMENT OF PHTHISIS PULMONALIS. 297 The emetic is to be given every second, third, or fourth day, according to the strength ofthe patient. There is yet another remedy, and as the last recommended for the cure of consumption, it is, of course, assumed to be better than all its predecessors. It is Naphtha, introduced by Dr. Hastings, and alleged by him to have suc- ceeded in his hands in the treatment of undoubted cases of phthisis. Were we to adopt the views of this writer, we ought to regard it as a specific in this disease. The fashion in which he announces his success is itself cal- culated to beget suspicion, as when he tells us, that—" From the very first moment I employed naphtha in pulmonary consumption up to the present time, it has been so successful in my hands, that I have no doubt it will be found, upon careful and judicious use, to be little less than a specific in the earlier stages of the disease." This is tolerably strong ; but the following places the writer in the forward rank of boasting empi- rics : " Single-handed, if I may be allowed to use the expression, it has cured pulmonary consumption in almost every case in which it has hitherto been used, when the disease has been treated at an early stage ; and from what I have more recently observed, although I do not consider myself justified at present to publish it, I am most sanguine that even in the lat- ter stages of the disease a restoration of health may generally be calculated upon." The dose of naphtha which works such wonders is fifteen drops, taken thrice daily in a little water! As the disease advances, the dose is increased to forty or even fifty drops four times a-day. A melancholy commentary on this credulity is furnished by the fate of a warm partisan ofthe naphtha treatment, Dr. Hocken, who died, not long since, in Eng- land, from consumption,—notwithstanding his faith in and use of the medi- cine. Not many years since, hydrocyanic acid was announced by earnest and zealous physicians in terms of nearly equal confidence. In some cases of chronic bronchitis and catarrh in lymphatic subjects, naphtha, as a stimulating expectorant, is of service. As might have been foreseen, from a knowledge of the pathology of phthisis, the favourable representations made by different writers of the good effects of the inhalations of various gases and vaporized substances have not been borne out by recorded experience. The cases published some years ago, by M. Cottereau, in illustration of the curative influence of inhalations of chlorine in phthisis, have been subjected to analysis by M. Louis; and the result is, that not a single one of thera proves the effi- cacy of the pretended specific. This gentleman, notwithstanding the unfavourable issue of the scrutiny, submitted upwards of fifty phthisical subjects to the action of chlorine, and " without in a single case obtaining a successful result." I have sometimes found it give temporary relief to the patient when oppressed by the accumulation of much muco-purulent matter in the bronchia?, and sometimes it seemed to aid in the temporary evacuation of a vomica: but I never found it exert a beneficial influence over the disease by retarding its course, or materially modifying its cha- racter. Of the inhalation of iodine I am inclined to think more favour- ably ; but must confess that I have no case to which I can point as having had its course suspended by the medicine. The alleged cures performed both by iodine and chlorine inhalations were doubtless of ex- hausting chronic bronchitis. Counter-irritants, useful as prophylactics, are still recommended among the curative part of the treatment of phthisis. I certainly have seen 298 DISEASES OF THE RESPIRATORY APPARATUS. relief, amounting almost to a suspension of the most troublesome symp- toms, including, of course, cough, procured by an eruption with croton oil and also by pustulation with tartar emetic. More, however, must be hoped for from the use of these and analogous means in the early than in the advanced stage of phthisis. Dr. Evans, who was once an assistant to St. John Long, celebrated not many years ago for his wonderful cures of consumption, so runs the history, has published some lectures on the disease. Dr. E., after the death of his principal, took to more honest courses, and applied himself diligently to the study of diseases and to their treatment in the usual way. I do not think it necessary to repeat his pathological novelties regarding phthisis, as I believe them not to be true,but refer to him just now as a witness of some experience on the merits of counter-irritation ; for it was in rubbing and making the back sore and raw, that St. John Long's treatment mainly consisted. Dr. Evans still thinks that this fashion of medication is entitled to more confidence than it obtains, provided it be conducted in conformity with the recognised prin- ciples that should govern us in having recourse to counter-irritation. These are, to abate the original irritation and to make the secondary irritation at a part distant from the original. Mere stimulus to the skin will not do good, even if it be not actually prejudicial. There must be a greater irritation#on the surface than that which exists internally. Dr. Evans prefers a liniment composed of vinegar and spirits of turpentine, croton oil, or the ointment of tartrate of antimony, and he particularly urges an extensive application of the liniment, which he states was the secret of the undoubted success in many cases of St. John Long. More reprehensible by far than the quackery of this individual, or of any other who has figured on the stage of imposture, is the proposition gravely made, and in one instance if not more carried into practice, to lay open, by perforating the walls of the chest, the tuberculous cavity. Dr. Hastings, of naphtha notoriety, has published a case in which an opera- tion of this kind was performed. The hoped for result was tobring in apposi- tion the sides of the tuberculous cavity. A more crude pathology can scarcely be entertained than this, one implying greater ignorance of pulmonary tuberculosis as well as of the circumstances under which tubercle is formed in the different organs of the body. It is not so much a cavity per se as the continual deposition of tuberculous matter on its walls, and still more the state of the blood and of the assimilating functions by which the matter is formed, that keep up phthisis and interfere with recovery. Let this perpetual supply from the blood and its deposit on the lungs be arrested by a change of diathesis, and we need not trouble ourselves about exposing a tuberculous cavity and attempting to aid its closing up. This will be done by natural processes, in a safer and more satisfactory manner than by any surgical operation, which can never, even in a well-constituted habit, be performed without danger. In the present case, paracentesis of the chest could not be thought of even by its most sanguine advocate unless the sides of the tuberculous cavity were adherent to the pleura: but we would ask, who shall insure a positive diagnosis on this point, and say that the cavity is not in the centre ofthe lungs or covered by some pulmonary tissue. Then again, if there be more cavities than one, must an opera- tion be performed for each cavity ? TUBERCULOSIS OF THE BRONCHIAL GLANDS. 299 LECTURE CIX. DR. BELL. Tuberculosis of the Bronchial Glands—Bronchial Glandular Phthisis—Morton's account of this disease, as Phthisis Scrophulosa—Studied only of late years—Different forms of—Changes in the tubercular glands—Effects of pressure of the bronchial glands on other parts—the great vessels, trachea and bronchiae, the lungs, nerves, and oesophagus—Communication between the bronchial glands and the lungs—Union of glandular and pulmonary tubercles—Symptoms—chiefly from compression—Dropsy- Hemorrhage—Alteration of the voice—Auscultation—Diagnosis—Prognosis—Causes —Age—Complication with pulmonary tubercle—The disease properly scrofulo-tuber- cular—Treatment—Curative and palliative—Prophylaxis.—Gangrene of the Lungs —Almost always a secondary disease—Is most common in children, and attacks men more than women—Anatomical lesions—Different forms of the disease—Change of pulmonary texture by—Cavities—Stages—Concomitant lesions in the lungs and other organs—Symptoms and Diagnosis—not very distinct—Causes—Associated with pulmo- nary apoplexy—The insane most liable to the disease—Treatment—regarding it as a disease ofthe blood—To correct putrescence and keep up the tone ofthe system. Tuberculosis of the Bronchial Glands — Bronchial Glandular Phthisis.—I am induced to deviate from the course pointed out by the anatomical connexion of parts, and their community of object for the dis- charge ofthe function of respiration, and to suspend, for a while, inquiry into the remaining diseases ofthe respiratory apparatus, in order to make a few remarks on those of the bronchial glands, and more particularly on that morbid condition of these bodies which consists in tuberculosis. My reason for this deviation is, that, although these glands serve no direct office in the respiratory function, yet situated, as they are, on the trachea, and sur- rounding its first bronchial ramifications, even down into the lungs, and con- tiguous to some of the great vessels, any morbid change in them, espe- cially by augmentation of size, produces considerable disorder in the respira- tion and the circulation. And again, they are so often affected with tubercu- lous deposit, especially in children, that their disease in this way gives rise to phenomena analogous to those of pulmonary tuberculosis, even when not complicated with this latter. This complication is, however, as I have before told you, quite a common occurrence, Morton, in the third book of his Phthisiologia, allotted to symptomatic pulmonary phthisis, describes a scrofulous variety of the disease, the seat of which he supposes to be in the pulmonary glands. This author in- dicates clearly the infarction or swelling of the glands juxta Trachccam atque ejus ramulos; and he finds collateral proof of their scrofulous cha- racter, at this time, in the occurrence of concomitant glandular tumours in other parts ofthe body, and, also, of ophthalmia, scabies, and other scro- tulous affections. He soon, however, in the farther progress of his de- scription, places under the same category and as constituting a part of scrofulous phthisis, tubercles of the lungs themselves, which he speaks of under the form of a cretaceous, steatomatous, and meliceritious nature. I may mention here, by the way, that Morton, on this occasion, describes two varieties of this form of phthisis ; chronic and acute. The chronic is modified by the presence of the cretaceous tubercles, the subjects of which live, he tells us, though as valetudinarians, from youth to advanced age. In the acute variety the disease terminates in a very short period. 300 DISEASES OF THE RESPIRATORY APPARATUS. Stark, to whom we are indebted for the first clear account both of tubercle and ofthe place and circumstances of its deposit, states that the lymphatic glands of the chest are of a dark colour, and sometimes contain a matter like cheese. But it is only of late years that the diseases of the bronchial glands have attracted much attention, owing, in a great mea- sure, to their prevailing chiefly in early life, and during a period in which its diseases were not investigated by the aid of morbid anatomy, and with a view to an illustration of symptomatology and treatment. Even now we must look to the writings of French physicians for the chief and most carefully made observations on the subject; and of these, in a more espe- cial manner, to the elaborate work of MM. Barthez and Rilliet, so often referred to and quoted by me in these lectures. It is but just, however, that I should mention the late Dr. Joseph Parrish, of this city, having many years ago pointed out, and dwelt with no little emphasis on the morbid states of these glands as part of evidence of the scrofulous cha- racter of phthisis. The chief form of disease of the bronchial glands is tuberculosis, which, both in itself and associated with tubercle of the bronchiae, merits care- ful study. Of all the varieties of tuberculous matter infiltration is the most common in these bodies, although we meet with grey and yellow granulations, and the miliary tubercle also. Commonly, the central part of the gland is the first affected, and the disease extends thence gradually to the circumference ; at other times, the tuberculous matter is irregularly distributed in different parts ofthe gland. We may find even grey granulations in the centre ofthe organ, whilst the periphery is already converted into tubercle : at a later period the entire gland is affected in its tissue ; and it may acquire the size of a filbert, an almond, or even of a chestnut. We are not to suppose, however, that all the glands in the same subject undergo the same enlargement. In some cases there are only five or six tuberculous glands surrounding the bron- chiae of one of the lungs ; but in other cases they are much more numer- ous, run into each other, and form large masses, equal, in some instances, in volume to a hen's-egg, or even to a large apple. Such enlargements are only acquired, however, by the glands external to the lungs. The internal ones, on the other hand, seldom exceed the size of a small hazel- nut, or of a small almond. We can trace them deep into the lungs on a level with the third and even fourth divisions of the bronchiae. Most commonly they adhere to the air-passages in the direction of the length of these latter; while, at other times, they form a kind of arch, surround- ing in part the bronchiae, the concavity of which is turned towards these latter and the convexity towards the lungs. In another direction, they are situated between the pericardium and the lungs, and along the oesophagus, in the posterior mediastinum ; and, finally, along the large vessels in the anterior mediastinum, and thence on the trachea and cervical plexus. These glands are inclosed in a cyst with very thin walls, to which tuberculous matter closely adheres. On removing this latter we often see on the internal surface of the cyst a very delicate vascular arborization; but in recent tuberculosis this structure is not perceptible. The tubercles which they contain undergo, at different intervals of time, a softening analogous to that which is observed in the tubercles of other organs ; and which begins sometimes in the centre, sometimes in the circumference of the gland ; and on occasions it may be going on simultaneously in both DISEASES OF THE BRONCHIAL GLANDS. 301 these directions. Abscess may sometimes simulate tubercle of the glands ; but the difference is easily detected by a careful inspection of the fluid, which is homogeneous in the former, but grumous and exhibiting the remains of tuberculous matter in the latter. Suppuration of the bron- chial glands is, however, a rare disease. Once softened, the tuberculous matter generally finds exit by a com- munication established between thecyst and the adjoining organs,although in a few cases there is reason to believe that it is absorbed but still incom- pletely. The next branch of inquiry connected with tuberculosis of the bronchial glands is the pressure which they exert on adjoining parts. To be able to appreciate properly the symptoms from this cause, we ought to be aware of the two kinds of bronchial glands and their respective distributions. One of these is external to, the other in the lungs. The latter are quite numerous and accompany the ramifications of the vessels and the air- tubes ; increasing in size as we trace them from the minute bronchise and vascular branches to the roots of the lungs, and the great vessels. Among the glands external to the lungs, anatomists distinguish, situated on the sides of the trachea and in the space between its bifurcation, the tracheal, the bronchial, the cardiac at the base of the heart and in connexion with the great vessels, and the oesophageal ones situated in the posterior medias- tinum and the vicinity of the oesophagus. These limits may be passed in disease, so that the cardiac glands fill the whole anterior mediastinum and extend from the base of the heart to the sternum, and even sometimes encroach on the space occupied by the lung. The tracheal and the bron- chial divisions in their hypertrophied state sometimes form a complete envelope to the tubes from which they derive their name and which they entirely surround, in place of their being simply in contact with the sides. It is easy to foresee, after this view ofthe situation of the glands, that by their enlargements they would compress important organs, and give origin to a great variety of symptoms, generally, it is true, of a physiolo- gical nature, as their occurrence is not maintained by any decided anato- mical lesion. I shall enumerate the chief organs liable to compression and consequent derangement of function from this cause. The Great Vessels.—The superior vena cava, the aorta, the pulmonary artery and veins, and the vena azygos, may be thus compressed ; and have their circulatory office much disturbed. M. Tonnelle relates a case in which the superior cava was completely obstructed. Among the second- ary lesions produced in this way are hemorrhages and dropsy ; the former of which has taken place in the arachnoid cavity and the latter manifested by edema of the face. Compression of the pulmonary vessels gives rise to pulmonary edema, and indirectly it may cause dangerous hemoptysis. May we not attribute to this cause some of those alarming and obstinate hemoptyses in young scrofulous subjects, in whom from early life the bron- chial glands had acquired an unusual volume and been partially tuber- culized. The Trachea and the Bronchia.—These organs are not so often unduly compressed as the great vessels; although instances are related of the almost entire obliteration ofthe bronchial tubes by this cause. The Lungs, from the number of bronchial glands distributed through them, are liable to suffer from pressure by the enlargement of these latter, which sometimes assume the appearance of pulmonary tubercles and thrust aside as it were the lungs. 