..'A '■ •' -,*'1' >--..> '*'. 'Y ' ; / J88^:fc^: ■■?■ : fSSK THE PRACTICE OF MEDICINE; OR, A TREATISE ON SPECIAL PATHOLOGY AND THERAPEUTICS. BY ROBLEY DUNGLISON, M. D., Professor of the Institutes of Medicine, &c. in Jefferson Medical College, Philadelphia, Lecturer on Clinical Medicine, and AuendingThysician at the Philadelphia Hospital, &c. &c. IN TWO VOLUMES, VOL. I. PHILADELPHIA LEA & BLANCHARD. 1842, we v., Entered according to Act of Congress, in the year 1842, by ROBLEY DUNGLISON, M.D.: in ihe office of the Clerk of the District Court for the Eastern District of Pennsylvania. T. K. & P G COLLIN'S, HUNTERS TO THE GENTLEMEN, WHO HAVE HONOURED THE AUTHOR BY THEIR ATTENDANCE ON HIS LECTURES IN THE COURSE OP THE LAST SIXTEEN YEARS, THIS WORK IS AFFECTIONATELY INSCRIBED. PEEFAOE. The improvements and modifications incessantly taking place in the departments of Pathology and Therapeutics, render it ad- visable, from time to time, to incorporate them, so as to. furnish those, to whom the different general treatises, monographs and periodicals are not accessible, with the means of appreciating their existing condition. Perhaps at no time has it been more necessary than at present to bring together those various elements: certainly, within the last ten or twenty years, greater activity has been exhibited amongst observers than at any former period, and the researches of recent pathologists have greatly altered the face of the science, in regard to certain lesions more especially. Different views are still entertained on some of these; but they ought all to be familiar to the observer, in order that his own investigations may receive the proper direc- tion, and—what is all important—that he may know when to re- main in doubt. The departments of Special Pathology and Therapeutics have necessarily occupied a large amount of the author's attention; en- gaged as he has been for upwards of sixteen years as a Medical Professor, and for a much longer period as a practitioner. His opportunities, too, for witnessing the phenomena presented by disease in both hemispheres, have been varied. During a long service as a medical student in the north of England, in Edinburgh, London and in Paris; during a practice of six years in London; of eight years whilst he was Professor in the University of ^irginia; of three years as Professor in the University of Maryland; and of upwards of five years as Professor in the Jefferson Medical College of Philadelphia, he has carefully noted the modifications that ap- peared to be produced by climate and locality. Moreover, his service for three years as Physician to the Baltimore Infirmary; and for a longer period as Physician to the Philadelphia Hospital, one of the largest charities in the country, has equally enabled him to appreciate the differences presented by the same malady, according as it may fall under the care of the private practitioner, 1* VI PREFACE. or of the medical officer of an eleemosynary institution; and to pro- nounce, as the result of such observation, that the great principles of Pathology and Therapeutics are the same everywhere, and that one, who has been well grounded in those principles, can exercise his profession with as much satisfaction to himself, and advantage to the sick, in the scorching presidencies of British India, as in the more temperate regions of our own country. As in the case of epidemics, differences are observable; but those differences are readily seized and appreciated by the well educated physician, and the appropriate treatment suggested accordingly. Hence, the medical officers of our army and navy, and especially the latter, whose duties carry them to every part of the globe, are found to be as successful in the management of the cases that fall under their care in distant regions, as they would be in the treatment of those that prevail in the spot where they received their medical education. In regard to the execution of the work, the author would merely remark, that he has endeavoured to give a faithful exposition of what he considered to be the existing views in relation to the subjects of which it treats. He is not conscious of possessing any exclusive opinions; and has endeavoured to be essentially eclectic. Neither is he aware of having any undue prejudices. It has been his good fortune to pass, thus far, through life without imbibing unpleasant feelings towards any honourable member of the profession; he has, accordingly, throughout the work felt a pleasure in referring to the labours of observers everywhere, and it has been no little satisfaction to him that he has been called upon so often to make mention of the investigations of those on this side the Atlantic. In the preparation of such a work, a large amount of labour and of reflection has been necessary; and the author humbly hopes, that it may not be found to have been bestowed in vain. Philadelphia, January 4, 1842. CONTENTS OF VOL I, BOOK I. DISEASES OF THE ALIMENTARY CANAL, CHAPTER I.—DISEASES OF THE MOUTH, . I. Inflammation of the Mouth, .... a. Simple Inflammation of the Mouth, b. Diphtheritic Inflammation of the Mouth, . 1. Pultaceous Inflammation of the Mouth, . 2. Pseudomembranous Inflammation of the Mouth, c. Follicular Inflammation of the Mouth, d. Gangrenous Inflammation of the Mouth, . Section I.—Diseases of the Tongue, I. Inflammation of the Tongue, .... II. Cancer of the Tongue, . . . Section II.—Diseases of the Teeth, I. Dentition, ....... II. Toothache, ...... a. Inflammation of the Alveolo-Dental Membrane, . b. Inflammation of the Dental Membrane, c. Caries of the Teeth, ..... d. Nervous Toothache, .... e. Exostosis of the Teeth, .... f. Tartar of the Teeth, .... Section III.—Diseases of the Gums, . I. Inflammation of the Gums, • II. Excrescence of the Gums, .... III. Shrinking of the Gums, .... Section IV.—Diseases of the Velum Palati and Uvula, CHAPTER II.—DISEASES OF the PHARYNX AND ffiSOFHAGUS I. Inflammation of the Fauces, II. Inflammation of the Tonsils, III. Inflammation of the Pharynx, . a. Follicular Inflammation of the Pharynx, b. Diphtheritic Inflammation of the Pharynx, c. Gangrenous Inflammation of the Pharynx, IV. Inflammation of the Oesophagus, V. Stricture of the Pharynx and GEsophagus, VI. Cancer of the Pharynx and Oesophagus, VII. Spasm of the Pharynx and GEeophagus, VIII. Paralysis of the Pharynx and CEsophagus, 25 28 viu CONTENTS. CHAPTER III.—diseases of the stomach, - 71 I. Inflammation of the Stomach, - - - - 71 a. Acute Inflammation of the Stomach, - - - 71 b. Chronic Inflammation of the Stomach, - - - 75 II. Gastrorrhcea, -------77 III. Softening of the Stomach, - - - - - - 79 IV. Perforation of the Stomach, ----- 81 V. Cancer of the Stomach, - - - - - - 81 VI. Hemorrhage from the Stomach, ... - 84 VII. Dyspepsia, - - - - - - -88 a. Transient Dyspepsia, ----- 88 b. Chronic Dyspepsfa, - - - - - 89 VIII. Pain in the Stomach, - - - - - 93 a. Heartburn, -------93 b. Gastrodynia, ------ 96 IX. Vomiting, --------98 CHAPTER IV.—diseases of the intestines, - 101 I. Inflammation of the Intestines, ----- 102 I. Inflammation of the Small Intestines, ... 103 a. Inflammation of the Peritoneal Coat of the Small Intestines, 103 b. Inflammation of the Mucous Coat of the Small Intestines, 107 c. Exanthematous Inflammation of the Mucous Coat of the Small Intestines, ----- 113 II. Inflammation of the Large Intestines, - - - 113 a. Inflammation of-the Caecum, - - . - - 113 b. Inflammation of the Appendix Vermiformis Caeci, - 116 c. Inflammation of the Colon, - - - - 117 1. Inflammation of the Peritoneal Coat of the Colon, 118 2. Inflammation of the Mucous Coat of the Colon, - 118 II. Perforation of the Intestines, ----- 123 III. Diarrhoea, -------- 125 Adipous Diarrhoea, ------ 135 IV. Cholera, - - - - - - - 137 a. Cholera Morbus, - 137 b. Cholera Asiatica, ------ 139 c. Cholera Infantum, ----- 157 V. Constipation, ------- 161 VI. Obstruction of the Intestines, - - - - - 164 VII. Enteralgia, - - - - - - -168 a. Common Colic, ------ ig8 b. Bilious Colic, -----. 170 c. Painter's Colic, ------ 171 VIII. Tympanites, - - - - - - -178 IX. Cancer of the Intestines, - - - - - \q\ a. Cancer of the Small Intestine, .... jgl b. Cancer of the Large Intestine, - - - - 182 X. Hemorrhage into the Intestines, - - - - - 184 XI. Hemorrhoids, ----.._ jo* XII. Prolapsus Ani, -----.. jgg XIII. Concretions in the Intestines, - - - - - 190 XIV. Worms in the Intestines, ------ 192 CHAPTER V.—diseases of the peritoneum, - 203 I. Inflammation of the Peritoneum, - 203 1. Acute Peritonitis, --..__ 093 206 2. Chronic Peritonitis, 3. Puerperal Peritonitii ropsy of the Peritoneun CHAPTER VI.—morbid productions in the peritoneum and intestines, 214 3. Puerperal Peritonitis, ----- 007 II. Dropsy of the Peritoneum, - - . . . -211 CONTENTS. IX BOOK II. DISEASES OF THE RESPIRATORY ORGANS. I. Anatomical and Physiological considerations, - - - 216 II. Physical Examination of the Chest, - 221 1. Percussion, - - - - - - . 221 2. Auscultation, ------ 223 3. Inspection, Succussion, Palpation, &c. of the Chest, - - 227 CHAPTER I.—diseases of the larynx and trachea, - 230 I. Inflammation of the Epiglottis, ----- 230 II. Inflammation of the Larynx, ----- 231 a. Acute Inflammation of the Larynx, - 232 b. Chronic Inflammation of the Larynx, - . - 235 c. GSdematous Inflammation of the Larynx, ... 241 III. Inflammation of the Larynx and Trachea, ... 243 IV. Spasm of the Glottis, - - - - - - 253 a. In Children, .-_-.. 253 b. In Adults, - - - - - - 257 V. Morbid Productions in the Larynx and Trachea, - - 258 a. Hypertrophy of the Cartilages, ... - 258 b. Ossification of the Cartilages, - - . _ 259 c. Tubercles, ------- 259 d. Polypoid and other Tumours; &c. &c., - - - 259 VI. Foreign Bodies in the-Larynx and Trachea, ... 259 CHAPTER II.—diseases of the bronchia and lungs, - 261 I. Inflammation of the Bronchial Tubes, ... - 261 a. Acute Bronchitis, - - - ... 261 1. Ordinary Acute Bronchitis, - - - - 261 2. Epidemic Acute Bronchitis, ... 265 b. Chronic Bronchitis, .... - 269 a. Summer Bronchitis, .... 277 II. Hooping-Cough, ------- 283 III. Hemorrhage into the Bronchia and Lungs, ... 291 a. Hemorrhage into the Bronchia, ... - 291 b. Hemorrhage into the Lungs, ... - 299 IV. Inflammation of the Lungs, ----- 300 a. Acute Inflammation of the Lungs, - - . 301 b. Chronic Inflammation of the Lungs, - - - 316 c. Typhoid Inflammation of the Lungs, - 317 V. Gangrene of the Lungs, ------ 319 VI. CEdema of the Lungs, ----- 322 VII. Emphysema of the Lungs, ----- 323 a. Vesicular Emphysema, ----- 324 b. Interlobular Emphysema, ----- 328 VIII. Asthma,.......330 IX. Morbid Productions in the Lungs, - - - - 340 a. Cancer of the Lung, ----- 340 b. Melanosis of the Lung, ----- 341 c. Serous Cysts and Hydatids in the Lung, - - 343 d. Calcareous Concretions in the Lung, - - - - 344 e. Tubercles in the Lung, ----- 344 1. Tubercle,......345 2. Tubercular Consumption, - - - - 353 X. Diseases of the Bronchial Glands, .... 385 X CONTENTS. 007 CHAPTER HI.—DISEASES OF THE PLEURA, I. Inflammation of the Pleura, - - 3g7 a. Acute Form, - _ gg7 b. Chronic Form, - - - c. Typhoid Inflammation of the Pleura, - * * II. Pleurodyne, - 404 III. Dropsy of the Pleura, - .406 IV. Air in the Pleura, - 409 V. Perforating Abscess of the Lung, - *JJ VI. Morbid Productions in the Pleura, - - - - *u» a. Cartilaginous and Osseous Depositions, - • - *"^ b. Serous Cysts,.......?{" c. Ulceration, - * d. Tubercles,.......JJJ e. Cancer, - CHAPTER IV.—asphyxia, - - 411 I. Asphyxia in General, - jM II. Varieties of Asphyxia, - ' " , " " . ", , «". , A\ a. Asphyxia from Mechanical Obstacle to the Expansion of the Chest, 4J1 b. Asphyxia from Insufficient Supply or Total Absence of Oxygen, 432 c. Asphyxia by Irrespirable Gases, - - " . . " 434 d. Asphyxia from Mechanical Obstacles to the Entrance of Air into the Lungs, ----- 437 1. Asphyxia by Submersion or Drowning, - - - 437 2. Asphyxia from Hanging and Strangling, - - 442 3. Asphyxia from Smothering, - . - - - 446 4. Asphyxia from Tumours and other morbid conditions, - 447 e. Asphyxia of the New-born Infant—Asphyxia Neonatorum, - 448 BOOK III. DISEASES OF THE CIRCULATORY APPARATUS. CHAPTER I.—MORBID CONDITIONS OF THE BLOOD, - 453 I. Fulness of Blood, - - - - - - - 457 II. Paucity of Blood, ------ 458 CHAPTER II.—diseases of the circulatory organs, - 462 Section I.—Diseases of the Heart and its Membranes, - 462 1. Position of the Heart, ----- 462 2. Size of the Heart, ----- 464 3. Weight of the Heart, ----- 464 4. Sounds of the Heart, ----- 465 5. Impulse of the Heart, ----- 466 6. Rhythm of the Heart, ----- 467 I. Inflammation of the Pericardium, - - - - 467 a. Acute Form, ------ 467 b. Chronic Form, ------ 472 II. Dropsy of the Pericardium, - - • - - - 473 III. Inflammation of the Heart, ----- 475 a. Acute Form, ------ 475 b. Chronic Form, ------ 478 IV. Hypertrophy of the Heart, ----- 478 V. Atrophy of the Heart, - - - - - - 484 CONTENTS. xi VI. Induration and Softening of the Heart, ... 485 VII. Rupture of the Heart, - - - - - - 486 VIII. Fibrinous Concretions in the Heart, - 486 IX. Adipous and other Formations in the Substance of the Heart, - 488 a. Adipous Formations, - - - - 488 b. Fibrous Formations, ------ 488 c. Cartilaginous and Osseous Formations, - - - 488 d. Tubercular Formations, ----- 489 e. Scirrhous and Cancerous Formations, ... 489 f. Encephaloid Formations, ----- 439 g. Melanotic Formations, Serous Cysts, and Hydatids, - 489 X. Diseases of the Cardiac Valves, - - - - 469 XI. Communication between the Two Sides of the Heart, - - 492 XII. Palpitation, ------- 494 XIII. Syncope, ------- 496 XIV. Angina Pectoris, ------- 498 XV. Neuralgia of the Heart, ----- 502 XVI. Displacement of the Heart, - - - - - 503 Section II.—Diseases of the Arteries, - - 503 I. Inflammation of Arteries, .--.._ 504 II. Ossification, and other Morbid Formations in the Arteries, - 506 a. Ossification; Arteriosteie, (Fiorry,) - - - . 506 b. Morbid Formations, ..... 508 c. Ulcerations, ------- 508 III. Aneurism, ....... 508 a. Aneurism of the Aorta, - 509 b. Aneurism of other vessels, - 512 IV. Contraction of the Arteries, ..... 512 Section III.—Diseases of the Veins, - - 513 I. Inflammation of the Veins, ..... 514 a. Uterine Phlebitis, ------ 517 b. Crural Phlebitis, ------ 519 II. Ulceration, Perforation, Dilatation, Obliteration, Ossification, &c. of Veins, - - - - - - - 523 a. Ulceration and Perforation of Veins, ... 523 b. Dilatation of Veins, ------ 524 c. Obliteration of Veins, Phlebectiarctie, (Piorry,) - - 524 d. Ossification, &c. of Veins, ----- 524 Section IV.—Diseases of the Intermediate or Capillary Vessels, 525 I. Hyperaemia, _.----- 526 II. Inflammation, .-.---- 533 BOOK IV. DISEASES OF THE GLANDIFORM GANGLIONS. CHAPTER I.—diseases of the spleen, - - 551 I. Inflammation of the Spleen, - - - - - 552 II. Hypertrophy of the Spleen, ----- 553 III. Atrophy of the Spleen, - - - - - - 558 IV. Tubercles, Calcareous Deposits, Serous Cysts and Hydatids, &c. in the Spleen, - - - - - - - 558 V. Dislocation of the Spleen, ----- 558 Xll CONTENTS. CHAPTER II.—diseases of the thyroid gland, - 560 I. Hypertrophy of the Thyroid Gland, - - - - - 560 CHAPTER III.—diseases of the thymus gland, and supra-renal capsules, - - - - 565 CHAPTER IV.—diseases of the mesenteric glands, - 565 I. Inflammation of the Mesenteric Glands, - - - - 566 a. Simple Inflammation of the Mesenteric Glands, - - 566 b. Scrophulous Inflammation of the Mesenteric Glands, - - 567 BOOK I. DISEASES OF THE ALIMENTARY CANAL. The diseases of the digestive tube are among the most com- mon to which the attention of the physician is directed. They are diversified in character; are frequently serious, and always occasion considerable discomfort. They are interesting too in their relations. Derangement of function or of structure cannot go on for any length of time in any other apparatus without sooner or later involving the functions of the alimentary canal. The stomach especially participates, and hence it has been often termed the " centre of sympathies." On the other hand, serious derangement of the digestive tube reacts upon other organs, and especially upon those in the immediate vicinity, which pour their secretions into it. The whole of the digestive tube, from the mouth to the anus, is lined by a mucous membrane, whose functions are identical with those of the lining membranes of other outlets; namely, to secrete a lubricating fluid, which may facilitate the progress of the matters destined to pass over them. In the supra-diaphragmatic portion of this mucous membrane, there are no crypts or follicles which demand much attention, excepting those of the pharynx, which are at times greatly enlarged, and give rise to suffering in de- glutition. In the stomach and in other portions of the infra-diaphragmatic division of the tube, peculiar secretions take place;—in the former, the gastric acids are secreted, which mix with the aliment, and impress the necessary physical changes upon it. In the small intestine, the solitary follicles or glands of Brunner exist; and the aggregate glands of Peyer, which do not seem to differ in their function from the ordinary muciparous crypts, but which have been elevated of late into importance, as being the seat, according to some, of typhoid fever. In the lower portion, too, of the small intestine, and in the large, follicles exist, which secrete a fluid of an offensive odour, which communicates part of the characteristic smell to the faeces: so that evacuations, possessed of fascal odour, may be passed, even when aliment has not been taken to any amount for a considerable period. vol. i.