302 DISEASES OF THE RESPIRATORY APPARATUS. The Nerves, particularly the pneumogastric and their divisions, are often compressed. Reference has been made in my lecture on croup, to the hypothesis of Dr. Ley, that compression of these nerves by enlarged cervical and bronchial glands gives rise to this disease, or at least to some of its prominent symptoms. The (Esophagus has been compressed, but without our having learned the accompanying disorder, if any, that was manifested. In farther prosecution of the subject of the effects of changes by the bronchial glands on adjoining parts, we have to note the communications between the glandular cyst and the thoracic organs. The chief example of this morbid connexion is in the bronchia?, which, unable to yield much to the pressure of enlarged glands, form adhesions to these latter, at first by loose cellular tissue, which afterwards becomes so dense that it is im- possible to detach the gland without bringing away a portion of the bron- chia itself. This intimate union is but the prelude to farther changes, which end in a softening of the tuberculous gland and a communication between it and the bronchia through a perforation in the cyst and the sides of the latter. At times, the accumulation of tuberculous glands is so great around the bronchia as to form a tuberculous investment of some degree of thick- ness. The appearances of the perforations in the bronchia? vary ; some- times they are well-defined and without any traces of inflammation. At other times they are deeply injected on both sides, and the borders ofthe opening are irregular. The cystic investment of the gland, after having been emptied of its tuberculous matter, through the opening into the bron- chia, shows in its interior a false membrane, which is not, as some have alleged, analogous in general appearance and colour to the bronchial mu- cous membrane, although it must be acknowledged that it is not readily distinguishable from this latter at the line of junction. There may some- times be seen, intermediate between the tuberculous gland and the bron- chia, portions of pulmonary tissue traversed by cavities, the sides of which are formed by the parenchyma ; the cavities themselves being a medium of communication between the bronchia and the gland. But when the bronchial gland is deep in the parenchyma of the lungs, and communi- cates with the bronchia or causes an ulceration of adjoining tissues, it is very difficult to determine the nature of the case; and it has doubtless happened that those tuberculous cysts situated in the interior ofthe organ have been described as true pulmonary cavities. Perforation of the vessels is a rare occurrence,—and the same may be said of that of the oesophagus. A union of glandular and pulmonary tubercles may take place — at first when they are in a state of crudity, and afterwards of softening. A similar junction is formed between the primitive bronchial tuberculosis and that in the bronchial glands. The coexistence of tuberculosis of the bronchial glands and of tuberculous meningitis has been noticed. Symptoms.—It is not easy to give the symptoms of a disease which is seldom met with alone, or uncomplicated with other lesions, before the primary ones or those of the bronchial glands have attracted attention. The enlargement simultaneously of the cervical and axillary glands may beget suspicion of a glandular tumour in the thorax or about the root of the lungs. MM. Rilliet and Barthez, after an investigation of this branch of the subject, recapitulate as follows : Compression by the vena SYMPTOMS OF DISEASES OF THE BRONCHIAL GLANDS. 303 cava may cause edema of the face, dilatation of the veins of the neck, violet colour of the face, hemorrhage into the arachnoid cavity. Com- pression of the pulmonary vessels may give rise to hemoptysis and pul- monary edema. When the glands compress the pneumogastric nerves, there may super- vene alteration in the tone of the voice, kinks, like those in hooping- cough, and paroxysms of asthma, which are so unusual in a child. The action of the glands on the lungs and bronchia? is still more remarkable. By compressing the air-tubes, the glands give origin to the production of intense, persistent, and sonorous rhonchi, of a peculiar quality. They also prevent the free circulation of air in the lungs, and thence results obstruction of the respiratory murmur. This phenomenon may also depend on edema caused by compression on the pulmonary organs. But the glands may act not only on the bronchiae by pressure, but, like- wise, as conductors of sonorous impressions. Hence we have the fol- lowing phenomena : 1. The lung being quite healthy or nearly so, various alterations in the respiratory sound may be heard in different parts of the chest, such as prolonged expiration, bronchial respiration, and all the sounds which in their normal state are formed in the bronchiae and are not transmitted to the ear. 2. These symptoms are still more evident if there exist any pulmonary lesions, the stethoscopic indication of which, in common of little intensity, may seem to be exaggerated by the presence of the enlarged glands. 3. The stethoscopic sounds furnished by the lesion of one lung may be transmitted to the opposite side and produce the impression that a double lesion exists. 4. The bronchial glands resting on the vertebral column of one side, whilst they surround the bronchiae on the other, transmit directly to the ear the sounds both normal and abnormal, which are evolved in a part of the lung remote from the thoracic cavity, and thus seem to be exaggerated. 5. These stethoscopic phenomena are especially perceived at the apex of the lungs behind and more seldom in front. All these symptoms, which result from the pressure of enlarged and hard- ened glands on the vessels, nerves, bronchiae, and lungs, are not always met with in conjunction, and when they do they may come and go, often in a curious and incomprehensible manner. Diagnosis.—This, as may have been inferred from an enumeration of the symptoms, is not an easy matter. It must be made from a careful sifting and analysis of the symptoms and an observation of their intermit- tence. It will be proper, after an investigation of the direct symptoms, to examine the lymphatic glands as far as they are visible ; and especially those of the neck, which seem to form beaded lines, passing behind the clavicle and continued down into the thorax, blending with the bronchial glands proper. Tuberculosis of the thoracic glands, including the bronchial proper as well as others in the chest, may be confounded with hooping-cough, phthisis, and tumours developed in the mediastinum. Prognosis.—If the tuberculated bronchial glands were the only disease, we might indulge in a rather favourable augury. Neither so extensive in their morbid changes nor exciting secondary inflammations as pulmonary tubercles do, still we find the tuberculous glands associated with, as pre- cursor or cause, accidents of an alarming nature, such as hemorrhage, per- foration of the lungs and oesophagus, pressure on the vessels, nerves, and bronchiae. 304 DISEASES OF THE RESPIRATORY apparatus. Causes. — Inflammation of the bronchial glands is not an adequate explanation ofthe causes of their tuberculosis; nor is bronchitis or pneu- monia more satisfactory. Age.—This disease is peculiarly one of early life, and in persons of this period it is more common than pulmonary tuberculosis. Of its frequent complication with this latter we may judge from the fact stated by Dr. H. Green, that in 112 cases of pulmonary tubercle, 100 had tuberculosis ofthe bronchial glands. Rarely are other organs tuberculous in children without the bronchial being eminently so. Under puberty there are two periods in which glandular tuberculosis is most rife : first in very young children ; and next in those from six to fifteen years old. As respects sex, it has been observed, that girls under three years of age are less liable to the disease than boys of the same age ; but that between eleven and fifteen years the susceptibility is equal. Among the most efficient predisposing causes should be enumerated the scrofulous diathesis; swelling and ulce- ration of lymphatic glands of the neck and other parts precede and accom- pany tubercle ofthe bronchial glands. Dr. Joseph Parrish used to dwell very emphatically on the connexion between scrofula and tubercle. The present disease might be well called scrofulo-tubercular. Treatment.— The same difficulties that embarrass us in the diagnosis are felt in the treatment of tuberculosis of the bronchial glands. When occurring in an advanced stage we can have but little hopes of any tho- roughly curative course ; but we may from analogy, after an observation ofthe effects of remedies on scrofulous lymphatjc glands which are visi- ble, infer the activity of suitable treatment in the disease. The primary indication is, to bring to bear as determinately as possible a wisely devised prophylaxis, which will be similar in all its leading fea- tures to that of phthisis or pulmonary tubercle. We cannot recognise, however, as part of prophylaxis, sanguineous and other depletion, under a belief that there is inflammation requiring removal by these means. Dr. Ley's opinion, that diseases of the scalp in children often give rise to irritation and enlargement of the cervical glands, which are continued down to the bronchial, and his advice to remove these diseases, merit at- tention. But when this is attempted, it must be with extreme caution, and by means of combined hygienic and therapeutical measures, which happily do not conflict with the preventive, nor subsequently curative treatment of the diseased bronchial glands, if this be still necessary. For the removal of tuberculosis, and a change in the glandular deposit so as to prevent its formation, we must encourage as much as possible the ab- sorbent function. With this view we rely most on iodine and its prepa- rations, used externally in the form of ointment, or even tincture, and internally in the form of solution of the iodide of potassium, or of the iodu- retted iodide (Lugol's solution), and in cases of greater debility the iodide of iron. The best ointment for prolonged use is that ofthe simple iodide of potassium, or its combination with some narcotic extract, as of stramo- nium or of belladonna. This is to be carefully rubbed along the line of glands in the neck on both sides down to the clavicle, and in a line with this bone, both above and below it, thence extending over Ihe sternum, and also in the space between the scapulae. Alternating or indeed combined with the iodide, we may prescribe ad- vantageously some largely diluted, simple saline, such as the sulphate of magnesia, and chloride of sodium, to be taken by the patient daily and GANGRENE OF THE LUNGS. 305 continued for a length of time. Bitters and other tonics may be used conjointly with the iodine treatment. The palliative treatment will be carried out by the exhibition of reme- dies adapted to allay particular symptoms. The cough is best relieved by extract of cicuta and lactucarium ; and these failing, we have recourse to the other narcotics. Among the articles possessing both tonic and anodyne properties is the wild cherry-tree bark,—a syrup of which is now prepared by our apothecaries, both pleasant and efrtcacious. Asthmatic attacks are to be relieved in a similar manner. The extract or tincture of belladonna I have found to be most serviceable for this purpose. Plasters of assafcetida or other fetid gums and liniments rubbed on the chest, are useful auxiliaries to a more active treatment, and correspond with the indications at this time. But while recommending an alterative and tonic course we must not persist in remedies of this latter class when there is much fever. Under such circumstances we try soothing medicines, and light vegetables and milk diluted, for food. The preparations of iodine should be suspended at this time, and some ofthe milder ones of iron substituted for them. There yet remain some diseases affecting the lungs to be described, in completion of the entire circle of those of the respiratory apparatus. These -are gangrene, melanosis, and cancer; which, although of rare oc- currence, merit a brief notice at this time. Gangrene of the Lungs.—This is almost always a secondary disease and in a majority of cases is coexistent with gangrene of other organs, evincing what may be termed a gangrenous diathesis. It occurs much oftener in children than in adults, being consecutive, in the former, on the exanthemata, and attacks men more than women, in the proportion of 11 to 4: the insane, also, suffer in this way. Anatomical Lesions.—Pulmonary gangrene presents itself in two differ- ent forms, the nucleated or circumscribed, and the diffuse, 1© which M. Boudet, who has written a valuable memoir on the subject (Archiv. Gen.y 1843), adds a third, the laminated. The circumscribed form presents itself chiefly in the right lung and in its lower lobe. The pulmonary tissue, when gangrenous, is softened by conversion into a pulpy detritus of various colours, from a yellowish or greenish-grey to a deep-green or slate colour; it exhales a characteristic odour, most fetid and insupportable. There is no longer any trace of pulmonary vesicles, bronchiae, vessels, or even of cellular tissue ; but a mere putrescent mass, removable with the least effort. At first adherent to the adjacent tissue of the lungs, it is gra- dually detached from this latter, leaving an excavation in it of variable form and size, and filled either with a gangrenous core or an almost liquid detritus. The sides of this cavity are soft and tufted, and formed of gan- grenous or sometimes hepatized pulmonary tissue, interspersed with putrid shreds: occasionally, though but seldom, there is a white or yellow mem- brane lining the cavity, of a thick but friable and soft nature ; on occa- sions, it is traversed by strips of different sizes, composed of the remains of pulmonary tissue, or of vessels which had escaped the gangrene. Pulmonary gangrene exhibits itself under three aspects, corresponding to three different stages—1st. The gangrenous tissue, or slough. 2d. Liquefaction. 3d. The gangrenous excavation or cavity. The parts surrounding and contiguous to the mortified tissue are of diversified ap- vol. n.—21 ^ 306 DISEASES OF THE RESPIRATORY APPARATUS. pearance ; sometimes exhibiting a sanguineo-serous congestion, of a violet or slate and livid colour; and at other times gorged with black blood, and as it were apoplectic. More generally it is hepatized or carnified, and bears marks of a phlegmasia surrounding the gangrenous part. It is very obvious, after a view of the latter lesions, that if the subjects had survived a few days longer, this hepatized tissue would have been struck with gangrene. I have already mentioned the chief forms under which gangrene ofthe lungs is met with. The appearances under these divisions are numerous and diversified ; in there being sometimes only some greenish striae, formed by a liquid of a gangrenous odour, and situated in the centre of a portion of lung affected with lobular pneumonia, but without communicating with the bronchiae ; while, again, in other subjects, we meet with a number of portions of lung apoplectic or changed by lobular pneumonia, of a deep- red and almost black colour; in the centre of which are seen small exca- vations containing a sanious liquid of a reddish-brown colour, or else a dark detritus of a gangrenous odour. Many of these abscesses commu- nicate with the bronchiae, which latter are of a livid hue, but are not mortified. These gangrenous abscesses are disseminated, in different de- grees of advancement, through a lobe or a lung, or even both lungs, show- ing that they were a part of several successive gangrenous changes. We also meet with true gangrenous excavations or cavities, sometimes single, sometimes numerous, varying in form and capacity, and surrounded with hepatized lung in the manner before described. In other cases, again, the gangrene reaches the walls of a tuberculous excavation, and even involves them in destruction. In yet another variety, the gangre- nous cavity is near the pleura, through which a perforation is made and a communication established with the pleural cavity. MM. Rilliet and Barthez, to whom I am indebted for the preceding description of the morbid anatomy of pulmonary gangrene in children, enumerate concomitant lesions in the lungs, and, also, other organs, viz., 1, in the diseased lung or in that ofthe opposite side, lobular pneumonia or a splenization to a greater or less extent; 2, when there is pleuritic effusion the gangrene coincides with the carnification ; 3, edema sur- rounding the gangrene and sometimes general, with or without pneumo- nia ; 4, the bronchiae are almost always in a morbid state, either around the gangrene or at a distance; sometimes inflamed, sometimes dilated; 5, the bronchial glands are often altered ; 6, in nine of sixteen cases, a lesion of the digestive tube, inflamraation or softening ; 7, conjoint gan- grene of other organs, in the proportion of ten out of eighteen cases. M. Boudet gives the number of cases of gangrene in adults as fifteen, of which eleven exhibited the disease both in the lungs and in other organs ; whilst of five cases in children, four had pulmonary in addition to other gangrene. The existence of gangrenous with tuberculous lung has been noted, but they have no positive relations either of affinity for or antagonism to each other. Symptoms and Diagnosis.—The symptoms are far from being very dis- tinct, and the diagnosis is not easily made out in pulmonary gangrene. Cough and dyspnoea are sometimes slight, or even entirely wanting. He- moptysis, so rare a disease in children, is quite common when they are affected with gangrene of the lung. Fetor of the breath, a characteristic symptom in the adult, is often wanting in the child ; or if there be CAUSES AND TREATMENT OF GANGRENE OF THE LUNGS. 307 accompanying gangrene of the mouth, its fetor will mask that of the breath. The expectorated matter is often very fetid, exhaling an intolerable stench. Sometimes the fetor of the breath ceases, even while the disease is fast tending to death. There is, also, a thoracic gurgling which is a valuable sign in a subject who never had tubercles, as it indicates a cavity in the lungs. The pulse is generally very weak; there is great prostration, and a peculiar expression ofthe face, which is of a dark-violet hue. M. Boudet speaks of dulness of the chest on percussion, resonance ofthe voice, raucous rhonchus, and greenish sputa, among the diagnostic signs. Dr. Gerhard (Clinical Lectures by Graves and Gerhard) describes two kinds of expectoration met with in gangrene of the lungs. "The most common is blackish, anil resembles an inky sediment. The other kind, of which we have an example in the present case, is a greyish, frothy fluid, having some resemblance to yeast, with a fetid odour, which you may perceive is like that of putrid oysters. This, though the least common, is the most favourable variety of sputa. It is generally discharged in very large quan- tities—amounting, sometimes, to a pint or a quart daily." The prognosis in pulmonary gangrene, as you will have readily inferred from the antecedent description, is very unfavourable. Causes.—In inquiring into the causes of pulmonary gangrene, we must bear in mind the fact,that it is rarely idiopathic, rarely seizes on a person— child oradult—who is in full health, and that its supposed antecedent even, pneumonia, is secondary in the subjects attacked with gangrene. Its occur- rence after pneumonia or during pneumonia does not prove this latter to be the cause, and we are therefore obliged to look for more extended and general influences. More stress should be laid on pulmonary apoplexy or congestion in this relation. Certain diseases, which powerfully impress and derange the whole economy, such as the exanthemata and typhoid fever, predispose to gangrene of the lungs. M. Leuret mentions, as a fact within his own observation and that of other physicians attached to hos- pitals for the insane, that instances of this disease are more common among lunatics than among others. Abscess of the liver, spleen or kidneys open- ing into the lungs has sometimes given rise to gangrene of these last-men- tioned organs. If we go back a little farther in the theory of causation ofthe gangrenous diathesis, we must seek for it in the blood itself, which, as we learn from the observations of MM. Andral and Gavarret, loses some of its fibrin in the exanthemata and acquires a more alkaline and dissolved state, with also a tendency to scorbutic disorders. Just such a change occurred in the cases recorded by M. Boudet, who informs us that he never found after death, in any case of children, such diffluent, serous, and non- coagulable blood as in the subjects who fell victims to an exantheme, a spontaneous gangrene, or a malignant typhoid fever; and of these diseases, measles or scarlatina complicated with gangrene furnished him most fre- quently with these peculiarities ofthe blood. A poisoning similar to that in the exanthemata is sometimes brought about by the excessive and pro- longed use of ardent spirits. In all the cases seen by Dr. Stokes, the pa- tients had been long addicted to these drinks. This gentleman supposes, but without suggesting in what it consists, that a septic poison is intro- duced into the system, and gives rise to gangrene ofthe lungs. Treatment.—^Giving colour of probability to the hypothesis of cause ad- vanced by Dr. Stokes, there is only one kind of remedies, viz., those calcu- 308 DISEASES OF THE RESPIRATORY APPARATUS. lated to check putrescence, which he has seen to be of any service. He advises the use of chlorine, exhibited either in the form of chloride of lime or soda with opium; and the strength of the patient to be sustained by wine and nourishing food. In discussing the treatment of pulmonary gangrene, M. Boudet attaches small value to the remedies used under the idea that it is the result either of inflammation or of debility. Regarding it as dependent on a deteriora- tion or depravation of the blood, he thinks the ratio medendi ought to be shaped in accordance with this view; and hence the recommendation, first of suitable prophylaxis, such as keeping children out of the way of the contagion of exanthemata, and subjecting them early to vaccination, by which these diseases, if they do make their attack, are, he thinks, rendered of a less virulent character. If measles or scarlatina should, however, unhappily appear, then we are required to watch with the greatest care the progress of the disease; and as soon as we see any serious general symp- toms,—hemorrhage, or purple spots, for example, or any precursor of gan- grene of the gums, a disease which frequently precedes or accompanies pulmonary gangrene, and which is developed under the operation of the same causes as this latter disease, M. Boudet advises that we should put the patient on the use of citric or sulphuric lemonade; at the same time that we direct the use of acid and antiseptic gargles, and friction of the limbs with an acid and aromatic liquor. He refers to his having, in com- mon with a great many others, seen scorbutic subjects, reduced to the last .degree of weakness and cachexia, emaciated, ecchymosed, and without appetite, who were rapidly cured under the operation of acids, employed both externally and internally. By the use of similar means in the case of children, we might, M. Boudet believes, probably succeed in saturating the excess of alkali in the blood, by which latter cause this fluid loses in a great measure its property of coagulating; and at the same time, by the use of analeptics, we might combat efficaciously its tendency to lose fibrin. Conformably with this view, although M. Boudet does not allude to the remedy, we might advantageously give, in small but repeated doses at short intervals, the tincture of chloride of iron, or the etherial tincture of iron, and the citrate of quinia and iron; while following out the other parts ofthe treatment recommended by Dr. Stokes. Dr. Durrant (Provin. Med. and Surg. Journ.) relates of his patient having derived much benefit from the inhalation of creosote, beginning with one. drop three times a-day, in- creased to four. Iron and quinine, with the iodide of potassium and dilute nitric acid, were prescribed at the same time. The case was one of circum- scribed pneumonia ending in gangrenous abscess. MELANOSIS. 309 LECTURE CX. DR. EELL. Melanosis or Melanoma—Its generic character—Its division into true and spurious— Its seats—True pulmonary melanosis—Histological elements of melanotic tumours— Causes—Deficient elimination of carbon—Concomitance between black infiltration and reparation of pulmonary tubercle—M. Guillot's observations on carbonaceous deposits in the lungs—Aged persons its chief subjects—The black colouring matter is carbon— Spurious melanosis attributed to the inhalation of carbonaceous matters—Exposure in coal mines—Dr. Makellar's observations—Dr. Graham's analysis of carbonaceous deposit—This deposit common without any special exposure—Symptoms—At first slight, afterwards cough, expectoration, sometimes dark or black sputa, hemoptysis in the last period ofthe disease, weak circulation, loss of appetite, diarrhoea, colliqua- tive sweats, slow pulse, dyspnoea, vertigo and syncope—General diagnosis—Post-mor- tem appearances—Black deposit at first, in the walls of the pulmonary vesicles—Oblite- ration ofthe minute vessels and the vesicles—Conversion of affected part of lung into a peculiar lough elastic tissue—Sometimes general infiltration of the lung with black matter—Cavities—Heart flabby and soft—Misapplication of the term black phthisis— —Subjects of melanosis, not tuberculous—Treatment—Reparation of Tubercle in con- nexion with black deposits in the Lungs—Hasse's and Guillot's descriptions and conclu- sions.—Cancer of the Lungs—Cancer a malignant heterologous tumour—Its analo- gies to tubercle—Is more organised—Resemblance in the manner of softening—Ef- fects of cancer on the system—Cancer of the lung, a rare disease—Is primary or se- condary—The last most common—IVimary carcinoma, mainly in one lung, and by infiltration—Secondary variety, as isolated tumours—Bones and testicles, the most frequpnt origin of secondary pulmonary cancer—Pleura sometimes affected—Symp- toms and Signs—Dr. Stokes's summary of. In a natural arrangement, the malignant products or formations—mela- nosis and cancer or encephaloid growth in the lungs—ought either to pre- cede or follow tubercle; and that which separates them in my course, gangrene, ought, if it have any organic affinity, to come after pneumonia. As it is, however, your attention will be, I hope, but little distracted by the separation. Melanosis, or Melanoma as it is called by Dr. Carswell, is divided into the true and the false or spurious. True melanosis is supposed to owe its origin to a morbid secretion. Spurious melanosis is attributed to the introduction of carbonaceous matter from without the body and mainly by inhalation. Melanosis in its generic character is described to be a morbid product, presenting a black colour of various degrees of intensity, somewhat humid and opaque, and possessing the consistence and homo- geneous aspect of the tissue of the bronchial glands of the adult. The most frequent seat of true melanosis is the serous tissue, more especially where this tissue constitutes the cellular element of organs. Here the me- lanotic matter is formed after the manner of secretion, accumulates in the cells of which the serous tissue is composed, and gradually acquires the form of tumours of various sizes. A similar mode of formation of this matter is observed to take place much more conspicuously in loose cellu- lar tissue, and particularly on large serous surfaces, such as those of the pleurae and peritoneum. The next variety observed in the seat and mode of formation of melanotic matter is that in which it is deposited in the sub- stance or molecular structure of organs, after the manner of nutrition. And, lastly, the melanotic matter is found in the blood, contained chiefly in the various capillaries, and under circumstances which show that it must have been formed in these vessels.—(Carswell—Illustrations ofthe Elementary Forms of Disease.) 310 DISEASES OF THE RESPIRATORY APPARATUS. True melanosis is often met with in the lungs of old persons, either in the interlobular tissue or on the sides of the vesicles; and in some instances the black pigment occurs in extraordinary abundance immediately beneath the pulmonary pleura, where it forms irregular superficial elevations dis- posed like network. At a less advanced period of formation it may be seen in a liquid form, infiltrating the pulmonary parenchyma, both in its healthy and morbid states. It is sometimes in isolated masses or encysted. This last constitutes the tuberiform variety of melanosis, which includes both the masses and cysts. M. Andral regards it as a form of chronic pneumonia. Melanotic matter, as seen in the lungs, may also be found at the same time in the liver, spleen, brain, &c. Sometimes melanosis is confounded with the dark matter of the bronchial glands. These latter, it should be remembered, are small, contiguous to the bronchise, with smooth surfaces, and whose interior is seldom of any uniform blackness, nor is the liquid oozing out of a pitchy character. It scarcely colours the finger rubbed against it; and in this respect differs from the colour of Indian ink which melanotic matter leaves on the skin to which it is applied. The histological elements of melanotic tumours are different in different cases. In many of these they consist of dark (brown or black) granules; some- times inclosed in more or less distinct rounded orelongated cells ; but more generally dispersedin dense irregular masses between cellulartissue; some- times itisaltered blood pigment,and occasionallyitis composed of granules of sulphuret of iron. These last are met with in false melanosis. But the pigment is never the sole constituent of melanotic tumours: it forms, as Vogel remarks, only a portion of the whole, and is scattered amongst other histological elements, such as perfectly developed or comparatively amor- phous fibrous tissue, vessels which, however, are never abundant, and malignant formations, as tubercle, encephaloid and scirrhus. Melanotic tumours are, therefore, always compound ; although we may say, that, in general, true melanosis is non-malignant; and so of its combination with fibrous tumour. False melanosis is generally injurious from its very nature, since its occurrence pre-supposes an important decomposition of the fluids ; but when it remains localized it is of less importance. In true melanosis the colour is brown, of a bistre tint, blackish, or if only a little pigment is present, grey. In the false variety depending upon sulphuret of iron, it is slate-grey, or greenish-black ; in that resulting from altered blood pigment, it is blue, violet or brownish-black. A more natural division than that into true and false is the one suggested by Schelling, into innoxious and malignant; the former purely and essen- tially local, the latter prone to become constitutional and contaminate every part of the system. Causes.—Heusinger has advanced the opinion that black deposits in different parts ofthe body depend upon a deficient elimination of carbon, and, in particular, of carbonic acid. He believes that they, to a certain extent, compensate for such defective process, being especially prone to form in organs which afford the natural outlets for carbon, although other organs may be similarly predisposed by disease. In confirmation of this view is the fact, that black infiltration is the almost unfailing concomitant of the reparation of pulmonary tubercle, and in a greater or less degree of senile atrophy of the lungs. M. Guillot, whose interesting observations on the anatomical relations CAUSES OF MELANOSIS. 311 of pulmonary tubercle to contiguous parts have been mentioned in a former lecture, has made some valuable researches on the carbonaceous deposits which take place in the lungs during life. Having had, as its physician, charge ofthe great hospital for the insane, at Bicetre, in which are assembled several thousand old men, he has enjoyed great opportu- nities for investigating a question of pathology, the subjects for which are chiefly among the aged. M. Guillot endeavours to prove, and he has apparently succeeded in the attempt: 1st. That the black colouring matter ofthe lungs in old persons is carbon ; not carbon (charcoal) produced by the action of the chemical re-agents employed, but carbon deposited in its solid state, during life, in the tissues of the respiratory organs. 2d. That this substance may, by its impeding the circulation and respiration, cause death in the aged and aggravate the effect of acute or chronic affec- tions ofthe lungs in this class of persons. Analysis showed the black deposit to possess all the physical and chemical characters of charcoal. Only once did M. Guillot meet in the lungs with a compact mass of carbonaceous substance deposited in layers : it was black, very hard, broke with a metallic shining fracture, infusible, burnt on platinum without flame, and gave scarcely any odour when heated. Carbon is not found in the lungs of children. Spurious melanosis is attributed, especially by English writers, to the inhalation of carbonaceous matter by those who inhale smoke from lamps and other sources of imperfect combustion, and the volatilized coal-dust in mines. The physical characters of this form of spurious melanosis: viz., the uniform black colour of both lungs, the absence of any similar discolora- tion of any other organ ; the occurrence of the disease in those habitu- ally exposed to the inhalations of the coal-dust always contained in the atmosphere of a mine ; and the black matter found in the lungs consisting essentially of this substance, are, Dr. Carswell observes, circumstances which demonstrate clearly the origin of the black matter, and its iden- tity with the carbonaceous powder inhaled with the air in breathing. In corroboration of this view it was asserted, that the greatest amount of black infiltration affected the lungs of those who worked in coal-pits, and it was termed, accordingly, anthracosis. M. Andral, on the other hand, who does not draw the distinction be- tween two kinds of melanosis of the lung, adverts to the opinion of its originating from carbonaceous matter introduced into the bronchia? by inhalation, and thence into the lungs ; but, he adds, that this disease has been met with in all conditions of persons and modes of life, m the country as well as in town, in the houses of the latter as in those of the former. These remarks must apply to true melanosis. Valuable additions to our knowledge of the subject of spurious melanosis have been recently made by Dr. Makellar of Edinburgh, who calls the disease " Black Phthisis, or Ulceration induced by carbonaceous accu- mulation in the Lungs, of Coal Miners and other operatives." Not having this work by me I shall make use of the digested notice of it in the Dublin Quart. Jour. Med. Science, 1847. The author believes that this variety of melanosis arises from carbonaceous inhalation in the first instance ; and that it terminates in marasmus and is accompanied by a singular condition of the lungs. Not alone, however, or even chiefly," is the carbonaceous matter furnished by the coal; but rather, he thinks, by the smoke from the 312 DISEASES OF THE RESPIRATORY APPARATUS. lamps and candles, and above all from the explosion of gunpowder, which are rendered more deleterious by the want of ventilation in the mines and the consequent disengagement, without chance of its escape, of carbonic acid in large quantities. In proof of this view, we learn from Dr. Makellar that stone mining is more injurious than the raising of coal, by its giving rise sooner to the symptoms of carbonaceous accumulations and in a more acute form than the latter. A few years ago a very extensive coal level was carried through the colliery of Tranent, at which a great number of young and vigorous men were employed in blasting, every one of whom expectorated carbon, and all died before the age of thirty-five years. Dr. Graham has declared his conviction, resulting from experiments made by hira, for the purpose, that the black powder derived from the lungs (after analysis) is unquestionably charcoal, and in reference to another case he describes it as having the appearance of lamp-black. One patient gave out in black expectoration a quantity of this black powder or precipitated carbon equal to a drachm and a half daily. It is very clear from the preceding statements ; 1st. That carbonaceous deposits in the lungs, pseudo-melanosis, take place in old persons, par- ticularly, without any known or appreciable origin, in the constitution of the air which they breathe or in any volatile substances suspended in it; and 2d. That the lungs of persons, young and in the prime of life, under certain circumstances of exposure to air constantly contaminated with carbonaceous substances, as in mines, &c, also exhibit carbonaceous deposits in greater abundance even and aggravation than is exhibited in the lungs of old persons. Strong as is the connexion between such exposure and the occurrence of these deposits, the relation of cause and effect may still be legitimately doubted, when the alleged effects or iden- tical anatomical phenomena occur in the absence of the presumed cause, as in the class of subjects mentioned by M. Guillot and others. It is pos- sible, that the dark treacle-like expectoration of the miners described by Dr. Makellar, derived its colour from mixture with the minute dust of coal, accumulated in the pulmonary cells and minute bronchial termina- tions ; and that the expectorated matter was not primarily or properly a dark or black secretion. We need not of necessity, in this view, admit that the carbonaceous deposit was the direct result of the inhalation of smoke or volatilized coal-dust and of its passage through the air-cells, but rather that this kind of exposure predisposed the individual in a greater degree to the formation of carbon in the state in which it is found in the lungs of both classes of subjects, the one described by M. Guillot and the other-by Dr. Makellar. Symptoms.—The leading features of the disease have been well de- scribed by Bayle under the name of" Phthisis with Melanosis." They are, at first and often for a length of time, slight, and consist of cough accom- panied with a white expectoration, the sputa of which are generally round and rather opaque, and swim in a large quantity of diffluent pituity. In some there is no complaint of pain or oppression, but only of their cough preventing them from sleeping. They gradually, however, become thinner, and their pulse is usually more frequent than in health. In the latter period of their life, these patients exhibit an extreme of marasmus, but appear to be scarcely indisposed, although they often expectorate a great deal. Some die in a few days after they had been for the first time considered seriously ill. POST-MORTEM, APPEARANCES OF MELANOSIS. 