—3 26 DISEASES OF THE ALIMENTARY CANAL. The exhalation from the mucous membrane and the secretion from the mucous follicles are poured into the canal, and, in addi- tion to these secretions, the fluids from the salivary glands—the parotid, submaxillary, and sublingual—flow into the mouth; and the products of the secretion of the liver and pancreas into the commencement of the small intestine. These are all the glandular secretions that are poured into the digestive tube. Throughout the whole of the tube, from the pharynx downwards, the muscular coat is situate to the exterior of the mucous coat; and from the lower part of the oesophagus downwards, a move- ment of peristole—a gentle, oscillatory contraction, alternating with relaxation, and commonly termed "peristaltic action"—is going- on from above to below, by which the alimentary and excremen titious matters are urged onwards. The muscular coat varies in its arrangement in different parts of the canal. In the oesophagus, it is thick, especially near the cardiac orifice of the stomach; in the stomach, thin; and, in the small intestine, the fibres are both circular and longitudinal, so that, by the contraction of the former, the contained matters can be pressed upon, whilst, by that of the latter^the length of the intestine to be passed over is diminished. In the first portions of the large intestines—the caecum and colon—the arrangement is different. The muscular fibres, which proceed longitudinally, are collected into three separate bands or fasciculi; the circular fibres are likewise in fasciculi, and give the colon the saccated or pouched appearance which it is known to present. The effect of this is, that, in the pouches, there are but two coats, the mucous or inner coat, and the peritoneal or outer. In the rectum, this arrangement does not hold. Its strong mus- cular coat exhibits that it is adapted for energetic contraction. The whole appearance of the alimentary canal sufficiently ex- hibits, that its different parts are destined for different functions. The shape of the stomach shows that it is a place of sojourn, or a reservoir of detention, in which the food undergoes admixture with the supra-diaphragmatic. «jeer,etions and those from the stomach itself. The character of the small intestine, as seen externally, shows it to be a mere canal for the passage of food along it. It has none of the aspects of a reservoir; but when we inspect the internal sur- face of the upper portion more especially—the duodenum and je- junum—we notice folds of the mucous membrane, called valvule conniventes, whose effect must be to detain the alimentary matter for a longer period than the smooth lower portion of the same intestine—the ileum. These valvulae have likewise the additional effect of affording a larger surface for the chyliferous vessels, which have their origin, in greatest abundance, in the part of the canal where the valvulae exist. Here the digestion is completed: for, although it may still take place lower down, and to a certain extent even in the caecum as has been behoved by many, (Viridet, Voisin,) the main diges- DISEASES OF THE ALIMENTARY CANAL. 21 tive operations are certainly stomachal, and perhaps we may say duodenal. The whole arrangement of the large intestine exhibits, on the other hand, that it is a reservoir, and intended for the detention of the excrementitious matter, until the desire arises to expel it. It is not true, that the excrement always passes onwards into the rectum, and there accumulates. The rectum is generally empty, or contains but a small amount of faeces, even when the colon may be distended; but when the faeces are very thin, they descend into the rectum, and, were it not for the sphincter, would be constantly passing off. The part, which usually acts as a sphincter, is the annulus at the top of the rectum, or at the termination of the sigmoid flexure of the colon; and it is important to bear this in mind in certain pathological cases to be referred to hereafter. When the faeces are detained long in the pouches of the large intestine, and especially in the heat of summer, when the watery portions of the blood are largely thrown off from the cutaneous Surface, the liquid parts of the excrement are taken up, and the fasces, when extruded, have the shape of small balls, and are ex- tremely hard. These scybala, as they are termed, by remaining in the pouched portions of the colon, may readily become the source of disease in the lining membrane. The arrangement and position of the caecum facilitates this kind of detention, and gives rise- to a form of enteritis, to which atten- tion has been directed chiefly of late years. Lastly;—inasmuch as the membrane, that lines the canal, ex- tends along the excretory ducts as far as the glandular organs, which have been described as pouring their secretions into the digestive tube, it can be readily seen, that pathological condi- tions of the former may implicate the latter; and that many of the diseases of the liver and pancreas, for example, may have their origin in the alimentary canal. In like manner, agents, which affect the latter, may exert their remedial agency upon the glands through continuity of membrane;'Without its being necessary to invoke the more operose process of absorption into the mass of blood, and action on the secretory organ through that fluid. In like manner we can explain how affections of the throat may interfere with audition. Of late years, more especially, the attention of pathologists has been directed to the morbid states of the Eustachian tube, on which many cases of deafness have been found to be dependent. The Eustachian tube opens into the pharynx, and is lined by a prolongation of the pharyngeal mucous membrane. Hence, if inflammation attacks the pharynx, it may spread along the tube, and by obstructing it occasion deafness, either temporary or permanent, according as the obstruction of the tube passes off with the inflammation that caused it, or continues, 28 DISEASES OF THE ALIMENTARY CANAL. CHAPTER I. DISEASES OF THE MOUTH. I. INFLAMMATION OF THE MOUTH. Synon. Stomatitis; Fr. Stomatite, Inflammation de la Bouche; Ger. Mund- entzundung. The mucous membrane of the mouth is liable to various forms of inflammation, which may be simple or erythematous, accom- panied by a pseudo-membranous or diphtheritic exudation, or by an eruption; or the follicles of the mouth may become ulcerated, or the stomatitis may end in gangrene. All these pathological conditions it may be well to inquire into separately. a. Simple Inflammation of the Mouth. Synon. Simple Stomatitis. Diagnosis.—The mucous membrane is unusually red, hot, and dry, extremely sensible to the contact of foreign bodies, and even of the tongue. The redness is generally in patches, and the affection rarely gives rise to general symptoms. It usually passes off in a few days by resolution, but occasionally terminates in ulceration or gangrene. The latter is not, however, to be antici- pated, but induration of the submucous tissue is at times left by it. Ptyalism is not an unfrequent concomitant. Causes.—The most frequent cause is the ingestion of hot or acrid substances; injuries done to the mouth by bruises, or the operations of the dentist, or by the accumulation of tartar around the teeth. During the age of the first dentition, it may arise from this source, when it may be accompanied by signs of general pyrexia. Occasionally, too, erythematous stomatitis would seem to be induced by disorder of the tube lower down. Treatment.—This form of stomatitis generally yields readily. If induced by acrid or hot substances, it passes off spontaneously in a short time. Milk diet and mucilaginous gargles, as of flax- seed tea, or infusion of slippery elm, or a lotion of the white of egg mixed with water, are all that can be demanded. If the stomatitis be dependent upon gastric derangement, it disappears as soon as the derangement ceases. Small doses of magnesia, combined or not with charcoal, may generally be prescribed in such cases with marked benefit. b. Diphtheritic Inflammation of the Mouth. Synon. Diphtheritic Stomatitis. This is the stomatitis with altered secretion of some, (Billard,) and ought to include both the thrush or muguet of the French writers, and the pseudo-membranous stomatitis, stomatite couen- neuse, (rfndral,) or diphthirite buccale. (Bretonneau.) Both are OF THE MOUTH. 29 varieties of the same kind of inflammation of the mucous mem- brane, but it may be convenient to examine them separately. 1. Pullaceous Inflammation of the Mouth. Synon. Aphthae of Children, Aphtha seu Aphthae Infantum, A. Neonatorum seu Lactantium, A. Lactucimen, Lactucimina, Lactumina, White Thrush, Thrush, Milk Thrush; Fr. Aphthes des Enfans, Muguet, Stomatite Cremeuse Pultacee; Germ. Aphthen der Sauglinge, Schwaramchen der Sauglinge. The thrush attacks the new-born" infant chiefly, although it is described as occurring in the course of certain diseases, as of phthisis in the adult. This last condition, however, is not stoma- titis with altered secretion, but the aphthous stomatitis to be de- scribed presently. Diagnosis.—The thrush is easily recognised. The whole of the surface of the tongue exhibits unusual redness, and here and there small curd-like exudations are perceptible, especially behind the lips and about the tip of the tongue; these gradually increase in number, and coalesce so as to form irregular patches, which are thrown off, and renewed, leaving the mucous membrane, from which they are detached, of a vivid red colour. In slight cases, the exudations are discrete; but in the more severe, they always run together, until occasionally the whole of the mucous mem- brane of the mouth, as well as of the pharynx, and perhaps oeso- phagus, is implicated. The skin is commonly hot and dry, and the thirst considerable. The disease is usually of but little consequence, and terminates in a few days in health; but in the foundling hospitals, where numbers of children are crowded together in a small space, and where appropriate ventilation and nourishment cannot readily be obtained, it is a serious malady, the inflammation extending down the digestive tube, and in this way proving at times fatal. In the milder cases that occur in private practice, this extension of the disease,—indicated by diarrhoea, with an irritating character of the alvine discharges, occasioning redness and excoriation around the anus,—is an almost constant concomitant. Causes.—The early period of infancy, with imperfect nutrition, and the atmospheric deterioration occasioned by crowding a num- ber of children together within a restricted space, must be ranked among the predispositions. There is evidently, too, in young in- fants, a greater predisposition in the mucous membranes, when inflamed, to be covered with diphtheritic exudations or concretions. By many, it has been supposed to be propagable by contagion from the nipple; (Evanson;) but others are not of this opinion. (Billard, Baron.) Children have often been seen to drink from the cup used by others affected with the disease, without receiv- ing it themselves. The author is unable to speak positively from his own experience as to this point. Treatment.—Generally, little more is needed than in simple stomatitis. The mouth may be wetted several times a day with a linen rag dipped in some emollient liquid, as the infusion of the 3* 30 DISEASES OF THE ALIMENTARY CANAL. slippery elm, or simply in milk and water. As, however, the lining membrane of the intestinal canal is generally more or less affected, and the source likewise of altered secretions, an occa- sional dose of magnesia alone, or associated with rhubarb, may be advisable. A common mouth medicine, in these cases, is the borate of soda mixed with honey, in the form of the mel boracis of the London Pharmacopoeia, or in such proportion as the practitioner may deem advisable:— R.—Sodae borat. in pulv. p. i. Mellis despumat. p. viii. By some, the mouth is directed to be cleansed by vinegar diluted with water, applied like the e\nollient liquid directed above. The diet should be demulcent, and of the character recom- mended for simple stomatitis. 2. Pseudomembranous Inflammation of the Mouth. Synon. Pseudomembranous Stomatitis; Fr. Stomatite Pseudomembraneuse ou Couenneuse, Diphtherite Buccale. This can be regarded as only a severe variety of the last, affect- ing the same parts; the exudation being detached in large flakes, having the ordinary appearance of false membranes. These are soon renewed, but in favourable cases, the inflammation, that gave rise to them, gradually disappears; in other cases, signs of gangrene supervene; but this termination, and indeed the variety of the dis- ease itself, is rare, except in large foundling establishments, where the mortality from it is at times frightful; of 193 cases, observed by a recent writer, {Valleix,) 153 terminated fatally. In such cases, a disagreeable sense of heat is experienced by the little sufferer, with pain augmented by the contact of foreign bodies; the breath is fetid, and the submaxillary glands enlarge and become painful. Later on, the lips and gums are tumid and bloody; a sanious saliva flows copiously from the open mouth; the breath becomes more and more fetid; and the face flushed and swollen. The fever is more or less intense, with headache, restlessness and want of sleep. [Andral.) Treatment.—Where an impure air is connected with the origin of the disease, it is, of course, important that the patient should be removed from its influence. In the early period, the mucilaginous collutories, recommended in the last variety, may be used, with gentle laxatives of magnesia or castor oil. Afterwards, a mixture of muriatic acid and honey may be employed to touch the pseudo- membranous patches; this may be done by means of lint rolled around, or of sponge attached to, a small stick. Collutories of chlorine water,1 chloride of lime,2 creasote,3 and vinegar and alco- hol,4 have likewise been recommended. 1 R.—Mucilag. acaciae, gr. xij. * R—Calcis chlorin. gr. xv. Aquae chlorin. Mucilag. acaciae, |j. Syrup, aa gss. Syrup, cort. aurant. gss—M. Aquae, giv.—M. OF THE MOUTH. 31 R'~£rea-sot* gtt' xv* 4 R.—Aceti, gij. Mucil. acac. ^iss. Alcohol. 3iij. Aq. camphor. £xss—M. Aquae, |iv__M. The application of the muriatic acid, as well as of the other col- lutories, must be made once or twice, or oftener, in the twenty- four hours, as the case may require. Alum,1 the nitrate of silver,2 and the sulphate of zinc,3 have all. been used as collutories, but they are not possessed of any advantages over the articles already mentioned. 1 R—Pulv. alumin. gr. xx. 2 £—Argent, nitrat. gr. ij. ad gr. iv. Aquae, giv.—M. Aquae, |j.—Solve. 3 R.—Zinci sulph. £ss. ad ji. Aquae, gvj.—Fiat solutio. c. Follicular Inflammation of the Mouth. Synon. Aphthous Stomatitis, Aphthae, Emphlysis Aphthae, Follicular Stoma- titis, Aphthae Adultorum; Fr. Stomatite Aphtheuse ou Apthes; Ger. Schwamm- chen der Erwachsenen. Much difference of sentiment has existed as to the precise nature of aphthae; some regarding them as synonymous with stomatitis in general, and especially with the two last varieties; others, that they consist in an inflammation of the follicles of the mucous mem- brane of the mouth (Billard); others, that they are eruptive and divisible into three species—the papular, the vesicular, and the pustular (Jlndral); and others, again, believing them to be entirely vesicular, and to strikingly resemble the follicular ulcerations of the oesophagus and intestines. Aphthous stomatitis may be either discrete or confluent. It attacks the parts especially where the epithelium is most apparent. In foundling hospitals, however, an ulcerous form of gastritis is occasionally seen, which strikingly resembles aphthous ulcerations of the mouth. The whole of the internal surface of the stomach is studded with superficial, rounded, or oval-shaped ulcers, a line or two in diameter, having a yellow base, and slightly tumefied edges of a beautiful red colour (Sestier). The discrete form is not often met with in infants, but is com- mon in children who have passed the first dentition, and in adults; and is often preceded by some degree of fever and signs of gastric derangement, which pass off in the course of a few days, hence it has been termed ephemeral aphthae. The confluent form, which, in consequence of its slow progress, has been termed "stationary" (Guersent), is rarely confined to the mouth like the discrete, but extends to the fauces, and at times even to the infra-diaphragmatic portion of the digestive tube. It is not common with us; but is said to be very often met with in moist countries, as in Holland, where it reigns at times epidemi- cally, and is a serious affection, attacking adults and childbed females especially. (Guersent.) This form is accompanied by great cephalic, gastric, and general disturbance, and at times the eruption appears to extend to the 32 DISEASES OF THE ALIMENTARY CANAL. intestinal canal, giving rise to severe pain in the abdomen, diar- rhoea and typhoid symptoms, under which the patient may sink- Pathological characters.—When the mucous membrane of the mouth is inspected at an early period of the disease, it presents the appearances of simple stomatitis. Subsequently, when the eruption has occurred, small, transparent, grayish, or whitish vesicles are perceptible; and, at the base of each vesicle, there is a raised ring, which is resisting, and of a white colour. Still later, the vesicle breaks at the top, so as to allow the fluid to escape from it; after which, it becomes transformed into an ulcer, which spreads, and is bounded by a red circle, the raised border, that occupied or surrounded the base of the vesicle, gradually disap- pearing. The last stage is fhat of cicatrization, which occurs at times rapidly; the patient, who has suffered much one day from the soreness of the ulcers, finding himself entirely well on the day following. A slight degree of redness may still remain, but it gradually disappears, and, whilst it exists, occasions little or no inconvenience. Treatment.—The discrete form requires merely the treatment recommended in the mild cas.es of diphtheritic stomatitis; in the first instance, mucilaginous collutories, and subsequently astrin- gents. The confluent kind requires the antiphlogistic treatment, regulated according to the symptoms. Blood-letting is rarely needed: quiet in bed, the Warm bath, emollient collutories, in the first instance, and subsequently the more astringent, should be directed. At times, the affection is manifestly asthenic, and re- quires the internal use of tonics, as the cold infusion of cinchona, R.—Infus. cinchon. (sine calore praepar.) §vss. Syrup, aurant. §ss.—M. Dose, a fourth part four times a day. and of the acidulous and astringent gargles referred to under the head of pseudomembranous stomatitis. In such cases, and indeed in aphthous sores in general,.touching the ulcerations with the nitrate of silver, has been found by the author to be the most effectual remedy. The solution of the persesquinitrate of iron, internally, has been highly extolled in cases of aphthous sores. [Adam, of Michigan.) R.—Liq. ferri persesquinit. gtt. xl. Syrup, aurant. gss. Aquae, ^vss.—M. Dose, a fourth part four times a day, to a child three or four years old. At times, these aphthous ulcerations are extremely difficult of management, and very apt to recur after they have been healed. The author has observed some obstinate cases in women who were nursing,—the affection appearing to be induced by the con- stant drain from the mother, interfering with nutrition. Weanin°- the child has, in such cases, been indispensable. In those who are affected with the obstinate forms, it is indis- pensable to change all the physical influences to which they are subjected: the thorough revulsion, induced by travelling air, and OF THE MOUTH. 33 exercise, will often effect that beneficial change, which has resisted every remedy that could be thought of, whilst the patient remained under the same influences in which the malady had been engen- dered. When aphthous ulcerations have persisted for any length of time, they are to be regarded in the same light as other cases of faulty nutritive action of the dermoid tissue, and the same treatment applies to them strictly. The various eutrophics,* as arsenic, iodine, sulphur, &c, are accordingly beneficial, either alone, or associated with the thorough revulsion recommended above. d. Gangrenous Inflammation of the Mouth. Synon. Gangrenous Stomatitis, Gangraena Oris, Stomacace Gangraenosa In- fantum, Cancer Aquaticus, Noma, Cancrum Oris, Cheilocace, Ulocace, Cheilo- malacia, Scorbutus Oris, Canker of the Mouth, Sloughing Soremouth of Chil- dren, Gangrenous Soremouth, Sloughing Phagedaena of the Mouth, Water Canker; Fr. Cancer aquatique, Stomatite Gangreneuse, S. Charbonneuse; Germ. Wasserkrebs des Mundes, Mundkrebs, Lippenkinderbrand, Mundkinderbrand, Wangenkinderbrand, Sphacelose Mundfaiule. Many of the French writers have a division of* gangrenous stomatitis; and it may be retained for the purpose of describing a scourge of our establishments for infants, which does not succeed to any well characterized inflammation, and may perhaps be con sidered gangrenous ab origine;—the inflammation that may exist being secondary. [Symonds.) It need scarcely be said, that all the forms of stomatitis, which have been described, may be followed by one form or other of gangrene; the ulcerations may become of a brown colour, and covered by a soft slough, which, when it is detached, leaves the surface beneath highly red and of a granulated appearance. The surrounding parts, in such cases, are commonly much tumefied, and of a livid appearance, the breath at the same time having a gan- grenous fetor, and the saliva flowing more or less copiously from the mouth. The sloughing sometimes makes frightful progress, so that the cheeks and gums are occasionally destroyed by it before the little sufferer sinks. These symptoms have frequently been ascribed to mercury, but extensive and spreading ulcerations, with great foetor oris occur where not a particle of mercury had been taken. A terrific form of gangrenous stomatitis, which, as remarked above, is one of the scourges of establishments for infants, is that which is most commonly known under the unclassical name of cancrum oris Diagnosis.—This affection does not always present the same symptoms. At times, on the inside of the lips or cheeks, small vesicles, of a grayish or livid red, or even black colour, appear, * For want of a more appropriate term, the author, in his lectures on Thera- peutics, has been accustomed to apply this to agents which, through the blood, modify the action of the system of nutrition, without necessarily producing a sensible increase of any secretion. 34 DISEASES OF THE ALIMENTARY CANAL. without much pain or swelling, but surrounded by a red base, pre- ceded occasionally, or accompanied at their inception, by consider- able fcetor oris and augmented secretion from the salivary glands. These speedily pass into a state of gangrene. The swelling, sur- rounding hardness, heat and pain increase; the vesicle sinks, and in its vicinity livid or black points are observed, which pass into exten- sive sloughs, surrounded by a glossy tumefaction, and spread so rapidly, that often, even in the course of two days, the lips, cheeks, nose, tongue, palate, and tonsils, and even the whole face, become gangrenous, and slough off by piecemeal; the unprotected teeth falling at the same time from their sockets. At other times, the disease commences at the edges of the gums, opposite the incisors of the inferior jawbone; the gums present a white appearance at these points, become spongy and separated from the teeth, and the whole appearance is like that induced by mercury taken so as to affect the system. Ulceration now begins, and extends along the gums until the jaws are implicated; and, as the disease advances, the cheeks and lips begin to swell, and form a tense and indurated tumefaction; the gums are gradually de- stroyed by ulceration; the teeth become loose, and fall out: the gums and inside of the cheeks soon assume a gangrenous appearance, and the breath is insupportably fetid. The exterior of the cheek, or the part where the tumefaction existed, now becomes of a purple colour, and vesicles often form from one-fourth of an inch to an inch in diameter, filled with a dark coloured fluid, which soon burst and discharge, and are speedily followed by the formation of sloughs. (B. H. Coates, of Philadelphia.) The discharge from the affected portions is often very acrid, and occasions excoriations of the unaffected parts with which it comes in contact. In the very early stages of the disease there is not much con- stitutional disturbance,—scarcely any fever or loss of appetite; the desire for food is indeed, at times, great; but, as the disease pro- ceeds, and involves a greater extent of parts, irritative fever super- venes, the appetite is destroyed, colliquative diarrhoea sets in, and death closes the scene. Yet, formidable as the disease always is, the deaths are not always in a very large proportion. In the year 1838, of twenty-three cases treated in the children's asylum of the Philadelphia Hospital, nineteen recovered, and four proved fatal. Causes.—The essential nature of this disease is unknown to us. It is strikingly analogous to that of gangrene of the lungs, putre- scentia uteri, (Boer), hospital gangrene, and the pustule maligne. All these affections have been believed by some, indeed, to be identical. (Wigand.) Among the predisposing causes must be reckoned the age of childhood; but infants at the breast are rarely affected by it. It is most frequently observed between the age of twenty months and seven years. A great predisposing cause exists in the impure OF THE MOUTH. 35 air and imperfect nourishment in large establishments for children. It is hence important, that all such establishments should have their windows constructed so that they can open to the floor; in any other form, perfect ventilation is impracticable; the unchanged and impure air stagnates beneath the window sill, and must neces- sarily be breathed by the infants, whilst those of larger growth may not inhale it. The cachexia, thus induced, is extremely favourable to the production of the disease. In like manner, the state of the system that follows measles or scarlatina constitutes a predisposition. The most serious epidemics, which the author has observed, have supervened on the former disease. As the disease often occurs endemically in hospitals, attacking a great number of children about the same time, a question has arisen whether it be not propagable by contagion. Opinions have differed on this subject. It has indeed been affirmed, that, when sloughing or gangrene is present in stomatitis, or a disposition to such is manifested, all agree upon the necessity of separating chil- dren not affected from those that are ill. (Evanson.) This will be proper, whether we regard the disease to be contagious or not. On the other hand, many of the best observers consider, that there is nothing to prove the contagiousness of the disease, and affirm, that it is usually observed in one patient at a time, in an hospital, even when surrounded by numbers of other children. {Billard.) Treatment\—From the nature of the disease, and the indivi- duals that are generally affected by it, the proper treatment of gangrenous stomatitis will be readily appreciable. The great indi- cations are, to support the strength of the system, and to modify the condition of the gangrenous parts. The treatment will conse- quently resolve itself into first, the internal, and secondly, the external. 1. Tonics and antiseptics are here indicated. Of the former, the best, perhaps, is the cinchona, and especially the salts of its active principle, quinia. As the subjects of gangrenous stomatitis are commonly young, these preparations have the advantage of being administrable, owing to their potency, in small quantities; and when they cannot be taken by the mouth, they may be given in enemata, or be sprinkled on the ulcerated surfaces. R.—Quiniae sulphat. gr. viij. Syrup, simpl. %\v. M. Dose, a dessert spoonful every three hours to a child six years old. Or, R.—Quiniae sulph. gr. viij. Aq. chlorin. 3L vel Acid, sulph. dil. gtt. v. Syrup, limon. §iv. M. Dose, same as the last. Chlorine water and the chloride of lime, or the chloride of soda, may also be administered with advantage. R.—Calcis chlorin. gr. x. vel Liq. sodas chlorin. gtt. viij. Syrup. 3ij. Aquae, %iv. M. Dose, same as the last. 36 DISEASES OF THE ALIMENTARY CANAL. The disease obviously consists in a morbid condition of the func- tion of nutrition, and everything that modifies it can scarcely tail to be beneficial. The iodide of iron may, in this manner, serve a most useful purpose. R.—Vini Hispan. (sherry) %iv. Ferri iodid. 31. M. Dose, a teaspoonful four times a day. All these agents act as eutrophics, by modifying the condition of the blood in the vessels: and as the modified fluid circulates through the tissues that are in a pathological condition, it im- presses their sensibilities in a different manner, and breaks in upon the morbid state, especially when aided by the agents that con- stitute the external treatment. 2. The great object in the external treatment isto arouse the living portions, beneath the sloughs, to action, and to promote the separation of the latter. When the cheek is observed to be tumid and hard, leeches and blisters have been applied, but without affording essential relief. The inflammation is, indeed, of the asthenic character, and will not bear depletion, although advantage might be presumed to fol- low the application of blisters, as in cases of erysipelatous inflam- mation. The best plan would appear to be to scarify the sloughs down to the diseased parts, and then to apply remedies that are appropriate for exciting a new action in the parts. These remedies belong to the class of excitants, and some of them act as powerful escharotics, and antiseptics or disinfectants. By some, it has been recommended, when a slight erosion is perceptible on the interior of the mouth, and a violent ecchymosis internally, to cauterize the central part of the swelling, either with the butter of antimony, or with undiluted muriatic acid, (C. Tau- pin,) introduced to the bottom of a crucial incision made on the outside of the cheek, or with the actual cautery, which is preferred by some, (Billard, Baron.) The latter individual recommends it as the sole means of restoration, and that it should be employed as early as possible to avoid extensive loss of parts. Others, how- ever, are not favourable to its employment. (Most.) In the epidemic in the Philadelphia Hospital, before alluded to, the author suggested the use of the creasote, applied after incisions had been made through the gangrenous parts. R.—Creasot. Alcohol, aa Jss. M. To be applied by means of a pencil. Potassa, in the form of the liquor potassae, nitric acid,1 pyrolig- neous acid,2 chlorine,3 chloride of lime,4 chloride of soda,5 and tinc- ture of muriate of iron,6 with or without incisions, have likewise been advised; but the caustics or excitants, which have met with most favour, have been the sulphate of copper, and the nitrate of silver used in the solid form, so as to produce an eschar over the whole of the sloughing parts. OF THE MOUTH. 37 > R.—Acid, muriat. 3iss. vel 2 R.—Acid, pyrolign. ^ss. Acid, nitric. 3L Syrup. 3-i. Aquae, Oj. f. lotio. Aquae, giv. f. lotio. 3 R.—Aq. chlorin. * R.—Calcis chlorin. gr. xx.—xxx. Syrup, aa ^ss. Mucilag. acaciae, ^j. Pulv. acaciae, gr. xij. Syrup, gss. f. collutorium. Aquae, t:$iv. f. lotio. 6 R.—Sulph. cupri, 31J. 6 R.—Liq. sod. chlorin. Pulv. cinchon. ^ss. Aquae, aa p. ae. f. lotio. Aquae, §iv.—M. (B. H. Coates, of Philadelphia:) or, the bark may be omitted. Whatever preparation is employed, it is well to make it come in contact, as far as is practicable, with the diseased tissues. When sloughs have formed on the cheeks, the yest cataplasm, or poultices containing powdered bark or the chlorides of lime or soda, or the pyroligneous acid, may be applied to the part previ- ously washed with any of the lotions already mentioned. Should diarrhoea supervene, it may be treated by a small dose of castor oil and laudanum, R.—01. ricin. 3j. Tinct. opii, gtt. ij.—M. in the first instance, and subsequently by starch and laudanum glysters, to which the sulphate of quinia may be added, if esteemed advisable. The diet, throughout the disease, should be nutritious, consisting of beef tea, beef essence, wine whey, the farinaceous vegetable preparations, as arrow-root, sago, and tapioca to which wine has been added, in quantities suitable to the condition of the patient; and it need scarcely be said, that where practicable the child should be removed from the atmosphere in which the disease was generated. SECTION I. DISEASES OF THE TONGUE. The condition of the tongue is an important index in disease. It shows the degree in which the function of secretion elsewhere is modified, is indicative of morbid conditions of the lining mem- brane of the alimentary canal at a distance from it, and of the extent of general disorder; and in some diseases, as in scarlatina, it presents appearances that are peculiar. Its state of moisture or dryness has likewise to be noted in disease. It may, however, become unusually dry under the influence of nervous agitation;— one of the circumstances, which exhibits—that although we may regard the process of secretion to be carried on independently of the nervous influence, such influence is capable of modifying it in some degree. In the case of the secretion from the lachrymal vol. 1.—4 38 DISEASES OF THE ALIMENTARY CANAL. gland, we have an example in which the secretion is augmented under mental emotion. These, however, are symptomatic condi- tions. The idiopathic affections of the organ concern us here. I. INFLAMMATION OF THE TONGUE. Synon. Glossitis, Inflammatio Linguae, Glossoncus Inflammatorius, Angina Linguaria; Fr. Glossite, Inflammation de la Langue; Ger. Zungenentzundung. Inflammation of the tongue may be superficial, or deep-seated. The former, affecting the mucous membrane, has been considered under stomatitis. The latter is a different affection. Diagnosis.—The tongue is observed to be painful, hot, red, and swollen; and, when attempts are.made to move it, the pain be- comes excessive. At first, the affection may be limited to a part, and a small part, of the organ; but gradually it extends; the pain becomes acute, lancinating, and burning; and the smallest contact of a resisting body is almost insupportable; deglutition, articula- tion, and, in short, every muscular motion in which it is implicated, excite the most excruciating torment. At times, the tongue is so enormously swollen as to threaten suffocation, and to hang out of the mouth; and, occasionally, by the pressure of the teeth, indenta- tions are made, and livid or black appearances presented on the pro- truded part, which threaten mortification. Whilst the tongue is in this condition, and covered frequently with a thick fur, saliva flows copiously from the mouth; and, during the existence of the phlegmasia, the general symptoms are such as are present in all forms of inflammation, and are proportionate to the severity of the inflammation. A tumour is sometimes met with on the upper surface of the tongue, which is, at first, hard, and slightly painful on pressure: this suppurates slowly, and afterwards forms a deep ulcer. At other times, the tongue presents a diphtheritic appearance, under which ulcers form, which may even perforate it. (M. Hall.) The edges of the tongue may be ulcerated, owing to the pressure of sharp spicula of teeth. The sores are tender, and surrounded with a hard base, and may be considered as belonging to stomatitis. They do not, at least, require any separate management. Causes.—These are usually acrid substances taken into the mouth, or injuries inflicted by the teeth, or by external bodies. It is one of the results of the ptyalisin induced by mercury; and the most alarming cases, which the author has ever seen, occurred in this manner. It is met with also in the course of smallpox and scarlet fever, and exists not unfrequently in severe cases of isthmitis and amygdalitis. Pathological characters.—These may be gathered from the detail of the symptoms. The great tumefaction is owing to the infiltration of serum; but at times coagulable lymph is thrown out, which accounts for the circumscribed hardness. Superficial glossitis is rarely a disease of any consequence, and yields to the use of the washes recommended under simple, or OF THE MOUTH. 