313 The subjects ofthe disease coming under M. Guillot's notice were thin, pale and weak. They had cough, and expectorated for a great length of time. Some had hemoptysis, but this symptom was most common in the latter period of their life, when the hemorrhage wasconsiderable. The move- ments of the chest were slow and barely appreciable, the pulsations of the heart were feeble, and if febrile reaction even supervened, itwasslightand of short duration ; the digestive functions became more and more languid, the appetite was gone and the ingestion of food only produced diarrhoea. The last craving evinced was for wine or other stimulants. The intellectual faculties were scarcely disturbed. The character of the cough varied ; sometimes it was dry, but more generally accompanied with the expecto- ration of abundant and fluid sputa, amounting to nearly a pint in the twenty-four hours. They may be mixed with blood, or pure blood may- be expectorated. When this is the case, the lungs were found to be loaded with a great quantity of carbonaceous matter. Hemoptysis, which is the symptom of the approaching end of the patient, is, itself, not pre- ceded by any appreciable cause or any appreciable symptom. It always lasts for several days. Percussion indicates dulness in all parts of the thorax corresponding with the deposit of carbonaceous matter. These are generally most con- siderable in the upper lobes of the lungs. On ausculting the chest, bron- chial respiration is heard both during inspiration and expiration, and this sign, in its intensity, corresponds with the extent of the deposit. Ca- vernous rhonchus, and pectoriloquy, are also heard, when there are cavi- ties communicating with bronchial tubes. The symptoras ofthe disease, as it attacked the colliers, and described by Dr. Makellar, are, in the main, similar to those just enumerated. The cough is at first dry, as in dry bronchitis; but expectoration when estab- lished is mucous, and sometimes bloody ; the appetite fails, emaciation and loss of strength result. In the advanced stage of the disease, the patient has remarkable feebleness, and slowness ofthe action ofthe heart; the pulse varying from thirty-six to forty-five beats in the minute. There are occasionally colliquative sweats, and vertigo and syncope close the scene. The symptoms in this class of patients, different from those pre- cedingly described, are, frequently, a black expectoration, dyspnoea at an early period, orthopnoea at a later, the surface of a leaden hue, and dropsical effusions. These symptoms indicate a greater impediment to the pul- monary circulation than in the melanosis of old men ; and would seem to countenance the view which I suggested a little while ago, that the air-cells and bronchise might be really clogged with carbonaceous matter taken in by inhalation ; and in this way there would be symptoms of laboured respiration, and impeded circulation, additional to those that ensue on the deposit or infiltration in the cellular tissue or on the mem- branes of carbonaceous matter from the blood, the common melanosis senilis. The general diagnosis ofthe disease described by Dr. Makellar, may be thus stated. The fact of the patient having been exposed to carbona- ceous inhalations at some former period. The existence of a cachectic state, with a feeble and slow circulation ; evidences of progressive infil- tration or consolidation, preceded or accompanied by signs of bronchitis, with or without the black expectoration. Post-Mortem Appearances.—The black deposit is made, as M. Guillot 314 DISEASES OF THE RESPIRATORY APPARATUS. represents, at first in the parietes of the pulmonary vesicles. At a some- what more advanced period, the increase ofthe black matter causes those polygonal star-like figures which are perceived on the surface of the lungs. They are most marked in the upper lobes and along the course of the large bronchial tubes. By its accumulation, the deposit obliterates the small vascular extremities of the pulmonary artery and veins ; and sub- jects, almost at the same time, the pulmonary vesicles to a similar con- version. The exterior of the lung, generally the superior lobe, is wrinkled, puckered, and presents here and there inequalities of surface, easily ap- preciated by the touch. These characteristic appearances are best seen, by insufflation of the lung. The accumulations of carbonaceous matter vary in size from that of a hemp-seed to that of a walnut. Some- times one-third of the lung is thus rendered unfit to fulfil its functions. The diseased tissue apart from some few Venous arterial branches, or a few bronchial tubes, forms a kind of tough and hard but slightly elastic tissue, similar to pasteboard boiled in water loaded with soot. M. Guillot never met with the black matter, in the encysted form, which melanosis so often assumes in other regions ofthe body. The subjects examined by Dr. Makellar exhibited disorganization of the lung, varying from the* impaction of some bronchial tubes with car- bon, to an almost universal infiltration with a substance like liquid black- ing. In some cases, the carbon forms semi-solid matter, encysted in the lung ; while in others, large cavities are found capable of containing a pint, and filled with the black liquid. These cavities seem to have been formed by the coalescence of many smaller ones, and death may result from their rupture into the trachea. They are traversed, as in great tuber- cular cavities, by bands of pulmonary structure and vessels. The pleurse exhibit adhesions, and are frequently the seat of liquid effusion of a dark colour. The heart is found flabby and soft, and the blood generally dark and pitchy. Enlargement of the liver is common, and in one case, Dr. Makellar found the carbonaceous accumulations in the liver itself. Nothing very remarkable was observed in the cerebro-spinal system, or the digestive tube. The misapplication of the term phthisis to the disease is practically demonstrated by Dr. Makellar himself, who tells us, that pulmonary con- sumption is rare among the miners with whom he is acquainted, and that when it does occur, it is principally among the female colliers, who, it is important that we should know, have never furnished a case of carbona- ceous deposit. This last exemption is to be explained from the fact, that women are only employed as carriers, and from their continually returning to the pit shaft they are enabled to breathe a purer air. The treatment of spurious melanosis must consist primarily and mainly in withdrawing the patient from the operation of the causes of the disease. After this is done, remedies will be directed according to the indications furnished by the symptoms, preference being given to the means of pro- moting free pulmonary transpiration and expectoration ; and among these moderate exercise in a pure air and attention to the state of the skin must rank among the foremost. The prevalence of a cachectic habit, if not of po- sitive anemia will suggest the use of chalybeates and analogous remedies. Reparation of Tubercle in Connexion with Black Deposits in the Lungs.—I shall conclude this notice of melanosis by the remarks of Hasse and Guillot, on the reparation of tubercle in connexion with the deposit REPARATION OF TUBERCLE. 315 of black matter in the lungs. They will serve as a completion of the evidence, adduced in a former lecture, of the curableness, or at least the suspension of all the bad symptoms, of phthisis pulmonalis, and an ave- rage enjoyment of life for a term of years subsequently. "During the reparation of tubercle the black discoloration is both fre- quent and conspicuous, and is not limited to any particular period of life. Andral witnessed it in a girl of 9 years. Black, indurated nodules of irre- gular outline, from the size of a cherry-stone downwards, are found dis- tributed through the sound portions of the lung, but chiefly in the upper lobe of each. They mostly contain a nucleus of curd-like, or moist chalk- like tubercle ; frequently, however, the mass is perfectly homogeneous, of cartilaginous hardness, and affords a glistening section. We are jus- tified by analogy in regarding the above nucleus as the remains of tuber- cle, thoroughly pervaded with black pigment. Secondly, the apex of the lung, perhaps the greater portion of the upper lobe, is totally trans- formed into an almost cartilaginous black mass, in which not a vestige of pulmonary texture is visible. A few, often dilated, bronchial tubes, with blind extremities, permeate the adventitious structure,—whilst the greater number, like vessels, are entirely obliterated. These indurated spots always firmly adhere to the walls of the chest, and generally con- tain the heterogeneous remains of tubercular reparation. Thirdly,—either in the midst of the induration just described, or adjacent to the black nodule, are to be seen shrivelled, shut cavities, whose walls consist of black hardened texture, and whose interior is filled with a grey-black, smeary mass, sometimes interspersed with calcareous granules. Oblite- rated vessels and bronchi terminate in the vicinity. Fourth, and lastly, in certain rare cases, shut cavities, lined with a thin, but firm, black shining membrane, occur at the top ofthe lungs, in which situation slight traces of long extinct tubercular disease are perceptible. These cavities contain nothing but air, and are sometimes traversed by strong and very tight cords, attenuated towards the middle. I do not hesitate to regard all these changes as resulting from the reparation of tubercular mischief, because, in most instances of the kind, whether in the lungs or elsewhere, I have found unequivocal evidence of tubercular disease. This, indeed, was the only affection which could be deduced from the history of the case, as adequate to account for all circumstances present. Further, the black tint displays itself in the bronchial glands, almost under the iden- tical forms and conditions above assigned. In other organs, on the con- trary, the reparation of tubercle is associated with incomparably less of the black degeneration. Hence the black colouring in the lungs would appear to be intimately connected with the disturbance ofthe respiratory function during phthisis, and quite independent of the accidental intro- duction of extraneous matter. It is doubtful whether it is ever the sequel of a sustained sub-inflammatory condition of the pulmonary texture. At least there is no good proof that black pigment can be thus produced, apart from tubercular disease." (Hasse.) M. Guillot assures us that the number of tuberculous persons who arrive at old age is much greater than is generally believed. I do not exaggerate, says M. G., when I state that four-fifths, at the least, of the old men whose organs I examined after death, present evident incontestable traces of tubercular disease ofthe lungs, not of recent, but of a former malady. Sometimes, indeed, the interrogation ofthe patient during life has led me to conclude that it originated during youth. 316 DISEASES OF THE RESPIRATORY APPARATUS. It would appear that the deposit of carbonaceous matter which takes place in the lungs of the aged exercises an important influence over the arrest of tubercular .growth. Around modified tubercles and around caverns no longer suppurating, in this class of subjects, M. Guillot has con- stantly found a more or less considerable deposit of carbonaceous matter. It is in the centre of masses of this matter that evidences of tubercular dis- ease should be principally sought. Miliary and semi-transparent granula- tions are also surrounded and imbedded, as it were, in carbonaceous deposit, which seems to set a limit to farther tuberculous development or formation. The pulmonary cicatrices which have attracted so much attention, are found in the lungs of the aged under the same circum- stances—that is, surrounded by carbonaceous matter. An explanation of the influence of carbonaceous deposit in arresting the progress of tuberculosis is offered by the anatomical researches of M. Guillot. He found that the abnormal circulation established, after a time, around tuberculous formations, is in its turn obliterated by the carbon; so that the tubercles, being cut off from communication with the pul- monary circulation, normal or abnormal, cease to increase and gradually assume the characters which have been just described. Hence we can understand how it is that tubercular persons, thus circumstanced, may live to a very advanced age, and only present, after death, to the ob- server, the traces of a disease, the progress of which has been arrested by nature. Cancer of the Lungs.—Cancer, like tubercle, belongs to the malig- nant heterologous tumours or Pseudo-plasmata ; and, like it, occurs be- tween original elementary parts of the parent-tissue, and occupies, more or less perfectly, all the interstices. In both, in proportion as the infiltra- tion becomes complete, the elements of the original tissue are compressed, and appear to be blended with the deposit into a homogeneous mass, and are gradually atrophied and disappear. The cytoblastema, or matter giv- ing rise to organised formations in the shape of cells, in the case of can- cer as of all other morbid epigeneses, is derived, doubtless, from the blood, is originally fluid, and is identical with the liquor sanguinis. The chief elements of carcinomatous tumours were detailed when the subject of cancer of the uterus was before us; and to that enumeration I now refer you. It must be borne in mind, however, and I believe the remark has been made to you before, that the anatomical and histological relations of carcinomatous tumours exhibit the greatest variety ; and that even in the sarae tumour different parts present very different characters. They are distinguished from the pseudo-plasmatic deposits, typhous and scrofu- lous, and from tubercle by a higher degree of organization, in their not only showing a more highly developed cellular structure, but frequently, also, in fibres, vessels, and granulations entering into their composition. But, still, in addition to the points of resemblance which I stated, a minute ago, between cancer and tubercle, there is another feature in com- mon; viz., in their softening, and in the manner of this softening. It begins in the centre, or in several points of the tumour in cancer, and proceeds even independently of cell-formations. The effects of cancer on the system at large vary with the stage of growth of the tumour. At first they are purely local and of small mo- ment ; but, in proportion as the adjoining elementary tissues and the organs are pressed on, inconveniences if not derangements of function are expe- VARIETIES OF CANCER OF THE LUNG. 317 rienced. When softening takes place the consequences are more serious. There is excitement analogous to inflammation of the surrounding parts, and the tumour begins to be painful : an unhealthy suppuration ensues, the tissues being affected with the ichorous discharge ; the bloodvessels and lymphatics in the tumour and in its vicinity are destroyed ; and the veins, unless they had previously been obliterated,often give rise to such very serious hemorrhages as to threaten lire itself. Still farther, the soft- ened cancerous matter may enter the veins and lymphatics, and produce inflammation of these vessels and its consequences. Cancer-cells may, also, enter into the circulation, and, becoming deposited from the capil- laries, give rise to secondary cancerous tumours. Cancer of the lung, the more immediate subject for consideration at this time, is a rare disease. When it-does occur, males are much more fre- quently its subjects than females ; tire proportion being, in the 22 cases collected by Hasse, 17 men and 5 women. The disease is not met with in childhood. The morbid predisposition is greatest in the prime of life. Varieties of Cancer.—Of the four varieties of cancer, the encephaloid or medullary is that which chiefly attacks the lungs. In one case alone did Hasse meet with the colloid variety. Pulmonary cancer may be either primary or secondary,— more frequently the latter. But even where cancer originally and mainly occupies the lungs it is always deeply rooted in the organism, other parts being simultaneously more or less involved. This remark applies more particularly to the secondary affection which is preceded by carcinomatous degeneration, in all its stages, of mcst of the viscera and entire groups of lymphatic glands. Primary medullary infiltration usually takes place in one lung only ; the neighbouring lym- phatic glands participating in the sarae species of degeneration. The affected lung may be cancerous throughout, or else isolated patches of healthy pulmonary cells may still be detected. The bronchial tubes dis- appear gradually in the encephaloid mass ; the bloodvessels are partly- compressed—partly obliterated—or, in part, charged with adventitious products. The nerves are not traceable into the growth. The whole tumour, continues Hasse, presents a uniform lardaceous structure, here and there pervaded by fibrous texture, and by darkish strise and clots, cor- responding with the amount of displaced pulmonary substance which may remain. Secondary cancer of the lung assumes the form of isolated tumours rather equally dispersed throughout both lungs—superficially and deeply, —from the apex to the base. Of the various parts whence the cancer originates, the bones and testicles are foremost. It has been observed that cancer, in organs whose veins are tributary to the portal system, does not appear to spread to the lungs, although it is known to lead very often to corresponding disease of the liver. Secondary tumours within the lungs vary much in magnitude ; being found in the same lungs as dimi- nutive as hemp-seeds, and as large as a man's fist: their average size is about that of walnuts. Medullary cancer of the lung appears to occupy, cell for cell, the place of the pulmonary texture, or else, in its progressive growth, merely to displace the adjacent pulmonary cells. The pleura is found studded with medullary tumours, the bronchial and mediastinal glands in the last degree disorganised. Some of these glands often attain the size of hen's-eggs, and press in various ways upon the lungs, the great vessels, and particularly the oesophagus. Cancerous disease of the lungs 318 DISEASES OF THE RESPIRATORY APPARATUS. never coexists, we are told, with pulmonary phthisis. In rare instances, cancer is confined to the pleural cavity and to the lymphatic glands ofthe thorax, embarrassing the respiratory function, by pressing against the lungs or air-tubes. The symptoms and signs constituting the diagnosis of pulmonary cancer are set forth with more fulness by Dr. Stokes than by any other writer with whom I am acquainted, and I shall terminate the present notice of this disease by repeating his conclusions, viz.:— u I. That the facility of diagnosis mainly depends on the anatomical disposition ofthe disease. " II. That we may divide the cases with a view to diagnosis into those in which isolated tubercles exist, with the intervening tissues healthy; those in which simple degeneration occurs without ulceration and with ulceration ; and those in which a tumour of the mediastinum exists, caus- ing compression. "III. That the diagnosis in the first case is difficult, from our being seldom able to avail ourselves ofthe signs of irritation and ulceration, so important in ordinary tubercles, and the fact of the equable distribution ofthe disease preventing comparison. " IV. That in some cases of isolated cancerous masses, the diagnosis may be founded on the same general principles as that of acute phthisis. " V. That in simple cancerous degenerations of the lung, the principal ^physical signs are the gradual diminution of the vesicular murmur, with- out rale; its ultimate extinction; and the signs of perfect solidification. " VI. That the evidences of perfect solidification are better found in this disease than in any other pulmonary affection. " VII. That this form of the disease may exist, simply, or in combina- tion with empyema, and may be secondary to cancerous tumours of the mediastinum. " VIII. That the sides may be symmetrical in this affection, and that either dilatation or contraction of the sides may occur. " IX. That the mediastinum may be displaced, even though the side be contracted. " X. That under these circumstances we may have the signs of perfect solidification, accompanied by imperfect pectoriloquism, and increased vibration to the hand. " XL That the mediastinum may be displaced and the liver depressed without protrusion of the intercostal spaces. " XII. That the heart may be compressed and dislocated in this form of disease.