39 diphtheritic stomatitis. The deeper seated form is a cause of some anxiety. Generally, it terminates rapidly by resolution, rarely by suppuration, and still more rarely by gangrene and death. Treatment.—In deep-seated glossitis, accompanied by much swelling, general bleeding may be needed; leeches may, likewise, be applied to the under surface of the tongue, and scarification be made on the upper surface. The last measure affords great relief, by discharging not only the blood contained in the hyperaemic vessels, but the serous fluid effused into the cellular membrane. Relief may also be obtained from the application of ice to the sur- face of the tongue, and of a blister to the throat and neck. Occasionally, the tongue, on one or more parts, has the appear- ance of gangrene, constituting the affection termed, by some, gloss- anthrax. In these cases, it has been advised to apply the actual cautery to the mortified portion, and to make use of the collutories of chloride of lime or soda, or the other excitant and antiseptic washes, described under gangrenous stomatitis. In all forms of glossitis, revulsion, by means of active cathartics, or cathartic enemata, may be attempted; and, if the swelling be so great, that the tongue is protruded from the mouth, and pressed upon by the teeth, the organ may be enveloped in a cloth, and be pressed firmly for some time, so as to force the effused fluid into the cellular membrane of its posterior part; and, when once the organ has been returned into the interior of the mouth, it may be retained there by means of a piece of gauze fastened firmly over the mouth, which will enable the patient to breathe without diffi- culty. The author knew a case of excessive infiltration of the tongue accompanying mercurial ptyalisni, which was treated suc- cessfully by this method. If, owing to the excessive tumefaction of the tongue, suffocation should be threatened, the organ should be scarified deeply in the direction of its length, and, if the immi- nent symptoms still persist, tracheotomy or laryngotomy may be needed. In the cases in which a hard tumour forms, that suppurates slowly, and leaves a deep ulceration, the revulsive treatment by emetics and purgatives, aided by the local application of the solid nitrate of silver, may be entirely successful. Where the surface of the tongue is covered by a dry, white pel- licle, and is ulcerated or perforated—a condition which has been described as psoriasis, (M. Hall)—it is necessary, as in cutaneous affections in general, to act on the general system. This can be done by agents that modify the system of nutrition, of which arsenic,1 and iodine,2 are among the best, especially if given in simple syrup, which, of itself, is capable of modifying the chyle, and, through the blood, the nutrition of the tissues. At the same time, the nitrate of silver may be applied to the tongue itself. 40 DISEASES OF THE ALIMENTARY CANAL. • R.—Liq. potass, arsenit. gtt. xxiv. or, R—Acid, arsenios. gr. ij. . Syrup, simpl. ^ivss. f.-M. Micae panis, 9y. f. massa in pil. Dose, one-third, three times a day. xy. dividend. Dose, one three times a day. 2 R.—Solutio potass, iodid. (Lugol,) gtt. xxx. Syrup, ^iiss.—M. Dose, one-third, three times a day. The ulcerations, that are occasioned by any sharp projection of the teeth, usually heal readily, without any medication if the irri- tating body be withdrawn. Glossitis does not often pass into the chronic state, but cancer of the tongue may supervene in persons of the cancerous diathesis; and hypertrophy of the organ, which requires a surgical operation, has been observed among its consequences. (T. Harris, of Phila- delphia.) These hypertrophies appear to assume, at times, the characters of the erectile tissues. At others, the fleshy fibres of the tongue are found, on dissection, to have been converted into a substance of a semi-cartilaginous nature, leaving scarcely a trace of the primi- tive structure. (Professor Gross, of Louisville.) II. CANCER OF THE TONGUE. Synon. Cancer Linguae; Fr. Cancer de la Langue; Ger. Zungenkrebs. This is not a common disease. It is generally situate near the tip of the organ, and sometimes at the edge. Diagnosis.—When inflammation has not preceded it, tumefac- tion and induration are the first symptoms; after which, painful shootings are experienced, which augment as the disease makes progress. The movements of the tongue become difficult and painful, as well as the associated actions of mastication and deglu- tition. At length, the indurated tissue passes to a state of ulcera- tion; the ulcers are irregular, red, and hard, and generally with everted edges; and a sanious, bloody matter, of great foetor, flows from the mouth, along with an increased secretion of saliva. The sufferings, as in other cases of cancer, become insupportable, and the unfortunate subject is worn out by the irritative fever that accompanies it in its latter stages. Causes.—In all cases, there must be a diathesis, which predis- poses to cancer; and, when this exists, any injury done to the tongue may act as an exciting cause. Treatment.—In the early period, attempts may be made to modify the diathesis by agents, which induce a new action in the system of nutrition—as by the internal use of the preparations of arsenic or iodine given in syrup; but if these agents, accompanied by rest of the organ, produce no change, the only remedy is ex- tirpation of the part affected, which, as it is generally seated near the tip of the tongue, can be accomplished without much difficulty. OF THE MOUTH. 41 SECTION II. DISEASES OF THE TEETH. I. DENTITION. . Synon. Dentitio, Odonlia Dentitionis, Odontiasis, Odontalgia Dentitionis, Odaxismus, Teething; Fr. Dentition; Ger. Zahnen. The process of cutting the teeth, it need scarcely be said, is natu- ral, and not to be classed among pathological conditions; yet, at this period of the infant's life, the system is so impressible, and the irritation induced by the pressure of the teeth on the nerves of the gum so great, that the attention of the physician is frequently called to it. There are certain symptoms, which, to a greater or less degree, are universal concomitants of dentition. These are—pain, swell- ing, and heat of the gums, on which the teeth are pressing; con- stant flow of saliva, with a desire to bite objects—unless the gums are very painful, when they are carefully avoided, or, if introduced into the mouth, are speedily withdrawn. The child is, at the same time, restless and fretful; the sleep is disturbed, and the diges- tive organs are often more or less deranged. These symptoms are so generally present, that, in moderation, they can hardly be looked upon as constituting disease; but, where the nervous system is unusually impressible, the irritation from the teeth irradiates to the great nervous centres, and convulsions are the occasional con- sequences. It is important to attend to the state of the gums, whenever any diseased condition occurs simultaneously with dentition; yet there can be no question, that many affections are ascribed to it, which are mere concomitants. It is of the local condition we shall speak here. The affections that are induced by teething, will fall under consideration in their appropriate places. Treatment.—It has been a question, whether, during the irrita- tion of teething, when the child is desirous of conveying every- thing to the mouth, hard substances should be permitted to press upon the gums. It is a common custom to allow the child the use of a piece of coral, or of sealing-wax, or, what is preferable—inas- much as it cannot be forced into the mouth and injure the soft parts of that cavity—an ivory ring. Some of the French writers discard all such substances, (Gardien, Billard,) but without much propriety. If the gums be extremely tender, the child will not use them; and, if pressing the gums upon them should afford relief, there appears to be no good reason, why their use should be for- bidden, as the pressure cannot fail to aid the absorption of the gum. It has been suggested, as a good plan, to allow the child the use 4* 42 DISEASES OF THE ALIMENTARY CANAL. of a small wax candle, a stick of liquorice root, or a crust of bread. The first of these may be unobjectionable; but the liquorice root may load the stomach with saccharine matter, if allowed too freely; and the crust of bread may excite alarm, by the softened portions getting into the glottis, and producing symptoms of strangling. The physician, however, is not often consulted on these points; the whole matter being generally regulated by the parent or nurse. Where the gums are extremely swollen, tense, and very tender —and especially if there be, at the same time, a morbid condition, which appears to be connected with the process—it may be neces- sary to relieve the hyperemia, either by scarifying the tumefied gums freely, or by dividing them down to the tooth, until we dis- tinctly hear or feel the tooth grating against the instrument. The restraint, under which the infant is placed during the opera- tion, generally occasions it to cry, and this is often ascribed to the pain of the operation. This is a mistake. It rarely happens, that much pain is experienced, and very frequently the child bites the lancet, as if the sensation were agreeable to it. The tooth appears, at times, soon after the operatidn; but, in many cases, it is long before it presents itself. In the latter cate- gory, it has been conceived, that mischief may result from the in- duration of the cicatrix, which, it is imagined, may retard the exit of the tooth. This is not so. It is well known, that, where absorption takes place upon parts on which there are cicatrices, the cicatrices are more readily taken up than the parts surrounding them. Free division of the gums is an admirable remedy in the cases above referred to, and the operation may be repeated again and again, should circumstances arise to indicate it. II. TOOTHACHE. Synon. Odontalgia, Odontia Dolorosa, Dolor Dentium, Toothache; Fr. Odon- talgic, Douleur des Dents; Ger. Zahnschmerz, Zahnweh. This disease is characterized essentially by acute pain in the teeth or their involucres, and is dependent upon various patholo- gical conditions, which may require a brief and distinct considera- tion. a. Inflammation of the Alveolo-Dental Membrane. Synon. Periodontitis; Fr. Periodontite, Inflammation de la Membrane Alveolo- dentaire. The membrane that lines the socket of the tooth is, at times attacked with inflammation, giving rise to much suffering. Diagnosis.—An uneasy feeling in the alveolus, or alveoli, of some part of the jaws when the teeth are pressed together; 'the teeth of the affected periosteum being evidently slightly forced' out- wards, so that the teeth cannot be accurately brought in contact. This painful sensation, pulsative and constant, may exist for a few OF THE MOUTH. 43 days, and then pass off; but, at other times, the inflammation spreads outwards, so as to be perceptible on the gums; the teeth become loose; and, at times, pus is secreted in the alveolus, which makes its way outwards, between the gum and the tooth. In other cases, the parietes of the alveolus become carious, and a fistulous ulcer is kept up. When the inflammation has recurred frequently, the tooth may become permanently loose, and act as a foreign body in the socket. Causes.—Periodontitis may be induced by caries of the fang, which is not often, however, the first cause. Cold and hot fluids, taken into the mouth, and partial exposure to cold and moisture, have been looked upon as exciting causes; but, as in every other form of inflammation, the precise etiology is by no means clear. Treatment.—The affection, generally terminates by resolution; but, should the excitement be great and the pain excessive, it may be necessary to apply leeches externally, to scarify the gums in the vicinity, and to give a full dose of opium, or of some of its prepa- rations. If the tooth is loose, and no chance exists of its becoming fixed, and the maintenance or recurrence of the disease is owing to this circumstance, it will be advisable to extract it. Periodontitis, followed by secretion of morbid matter, is a very common cause of the loss of teeth. Occasionally, it appears to be connected with some constitutional vice, when it has to be met by constitutional remedies. A recent author (Graves) gives the case of a gentleman, who had been affected by rheumatic perios- titis, which was relieved by the internal use of the iodide of potas- sium. Subsequently, he suffered greatly and repeatedly from periodontitis, which resisted every remedy, until the iodide of po- tassium was used, which completely removed it. b. Inflammation of the Dental Membrane. Synon. Endodontitis, Odontitis, Inflammation of the Lining Membrane l" the Tooth; Fr. Odontite, Inflammation de la Pulpe Dentaire. The membrane that lines the dental cavity may likewise be in- flamed; but it is not easy to distinguish this from the toothache dependent upon erethism of the nerve. It may be suspected, if no signs of caries be observed on examination; but it cannot be accurately diagnosticated. The same intermission in the pain— the same absence of inflammation of the gum—occurs in the early stages; but, afterwards, the pain may become more constant. Treatment.—If endodontitis is believed to exist, the same plan of treatment may be adopted as in periodontitis. c. Caries of the Teeth. Synon. Caries Dentium, Odontalgia Cariosa; Fr. Carie des Dents; Ger. Bein- frass der Zahne. This is one of the most common diseases of the teeth, and occurs in some countries more than in others. The traveller, in certain parts of the south of France and of the southern regions of this 44 DISEASES OF THE ALIMENTARY CANAL. country, is struck with the ravages of dental caries, whilst, in other districts, the inhabitants are equally characterized by the excellence of their teeth. Diagnosis.—Pain experienced when hot or cold liquids are re- ceived into the mouth, or the supervention of the ordinary signs of toothache, attracts the attention of the patient to the condition of the teeth, and careful examination exhibits, that there is either a cavity opening externally in some part of the tooth or teeth affected, or that an internal process of decay has been established, which leaves but a shell of bone between the cavity of the tooth and the open air, so that the dental nerves are readily affected through it by external agents. The precise part at which the caries or gan- grene takes place varies. It is usually considered to commence immediately beneath the enamel, in the osseous substance of the corona of the tooth. A small, dark spot is observed, which gra- dually spreads, until there is a free communication between the external air and the dental cavity. In this mode, the whole of the corona may be destroyed,—the fangs alone remaining, and often continuing to excite periodontitis, as extraneous bodies, until they are removed by the punch of the dentist. At other times, the gum closes over them, and they no longer excite irritation. The disease is seated in the system of nutrition of the tooth, and has been presumed, by some, to consist originally in inflammation. (Professor Gross, of Louisville.) Causes.—It is a common belief, that dental gangrene is univer- sally owing to the action of external agents upon the teeth, and the idea has been maintained for various reasons: in the first place, it gives the dentist an opportunity to form " innoxious" dentifrices, which he can recommend to his customers; and, in the second place, it is often convenient to the parent to hold up the idea to her child as a bugbear, when its desire for sweets and other objec- tionable articles is inordinate. The facts, already mentioned, that dental caries is more common in some regions than in others—that it is an evil affecting families in many cases—and that the caries is observed, first of all, beneath the enamel—would, of themselves, make us pause in admitting this belief. There is, moreover, a greater liability to the disease in some teeth than in others. The last molar tooth but one, and generally of the upper jaw, is most usually the first affected; and, after it, the corresponding tooth of the opposite side suffers, owing to their being anatomically situate alike; and, consequently, the immediate cause of caries, after having acted upon the one, wfll be more likely to affect the other. Often, too, the next tooth to the one that is carious becomes so likewise, and on the side nearest to the diseased portion of the first. This has been supposed to be owing to contagion, but there is no good reason for admitting this. Next to the corresponding tooth of the opposite jaw, the one in immediate proximity with the OF THE MOUTH. 45 tooth primarily affected, must be most likely to be implicated, seeing that its anatomical elements—blood-vessels and nerves— can vary but little from those of its neighbour. The upper incisors are often decayed, and, in unhealthy chil- dren, caries sometimes attacks almost the whole of the teeth of the first dentition. It is impossible to depict the kind of dyscrasy which predisposes to the affection. Some have imagined, that those of a tuberculous constitution are more subject to it; but we often see the teeth largely decayed in persons who are neither tuberculous nor strumous. The prevalent belief is, that acids are very destructive to the teeth, and, therefore, a common cause of caries. But destruction of the enamel does not necessarily give occasion to caries. We have seen many cases in which portions have been broken off the incisors, yet decay has not supervened, unless the individual was predisposed to it; and the dentist is in the daily habit of filing away the enamel, under the conviction, derived from experience, that caries will not necessarily, or be likely to, follow. In certain cases, too, the enamel, in the progress of life, scales off by what John Hunter called " the denuding process;" yet decay does not necessarily result. It would seem, consequently, to be improbable, that any agent, which acts chemically upon the enamel, could induce caries, when the removal of the enamel, by the file of the dentist or by mechani- cal injury, does not occasion it. Besides, it is not easy to conceive how any acid substance, having a greater affinity for the lime of the tooth than the phosphoric acid,—and there are not many such,— could remain in contact with the tooth in a state sufficiently con- centrated to exert any chemical agency upon it. The presence of acid in the mouth always augments the secretion from the salivary glands, so that it becomes speedily diluted. If such be the case with acids, how unlikely is it, that the free use of sugar should be directly injurious to the teeth? In sugar there is no acid, yet it has been imagined, that a chemical action may be exerted upon the teeth by indulgence in it. This—as before remarked—is a bugbear, which has doubtless been created, in the first instance, with the view of deterring children from the use of a substance of which they are fond, and the indulgence in which is objectionable for sumptuary and other reasons. It has, indeed, been observed, that the Negroes in the West India Islands, who drink the juice of the cane very freely, have unusually good teeth, and we know that the nutrition of the frame improves under its use. There cannot be a doubt, therefore, that external agents, of a chemical nature, are not as much concerned in the production of dental gangrene as is generally admitted; but we can easily com- prehend, that, in one who is predisposed to the affection, substances that disagreeably impress the nerves of the fifth pair in the mouth —as hot or very cold liquids—may act as exciting causes, by modi- 46 DISEASES OF THE ALIMENTARY CANAL. fying the nutrition of the teeth, and producing the condition in question. , . ,. Treatment.—The readiest method of cure, when caries is dis- covered in a tooth, is to plug up the hole, where this is practicable, with a metallic or other substance. But this is only admissible where the caries communicates externally, and where the cavity in the tooth is greater than the aperture. Where plugging is im- practicable, relief may be obtained by destroying the affected nerves either by the actual cautery, or by caustics introduced into the cavity. The pain may be palliated by substances that deaden the sensi- bility of the dental nerves, as the different preparations of opium; essential oils, as of cloves, mustard, alcoholic liquors, &c. One or two drops of the hydrocyanic acid, put into the hollow tooth, has assuaged the pain, (Elwert;) but it need scarcely be said, that so potent a remedy should be employed with caution. The pyrolig- neous acid has been used, in the same cases, dropped on cotton; and, of late years, its main energetic principle, creasote, has been more extolled, perhaps, than any other remedy. (Coster, Reich, Hahn, Kneisel, Heyfelder, Fichtbauer, Hauff, Otto, Guitli, Koh- ler, Meisinger, &c.) When the creasote is applied in the same manner as the agents above mentioned, or by means of a pencil imbued with it, it causes instantaneously acute pain and a con- siderable secretion of saliva. The patient is often relieved, but it generally recurs, and perhaps the advantage derived from its use is not greater than that from the stronger essential oils. The creasote may be reduced by the addition of an equal quantity of alcohol. (Radics.) The tincture of muriate of iron, and the solu- tion of persesquinitrate of iron, have also assuaged the pain. Revellents, which act on other nervous ramifications than those implicated, often afford relief even in dental caries, although they would seem to be more advantageous in the neuralgic form. Hence, the chewing of tobacco to one unaccustomed to it; of pepper, the pyrethrum, ginger, the bark of the aralia spinosa, (angelica tree, or toothache tree, of the United. States,) horseradish, calamus, mezereon, or of any agent, in short, which belongs to the class of local sialagogues, may yield relief. A union of narcotics and sia- lagogues has been proposed, and highly extolled. (Rust.) R.—Extract belladon. ------ hyoscyam. Opii, aa, gr. v. Pulv. rad. pyrethr. gr. x. 01. caryophyll. gtt. v___M. To be made into one grain pills, sprinkled with powdered pyrethrum, and kept in a stopper bottle. One of these to be put into the carious tooth. Where the decay is extensive, and the pain cannot be controlled • by any of these agents, the tooth will have to be extracted. OF THE MOUTH. 47 d. Nervous Toothache. Synon. Odontalgia Nervosa, Neuralgia Dentalis; Fr. Odontalgic Nerveuse; Ger. Nervose Zahnschmerz. Under this term, many writers describe "neuralgia of the teeth," which may be mistaken for ordinary toothache from caries, but may generally be distinguished from it by the history of the case, as well as by the pain being more periodical, and shooting with the utmost violence along the branches of the fifth pair distributed to the affected jaw. Treatment.—For the treatment of this form of neuralgia, the general rules, laid down under the head of neuralgia, will be appro- priate. The reliance of the practitioner has to be placed upon nar- cotics in large doses, administered internally, and applied locally —and upon revellents, as blisters behind the ears. In rheumatic odontalgia, which may be regarded as a variety of the nervous odontalgia, the insertion of a little cotton, imbued with creasote, in the ear of the same side, has been found serviceable. (Riecke, Giint her.) A tincture of the spilanthus oleraceus has been much recom- mended in France and Germany, as a secret remedy, in toothache, and it is only of late that its composition has been known. Take of the leaves and blossoms of the Inula bifrons, one part; blossoms of the Spilanthus oleraceus, four parts; roots of the Jlnthemis pyrethrum, one part; Alcohol, s. g. 1863, eight parts. Digest for a fortnight, and filter. Its virtues are probably dependent upon its acting like the sia- lagogues before mentioned; all of which, by the way, are indicated in nervous odontalgia. The tincture of the spilanthus is said to relieve toothache instantaneously, when applied to the gums and teeth. (Hufeland.) By others, it has been esteemed very uncer- tain. (Heyfelder.) The various stimulating liniments, the milder counter-irritant lotion of Granville,1 and sinapisms, have been used with advantage, applied over the cheek or behind the ears; and the more rapid the revulsion, the more effective it is in general. It is in such cases, too, that the efforts of the animal magnetizer and the Perkinist, and the employment of the mineral magnet, may be expected to prove beneficial. ' R.—Liq. ammon. fortiss. §j. Sp. rosmarin. 3vi. Tinct. camphor, ^ij.—M. A piece of thick, coarse flannel to be impregnated with the lotion, and pressed on the part for a few minutes. To this division of toothache, belongs that of the pregnant female, which may, likewise, be relieved by the agents just indi- ' cated. It cannot often be necessary to extract the tooth, an opera- tion, which should always be avoided, where practicable, for fear of the shock inducing abortion. 48 DISEASES OF THE ALIMENTARY CANAL. e. Exostosis of the Teeth. Synon. Exostosis Dentium; Fr. Exostose des Dents. Like the bony structures elsewhere, the teeth are liable to ex- ostosis. The deposition usually occurs in the fangs, but scarcely admits of detection. Violent, deep-seated pain, not relieved by the ordinary methods, induces the patient to have the tooth extracted, when the affection is, for the first time, apparent. f. Tartar of the Teeth. Synon. Odontolithus* Tartarus Dentium, Odontia Incrustans; Fr. Tartre des Dents; Ger. Zahnstein. From the saliva, a calcareous matter is deposited, which con- cretes around the base of the coronas of the teeth, and, at times, where due attention is not paid, accumulates in considerable quan- tities, causing the gums to inflame, and to be absorbed, so that the support of the teeth afforded by them is lost. The main constitu- ents of these concretions is phosphate of lime, which is cemented by means of animal matter. When first deposited, the " tartar" of the teeth—for so it is termed—is soft, of a yellowish colour, and easily removable; but, as it hardens, the colour becomes of a dark brown or black, and is extremely unsightly. When it accumulates in any quantity, it is impossible to cleanse the mouth properly, so that the secretions are retained there, and at the temperature of the mouth, 98°, they readily undergo decomposition, so as to taint the breath. Treatment.—Attention to cleanliness, by the daily use of the tooth brush, will prevent the formation of this concretion. The brush itself may be sufficient, but any of the ordinary dentifrices may be used along with it. There is no better " tooth powder" than a mixture of powdered charcoal and powdered orris root,1 but there is no end to the dentifrices that have been recommended. 1 R.—Pulv. carbon, ligni, part iij. ---- irid. florent. part i.—M. Each dentist,—nay, each druggist,—has his own, which is, of course, extolled by him as the best; and none are, perhaps, posi- tively injurious. It may be well, however, to bear in mind, that the reiterated friction of a hard brush, employed daily and for years, may have some effect, of jtself, in injuring the teeth; and, therefore, that the brush should be used no longer at a time, and with no more force, than is necessary for the removal of the secretions. Where the tartar has already formed, and does not yield to simple friction of the kind advised, dilute acids—which, as has been already observed, are objected to by the dentist, but without sufficient reason—maybe employed. Weak sulphuric acid will usually remove the concretions without much difficulty; but, should it fail, the services of the dentist are demanded, to scale the teeth; after which, the re-formation of the tartar may be prevented, by the tooth brush and dentifrices. OF THE MOUTH. 49 SECTION III. DISEASES OF THE GUMS. Under stomatitis, the inflammatory affections of the mucous membrane, investing every part of the mouth, were included. The substance of the gum is, however, liable to affections, which require special consideration. I. INFLAMMATION OF THE GUMS. Synon. Ulitis, Inflammatio Gingivae; Fr. Ulite, Gengivite, Inflammation des Gencives; Ger. Entzundung des Zahnfleisches, Zahnfleischentzundung. Inflammation of the gum is a common occurrence, and is de- noted by pain, heat, throbbing, tumefaction, and redness in some part of the alveolar coverings. In a state of health, the gum is not possessed of much sensibility; but when inflamed, like many other structures, it becomes highly painful. At times, the inflammation terminates by resolution, but very frequently it passes on to suppu- ration, constituting Gum Boil, (Synon. Parulis, Phlegmone Paru- lis, Apostema Parulis; Fr. Parulie; Ger. Zahnfleischgeschwulst.) The formation of pus takes place, indeed, most rapidly in this structure. Causes.—As in other inflammations, the causes of ulitis are not often apparent. At times, however, the constant formation of abscesses is owing to some morbid condition of the alveolus; a carious tooth inflames the lining membrane of the socket; pus is secreted; ulcerative absorption takes place, and the abscess gradu- ally makes its way to the surface of the gum. In this case, it is sometimes termed " alveolar abscess." In particular conditions of the general system, when neither the teeth nor the alveoli appear to be in fault, abscesses frequently form in the gums, which are not attended with any other inconvenience, than that which results during their presence. After a time, and under some new evolu- tion of the system, this tendency disappears. Treatment.—Scarifying the gums, in the early stages, is one of the best remedies. A leech or two applied to the inflamed part will also frequently arrest the inflammation. If suppuration be likely to result, it may be encouraged by the application of any substance which will retain heat, and be, at the same time, moist. A roasted fig answers the purpose. Yet it may be questioned, whether, in the ordinary moist condition of the mouth, and at a temperature of 98°, the parts may not be in as favourable a con- dition for the production of suppuration, without the use of " sup- puratives" as with them. When pus has unequivocally formed, it is well to open the ab- scess, provided it exhibits any disposition to spread; but, usually, vol. i.—5 50 DISEASES OF THE ALIMENTARY CANAL. it is left to itself, breaks, and discharges its contents, without the supervention of any mischief. If the recurrence of the abscesses be owing to the presence ot a carious tooth, or to any source of irritation in the alveolus, it must be removed where practicable. II. EXCRESCENCE OF THE GUMS. Synon. Excrescentia Gingivae, Epulis, Uloncus, Odontia Excrescens, Sarcoma Epulis; Fr. Epulie; Ger. Auswuchs am Zahnfleische. The gums occasionally become hypertrophied, and so exube- rant as almost to cover some of the molares, and behind the upper incisors, so as to interfere materially with the closure of the jaws. Frequently, the hypertrophied portions rise into distinct hard pro- jections, having the general character of the gums themselves. The cure consists in removing them by the knife, ligature, or caustic. Being supplied, however, with blood-vessels of consider- able size, their removal by excision often occasions considerable hemorrhage; and, on this account, recourse has been more fre- quently had to the latter means. The protuberances, when re- moved, are apt to return. They have been reproduced six times in succession. (John Hunter.) Occasionally, the gums—especially those at the buccal side of the superior incisors—are attacked'with hyperaemia and some de- gree of inflammation, but no tendency to suppuration, as in the cases of ulitis before described. In this condition, they may remain for a few days, preventing the jaws from being closed, and ex- citing more or less uneasiness. It has been suggested, that the tumidity of the gums, which consists in their growing up in front, between the teeth, and in the posterior part of the mouth, so as to cover some of the molares, is usually induced by a loaded state of the colon, (M. Hall;) but it is not easy to see the relation between the two morbid states. If the digestive function be deranged, mild aperients and tonics may be prescribed with advantage; and nothing better can be given than a combination of charcoal and magnesia. R.—Magnes. gr. v. Pulv. carbon, ligni, gr. xv. f. pulvis. Dose, one three times a day. Scarification, early employed, is also of essential benefit; and, if the protuberance becomes permanent, it will have to be removed by the means already mentioned. Another form of uloncus is the fungous or spongy condition, which has been commonly termed " scurvy of the gums." This is a concomitant of scorbutus; but it occurs in conditions of the digestive organs of various kinds, especially in such as are of an atonic character. At other times, it seems to be entirely local, from causes seated in the gums themselves, or in the teeth or al- veoli. The gums exhibit a soft, protuberant, or spongy appear- ance, and bleed on the slightest touch. OF THE MOUTH. 51 Treatment.—In simple sponginess of the gums, in which their texture is lax, and their nutrition consequently executed imper- fectly, simple division of the gums with the shoulder of a lancet, in many parts of their surface, is one of the best remedies that can be employed. The hyperasmia of the capillary vessels is in this manner removed, and the new action, thus induced, will of itself lead to a cure. Where the affection is to a less extent, friction with a hard brush, where the gums will bear it, may be advisable; and, in both cases, the use of excitant collutories, or pastes, especially after scarification, will be advisable. R.—Tinct. myrrh, ^ss. Or, R___Pulv. cinchon. rubr. -----cinchon. ^j.—M. ---- carbon, lign. Or, R.—Ferri iodid. 3j. ---- irid. florent. aa sjij. Aquae Oss. fiat solutio. Mellis, ^ij.—M. Or, R.—Creasot, gtt. iv. Aquae destillat. ^ij.—M. A small portion of the paste to be rubbed upon the gums, night and morning. As a dentifrice, the powders may be used alone. When the gums will readily bear the tooth brush, gently astrin- gent dentifrices may be used. It need scarcely be said, that if the nutrition of the gums be deranged by reason of the state of the teeth or their sockets, the cause, where this is practicable, must be removed; and where the washes, and other preparations, already described, prove insuffi- cient, washes of the nitrate of silver, or stronger solutions of crea- sote, may be had recourse to, applied by means of a camel's hair pencil. When the affection is connected with an asthenic condition of the system, such as prevails in scorbutus, or when there is simple disorder of the system of nutrition of the part, owing to derange- ment of the digestive apparatus in particular, these conditions must be removed by appropriate remedies. A more violent form of epulis is occasionally seen, in which the spongy gums throw out polypous excrescences, which bleed on the slightest touch, and are often connected with some vice in the system, or disease about the alveolar processes. These must be removed by the knife, and every care must be taken that the whole of the disease is extirpated, otherwise they may return. They are accompanied by great pain and irritation; and, sooner or later, the system sympathizes, hectic fever is established, and, unless a stop can be put to the disease, a fatal termination ensues. III. SHRINKING OF THE GUMS. Synon. Ulatrophia, Falling away of the Gums. Under the influence of mercurials, the gums shrink fiom the teeth, so that they become loose in their sockets; but this condi- tion passes away along with the other effects of the agent that induced it. In other cases, a similar shrinking of the gums occurs indepen- 52 DISEASES OF THE ALIMENTARY CANAL. dently of such agency; the teeth are left exposed, and, at times fall out, without exhibiting any evidence of decay. This is often owing to incrustations of tartar, which—as has been shown—give occasion to ulcerative absorption of the gums. Where such is the case, scaling the teeth is the obvious remedy. In other cases, it is important to scarify the gums, and to endea- vour to excite a new action in them by any of the stimulating applications described under Excrescence of the Gums. SECTION IV. DISEASES OF THE VELUM PALATI AND UVULA. The velum pendulum, and the uvula, are liable to inflammation; the latter affection being known under the name Staphylitis, (Synon. Uvulitis, Cionitis, Angina Uvularis, Inflammatio Uvulae, Falling down of the Palate; Fr. Inflammation de la Luette; Ger. Zapfenentziindung, Entziindung des Zapfens, Niedergeschossener Huck;) the former under that of Hyperoitis, (Synon. Angina Palatina; Fr. Inflammation du Palais; Ger. Entziindung des hang- enden Gaumens.) The symptoms, causes, anatomical characters, and treatment, are essentially the same as those of stomatitis and pharyngitis. In certain cases, both the velum and the uvula are much swollen and infiltrated, (staphylcedema,) and interfere both with deglutition and respiration, but especially the former. When very greatly infiltrated and pendulous, it may give rise to threatening of suffo- cation. Scarification, or excision of the prolapsed membrane, is the best remedy. At times, the inflammation presents an asthenic appearance, having a dusky, red hue, and the capillary vessels are evidently much distended. Scarification is here essential, and afterwards the employment of stimulant gargles. Occasionally, after the inflammation has .subsided, the uvula remains perma- nently relaxed and elongated, so as to excite a very troublesome cough, and to induce the suspicion of serious thoracic mischief. Inspection of the throat will sufficiently indicate the affection.. Pro- vided this form of staphyloncus does'not yield to the excitant and astringent gargles mentioned under the next chapter, it will be advisable to remove a portion of the uvula, which is an extremely simple operation. OF THE PHARYNX AND CESOPHAGUS. 