—Hughes, Syms, Houston. " XIII. That the flattening of the upper part of the chest may occur from degeneration of the upper lobe.—Hughes. " XIV. That the absence of signs of ulceration is very characteristic of this disease. " XV. That we have observed these signs but in a single case, and that the phenomena, though they might be produced by other diseases caus- ing the same physical conditions ofthe lung, have never before been met with. " That cancerous tumours of the mediastinum generally coexist, with either degeneration ofthe lung, or isolated tubercles in its substance. " That they may be solid or fluid. " That they may coexist with cancerous infiltration of the lung, or the deposit of cancer in the bronchial tubes. PLEURISY. 319 " That they are to be recognised more by the signs of the tumour than by those of disease of the lung. " That dysphagia, tracheal stridor, feebleness of one pulse, difference of respiratory murmur, from pressure on the bronchial tube, displacement of the diaphragm, and dilatation of the heart, may occur in this form of the disease. " That a cancerous tumour may exhibit pulsation with or without bel- lows-murmur, but that pulsation is not always attendant on it. " That though the previous existence of external cancer may assist in diagnosis, yet that the disease may be all through internal, or the visceral precede the external cancer. " That the feebleness of pulsation connected with the extent of dulness may assist in distinguishing the disease from aneurism. " That in the advanced period, as in aneurism, gangrene of a portion of the lung may supervene.* " That the following symptoms are important as indicative of this dis- ease : pain of a continued kind ; a varicose state of the veins in the neck, thorax, and abdomen ; edema of one extremity ; rapjd formation of ex- ternal tumours of a cancerous character ; expectoration similar in appear- ance to currant-jelly ; resistance of symptoms to ordinary treatment. " That though none of the physical signs of this disease are, separately considered, peculiar to it, yet that their combinations and modes of succes- sion are not seen in any other affection of the lung." Examples of cancer of the larynx are rare. M. Louis relates one case ; M. Trousseau another. Albers of Bonn records two examples of primary encephaloid of the larynx. LECTURE CXI. DR. BELL. Pleurisy—Pleuritis—Its forms and complications—Chief symptoms—Fever, pain, diffi- cult breathing, hard and frequent pulse, and decubitus on the back—Even the chief symptoms not always present; and they may be present without pleurisy—Structure of the pleura—Anatomical lesions—Change in the pleura itself,—in its secretion ; imme- diate effects of this latter—Quality and changes of secreted matters—False membranes —their characters—Tubercles and cancerous bodies—Change in the secretion and state of the lung by the effusion—Causes—Identical almost with those of pneumonia— Cleghorn's description of bilious pleurisy—Physical signs:—altered conformation of the thorax, dulness on percussion,—resonance of voice in auscultation—cegophony —friction sounds—Diminished vibration ofthe parietes of the thorax—General symp- toms—Fever, state of pulse, buffy and cupped blood—Progress, duration, and termina- tion of pleurisy—Varieties—Complications—Prognosis. Pleurisy—Pleuritis (tt^v^itk, from TAtyga, the side ; also the membrane that lines the ribs, the pleura). * Dr. Stokes adds, in a note : " My friend Mr MacDonnell has shown, that from the anatomical disposition ofthe nutritive arteries ofthe lung, pressure upon any part ofthe main bronchus might cause the death of the lung. Of course, the liability in this is greater in the case of mediastinal tumours than in the simple degeneration. Dr. Greene has met with this gangrene, from the same physical causes, in aneurism. See the Trans- actions of the Pathological Society." 320 DISEASES OF THE RESPIRATORY APPARATUS. 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 itself are various and important. 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. I shall have, after a while, a few additional remarks to make on the varie- ties of pleurisy. The disease was for a long time confounded with pneu- monia, and until the time of Laennec there were no positive diagnostic signs between the latter and pleurisy. The chief symptoms of pleurisy are, fever after a chill, although this last is not uniform, and 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, as if jerking ; dry cough, hard and frequent pulse, flushed face, and, most generally, decubitus on the back or on the affected side. A few remarks will be in place on each of these leading symptoras; and first on the pain. Commonly, pain exists from the very beginning ofthe disease, but it is often wandering until after the first or second day, when it becomes fixed and permanent, and also circumscribed in one spot. Its seat is on a level with or just below one of the mammse at the part cor- responding with the lateral attachments of the diaphragm ; and it is thus fixed even when the inflammation pervades a much greater space, per- haps 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 sometimes over the whole of one side of the thorax; or on a line correspond- ing with the borders of the false ribs, or in either hypochondrium, 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 entirely, even before the ter- mination of the disease. Sometimes, after having thus ceased, it returns with intensity, indicating a renewal ofthe 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 rheu- matic character, closely imitate those of pleurisy ; and if they happen to be attended with feverish excitement the resemblance is perfect: even exalted sensibility of the pleura itself is not by any means a necessary accompaniment to its inflammation. On the other hand, there are cases in which there had been scarcely a suspicion of disease in the chest, and yet acute inflammation and its concomitant, copious effusion, had been for many days or weeks occupying the pleura. The symptoms of oppressed breathing, proceeding from the pressure ofthe effusion, will be distinct only when this latter has accumulated very rapidly. In such cases of embarrassment we seek to be enlightened, and generally 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 PHYSICAL SIGNS OF PLEURISY. 321 being present, the dyspnoea is generally proportionate to the quantity of the effused fluid. But even to this state of things there are marked ex- ceptions; some persons, with effusions, as we learn from Andral, 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 re- spiratory act will depend mainly on the portion of the pleura inflamed ; in costo-pulmonarypleuritis,the breathing is chiefly diaphragmatic; while in inflammation attacking the pleura which lines the diaphragm, the tho- rax is mainly 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, proportionate in frequency or force either to the intensity or the extent of the inflammation. Should the sputa assume more consistence and other different appearances, we may suspect complication, as of pneumonia and bronchitis, or, a rare case, the opening ofthe pleuritic effusion into the bronchise. 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, or on the affected side. For the most part pleurisy is accompanied by fever. In the first or acute stage, the skin is hot, and the pulse hard and frequent: indeed a tense pulse is one of the most characteristic symptoms of the disease. In a more advanced period, either from an abatement of the inflammation, or the passage of the disease into a chronic state, the skin loses its heat, but the pulse retains its frequency with less resistance. Profuse sweating only comes on when tubercles are developed either in the pleura itself, or in the false membranes formed on it. When pleurisy becomes deci- dedly 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 per- cussion 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 coagulura covered with a thick buffy coat. The fibrin averaged 5 parts in 1000,, in MM. Andral's and Gavarret's experi- ments, and 6-1 in M. Becquerel's. The blood-corpuscles and albumen are considerably diminished. Unless in the case of complication, such as bilious pleurisy, the digestive organs are not disordered. As happens in other phlegmasia? of the serous membranes, the secretion of urine is diminished, and deviates from its natural properties. Nutrition is pro- foundly affected ; chronic pleurisy with effusion giving rise almost always to marasmus. Physical Signs.—First among these, as the sign which more obviously meets the eye ofthe 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 ihe measure of the two sides, by means of a ribbon, one end of which vol. ii.—22 322 DISEASES OF THE RESPIRATORY APPARATUS. is to be held on a spinous process of the dorsal column and the other brought to the middle line of the sternum, or we use 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 posi- tion, as they would during a very full inspiration ; the intercostal spaces are increased, protruded beyond the ribs, and allowT of a fluctuation being felt within. But there may be considerable effusion without external dilatation,—the space for the fluid in the chest being made at the expense 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 band, the effusion is absorbed, and the lung is pre- vented 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 diseased. 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 circumstances, 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 than common. This depends on the patient's instinctively dilating his chest less, and of course expanding less his lungs also, owing to the violence of the pain. So soon as effusion takes place, the respiratory murmur is heard less distinctly on the affected side ; and in proportion as the effusion increases, this sound 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 pro- truded towards the spinal column, the 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 ofthe thorax, will cause an extinction of the sound in front, but allow of its being still heard, though feebly, behind. When the effusion which extinguishes the respiratory murmur is con- siderable, 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 persons 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 discordant sound, resembling the SYMPTOMS OF PLEURISY. 323 voice of Punch ; an apt comparison for whoever has heard this distin- guished character, and whoever has not, and proposes to travel, will hear it in perfection, on the Mole at Naples. At other times, it seems as if the voice 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. OEgophony is not heard when the effusion is inconsiderable ; and it ceases after the effusion becomes very great. Sometimes the effusion, though slight, is diffused so that dulness and tubular sound are heard at first over a great extent of surface ; and after the subsidence of the fluid to the lower por- tion ofthe lung, the pressure in the bronchial tubes is such as to prevent the passage of any sound to the air. 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; a division this, by the way, which some eminent pathologists deny the existence of. The region for hearing it is between the spine and scapula, or be- tween this latter and the mamma. Change of posture sometimes causes a difference in the physical signs by changing the place ofthe effusion. M. Reynaud points out another easily recognised sign of pleuritic effu- sion. 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 parenchymatous inflammation are generally wanting, one of these, crepitation, may be removed by causing the patient to lie on his face. At this time, also, the oegophony becomes bronchophony. We may sum up the leading features of pleurisy, in its different stages, under the heads of progress, duration, and termination. Pain, commonly seated beneath one or other of the mammae, preceded 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 oegophony are heard, and the parietes of the chest on the affected side present 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. Diminished effusion and beginning ab- sorption are indicated by a return of the usual sonorousness and respira- tory murmur, first at the spine and clavicle, and then extending forwards and downwards. If there be false membranes, oegophony is sometimes replaced by friction sounds, ofthe middle and lower part ofthe lungs. If the leading symptoms of pyrexia and laboured breathing are only abated in violence, without being removed, 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 maras- 324 DISEASES OF THE RESPIRATORY APPARATUS. mus, 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 suppuration 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, and in rare cases through the diaphragm. But even under these alarming cir- cumstances there may be a favourable issue. Critical discharges, such as metrorrhagia, copious sweats, or a bronchial flux, sometimes announce the absorption ofthe effusion. Anatomical Changes.—Before I speak of the anatomical changes in pleurisy, it is fitting that 1 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 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, but endowed in that particular situation with a still greater degree of strength for purposes sufficiently obvious. The fibrous coat covers the diaphragm, where it is more opaque, and, in connexion with the pleura, lines the ribs, and, turning, forms the mediastina, which thus are shown to consist of four layers—two serous, and two fibrous. Henle's researches lead him to a belief in the pleura consisting of several layers of super-imposed cellular tissue barely attached to each other, the inner surface being a thin layer of epithelium-cells. There are bloodvessels in all the layers, except the last. The pleura is susceptible of inflammation of the adhesive kind, which is accompanied merely by pain ; and by the pouring out of serum, coagula- ble lymph, pus or blood. Pleurisy gives rise to textural alterations of the pleura, to alterations in its secreting function, and to modifications in the condition of the lungs, such as compression, displacement, changes of volume, of situation, and connexions. The pleura, in pleuritis, is sometimes reddened by a delicate injection, but more commonly this redness is owing to the injection of varying in- tensity in the sub-serous cellular tissue. In many cases the membrane itself preserves its transparency, and exhibits no marks of vascular ramifi- cation. Inflammation of a more intense kind 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, and 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 transparency of the pleura, it is seldom thickened, soften- ed, or ulcerated. But the spots originally reddened by repletion of the vessels present little dull white or yellowish points, which rise above the MORBID PRODUCTS IN PLEURISY. 325 serous surface, in the shape of flat granules, and ultimately coalesce; and thus constitute the first rudiment of an adventitious membrane. This first delicate investment of the free surface of the pleura veils its inflam- matory redness. The changes of secretion are more numerous and diversified than all its other abnormal peculiarities. According as the 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 down- wards 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 preter- naturally 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 inter- costal spaces and diaphragm results from a paralysed state of these expan- sions—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 dis- solved 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 (hemorrhagic pleurisy), which is most apt to occur in the tubercular form of pleurisy. These liquid products of secretion from the pleura are alleged to become concrete in part, and to pass into a solid state; and in this way false membranes are formed, varying, as regards organization, in their figure, colour, extent, consistence, and thickness. They are the most common products of pleural inflammation. The more immediate material for this membranous formation is an almost transparent yellowish jelly, consisting almost entirely of the fibrin and the serum of the blood. It is the blood plasma. It soon acquires an increase of consistence, puts on an albumi- nous appearance, is diffused in layers, 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 effused matter. These streaks soon become distinctly vascular, and the newly-formed vessels inosculate with those of the pleura, from which indeed they originally diverged. The adhesions thus made are of very different forms and sizes ; being sometimes merely miliary granula- tions, separated from each other; at other times large concretions of a cellular texture uniting the two surfaces of the pleura by various bands. The thickness of the newly-formed membrane is sometimes no greater than that ofthe pleura itself; but more commonly it exceeds this latter : the thickness of the new formation is made, however, of several larainse resting one upon another. Sometimes these false membranes are formed after a few days' sickness; and again, not after a period of three weeks 326 DISEASES OF THE RESPIRATORY APPARATUS. from the invasion ofthe disease. These membranes and their adhesions are more frequently in a line with the inferior lobes and at the base of the lung. 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. False membranes may pass into a fibrous, cartilaginous, or even osseous tissue. In pleuritic effusions, however, substances are not always met with which allow of such ready organization ; but they stop short at imperfect co- agulation, and the disease is apt to assume a chronic character. The con- tained fluid is slow in being absorbed and is liable to a kind of decora- position ; and a febrile state passing into hectic supervenes. Sometimes the plastic matter lies loosely agglutinated to the pleura, like uniformly honey-combed false membranes or imbricated layers. Purulent forms of effusion result from high inflammation or from the access of air. Tubercles are not unfrequently met with in 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 the seat of 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 destroyed. On occasions, it is only a fobe that is thus displaced ; and the lung itself has sometimes been pushed towards the side of the thorax backwards or laterally, in place of on the vertebral column. It is never found to crepitate unless the effusion be quite inconsiderable ; it is denser than natural, and sinks when put in water. We sometimes meet with pleuritic effusion and inflam- mation of the pulmonary prrenchyma at the same time. The effusion may either precede or be subsequent to hepatization ofthe lung. Seat.