53 CHAPTER II. DISEASES OF THE PHARYNX AND (ESOPHAGUS. To many of the affections of the throat, the. terms Angina and Cynanche have been given by the older writers, and they are still retained by many of the more modern. They have been applied, however, to so many different affections, that they ought to be-dis- carded. For example, simple cynanche or angina means the com- mon sore throat or inflammation of the mucous membrane of the fauces; whilst angina pectoris has been appropriated to an anoma- lous affection, in which the parts about the fauces are in nowise Concerned. In like manner, we have Cynanche tonsillaris, C. paro- tidea, C. laryngea, &c. to designate, respectively, inflammation of the tonsils, parotid glands, larynx, &c* These we shall consider in their appropriate places. I. INFLAMMATION OF THE FAUCES. Synon. Isthmitis, Angina, Cynanche, Empresma Paristhmitis, Paristhmitis, Paristhmia, Cauma Paristhmitis, Inflammatio Faucium, Squinancy, Squinsy, Quinsy, Common Sore Throat, Inflammatory Sore Throat; Fr. Angine, A. Gutturale, Esquinancie; Ger. Braune, Halsgeschwuhst, Halsentzundung. Isthmitis or paristhmitis is an inflammation of the mucous mem- brane covering the fauces. It is, as has been remarked, the simple angina or common sore throat, and it does not differ in its essential characters from stomatitis, or from simple inflammation of the mucous membranes in general. Diagnosis.—The symptoms are unequivocal. The patient com- plains of difficult deglutition; and, on inspecting the mucous mem- brane covering the fauces, it is observed to be extremely red, dry, and glossy; the secretion, in the first instance, as in other cases of inflammation of the mucous membranes, being diminished; but, subsequently, a ropy mucus is secreted from it, which gives rise to much inconvenience in deglutition. WThen the inflamma- tion extends to the uvula, and it becomes tumefied, a perpetual desire for deglutition is experienced; and the elongated uvula and ropy mucus, hanging down into the pharynx, induce violent retch- ing. The inflammation spreads, at times, into the posterior pares, the top of the larynx, and the Eustachian tubes, so that the smell, the passage of air to the lungs, and hearing may become impaired. The duration of this affection is commonly brief. It usually * A recent writer (Symonds) says, "the term Angina implies inflammation of the parts bounded anteriorly by the velum pendulum palati and its columns, and posteriorly by the upper part of the pharynx;" but certainly the most com- mon acceptation is more extensive. Like cynanche, it has been usually employed to designate inflammation of some part of the supra-diaphragmatic portion of the alimentary tube and of the air passages above the lungs. 54 DISEASES OF THE ALIMENTARY CANAL. passes off in a few days by resolution, but, at times, goes on to suppuration. This stage maybe detected by the appearance of the different parts of the throat; the swelling being more decided at some one point than another; and, by passing in the finger, and pressing upon the tumefied portion, the presence of pus may be detected. The character of the pain likewise varies: at first, it is extremely acute on s.wallowing, but, when suppuration has become established, it is more dull. Causes.— As in all cases of inflammation,—irregular exposure to cold and moisture, by which the harmony of associated actions is broken in upon, is the cause usually assigned. Hence, it is more common in winter and spring, whilst cold and moisture exist in vicissitudes, than in the height of summer, or the early part of autumn. Some persons are extremely prone to it, on the slightest exposure; and, when it has appeared a few times, it is apt to recur by habit,—a predisposition being, in this manner, induced, which requires but a slight exciting cause to develope the disease. Like stomatitis, it may be caused by hot or acrid bodies irritating the fauces, but this is uncommon. In very young infants, the mucous membrane of the fauces is apt to be more or less hyperaemic or congested, so as to resemble the redness of inflammation, and to occasion obscurity in the diag- nosis. A recent pathological writer remarks, that the fauces may be considered to be inflamed;—1st, when the duration of the red- ness continues beyond the ordinary time of the disappearance of the congestion in young infants—ten or twelve days for example; 2dly, when, instead of being uniformly spread over every part of the throat, it occupies separate points; 3dly, when some of the symptoms of amygdalitis, to be mentioned presently, exist at the same time as the redness. (Billard.) The presence of fever, with difficult deglutition, and alteration of voice, will of themselves be sufficient to diagnosticate, that the redness is owing to isthmitis. Isthmitis—like amygdalitis and pharyngitis—is one of the symp- toms of scarlatina and syphilis, and it is generally present in hy- drophobia. The attending fever, as in amygdalitis, is frequently very active, but the general prognosis is favourable. It almost always termi- nates in health. Treatment.—The pulse is rarely so excited as to indicate the necessity of general blood-letting. Confinement to bed, where practicable; the employment of saline cathartics,1 chiefly as revel- tents, will relieve the milder cases. 1 R.—Magnes. sulphat. gvj. ------carbonat. gj. Aqua? menthae pip. giij.—M. Dose, one half, to be repeated if the first half does not operate. When more severe, in addition to this management, leeches may be applied around the throat; and, after they have dropped off, a OF THE PHARYNX AND 03S0PHAGUS. 55 warm emollient poultice may be placed over the leech bites, and, if the disease still persists, sinapisms, or stimulating liniments, or a blister, may be applied to the throat. Along with these agents, the steam of hot water may be inhaled, and the throat be gargled with flaxseed tea, or any mucilaginous fluid. As the vessels are loosely protected by the parts in which they creep,—after the first day or two, it may be advisable to prescribe gargles, which are somewhat stimulating, and may thus cause the contraction of the overdilated capillaries, so that they may force the stagnant blood from them, and be restored to their healthy condition. Gargles of muriatic acid,1 or of ammonia, or of capsi- cum,2 will accomplish this, taking care that they are not made too powerfully astringent or excitant. ' R—Mellis, 3'iij. 2 g.—Tnfus> capsic. gvj. Acid, muriat. vel Mellis, ^iij.__M. Liq. ammon. gtt. xxv. Aquae, |vj—M. Perhaps, however, the most effective agent, at all periods of the disease, is scarification with a lancet, which may be superficial, if the inflammation be confined to the mucous membrane; deeper, if the parts beneath are involved. (Ghardin.) The author has found the advantage of this course in his own case, and has seen it successful when practised on others. Where suppuration has taken place, the pus may be left to itself to make its way outwards; but the best course is to give issue to it, especially if it interferes with deglutition or respiration. II. INLFAMMATION OF THE TONSILS. Synon. Amygdalitis, Cynanche Tonsillaris, Angina Tonsillaris, Inflammatio Tonsillarum, Tonsillitis, Antiaditis, Antiadoncus Inflammatorius, Paristhmitis, Empresma Paristhmitis Tonsillaris, Quinsy, Inflammatory Sore Throat, Sore Throat; Fr. Amygdalite, Inflammation des Amygdales, Angine Tonsillaire, A. Gutturale Inflammatoire; Ger. Entziindung der Mandeln, Mandelnentziindung. The essential difference between inflammation of the tonsils and isthmitis is, that in the former, along with the ordinary signs of inflammatory fever and the local symptoms accompanying isth- mitis, on inspecting the throat the tonsils are found greatly en- larged in some cases, so as almost to meet. Along with this, there is extreme difficulty in deglutition, and the sensation of a foreign body in the throat during the effort. To inspect the throat well, in this as in other diseases, the patient should be directed to open his mouth widely; the tongue must then be depresed with some flat body, as the handle of a spoon; and, if he be directed to draw in a full breath, the tonsils can gene- rally be seen without much difficulty. In the early part of the disease, the membrane covering the in- flamed part is dry, and, at times, has white specks upon it, of the diphtheritic kind. Generally, amygdalitis terminates by resolution; but not unfre- 56 DISEASES OF THE ALIMENTARY CANAL. quently it ends in suppuration, or in permanent enlargement of the tonsils. , „ . „ It is asserted to affect children and females more especially, 'Andral,) but this is questionable. Testimony, indeed, is not wanting to show, that males are more frequently attacked with it than females. (Louis, Rufz, Latour.) The left tonsil, in the observation of many, (Kopp, Mehlis,) is more frequently affected than the right. Treatment.—This is much the same as in isthmitis:—general blood-letting is rarely needed. The depletion and revulsion, effected by the application of leeches to the throat, followed by a warm cataplasm, are more efficacious. Revellent cathartics and sina- pised pediluvia, with the use of excitant liniments or sinapisms to the external throat, and emollient and cooling gargles, with the inhalation of steam, constitute the main treatment in the early stages, and, when suppuration threatens, it must be fostered, and the abscess treated in the manner recommended under isthmitis. Recently, the free use of the pulvis ipecacuanhae et opii, aided by warm.diluents, has been strongly recommended, with the view of cutting short this phlegmasia as well as others. (Christison.) Cases have occurred, in which the danger of suffocation has been so imminent, that it has been advisable to perform the opera- tion of laryngotomy or tracheotomy. When an abscess has formed in the tonsils, it generally breaks during some effort of the organs concerned in deglutition, and fre- quently the discharged pus has a fetid odour; in other cases, the abscess makes its way externally, but this is rare, and more fre- quently occurs in the anginose affections of the throat that form a part of scarlatina. When the tonsils remain permanently enlarged after amygda- litis, and interfere with deglutition or the voice, (angina scirrhosa, amygdalotrophia,) they can be readily removed by an appropriate instrument. At times, however, the enlargement passes away under the use of powerful stimulants, as of the capsicum in the form of infusion. The application of the solid nitrate of silver freely over the surface of the enlargement has likewise been of service. It must be borne in mind, too, that, in the evolutions which take place at puberty, a change in the nutrition of the ton- sils not unfrequently occurs, under which the enlargement totally disappears. In rare cases, calcareous concretions have been found in the tonsils. III. INFLAMMATION OF THE PHARYNX. Synon. Pharyngitis, Angina Pharyngea, Cynanche Pharyngea, Empresma Paristhmitis Pharyngea, Inflammatio Pharyngis; Fr. Angine Pharyngee A. Gutturale; Ger. Entzundung des Schlundes, Schlundentziindung. ' This affection differs from isthmitis only in its seat: similar tis- sues are implicated in both; it is induced by the same causes and OF THE PHARYNX AND OESOPHAGUS. 57 requires the same treatment. It is detected by inspection of the throat, when the inflammation is observed to be seated in the mucous membrane covering the posterior parietes of the pharynx. At times, it spreads into the nasal fossae, and, at others, implicates the larynx; but the respiration and voice are often—generally, indeed—unaffected. At other times, the voice is raucous, as in the various forms of angina. It is frequently accompanied by amygdalitis. The disease generally passes off by resolution; but pus may form, which may require to be set free. This may be done by the pointed bistoury, or by an appropriate instrument, termed the pharyngotome. It has been advised, too, when there was reason to suppose the existence of an abscess, that an emetic should be ad- ministered, in order that the rupture of the walls might be favoured by the efforts at vomiting. As the object, in such case, is not to induce any revulsion, one of the direct emetics, or those which operate without inducing any previous nausea, is to be preferred.1 ' R.—Zinci sulphat. gr. xx.—xxx. Or, R.—Cupri sulphat. gr. ij.—x. To be taken in sugared water. To be given in the same manner. Not long ago, the author met with a case of pharyngitis, which appeared to be of the rheumatic kind, and to be seated in the con- strictor and stylo-pharyngei muscles. The pain, on pressure made at the sides of the heck, was very severe; and when fluid was taken, owing to the irregular and spasmodic action of the muscles, it was partly returned by the mouth and nose. Leeching and the general antiphlogistic treatment produced a cure. Pharyngitis, like stomatitis and isthmitis, may terminate by the formation of false membranes, or by gangrene;—varieties which will require a separate notice. a. Follicular Inflammation of the Pharynx. Synon. Follicular Pharyngitis. This variety of inflammation—so far as the author knows—has not been described in pathological or therapeutical works, yet it is by no means uncommon. He has seen many cases of it; and it is very frequently presumed to be an affection of more dangerous import than it really is. Many of the cases of what has been called "Clergyman's Sore Throat," which have fallen under his care, have been of this affection. It has been recently described (Popken) under the name " Tubercles of jhe Larynx and Fauces;" but Dr. Popken at the same time remarks, that he gives the name at the risk of its being objected to, inasmuch as the disease does not consist of true tubercles, but only of diseased mucous follicles. Diagnosis.—Follicular pharyngitis is first indicated by huski- ness of the voice, with more or less coughing and hawking, so that the disease appears to involve the respiratory, rather than the digestive, organs—especially as there is often little or no pain on deglutition. Should, however, uneasiness of the throat suggest an 5S DISEASES OF THE ALIMENTARY CANAL. inspection, the appearances are such as cannot be mistaken. The follicles of the isthmus of the fauces and the pharynx are observed to be unusually apparent, so that the mucous membrane seems to be studded with granulations, varying, in size, from a pin's head to a pea. The larger bodies frequently have the appearance of a split pea, and of crypts or follicles distended with a semi-fluid substance. The disease is apt to persist for a long time, even for years, and to give occasion to more or less irritation of the larynx, as indi- cated by coughing and hawking; but still the general health may remain "unaffected, unless the affection should exist also in the larynx, when it may, by irritation, in one of tuberculous predis- position, occasion the formation or development of tubercles of the lungs. The disease generally occurs in young subjects, rarely before puberty, or in advanced life, and it is affirmed, (Popken,) chiefly in the male sex. The author, just cited, remarks, that he never could trace any connection between this form of pharyngitis and any constitutional chronic disease, as syphilis, or scrofula; and that he has so rarely found it coincident with other local affections, and especially with those of the lungs, that, in a doubtful diagnosis, he rather regards the disease in the throat as a sign, that there is not a vomica in the lungs. Certainly, in the cases that have fallen under the author's care, there was no chronic pulmonary disease. The author has always regarded the affection to consist in an accumulation of mucus in the follicles of the throat, similar to that which takes place in the congenerous sebaceous follicles of the skin in acne; and in a case, which he saw with his friend Professor R. M. Huston, during the last winter, the enlarged follicles pre- sented all the appearances of acne punctata. Occasionally, the fol- licles break, and discharge small masses of an elastic matter, which is often the source of much anxiety to the patient, causing him to apprehend serious pulmonary mischief. Sometimes, ulceration suc- ceeds, which may be defined or irregular, and is often surrounded by a vivid red inflammation. This may continue for a long time, when the tone of the constitution is impaired, or some scrofulous or other vice exists. Treatment.