—Simple pleurisy occurs most frequently on one side only, or is single ; and rather oftener in the right than the left side. Pleuro-pneu- monia is also mostly single, but more generally in the left than the right side. Double pleurisy occurs mostly as a consecutive disease. 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. Early spring is the chief season for pleurisy. Its subjects are, preferably, the young and those in the vigour of life. Organic lesions of the lungs, as pneumonia and tubercles, are frequent causes ofthe disease. But while pneumonia readily produces pleurisy, this latter is not so apt to produce pneumonia. A rupture of the pulmonary vesicles which estab- lishes a communication between the cavity of the pleura and bronchise sometimes causes partial pleurisy. A particular distemperature of the air will give rise to epidemic pleurisy, which generally is of a more asthenic nature than isolated or sporadic cases are. Varieties.—The two chief kinds of pleurisy are the primary and the se- condary; the last is the most frequent. The varieties of pleurisy proceed either from the symptoms or the seat of the disease ; and, sometimes, from particular causes. There are pleurisies, with, as there are those without effusion,and unaccompanied by pain,cough, dyspnoea, oraccelerated pulse. There are others, again, that do not give rise to any dulness of sound, VARIETIES OF PLEURISY. 327 nor to any modifications of the respiratory murmur or of voice. Some, most pleurisies, are manifested by characteristic symptoms; some are latent. When the pleurisy is interlobular, nothing is revealed by either percussion or auscultation ; although sometimes a collection of pus is found simulating pneumonic abscess. Dyspnoea may be evident, with slight pain ; the fever is hectic, and death closes the scene. If the disease be mediastinic, 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, and there are hiccup, nausea, and sympathetic vomiting. If the pleurisy is on the right side there is jaundice, owing to transmitted irrita- tion ofthe liver. This last form presents a very difficult diagnosis, since it simulates hepatitis, partial peritonitis in the hepatic region, gastritis, and, finally, rheumatism ofthe diaphragm. I had occasion, when a stu- dent in Virginia, to watch a case of this nature, in which, conjoined 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 an antiphlogistic course,—venesection, purging with calomel and appro- priate adjuncts, antimonials, and subsequently blisters. It is this asso- ciated derangement of the digestive system with pleuritis that constitutes bilious pleurisy. The disease described byCleghorn (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, immoderate thirst, inward heat, headache, and other feverish symptoms. In a few hours the respi- ration 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 vertebrae ofthe 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 heavi- ness 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 preceded 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 return 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, and start out of bed, imagining 328 DISEASES OF THE RESPIRATORY APPARATUS. that the house was in flames ; and that those about them were endeavour- ing to push them over a precipice ; to pierce their sides with daggers ; to bind them down with cords, or iron hoops, and things ofthe like nature." The most frequent complications with pleurisy are, pneumonia, pericar- ditis, and pneumothorax ; and, but less seldom, bronchitis and even peri- tonitis. Laennec describes three varieties of the complications of pneu- monia with pleurisy. The first is the ordinary one of pneumonia with slight, dry pleuritis. In the second, inflammation ofthe compressed lung may occur, producing that variety of hepatization which he has denomi- nated carnification ; while in a third, severe inflammatory action affects both the pleura and lung. This, says Dr. Stokes, is by far the rarest case. In children, pleurisy is complicated with and occurs during hooping-cough and scarlet fever, and is occasionally met with in typhoid fevers. In the diseases of this class of subjects, secondary pleurisy is sometimes replaced by convulsions or other cerebral disorder. Diagnosis.—Pleurisy can only be confounded with pneumonia, from which it is distinguished by the absence of rust-coloured sputa, dry crepi- tated rhonchus, nor does the severity ofthe constitutional symptoms corre- spond with the extent of dulness on percussion in pleurisy as it does in pneu- monia. There is not, however, any strictly pathognomonic sign of pleurisy. Prognosis.—Pleurisy must always be regarded as a serious disease; the prognosis in which will vary, however, according to the nature and inten- sity of the causes, the extent of the pleuritic inflammation, and the pre- sence or absence of effusion. In a subject previously enjoying good health, the disease almost always terminates favourably. Pleurisy induced by tuberculous irritation must alwrrtys 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 than either of the fluids just mentioned. Tht persistence ofthe 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 suspi- cion of tubercles in the inflamed pleura. LECTURE CXII. DR. BELL. Treatment of Pleurisy—Bloodletting, by venesection, the first and chief remedy__Tn feeble habits and in advanced stages, cupping or leeching—Cupping followed by saline purgatives—Tartar emetic—Opium in full doses after venesection—Blister to the side —Purging most useful in complicated and epidemic pleurisies—Diuretics; nitre, digi- talis, colchicum—Calomel with nitre and a little opium—Treatment of children.__Ty- phoid Pleurisy.—Puerperal Pleurisy.—Chronic Pleurisy—Not always resulting from the acute form—Symptoms and physical signs—Dilatation ofthe side—Diagnosis —Absorption going on—Contraption of the chest—Trwtment—Calomel__Iodine__Hy- gienic measures.—Pleurodynia—Its symptoms—Diagnosis between it and pleurisy —Treatment.—Pneumothorax—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 TREATMENT OF PLEURISY. 329 the invasion ofthe 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 symp- toras, and the relief afforded. The pulse, which is generally frequent, hard, and resisting, 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 than the dyspnoea and pain our guide as to the freedom with which we are to bleed in pleurisy. As a general rule, the blood ought to be 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 fre- quency of pulse, it is of little moment in the case before us; it can never alone indicate the propriety 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 material of vascular excite- ment 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, without 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 conva- lescence. We are fain, in such cases, to accomplish our end by free cup- ping or leeching 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 purgatives and diuretics. The former will consist of salines with antimonials, 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 by its revulsive operation on the liver and gastro-intestinal fol- licles, and its decidedly sedative impression. Its use subsequently will be under the same belief, and not in reference to what the English writers persist in regarding its specific, that is, its sialagogue operation, or at any rate the production of a slight soreness and inflammation of the mucous membrane ofthe 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 in phlegmasia of the serous or sero-fibrous membranes generally, than in those of parenchymas and mucous membranes, with whose secretory function it is more apt to 330 DISEASES OF THE RESPIRATORY APPARATUS. interfere unseasonably at this time. A full, or rather a large dose of opium, two to three grains, may be 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. The repetition of this medicine will depend on the intensity of the pain, and the diminished hardness of the pulse. In the form of Dover's powder, it is often very serviceable. 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 previ- ously practised, a blister. More especially is this remedy useful when ef- fusion 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 dis- ease. 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 necessary 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 occasional 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 prejudicial in pleurisy ; nor was the opinion without foundation, for the necessary inter- ruption to the respiratory movements during defecation, by the 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 in- terfered 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 efficacy, and must often take the place of bloodletting. Diuretics have acquired more re- putation 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., ^iss. Potass, tart, antim., gr. j. Aqua fluvialis, ^iv. M. ft. solutio, et adde. Lin. sent, infus., ^xij. M. Sum. 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 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 prescription which I have just TYPHOID PLEURISY —PUERPERAL PLEURISY. 331 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 1 have seen no disadvantage from this, although it is deprecated by many writers, and is made a ground of objection to the contra-stimulant 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 sub-acute 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. The preceding treatment is that which the largest experience has shown to be more serviceable in the pleurisy of adults whose constitutions have not been greatly debilitated or perverted by prior diseases and vicious excesses. In children a less vigorous course is demanded. Some indeed would persuade us that the expectant method is the best with them : but this is going to the other extreme. The first indication is the same in infantile pleurisy as in pneumonia and bronchitis; viz., to abate the inflammation by bloodletting, and in the class from two to five years of age it will suffice to apply from ten to twenty leeches over the affected side at the lower part ofthe chest, allowing the bites to bleed for about two hours. In children somewhat older the lancet may be had recourse to, and four to six ounces of blood abstracted. We are not called upon to follow out the other indications in pleurisy, as in bronchitis and pneu- monia, by giving expectorants; but restrict ourselves at first to counter- stimulants and afterwards to the remedies that may be supposed to pro- mote absorption ofthe effused fluid in the cavity of the pleura. Of these latter diuretics are entitled to preference, and especially in secondary pleurisy following the exanthemata, and in which the breathing is greatly oppressed. We direct at this time squills and digitalis, either in tincture or, preferably, an infusion with some aromatic in addition. Given alter- nately with calomel, their operation as a diuretic is rendered more active. Purging is not recommended by MM. Barthez and Rilliet: nor do they think well of blisters in the pleurisy of children. They advise, however, the application of a diachylon plaster over the side with a view of keeping up a grateful and uniform warmth and protecting the skin against the access of air. Typhoid Pleurisy.—Resembling typhoid pneumonia so much in its causes, general phenomena and the circumstances under which it appears, as regards the habits and constitutions of the patients, typhoid pleurisy calls for no amplitude of description, nor minuteness of therapeutical detail for its treatment, after what has been said on the subject of typhoid pneumonia. Puerperal Pleurisy.—There is, however, yet another variety of pleu- risy of which mention has been seldom made. I refer now7 to the super- vention of pleuritic disease in puerperal fever. Next to peritonitis and inflammation ofthe lymphatic vessels of the uterus, pleurisy ranks as the most frequent complication of organic disease with this fever, but more particularly with puerperal typhus. M. Cruveilhier (Diction, de Med. et de Chir. Pract) states, that he has seen puerperal pleurisy occurring both sporadically and epidemically. 332 DISEASES OF THE RESPIRATORY APPARATUS. This variety of pleurisy is seldom simple and primitive ; it occurs as a sequence to peritonitis, though sometimes it precedes this latter. Both come on usually at the same time, viz., at the epoch of milk fever. Analogous to the puerperal variety is the pleurisy which attacks some females just before delivery, and which, M. Cruveilhier asserts, is always aggravated by this latter process. This is too sweeping a dogma. I had during the last summer (1844) under my charge a lady whom I visited in the course of the day, and had freely bled for pleuro-pneumonia, and whom I was called upon to attend in labour on the following morning. She had been a patient of mine on two former occasions for pulmonary inflam- mation of long duration and great violence; but in the present instance she was soon relieved, nor did labour interpose any difficulty or compli- cation to the pleuro-pneumonia, or this latter interfere with the progress of convalescence after delivery. So much importance did the author whom I have quoted attach to the occurrence of pleurisy in puerperal women, that at the large Lying-in Hospital (La Maternite), he percussed all the subjects in whom feverish movements were protracted beyond the common limits, or in whom there was any symptom of an unusual character. Increased frequency of breathing and redness of the face are premonitions of the approach of pleurisy that ought not to be disregarded. Quite recently (1847), I had a case of puerperal pleurisy. It set in with great severity on the right side, fourteen days after delivery. The patient was freely bled from the arm and cupped on the chest. She soon recovered. The prognosis of puerperal pleurisy is bad, as few in hospital practice, of those attacked with it survive. The treatment cannot be arbitrarily laid down. We shall feel justified, however, when our diagnosis is suf- ficiently made out, in having recourse to sanguineous depletion, with raore freedom than in simple puerperal fever. Whether this is to be done by the lancet, or by cups or leeches, will depend on the strength and habit of the patient, and the state of the system at the time, as well as the amount of natural evacuations, such as of the lochia antecedently. The rest of the treatment will merge itself into that of puerperal fever, in which tartar emetic and opium should not be forgotten. Chronic Pleurisy—Empyema.—Too commonly, in place of having studied the phenomena of chronic inflammation of the pleura, practitioners and writers restrict their observations to one of its effects, viz., the occur- rence of purulent effusions filling up the inter-pleural cavity, or sac ofthe pleura, and constituting the disease termed empyema. This separation of effect from cause is hardly more rational than would be the study of abscess as a distinct disease from the inflamraation which ended in abscess and the formation of pus. Both in diagnosis and treatment, embarrass- ments grow out of this separation. With a knowledge of the antecedent symptoms and progress of pleural inflammation, we shall have but little difficulty in reaching a diagnosis of the dilatation of the chest, displace- ment of the heart, &c, which present themselves in the advanced stages of pleurisy, whether it be acute or chronic. So, also, if attention be given to the inception and early period of the disease, we shall see the symptoms of phlogosis, and be induced to adopt a treatment which will either arrest the disease or prepare the system for the remedies commonly prescribed for fixed effusions of purulent matter or empyema. These remarks ap- ply with equal force to the termination of inflammation of the pleura, CHRONIC PLEURISY. 333 in the effusion of a large quantity of serous fluid, constituting hydro- thorax. The term chronic is less applicable, in its literal signification, to the mo- dification of pleurisy than to many other diseases denominated chronic, in which there is not only duration but a notable difference in the degree and sometimes nature of the organic lesion. Chronic pleurisy some- times develops acute symptoms, as e converso acute may prevail with little or no irritation or notable disturbance of function. In the former we have effusion and false membranes, displacement and condensation of the lung—symptoms all of which are met with in the latter. More usually, it is true, there is less general disturbance with these symptoms in the chronic than in the acute. Symptoms.—Chronic pleurisy may come on gradually if not insidiously. We suspect its existence when there is dry cough, a remittent fever with evening paroxysm, an habitually frequent pulse, shortness of breath after any exertion, inability to lie on the healthy side, and emaciation. If with these symptoms we meet also the physical signs of accumulation, com- pression and displacement, we may safely allege that we have before us a case of chronic pleurisy with effusion. In certain instances, Dr. Stokes remarks, with a view to show the paramount value of physical signs when most of the symptoms are wanting, that he has repeatedly known persons with copious effusions to look well, to be free from fever, pain, or any local distress ; to be equally well on both sides, to have good appetite, which they could indulge without apparent injury ; and all this when the heart was pulsating to the right ofthe sternum. Displacement of the heart occurs at a very early period, when the effu- sion is on the left side, and long before any protrusion ofthe intercostals or diaphragm. Among the signs of eccentric displacement we may ex- pect to meet with dilatation of the side to the extent of from one to two inches. This sign is more valuable in the left than the right side, as this last is habitually the more developed of the two. Associated with dila- tation ofthe side is obliteration of the intercostal spaces and smoothness of the affected side. The diaphragm is also displaced, and causes, in consequence, a protrusion and resistance of the upper portion ofthe abdo- men. If the effusion be in the right side the liver is pushed downwards; if in the left the spleen is displaced. The sound on percussion is dull in chronic pleurisy with effusion. But in this respect we find considerable differences, according to the posture of the patient, and provided adhesions have not yet been formed. When the patient turns on his face the postero-inferior portion which had been dull becomes clearer, and, in few instances, it has been observed that there was a return of clearness in the lateral portion when the patient turned on the opposite side, so as to allow the fluid to accumulate along the median line. Respiratory murmurs are totally suppressed except close to the spine and under the clavicle, where the sound is harsh, bronchial, or even slightly blowing. QSgophony is not heard when the effusion is considerable : the same may be said of every other sound, whether natural or morbid. On this point, however, there is some discrepancy of opinion : Dr. Jack- son, of Boston, relates cases in which strong bronchial respiration was heard, although the chest was full of fluid. The pleura is deeply iniected in this disease, and false membranes with sero-purulent fluid abound. The membranes are thicker, but less 334 DISEASES OF THE RESPIRATORY APPARATUS. plastic and organisable than in the acute variety of pleurisy. The effused liquid, in place of being of a citron colour, is milky, opaque, or purulent, and exhales a garlicky, sometimes fetid, odour. Progress and Duration.