—The local remedies, to be recommended in follicular inflammation, are the same as those advised in other forms of slug- gish phlegmasia of the mucous membrane of the pharynx. A solution of the nitrate of«silver, or a creasote lotion, with the ap- plication of croton oil to the exterior of the throat, comprise the local means that are most beneficial. Time, however, is an ele- ment in the cure, as the disease is essentially chronic in its charac- ter. It is advisable, too, to keep the throat warm. This may be done, in the female, by wearing flannel around the throat, and in the male in the same manner, or by permitting the hair to grow around the neck. A nutritious, but not stimulating, diet, and the administration of aromatic and tonic medicines, such as ammonia- OF THE PHARYNX AND (ESOPHAGUS. 59 cum and myrrh, or myrrh, extract of bark, and sulphate of iron, has been recommended, (Popken;) but the author has not ob- served much effect from such agents. Like acne of the face, it is often, indeed, but little under the influence of medicine; and even change of air and the use of therapeutical agents, that essentially modify the system of nutrition, are of but limited efficacy. The parts, however, gradually become accustomed to the presence of the enlarged follicles, so that little or no irritation is ultimately in- duced by them. In process of time, too, they may be gradually diminished by absorption; yet, in one case, that was subjected for years to the treatment mentioned above, the follicles remained almost as large and prominent as at first. They had ceased, how- ever, to excite uneasiness. In cases of ulceration of the pharynx, it may be necessary to employ the solution of the nitrate of silver, or creasote water, or a diluted mineral acid, and, if these fail, the solid nitrate of silver. If any vice, however, exists in the constitution, it is indispensable that it should be removed, by the agents that are appropriate to the particular cachexia. Usually, there is a state of defective, along with disordered, action, which demands the use of tonics, and especially of the iodide of iron, for a long period. R.—Ferri iodidi, gr. xxiv. Aquae destillat. gj.—M. Dose, an ordinary teaspoonful—which contains about three grains—two or three times a-day, in simple syrup. The dose to be gradually increased. b. Diphtheritic Inflammation of the Pharynx. Synon. Diphtheritic Pharyngitis, D. Sore Throat, Angina Pseudo-Membra- nacea, A. Membranacea, A. Pellicularis, A. Plastica, A. Diphtheritica, Pseudo- Membranous Inflammation of the Throat; Fr. Angine Couenneuse, A. Gutturale Couenneuse, A. Pseudo-Membraneuse, A. Plastique, A. Diphtheritique. Under the head of stomatitis, two varieties were described, which, in their essential characters, resemble the-same form of in- flammation, when it attacks the mucous membrane implicated in isthmitis and pharyngitis. It may be convenient, therefore, to consider here pseudo-membranous inflammation of the throat in general. Diagnosis.—The disease is often insidious at its onset;—deglu- tition being less affected than in isthmitis or amygdalitis, and neither fever nor general indisposition being present. At other times, an uncomfortable feeling of heat and dryness is experienced in, the throat, with fever, difficult deglutition, and pain on moving the neck, which is observed to be slightly swollen. After this, the cervical and submaxillary glands may become enlarged, and the difficulty of deglutition appears to be rather in a ratio with this en- largement, than with that of the diphtheritis of the pharynx. (Jln- dral) At times, the parotid glands enlarge, and, in particular epidemics, this enlargement has been observed to precede, or ac- company, the formation of false membranes. At this early stage, the pharynx, on inspection, may merely 60 DISEASES OF THE ALIMENTARY CANAL. exhibit more or less redness and tumefaction of one or both tonsils; but it rarely happens, that the physician sees the case at this early period. Generally, when he first observes the throat, he finds the membrane investing the velum pendulum, uvula, tonsils, and pharynx, exhibiting small, white or yellowish patches, irregularly circumscribed, and having a lardy or curdy appearance, and, in some cases, it is not until these exudations have been thrown out, that the submaxillary glands and cervical ganglions become swol- len. The patches are, at first, small and discrete, but they gradu- ally approach until they ultimately coalesce, become confounded, and cover, at times, in a very short time, the whole of the pharynx, extending into the nasal fossae and the air passages. Owing to the semi-transparent character of the pellicles, the parts beneath—especially the velum palati and uvula—appear infiltrated. Where the inflammatory tumefaction is most marked, they are thickest, and are bounded by an elevated, red circle, which gives them the appearance of being depressed, and of ulcera- tions. In a short time, however, they project, become partly de- tached, and a slight oozing of blood, sufficient to colour the saliva, takes place from the parts beneath. The exposed mucous membrane appears red, dotted, injected, or ecchymosed. At times, however, it is of a gray colour, and dry, as if it had been cauterized by an acid; at others, eroded, but with- out any appreciable loss of substance. The nasal fossae soon participate in the disease; and from both the mouth and the nose there is a copious discharge of a sanious and fetid fluid, and occasionally epistaxis, so violent as to require plugging the nasal fossae. (Forget.) The pellicles or shreds, when thrown off, are reproduced, but their successors are usually thinner, and of a whiter appearance. The quantity of false membrane, disengaged in this manner, is sur- prising; and it has been conceived, that this circumstance, along with, the offensive odour exhaled from the mouth, especially in adults, led the older observers to mistake their nature, and to regard them as sloughs. (Forget.) In place of being thrown off as shreds, the false membrane is at times softened and mixed with the saliva, and in some cases, in- stead of being thrown off, it is absorbed. (Guersent.) The general symptoms that usually accompany this condition are—paleness and puffiness of the face, with alteration of the fea- tures; tumefaction of the tongue, with redness of the edges, aneen regarded as the effect of their presence, rather than the cause, (Andral.) The belief has been expressed, that persons in excellent health, and with the intestinal canal in a healthy state, may have worms, (Stokes;) and it appears to us, that there can be no doubt of this being the fact. The existence of worms can scarcely perhaps be regarded as a pathological state, any more than the presence of parasites in the hair; but it may be laid down as a rule, that entozoa are not present in unusual quantity in the intestines, without the existence of a state of imperfect health, which favours their multi- plication. In fact, any disorder or debility of the general system, or of the digestive organs, hereditary or acquired, a scrofulous habit, a sedentary and idle life, a poor diet, a residence in a cold, confined and damp situation,—in short, any thing, that can be the cause of an asthenic condition of the digestive tube, and the surrounding viscera, may be regarded as intimately associated with the undue prevalence of entozoa in the alimentary canal. It is asserted, (Annesley,) that the Hindoos who live entirely on rice are so infested with worms, that not more than one in ten is free from them; and it has been imagined by a distinguished helmin- thologist, (Bremser,) that the use of milk and farinaceous food, has considerable agency, in his, country, in the prevalence of intes- tinal entozoa. It is in consequence of the belief, that the generation of worms is usually connected with an asthenic condition, that the author has ranged the class of Anthelmintics,—in which he includes not only the agents that destroy worms, but those that prevent their generation,—next to Tonics in his « General Therapeutics." It has been already observed, that locality evidently predisposes to worms, of a certain kind especially; or that worms may be en- demic. A verminous diathesis may likewise occur epidemically. OF THE INTESTINES. 199 Such a complication appears to have existed during a recent visita- tion of cholera at Naples. (See page 150 of this volume.) Treatment.—The indications of treatment, in cases of worms, are clear;—first, to destroy or expel the parasites; and, secondly, to prevent their regeneration. The worms may be destroyed or expelled in various ways. The number of reputed vermifuges is, indeed, very great; but many of them are unworthy of notice, and their place may be well supplied by others that are more in vogue at the present day. Of the an- thelmintics, some are immediately poisonous to worms; others act mechanically upon them, and occasion their expulsion. Of the anthelmintics, that are usually denominated "true," or which are directly poisonous to worms, there are but few in general use. The seeds of the chenopodium—the "wormseed" of this country, and those of the santonicum—the wormseed of Europe, are some- times—frequently indeed—given, (gr. xx.—lx. pro dosi;) or the distilled oil, (01. chenopod. Tn_ v.—x.) in molasses, the dose being administered every night for three nights in succession, and follow- ed up on the following morning by a brisk cathartic;1 or the spigelia marilandica, in the form of powder; (gr. x.—lx.) or the infus. spi- gelias; (f. gss.—f. gj.) or the oleum terebinthinoe, (f. s;ij.—f. gss.) in molasses; or the following mixture:2 1 R.—Pulv. jalap. 9ss. 2 R___01 tereb. |ss. Potass, supertart. 9j.—M. Vitell. ovi. Aquae menthas, 3 ij. f. haustus. These are the anthelmintics or worm destroyers usually employed. In cases of taenia, however, especially, other remedies have been recommended. The Germans extol highly the Oleum animate Dippelii, or " Dippel's animal oil," which is obtained by distilling animal matters, as bones or hartshorn shavings—on the naked fire. The product is excessively nauseous, so that many stomachs cannot tolerate it; (Dose, ttt v.—xx.) The empyreumatic oil of Chabert, which is made by adding one part of the animal oil to three parts of turpentine, leaving them to combine for four days, and then distilling, has been highly extolled. It, likewise, is extremely nauseous. The dose, advised to be taken, is a teaspoonful three times a day. (Bremser.) Should these means fail, but little reliance can be placed on the hundred other anthelmintics that are pre- scribed. A strong decoction of the helminthocorton (Fucus hel- minthocorton) has been recommended, on good authority, as the most powerful of all anthelmintics, (James Johnson;) and, it is affirmed, that when thrown into the rectum, it "destroys any worms domiciliating there as effectually as choke-damp would destroy the life of a miner." The mechanical anthelmintics—or those that act upon the worms by rendering their situation unpleasant to them, and thus inducing them to migrate,—are but few in number, and these are but little employed in this country. The granular tin, Stannum granula- tum, has been recommended. (Alston, Pallas, Block, Marx, 200 DISEASES OF THE ALIMENTARY CANAL. Brera.) It may be administered in molasses, (5j.—|ss.) and it can be readily understood, that the scraping of the metal over the lining membrane of the stomach and small intestines may augment chy- losis, and improve the tone of the digestive functions in general. The mode, in which the pubes or down of the dolichos pruriens acts, is singular. When placed in contact with the cutaneous sur- face, it excites intolerable itching; yet, when taken internally, mixed with honey and molasses, it excites no irritation of the mu- cous membrane of the digestive tube, but penetrates the bodies of the worms so as to lead to their expulsion. This strange circum- stance has led many to doubt the facts, that have been put on record in its favour, yet it is impossible to set aside the testimony of so many respectable observers. (Kerr, Cochrane, Bancroft, Macbride, Chamberlaine, Stokes.) It is given simply mixed with soft honey, syrup, or molasses, (dose, one teaspoonful to two or three, night and morning,) a cathartic being administered on the third morning. For the expulsion of worms, cathartics are valuable agents, but they must not be so often repeated as to induce debility of the digestive organs. For the expulsion of the ascarides lumbricoides, the purgative treatment has been esteemed, by some, the most suc- cessful of all. (Stokes.) Any of the ordinary brisk cathartics1 may be given every other day, or less frequently as the case may seem to require. 1 R.—Jalap, vel rhei pulv. gr. xv. Hydrarg. chlorid. mit. Pulv. zingib. aa, gr. v. —M. et f. pulvis. The croton oil has been extolled by some, (Poccinotti,) especially in cases of tape-worm. The occasional use of a brisk cathartic may also stimulate the digestive tube to a more healthy action, and at the same time remove the intestinal secretions that favour the reproduction of the entozoa. Such is the general treatment to be pursued; but where the par- ticular variety of intestinal worms is known, this may admit of a special management. Thus, as the oxyures vermiculares are chiefly in the rectum, they are more readily reached by enemata. Still, it may be advisable to conjoin remedies administered by the mouth, as they have occasionally been rejected by vomiting, and the enemata may induce them to migrate. The enemata may consist of a strong solution of common salt, or of the sulphate of iron;1 or aloes;2 or turpentine;3 and a dose of aloes, or of aloes and calomel,4 may be given. i R.—Ferri. sulphat. gij. < R.—Pulv. aloes, gr. x. 'Aquae. Oss.—M. Olei succin. gtt. v.—M. etdi- 2 R.—Decoct, aloes, vide in pil. ij.; or, Lactis, aa, giv.—M. R.—Pulv. aloes, gr. viij. s R.—01. tereb. gss. Hydrarg. chlorid. mit. gr. iij. Vitell. ovi. 01. succin. gtt. iij.—M. etdi- Aquae. Oj—M. vide in pil. ij. At times, the oxyures are collected in a ball, and so enveloped OF THE INTESTINES. 201 in mucus, that the enemata cannot reach them. In such case, it has been advised, that the patient's middle finger, smeared with lard, should be introduced as far as possible into the rectum, so as to rub the worms from the surface to which they are applied, and, as it were, to scoop them out from the rectum. (Howison.) This plan, the author has not found necessary. In cases of ascarides lumbricoides, anthelmintic enemata cannot be needed, as these entozoa are in a higher portion of the tube. They must be treated on the general principles already laid down; and, lastly, as regards the bothriocephalus latus and the taenia solium, the most powerful anthelmintics are needed. It is in such cases, that the oil of turpentine, and the oil of Dippel will be espe- cially required. The empyreumatic oil of Chabert is likewise highly extolled by some of the Germans. (Bremser.) It is prepared from one part of the fetid or empyreumatic oil of hartshorn, and three of the essential oil of turpentine. These are well mixed, left to combine for four days, and then distilled; the first three parts of oil, which come over, are the "empyreumatic oil of Chabert." It has been advised in doses of a teaspoonful three times a day, (Bremser,) but, like the oil of Dippel, it is extremely nausous. Several portions of taenia having been discharged after the ad- ministration of creasote, it has been prescribed as an anthelmintic, (Kraus;) five to eight drops being given to adults combined with oleum ricini, or with half a drop or a drop of croton oil. The male fern—Filix mas—which is the basis of Madam Nouffer's celebrated remedy, (3j.— 3HJ. of the powdered root,) as well as the ethereal extract,1 have been much extolled, especially by the physicians of Continental ~E>moipe,(Peschier,Hufeland,Radius, Buchner, Ronzel); but, perhaps, the remedy, that has received the most testimony in its favour, is the bark of the root of the pome- granate, (Boiti, Marchese, Chevalier, Deslandes, Merat. Pi- chonnier, Bayle, Ferrus, Wolff, Bert hold,) which is generally given in decoction.2 The alcoholic extract is also occasionally administered,3 followed by a cathartic. 1 R.—Ext. aether, filicis maris, ^ss. 2 R.—Cort. rad. granat. gij. Mellis, vel Aquae. Oij. Theriac. gss. Coque ad. Oiss. Dose, one half, at night, and the other, Dose, ^ij every hour: three or four next morning. doses are usually sufficient to expel the worm. 3 R.—Ext. spirit, cort. rad. granat. Jvj. Aquae menthae, ^iv. Succ. limon. ^ij.—M. Dose, one quarter, every quarter of an hour. Of late, the Brayera anthelmintica, a native of Abyssinia, has been advised in tape-worm. The flowers are the parts administered, and they are given in decoction; but sufficient quantities of the plant have not been exported from Abyssinia to test its efficacy. When a portion of taenia protrudes from the rectum, it has been 202 DISEASES OF THE ALIMENTARY CANAL. advised, with the view of destroying it, to apply the hydrocyanic acid to it. (Cagnola, Gelnecke, &c) After all, the most important agents are those that are strictly anthelmintic, or which prevent the development of entozoa. Should there be any evidence of gastroenteritis, it must, of course, be re- moved; but generally, the main predisponent, although it may be gastroenteric, is not gastroenteritis. It is a state opposite to in. flammation of the lining membrane; and any remedy, that will improve chylosis and the nutrition of the body, is a valuable agent. . Charcoal (Pulv. carbon, lign. gr. x.