—A different series of phenomena, but similar to those described as occurring in acute pleurisy, are observable when absorption of the fluid in the pleural cavity begins and is continued. The respiration, from having been inaudible as high as the scapular region or even the clavicle, now gives out a feeble murmur at this region, which gra- dually increases in extent downwards. In proportion as the respiratory or vesicular murmur is heard at increasing distances from the surface, the bronchial becomes more circumscribed until it is only sensible at the root ofthe lungs. The sound on percussion also gradually recovers its custo- mary clearness, first at the upper, then at the lower part of the chest. Friction sounds re-appear and continue audible for a length of time. The dilatation of the chest is removed by degrees, and the semi-circular and vertical measurements fall to the natural standard ; the distance between the nipple and median line decreases gradually to the normal extent. The heart, diaphragm, liver, and other abdominal viscera are restored to their natural position. The return of a dilated side to its natural circumference is sometimes exceedingly rapid. Dr. Stokes has known it to lose as much as an inch and a half in eight days. If the effusion have been considerable and the chronic pleurisy of longer duration, the absorption is accompanied by retraction ofthe chest, and the lateral circumference of this latter is much less than natural. Sometimes the contraction is confined entirely to the lower part of the chest, and is unaccompanied by depression of the shoulder. One of the first signs of absorption, with contraction, is the increased prominence of the inferior angle of the scapula. In many cases the retraction or depression of the chest is accompanied by projection and depression of the shoulders, ribs, and nipple ; the scapula is tilted towards its inferior angle ; there is lateral curvature of the dorsal spine, with the concavity turned towards the diseased side ; distortion of the ribs ; intercostal spaces unnaturally narrow ; diminished motions of expansion and of elevation, especially of the former, while the latter is affected in the same way as during the period of effusion with dilatation ; motions of ribs on each other much impaired (Wralshe, op. cit.). On mensuration we find the semi-circular and the an- teroposterior measurement diminished. At times pressure is exerted by the sound side, after absorption, causing displacements the very reverse of that which obtains when the effusion was going on with corresponding dilatation of the diseased side. In this way, after the absorption of an effusion on the right side, the heart was drawn over to that side, so that its pulsations were felt to the right and not to the left of the sternum. So, likewise, after the removal of pleuritic effusion in the left side, the heart was protruded upwards to the left, so that its pulsations were distinct from the fifth to the third rib near the axilla. An anomalous state of things is mentioned by Dr. Stokes to prevail in some rare cases of empyema. It is, a coincidence of effusion and dilata- tion with contraction on the same side. The duration of chronic pleurisy varies from two, three, and four, to six months, and even to one or two years. The diseases with which a pleuritic effusion is commonly confounded PROGNOSIS AND TREATMENT OF CHRONIC PLEURISY. 335 are solid growths on the pleura, tubercle ofthe lung, chronic pneumonia, and enlargement ofthe liver. The diagnosis must rest on a careful com- parison of all the symptoms of each disease respectively. The following symptoms and physical signs are summed up by Dr. Townsend,—Article " Empyema" (Cyclopaedia of Practical Medicine), as the most characteristic of empyema, and when they are all combined, may be considered as quite pathognomonic : difficult respiration, increased by motion or exertion of any kind, and considerably aggravated by lying on the sound side ; a sense of fulness and oppression on the chest, amount- ing in some cases to a sense of suffocation ; enlargement of the diseased side ; protrusion of the intercostal spaces, with obscure sense of fluctua- tion and edema ofthe integuments; dulness of sound on percussion, and absence of the respiratory murmur on the diseased side, which remains perfectly motionless ; puerile respiration in the opposite lung, accompanied with violent action of the respiratory muscles ; displacement ofthe heart; descent of the diaphragm, and consequent protrusion of the abdomen : to these characteristic marks may be added harassing short cough, small, rapid pulse, flushed cheeks, and other symptoras of hectic fever. The prognosis in chronic pleurisy with effusion and subsequent contrac- tion of the chest is more encouraging than appearances would seem to justify. In young and previously well-constituted subjects, the chest often recovers its normal proportions, and respiration and the functions gener- ally are carried on as well as ever. M. Chomel (Elemens de Pathologie Generate) states, that in the case of a physician of his acquaintance, in which chronic pleurisy of the left side with dilatation and subsequent re- traction had existed, he found on inspection and measuring the circum- ference and antero-posterior dimensions of the chest, that it had recovered not only the normal development but was actually fuller than the right. " Perhaps," he adds, " that it was originally so." This writer relates an instance of a phthisical girl, in which, consequent to pneumonia, there was pneumothorax, and afterwards effusion of fluid with dilatation and subsequent retraction ofthe left side : but in proportion as this increased the right became more dilated, as if the lung of that side expanded to compensate for the deficient size and function of the other. Treatment.—The indications in chronic pleurisy are to remove existing local irritation or the remains of inflammation in the chest, and to support the strength of the patient. The extent to which a preference will be given to the measures for carrying one or other of these indications into effect, will naturally depend on the presence of fever, some pain, dys- pnoea, and cough, with quickness and any resistance of pulse, as regards the former, and general debility and suspended hematosis, as respects the latter. We must suppose that the time and necessity for venesection are past; but it may still be proper, in cases, to apply a few leeches or cups to the diseased side ofthe chest, as much with a view to their derivative and absorbent effect as to direct depletion. If we find reaction after their use and still much functional derangement of respiration, we may have recourse to them with advantage even a second time. Less doubt will be entertained generally of the propriety of blisters applied in succession to different parts ofthe affected side. The bowels are to be early acted on by moderate but not often repeated purging. Diuretics are of more value, and rank still among the means of directly reducing irritation. Of these some give the preference to digi- 336 DISEASES OF THE RESPIRATORY APPARATUS. talis ; others, as Laennec, to certain saline preparations, such as the ace- tate of potassa and the nitrate of potassa ; the former in doses of half an ounce to two ounces, the latter of two drachms to half an ounce, and oc- casionally adding to them muriate (hydrochlorate) of ammonia and some preparation of squills. Doctor Stokes is partial to mild mercurials " steadily exhibited till a slight but decided ptyalism is induced." The use of this remedy, of so much power, for good or evil, must be governed by the constitution of the patient: who, if of a sanguineo-lymphatic temperament, will be bene- fited by it, but if a scrofulous diathesis prevail it should be withheld ; at any rate, short of its producing ptyalism. I have so often seen the salu- tary remedial effects of calomel as a diuretic and promoter of absorption when it is given in small doses, as a grain two or three times a-day, that I should have little hesitation in giving it in chronic pleurisy,—at the same time that I would deprecate its sialagogue operation. Still better adapted to the circumstances of the case, and a safer remedy in purulent formations, is iodine, and more especially the iodide of potas- sium, in doses of two or three grains three times a-day ; where the debility is considerable and the habit cachectic, iodide of iron is well adapted to the case. Dr. Stokes indicates a preference for Lugol's solution, and re- commends, at the same time, that from two drachms to half an ounce of iodine ointment be rubbed every day on the chest. Friction alone, in conjunction with exercise, is a good means of promoting absorption. To the full as important as the whole medicinal treatment is a well-re- gulated hygienic course. In the early period of the disease we enjoin entire quietness in bed and restriction, for a few weeks, to a diet of farina- ceous food and vegetables with milk. After a time, as the symptoras of irritation subside and the pulse becomes tranquil, light animal broth or even a little meat, is allowable. Restriction to an antiphlogistic regi- men for some time is laid great stress on by Broussais, and it is justly remarked by Dr. Townsend, in his article on empyema (Cyclopaedia of Practical Medicine), that so long as there are recurring paroxysms we must abstain from the tonic treatment. After absorption of the fluid, the tonic course, of which the best part is exercise in a pure country air, is to be more fully carried out. Moderate gymnastics may be regarded as a useful auxiliary to the main treatment. ' The use of an opiate is strongly recommended by Dr. Stokes. In cases of undoubted empyema, or fixed purulent effusions in the pleu- ral sac, the efforts of nature sometimes effect a cure, by the formation of a fistulous passage through the lungs, or through the walls of the chest, by which means an outlet is given for the matter contained within the pleura. Such a result only occurs, however, when the empyema is circum- scribed, and the fluid is prevented from occupying the entire cavity. Un- der such circumstances there may be several outlets, each corresponding with a distinct compartment of circumscribed empyema. Generally speak- ing, the escape of air through the bronchiae, or the walls of the chest, as the case may be, is followed by immediate relief of all the most urgent symptoms, and in some instances the fistulous passage soon ceases to discharge, and cicatrizes. Sometimes, the evacuation of matter, in place of affording any alleviation of the symptoms, seems only to aggravate the disease and to accelerate its fatal termination. When no prospect remains ofthe effused fluid being absorbed, and the TREATMENT OF CHRONIC PLEURISY. 337 oppression from its accumulation is great, an opening may be made into the chest by instrumental operation, constituting what, in the language of surgery, is called paracentesis thoracis. " This operation is at all times easy of execution, productive of little pain to the patient, generally fol- lowed by immediate relief, and has, in numerous instances, been crowned with complete success." Unhappily the term successful is too commonly used by surgeons to designate an operation which has been regularly and completely performed without the patient immediately sinking under it, or his dying within a short period afterwards. But, results of this nature cannot satisfy a conscientious and a reasoning physician, nor do they satisfy a surgeon who is fully alive to the responsibilities of his position, and who briggswith him the requisite amount of pathological knowledge, to enlighten him on the previous condition of the organ or part, as well as the probable changes, anatomical and direct, or functional and indi- rect, following the operation. In the present case, it must be borne in mind, that empyema, as 1 stated in the beginning of my remarks on chro- nic pleurisy,is a consequenceof pre-existing disease ofthe pleura,and some- times of the lungs also, and that the effect of the operation is merely to remove the effused fluid, while the organic or structural alterations still remain. Even if we were to suppose that morbid action, inflammatory and secretory, had ceased, the lung, we must be aware, has been so long compressed by the effused fluid, and tied down by numerous dense and adherent false membranes, as to have lost its elasticity and power of ex- pansion. Of this we can assure ourselves by abortive attempts to inflate the lung of a subject who has died from empyema. A copious purulent discharge may, also, in some cases, follow the operation and increase the debility of the patient, who suffers, at the same time, from new inflam- mation of the suppuratingsurfaces. Decomposition ofthe matter discharged from the'chest, attributed to the access of atmospheric air, is, also, another consequence of paracentesis thoracis. Another cause of objection to the operation was, we may say, rather than is, the difficulty of diagnosis, and the risk, in consequence, of making an opening into the thorax when in reality there is no empyema,—a mistake which has actually been made at different times. This objection no longer applies at the present time, and the physician is, therefore, left free to choose the period most proper for the performance of the operation. This is indicated in acute empye- ma, when the breathing is extremely oppressed, and the effusion goes on increasing. Still, even here, it is advisable to wait until the symptoms of inflammation shall disappear, before operating. In chronic empyema, or rather in empyema from chronic pleurisy of such duration as to show the inefficacy of the various therapeutical means used to cause absorption, the operation is particularly indicated. The probability of success from paracentesis will be in proportion to the youth and good constitution of the patient, the comparative recency of the effusion, and the absence of complication with organic diseases ofthe lungs. Dr. Davies, of London, furnished Dr. Townsend, author of the article " Empyema" (Cyclopedia of Practical Medicine), with returns of a number of cases of empyema in which the operation had been success- ful ; " eight of the patients out of ten having recovered. Of these, five were under six years of age, one was between eighteen and nineteen, and two above twenty-live." I shall not repeat the detailed directions for performing paracentesis tho- vol. n.—23 338' DISEASES OF THE RESPIRATORY APPARATUS. racis, as you will find them in all the works on operative or practical sur- gery,—to some one or other of which you would very naturally feel dis- posed to refer, before undertaking the operation. Pleurodynia (from T^g*, rib, and a>JW», pain) — Bastard Pleurisy.— Pleurodynia, formerly applied to all pains of the chest, is now restricted to those which affect either the intercostal and other muscles of the thorax or the thoracic fascia?, and which are believed to be analogous to rheu- matism, and still more to neuralgia. This affection acquires more signifi- cance and importance when it constitutes a part of general rheumatic dis- ease, and may then be converted into real pleural or even pericardiac inflammation. Pleurodynia is distinguished by a local pain in some part of, the thoracic parietes, of an acute and lancinating nature, increased by pressure and movement either of the trunk or arms, and by coughing or even breathing. The causes are sudden atmospherical vicissitudes, damp lodgings, expo- sure to currents of air and cold drinks when the body is perspiring. Some- times it has resulted from an excessive strain on the respiratory muscles, as in violent gymnastic exercises, carrying heavy burdens, &c. Men are more subject to it than women, and adults and old persons than young ones. Like rheumatism, it assumes at one time an acute, at another a chronic character — and again, from the rapidity of its onset and sudden disappearance, we can only compare it to neuralgia. Diagnosis.—Pleurodynia originating from many of the same causes and manifesting to a certain extent similar symptoms as pleurisy, we are re- quired to establish for it a correct diagnosis. In the former affection there is little or no fever, and the cough is transient; the pain, though pungent, is increased by pressure and the movements of the trunk and arms. In pleurisy, on the other hand, there is fever, with a hard, resisting pulse and dry cough, and often coloration of the face on the side corresponding with the pleuritic stitch. The physical signs give negative results in pleurodynia, whereas in pleurisy they are of a positive character, such as dulness of sound, oegophony, friction sounds, &c. Reference being had to the neuralgic character of the former disease, we may expect to find associated with it spinal, or, rather, intercostal nervous irritation. Pres- sure on the space between two vertebras has been, in cases coming under my own observation, productive of severe lancinating pain of the chest, similar to, if not identical with, pleurodynia. On other occasions, pain felt under the sternum and shooting through the chest arises from gastric indigestion, as that in the shoulders from disordered liver and disorder ofthe colon. The treatment of pleurodynia will be modified by the age and consti- tutional vigour of the patient. Venesection is in some cases decidedly beneficial. More frequently leeches will suffice, and they, when used, ought to be applied, in the instance of females, to the inside of the thighs. Sinapisms, or hot fomentations and stimulating plasters to the pained part, the warm and even hot bath and warm pediluvia, are so many means of counter-irritation or of revulsion, which are often sufficient to remove the pain. In chlorotic^females, or those of an anemic habit, it will be desira- ble to establish an afflux of blood and nervous excitement in the uterus, by the hip-bath, and warm aloetic purgatives, to which after a while we add some preparations of iron. I have found great and early relief pro- cured in cases of a neuralgic nature by the application of a few leeches CAUSES AND SYMPTOMS OF PNEUMOTHORAX. 339 to the tender spot, at one or both of the spino-intercostal spaces. A blis- ter to the same place has produced the like beneficial results. Pneumothorax (from intvu*, air, and 6&?i|. the chest)—Air in the Pleura.—Pneumothorax is one of the varieties of pneumatoses or abnor- mal collections of gaseous matter. They occur in the tissue ofthe organs, between the fibres of the cellular tissue, as in the parenchyma of the lungs and liver, constituting emphysema ; and in the natural cavities of the body, as in the intestinal canal and the peritoneum, tympanites; in the pleura, pneumothorax, in the uterus, physometra, &c. They are most common in the intestinal canal, and comparatively rare in the other cavities. Pneumothorax may occur in three different ways :—1. It may be the consequence of partial pleurisy, the effusion in which being absorbed leaves a void which is sometimes filled with air secreted by the mem- branes. This kind is quite rare. 2. Pneumothorax of an idiopathic kind arising from the effusion or secretion of air into the sac of the pleura with- out perforation, in a manner analogous to the secretion of air from the peritoneum, constituting tympanites. This is, also, an unusual occur- rence. 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 pulmonary pleura. The latter is the kind of pneumothorax usually spoken of, and constitutes a great majority of the cases met with in prac- tice. The perforation depends on the progress of ulceration, which is generally of a tuberculous character, and, but rarely, of gangrenous ab- scess, through the pleura. There are examples on record of pneumotho- rax resulting from a communication between the cavity of the pleura and one of the neighbouring hollow organs containing air, as from rupture of the oesophagus, cancer of the stomach, abscess of the liver, opening into the lungs and the pleura, &c. The post-mortem appearances will vary according to the cause. Most generally, together with gas there is liquid effusion, pleuritic membranes, and tuberculous cavities. The perforations are sometimes very small, even imperceptible. The causes of pneumothorax are detailed by M. Andral. Its idio- pathic origin is rare. Most commonly (if we except traumatic pneumo- thorax, or that proceeding from a penetrating wound of the thorax and costal pleura) the cause is external to the cavity of the pleura, and con- sists in a pulmonary lesion. Sometimes it is owing to a fistula which opens a communication between a tuberculous cavity and the pleura ; sometimes to an abscess, the consequence of pneumonia, opening on the pleura ; to pulmonary apoplexy destroying the lung and the pleura ; to a cancerous ulcer of the lungs, or, as M. Andral has twrice seen it, to a simultaneous rupture of some of the pulmonary vesicles and the pleura. The disease is most frequent between twenty and thirty years of age. 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 ofthe thorax ; but this is not a constant symptom. 3. An unusual sonorousness, on percussion, through the whole extent ofthe dis- eased 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 sonorousness. 5. Sometimes an amphoric or caver- nous respiration. 6. If there be air and liquid effused, a gurgling, at first not very sensible but augmenting each day, in the inverse proportion of 340 DISEASES OF THE RESPIRATORY APPARATUS. the amphoric respiration and 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 ofthe liquid against the walls of the chest. The diagnosis is well summed up, in its main features, by Dr. Hough- ton (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 overwhelm- ing dyspnoea and pain. Rarely absent, therefore very valuable ; still more so if succeeding last sign. u 3. Comparison of auscultation and percussion. Nullity of respira- tion 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. OZgophony rare. " 4. Fluctuation on succussion. Positive certainly, but should be un- questionably verified. " 5. Metallic tinkling. Positive certainly, but should be unquestiona- bly verified. This metallic tinkling is audible during coughing, speaking, and sometimes during respiration, or, more correctly expressed, after these movements." Besides this, adds Dr. Houghton, it is often heard independently of these, observing a certain periodicity, and finer in its tone. It coincides or alternates with amphoric respiration. Cough is a common adjunct. Among the general symptoms are a frequent and small pulse, hectic fever, emaciation, decubitus on the affected side; and edema, at first of the thoracic region, and afterwards of the entire peri- phery of the body. The duration of pneumothorax may be from a period of a few hours ending in death, or it may extend to several days, and more than a month, and even a year or two, to three years. Its termination may be favourable, and brought about by the absorption ofthe 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 often does, 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 re- duced by long prior disease ; and in other cases by leeches or cups to the chest. In fact, as perforation of the pleura and consequent pneumotho- rax 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 emer- gency. 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 ob- serves, to give vent to the air by puncturing the chest. Temporary relief has been afforded in several instances by this means ; but before having TREATMENT OF PNEUMOTHORAX. 341 recourse to it, we should consider whether, as it can give only temporary relief, the condition of the patient be such as to make this likely to out- weigh 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, in many cases, enough to deter us from the responsibility of recommend- ing it. 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 consider- able quantity of sound lung ; or if the effusion should have resulted from chronic pleurisy. The operation may be repeated if the air accumulate again. As it is impossible to avoid the continued introduction of air into the chest, the mode of performing the operation is a matter of much less consequence than in empyema. It is more desirable to puncture low down in the chest, to permit the discharge ofthe liquid as well as the air. The following case, recorded by Dr. Stokes, in his Treatise, &c, 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 discharge, but accompanied by prostration, lividity of the countenance, 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 resisting substance ; this was apparently perforated, and about three quarts of dirty, grey-coloured, fetid fluid given exit to. Great relief followed the operation. The pa- tient, however, passed a wretched night, with hectic paroxysms ; no dis- charge 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 uneasy night, with incessant cough and frothy expectoration ; the act of cough- ing 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 attendants. 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 cough- 342 DISEASES OF THE RESPIRATORY APPARATUS. ing, 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, but a great quantity escaped while the patient coughed ; the abdomen became tense and tympanitic, with exacerbation of all the symptoms, and the pa- tient 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 ofthe 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 sub- stance ; its lower and back part destroyed 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 passing 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 tenacious. 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 at- tempted an outlet for the fluid—the latter having made its way into the cellular tissue, beneath the skin, and between the peritoneum and abdo- minal muscles, down the side of the abdomen to the scrotum. The gene- ral cavity ofthe right side was much diminished by the liver having been displaced upwards 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." Interlobular Emphysema of the Lungs.—The term pulmonary em- physema applied to dilatation of the air-cells, though commonly used, since the time of Laennec, in this sense, is not applicable to the existing state of things. The affection in which the air is effused into the cellu- lar texture of the lung, is that alone to which emphysema is applicable. For the most part it is referable to the rupture of one or more pul- monary vesicles, owing to some violent exertion in lifting, straining, shouting, or coughing. Laennec believed the immediate cause to be the rupture of dilated cells. Interlobular emphysema is, upon the whole, a disease of rare occurrence and subordinate importance. Hasse declares that he has never seen it before death, nor detected its traces afterwards, except in subjects where rapid decomposition had caused the formation of gases within the cellular tissue of various other organs. There are cases, however, on record, of sudden death from the coming on of inter- lobular emphysema after fright or some violent mental emotion. The extravasated air is chiefly found beneath the pleura and around individual lobules. In the former situation it is sometimes seen in transparent, movable vesicles, of various sizes. Between the lobules it forms into parallel, and more or less narrow strata. By this extravasated air the pulmonary cells are proportionately compressed, but without causing the paroxysms of dyspnoea that we meet with in vesicular emphysema. As we cannot make out a clear diagnosis of interlobular emphysema, it would be useless to pretend to lay down a plan of treatment. SYMPTOMS AND DIAGNOSIS OF HYDROTHORAX. 343 Hydrothorax (from «/»§, water, and s»ga|, the chest)—Water in the Chest.—We may restrict the term to serous effusions in the cavity of the pleurae. One among the many evidences of an amended pathology de- duced from morbid anatomy 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 im- peded circulation. Recognising 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 diseases of the kidneys, from a febrile state connected with the exanthemata, par- ticularly scarlet fever; and from a sudden suppression of cutaneous exha- lation, implying, on occasions, an alteration in the state of the blood as a more immediate cause. In some of these cases it may be associated with, if it do not proceed from, edema of the lungs, increasing greatly the dis- tress and the danger. In more than two-thirds of bodies, opened for various purposes,—anatomical and pathological study—from two to three and four ounces of effused fluid are found in the pleural cavity. The symptomatology of hydrothorax is so little satisfactory that some of the best modern writers on the subject assert, that, if we except oppres- sive dyspnoea, there is really no symptom of the disease. That there must necessarily be variation in this respect is very evident from a sur- vey of the organic causes,—as to whether they consist in obstructions to the regular action and circulatory function of the heart, or in prior in- flamraation ofthe pleura, or in pulmonary obstruction. Still, it is well to be aware of the common association of morbid phenomena in these particu- lars, even if we are not able to reach a very exact diagnosis. The hurried breathing and panting on mounting the smallest ascent, the oppression and dyspnoea increased by lying down, the starting during sleep, so commonly spoken of as symptoms of hydrothorax, are, in fact, evidences of disease ofthe heart which preceded the effusion, and which would be manifested even if these latter were not present. The effusion will, however, no doubt, aggravate the original symptoms, and compli- cate the case. One of the earliest symptoms of hydrothorax, whatever may be the origin of the latter, is edema of the eyelids; but, although the precursor of swelling of the feet and ankles in the evening, it is often not noticed until in connexion with the latter. The dyspnoea, at first, may excite but little attention and cause but little inconvenience ; after awhile, however, its increase becomes marked, and it goes on until orthopnoea is established, and the patient cannot sleep except in a chair. The occasional, and, at times, periodical recurrence of paroxysms, during which the oppression and anxiety of the patient are extreme, are not well accounted for. Great disorder ofthe circulation is evinced by the blue and almost livid colour ofthe lips and cheeks. The physical diagnosis of hydrothorax is more precise than that derived from the general symptoms. Succussion can only be of service where there is a communication between the effusion in the pleural cavity and 344 DISEASES OF THE RESPIRATORY APPARATUS. the air of the lungs, or where gas is mixed with the effused fluid. Per- cussion, as may be readily supposed, yields a dull sound over the whole region corresponding to the effusion. By auscultation we hear, if the effusion be yet slight, oegophony; but more commonly the information afforded by the stethoscope is negative. No respiratory sound is heard except at the root ofthe lungs. The distinction to be drawn between hydrothorax or simple serous effu- sion and empyema or purulent effusion, are attained with some show of accuracy. Thus, we commonly see serous effusions in other parts of the body, as at the extremities and sometimes under the whole sub-cutaneous cellular tissue, and also in the lungs, associated with that in the chest: they, also, in general, precede the latter. In empyema there is, indeed, not unfrequently, similar effusions in other parts; but they follow at some intervals the purulent collection. In this latter case the respiratory sound is good on one side, whereas in hydrothorax it is deficient on both sides. The recommendation of Bichat, to make, in doubtful cases of hydrotho- rax, while the patient is lying on his back, pressure upon the abdomen, so as to throw the viscera upwards and thus diminish the capacity of the chest, is worth a trial, as an additional means of diagnosis between the disease in question and empyema. When pressure is made on the affected side no result follows ; but if made on the healthy one, the expansion of the lung is prevented ; and as the latter is the only one left for the perform- ance of the function of respiration, this is impeded and much distress ensues. The prognosis of hydrothorax, with our knowledge of its causes, must be always unfavourable ; nor can we say that at any moment death may not take place suddenly after a slight additional effort, in which respira- tion and the action of the heart are more tasked than common. The treatment of hydrothorax will be regulated very much by a knowl- edge of its cause. If the effusion have ensued on inflamraation 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 pneu- monia. Accordingly, we direct a few cups on the affected side or a blister to be 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, and pulmonary congestion depending on valvular disease of the heart, states of this organ associated with hydro- thorax, are sometimes to be met by venesection, followed by calomel and nitre, and digitalis with colchicum. In cases of irregular circulation, with much oppression and symptoms of venous congestion, digitalis, with the alkalies and tonics, will constitute the outline of treatment. Active hydragogue cathartics, which are well represented by the compound pow- der of jalap, gamboge with cream of tartar, or elaterium, 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 reason to believe, that hydrothorax is caused by diseased kidneys, mercu- rial purgatives, the blue mass with some narcotic, and diaphoretics, will be of most service. Counter-irritation must constitute a leading part of the treatment of hydrothorax. Blistering has been already mentioned, but in order to be POSITION OF THE HEART. 345 efficient the discharge must be kept up by the repeated application of some vesicatory substance. Setons have been highly recommended with similar intent. If hydrothorax were not always symptomatic of a grave, if not incura- ble disease, we might have more confidence in the operation of paracen- tesis to evacuate the contained fluid. When the oppression from the effusion is very great, and comes on suddenly, we have examples enough to encourage this operation, even though its effects are but temporary. DISEASES OF THE HEART. LECTURE CXIII. DR. BELL. Diseases of the Heart—Position and structure of the heart—its valvular mechanism —Beat or impulse ofthe heart; when felt—Percussion—Various tones according to the part ofthe chest struck—Auscultation—Two sounds ofthe heart: the first caused by the systole of its ventricles ; the second by the resistance and sudden tightening of the semi-lunar or sigmoid valves—Different organic affections ofthe heart—Functional disorders—Simple carditis, a rare disease—Sequences of—Softening—varieties and causes of—Diagnosis not easy—Treatment, similar to that of pericarditis—Perfora- tive ulceration and rupture—Recorded cases ofand complications with—Aneurism, ven- tricular—Thurman's summary of—Its precise seat and complications—Aneurism of the auricles. I cannot offer you more than an outline of the subject of the morbid states and the disorders ofthe heart; and even from attempting this, within the limits of a few lectures, I feel almost deterred, when I look over the works of Laennec, Bouillaud, Elliotson, and Hope, the lectures by Drs. C. J. B. Williams, Corrigan, Latham, Clendinning, Bellingham, the manuals of Aran and Andry, and the elaborate articles in the different Medical Dictionaries and medical journals, both French and English, as well as the contribution of Dr. Joy, in the Library of Practical Medicine. But a comparatively short period has elapsed since Corvisart, the favourite physician of Napoleon, was the only, as he was the earliest autho- rity, entitled to any consideration on the diseases of the heart. After him came Bertin in France, and Testa in Italy, 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 diagnosisofthe diseases ofthe heart,we must be familiar, first with its position in the chest, in health, and then with 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 point forwards, on the diaphragm, underneath which are the liver and stomach ; and it is bounded on other sides by the lung, except a small space of about two inches, where, enveloped in its coverings, it is in contact with the walls of the chest. Its base is directed upwards, backwards, and to the right side, looking towards the fifth, sixth, and seventh dorsal vertebra?, the oesophagus and descending aorta interven- 346 DISEASES OF THE HEART. ing ; and its apex consequently downwards, forwards and to the left, answering in the erect posture, 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 cartilage. When a person in health lies on the back, the apex is felt just below the nipple; the fifth rib being slightly heaved up ; and when on the left side, the apex is felt strongly beating between the fifth and sixth ribs, an inch or more to the left of the nipple ; and on the right side, where the impulse ofthe apex cannot be felt, there is a gentle heaving of the lower part of the sternum. When he lies on the abdomen the apex is felt to beat over the third and fourth intercostal spaces. About one-third ofthe heart, consisting principally of the right auricle and the upper and right side ofthe base ofthe corresponding ventricle, lies behind the ster- num. The orifice of the pulmonary artery and its valves, and conse- quently 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 ofthe auriculo-ventricular openings. The position ofthe 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 muscu- lar 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 lining membrane of the heart has been named by M. Bouillaud en- docardium (from «i/ov, within, and **g 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 ofthe right ventricle as a term of comparison, as has been generally done, in order to estimate the proportional thickness of the wall of the left ventricle, is the most defective means possible. The two following tables give the thickness of the walls of the two ventricles :— MALES. FEMALES. Lines. Lines. Ages. Base. Miildte. Apex. Base. Middle. Apex. 1 to 4 3 2T% I-9-1 9 2-5-16 21 »ft 5 to 9 3£ H 2$ »A *h 2T3u 10 to 15 3* 3$ 2$ 3T30 H 2f 16 to 29 4| 3| H 4f 4T* 3ft 30 to 49 417 ft 1 3II 41 4 327 Tic 3 6 If 50 to 79 4.37 R2 9 ^2 9 50 to 89 5 Medium from 16 to 79 4 6 5 ft J 9 Q 95 °T5J 16 to 89 43 4| m HYPERTROPHY OF THE HEART. 357 Right Ventricle. MALES. FEMALES. Ages. Base. Middle. Apex. Base. Middle. Apex. 1 to 4 9 1% 5 10 h\ 1 f3 2"v" 5 to 9 H 5 '6 5 ly35 1 7 T