—3j.) is in this way anthelmintic, as well as the free use of salt, the want of which gives rise to entozoa in both man and animals. (Mr. Marshall, Paris, Lord Somerville. See also, the author's Elements of Hygiene, p. 310, and General Therapeutics, p. 168.) A nutri- tious diet, especially of animal food; regular exercise and change of air, as far as is practicable; with which may be conjoined the use of the ordinary tonics, as colomba, gentian, &c, which may be prescribed in infusion. To remove the verminous habit, it has been recommended, (Bremser,) to combine aloes, iron, and the sulphuric acid. R.—Tinct. aloes, comp. 3j. Tinct. ferri. pomati, Jj. Elixir vitriol, ^ss. Dose, 10, 20, or 30 drops, three or four times a day, in a glass of wine and water. The tinctura ferri pomati, is not contained in the British phar- macopoeias, and, therefore, a substitute has been recommended. (Stokes.) R.—Tinct. ferri. muriatis. Tinct. aloes, aa p. ae. Dose, 20 drops, three or four times a day. The aloes acts as a vermifuge and cathartic, whilst the salt of iron exerts its tonic influence. Lastly, worms, or the larves of insects, are occasionally intro- duced into the intestinal canal by accident, where they occasion more or less intestinal disturbance. The animalcules, which have been most commonly swallowed, are the hair-worm, the leech, the grub of the fly and of the caddy insect, phalaena pinguinalis; the larve of the bee, the spider, the triton palustris, lacerta aquatica, &c. To these, the terms Helminthia erratica and Ectozoa have been appropriated. (Good.) In their new situation, they are often so much changed as not to be recognised. In ani- mals, the bots are produced by the animal swallowing the ova of the oestrus or gad-fly; and cases are on record of their occurring in the human subject. (Professor Morton, of Philadelphia, in Amer. Edit, of Mackintosh.) When "such adventitious parasites are supposed to be present, the true anthelmintics must be first recommended, and afterwards any of the ordinary cathartics. OF THE PERITONEUM. 203 CHAPTER V. DISEASES OF THE PERITONEUM. The peritoneum lines the abdominal parietes, and gives a eoat to most of the viscera. It is a serous membrane, and, like all membranes of the class, is the seat of a secretion of a thin albu- minous fluid, which keeps it moist. It forms a shut sac, in the cavity of the abdomen, and has, in reality, no viscus within it. If the diaphragm be assumed as the part at which it commences, it will be found extending thence over the abdominal muscles, re- flected over the bladder, and, in females, over the uterus; from thence over the rectum, the kidney, enveloping the intestines, and constituting, by its two laminas, the mesentery, giving a coat to the liver, and receiving the stomach between its duplicatures. Its use is to fix and support the different viscera, and, by means of its secretion, to enable the intestines to move readily upon each other. When we speak of the cavity of the peritoneum, we mean the inside of the sac: the fluid of ascites is contained within this cavity. After the peritoneum has covered the stomach and intestines, it forms reflections, which are fatty, and termed omenta, or epiploa. The peritoneum generally may be affected with disease; or the mischief may be partial, and the symptoms may be materially modified, according to the particular viscus which it invests. Of peritonitis of the intestines, for example, we have already spoken under the head of Enteritis of the peritoneal coat; and other peri- toneal inflammations are treated of under the diseases of the par- ticular viscera which are invested by it. It is convenient, how- ever, to treat here of those affections that appertain to the peri- toneum generally. I. INFLAMMATION OF THE PERITONEUM. Synon. Inflammatio Peritonaei, Peritonaeitis, Peritonitis, Empresma Peritoni- tis, Cauma Peritonitis; Fr. Peritonite, Inflammation du Peritoine; Ger. Entziin- dung des Bauchfells. Inflammation of the peritoneum may be described under three heads: 1, the acute form; 2, the chronic; and 3, the puerperal. 1. Acute Peritonitis. The phenomena of acute peritonitis are nearly identical with those of inflammation of the peritoneal coat of the intestines. Diagnosis.—The symptoms are essentially the same as those of acute enteritis of the peritoneal coat. An acute pain is experienced in some part of the abdomen, which may be circumscribed, or ex- tend over the whole lower belly, and is superficial when it affects the peritoneum lining the abdominal parietes, so that the slightest 204 DISEASES OF THE ALIMENTARY CANAL. pressure is insupportable; even the weight of the bed-clothes excites intolerable suffering. The parietes of the abdomen are more or less tense and tumid; the countenance has, at times, a peculiar expres- sion—the upper lip being drawn upwards, and bound tightly over the teeth. The patient breathes costally, without depressing the diaphragm more than he can help, and lies upon his back, with the thighs bent upon the pelvis, and the knees frequently raised, so as to take off the pressure of the bed-clothes. (M. Hall.) The pulse is generally small, and the skin hot and dry; and a recent writer (Sementini) affirms, as a fact, which he has tested by constant observation for upwards of forty years, that in all cases of perito- nitis, in whatever part of the abdominal cavity the inflammation is seated, there is pain in the pubes,and upon the great trochanters; which, if not felt spontaneously, is always developed by pressure, and of which the severity is directly proportionate to that of the peritonitis. This fact, which, according to Sementini, is confirm- ed by the clinical observation of others, has not been observed by the author. It is attempted to be explained by the relation of the nerves of the parts, in which pain is felt, to the peritoneum, and by its connection with the fasciae and muscles about them. Along with these local signs, the functions of the stomach and bowels are always more or less disordered; but often there is neither vomiting nor constipation; or, if the bowels are confined, they are easily moved by cathartics. Acute peritonitis may terminate unfavourably in a few.days; but when its course is more protracted, there may be evidences of sero-purulent effusion into the cavity of the peritoneum. This is not necessarily a fatal occurrence, as the fluid may be absorbed, or form a communication between the cavity of the peritoneum and the intestines. .The signs, that denote the termination of the inflammation in effusion, are—diminution of the pain and swell- ing, with a doughy feel of the abdomen, and infiltration of the parietes of the abdomen and the lower extremities. By percussion, also, the presence of fluid may be detected. (Rostan.) Auscultation may likewise afford evidences of peritonitis before and after effusion has taken place. As in other inflammations of serous membranes, the first effect is to arrest the secretion, so that the membranes are dry, and careful auscultation has detected a sound of frottement or friction. The effusion of coagulable lymph can likewise be detected in the same manner, as well as by the hand applied over the abdomen. In a case of peritonitis supervening onoVarian dropsy, when the hand was applied over the umbilicus and its neighbourhood, the sensation communicated to it, when a full inspiration was taken, was that of a grating or rubbing toge- ther of two uneven and rather dry surfaces. By the aid of the stethoscope, a loud and distinct friction sound was audible, over a space about five inches in diameter, with the umbilicus for a centre. (Beatty.) Another pathologist, (Bright,) states, that he has ob- served, on several occasions, that when the circumstances of the OF THE PERITONEUM. 205 disease had rendered it probable, that adhesions had taken place between the viscera and the peritoneum of the abdomen, a very peculiar sensation was communicated on touch, varying between the crepitation produced by emphysema, and the sensation derived from bending new leather in the hand. It has been presumed, that for the production of this sign, the effused lymph must be in an unorganized condition, (Corrigan,) and also, that it is observed only in cases, where one at least of the opposed surfaces is ad- herent to a solid resisting body, (Beatty;) and it would appear, that in twelve collected cases, nine presented an organic tumour. (Stokes.) Where the peritonitis is partial, the local phenomena are circum- scribed, and the general less marked. The tolerance of loss of blood, as in other inflammations of serous membranes, is great, and this circumstance must be regarded as a means of diagnosis, and as a guide in the treatment of the disease. (M. Hall.) The disease is not unfrequent in the fcetus. (J. Y. Simpson.) Causes.—Those, usually assigned—as in other cases of internal inflammation—^are cold and fatigue. An irregular state of the bowels may, also, give rise to il, as well as contusions and wounds. At times, it supervenes on surgical operations, on extensive ab- scesses, especially when of a specific kind, and on burns. The essential causes are those of internal inflammation in general. It is said to have been caused by the metastasis of rheumatism and gout, (Andral, Most;) but enteralgia is a more frequent conse- quence. Pathological characters.—When the peritonitis has terminated speedily, the peritoneum may be found red, sometimes of a violet hue; and dry, owing to the arrest of the wonted secretion, which takes place from it as from other serous membranes. It has been maintained, that fatal inflammation may have existed, and yet that on dissection there may be no redness,—in other words, that the absence of vascularity is no proof of the nonexistence of inflamma- tion, (Mackintosh and others;) but this has not been the result of the author's observation. It applies to hyperaemia, but not to inflamma- tion, which cannot exist for even a short time, and prove fatal, with- out organic changes being effected in the part, which leave manifest traces on dissection; and even if we do not agree, that increased redness is always perceptible after death, (Scoutetten,) we have no doubt as to the presence of other appearances, which can scarcely escape the eye of the practised observer. Where the inflammation has seriously implicated the peritoneum proper, as well as that covering the intestines, they are often found glued together by plastic lymph, the omentum adhering to the lower folds of in- testine, the adhesions being slight, or firm, according to the length of time that has elapsed between their formation and the fatal event. If the disease has continued for some days, the cavity of the abdomen will be found to contain a turbid whitish, yellowish, vol. i.—18 206 DISEASES OF THE ALIMENTARY CANAL. or greenish fluid, with flakes of coagulable lymph, the same mor- bid secretion as the bond of union between the agglutinated in- testines. It is at times very fetid. Occasionally, also, pus is secreted in considerable quantity from the thickened membrane; and cases occur in which there are evidences of gangrene. In rare cases, the intestines are perforated, and the contents of the digestive tube found in the cavity of the peritoneum. An exhalation of blood has also been met with—Hemuperitonirrhagie. (Piorry.) Treatment.—This is essentially that recommended for enteritis of the peritoneal coat, which is, indeed,—as elsewhere remarked,— peritonitis, somewhat modified by the subjacent intestine. As in other inflammations of the serous membranes, mercury administer- ed internally or by friction, so as to induce ptyalism promptly and effectually, has been advised, (M. Hall;) but this revulsive treat- ment must be subsidiary to the antiphlogistic. It is not easy, indeed, to produce the effects of mercury upon the system, unless the latter has been premised energetically. R.—Hydrargyr. chlorid. mit. gr. iij. Opii, gr. ss. Confect. rosae, q. s. ut fiat pilula. One to be taken every three or four hours. 2. Chronic Peritonitis. Diagnosis.—Acute peritonitis may terminate in the chronic, or it may have, from the first, the characters of the latter, and be very insidious, so as to require great attention in its detection. The symptoms are much less marked, the abdominal pain less acute, sometimes almost null, and only to be detected by careful pressure. It is even affirmed, that there may be no pain, tenderness, or tumour of the abdomen. (M. Hall.) The abdomen is tense, and doughy, as in the acute form; often, indeed, more manifestly so, and the fluctuation more perceptible, inasmuch as careful percussion can be practised. (Rostan.) The pulse is small, more frequent than natural, and especially towards evening. There is usually neither vomiting nor purging, and the appetite may persist; the emaciation is progressive, and there is evident hectic, under which the patient is gradually worn out. Pathological characters.—The appearances, on dissection, re- semble those of acute peritonitis. The effusion of fluid is, however, more considerable, and the organic mischief more complicated. The peritoneum itself is generally thickened, has entirely lost its transparency, and is variously discoloured. Often, there are numer- ous black patches, which have been considered melanic. (Andral.) They are not gangrenous sloughs, for they are firm, inodorous, and possess none of the characters of gangrene except the colour. The agglutinations of the different viscera are, at times, extensive, and constitute tumours or bands, which may occasionally be felt through the parietes of the abdomen; at other times, the intestines become perforated by ulceration, and death takes place speedily, owing to the effusion of the contents of the digestive tube into the cavity of OF THE PERITONEUM. 207 the peritoneum; whilst, in others, the pus makes its way through the abdominal parietes, owing to the union of the intestines to the peritoneum lining the abdomen, and is discharged externally. (Brichetcuu.) In a case of tubercular peritonitis, which fell under the author's care, the external orifice in the parietes of the abdomen was found to communicate with a circumscribed cyst, formed by the agglutination of the omentum to the anterior paries of the abdomen and by the intestine. It extended into the pelvis, and as deep as the vertebrae, dipping between the folds of the intestines. The walls were ulcerated, and in parts almost gangrenous, contain- ing a greenish, fetid matter. On pressing the intestines, bubbles of air issued from two or three openings, all of which communicated with the cavity of the cyst. On examining it more closely, three perforations were found near each other in the lower part of the ileum, and one in the colon. The intestines were glued in spots to each other and to the anterior paries of the abdomen, partly by old organized adhesions, and partly by new ones. In this case, the surface of the intestines as well as the omentum, and the peri- toneum lining the walls of the abdomen, was thickly studded with tubercles, varying in size from that of a pin's head to that of a small pea, and no lymph or serum was found in the cavity of the peritoneum. It has been remarked by an eminent pathological observer, (Louis,) that chronic peritonitis, which has been such from the commencement, is always complicated with tubercles; and the fact certainly is, that they are generally coexistent. (Baron, Hodgkin, Symonds.) The mesenteric glands or ganglions are often, also, greatly enlarged. Tuberculous peritonitis may exist without giving rise to any marked phenomena, and ultimately terminate very rapidly. The patient may have suffered under slight abdominal uneasiness, with falling off of the general health and strength, when suddenly he is seized with greater pain than usual; the vital powers fail rapidly, and he may die within thirty hours. (Symonds.) Treatment.—This in no respect differs from that .adapted for chronic enteritis of the peritoneal coat. 3. Puerperal Peritonitis. Synon. Puerperal Fever, Peritoneal Fever, Child-bed Fever, Febris Puerpe- ralis, Enecia Synochus Puerperarum, Erythematic or Nonplastic Peritonitis, Typhohaemic Peritonitis, Adynamic or Malignant Puerperal Fever, Low Fever of Child-bed; Fr. Fievre Puerperale; Ger. Kindbetterinfieber. The nature of puerperal fever has been a topic of warm contro- versy, in recent times more especially, (J. Hamilton, Jr., Campbell, Mackintosh); but there can be little hesitation in referring it to inflammation of the peritoneum, modified by the existing condition of the female, or by a prevailing epidemic constitution. Diagnosis.—It has been affirmed, that when peritonitis follows delivery, the abdomen—the walls of which have undergone con- 208 DISEASES OF THE ALIMENTARY CANAL. siderable distension, and have not yet resumed their wonted resistance—acquires a greater size than in ordinary peritonitis; the lochia are suppressed, the mammae shrunken, the secretion of milk suspended, &c. (Rostan.) On the other hand, it has been equally affirmed, that a striking mark of distinction between diseases which resemble each other in the prominent characters of fever and pain in the belly, is, that in the true puerperal fever, the lochial discharge never ceases. -(Hamilton) The truth would seem to be, that the discharge sometimes flows as in ordinary cases; is sometimes dimi- nished, and, in others, suppressed,—the condition described by Professor Hamilton being the least common, inasmuch as the extent of secretion is likely to be interfered with by the concentration of vital action towards the peritoneum. The same effect may be expected upon the secretion of milk, if it has been already estab- lished; but if the secretion has not taken place at all, it is apt to be postponed until two or three days after convalescence takes place. (Mackintosh.) If a patient, soon after delivery, has an unusually frequent pulse, and this state is not the result of nervous exhaustion from hemor- rhage,—the pulsations being, at the same time, not only frequent but quick and vibratory,—serious internal mischief has to be appre- hended; and if to this there be superadded—tenderness over the region of the uterus especially, or about the iliac fossae, with diminished lochial discharge, partial or general peritonitis may be anticipated. (Baudelocque, Professor Huston, of Philadelphia.) The diagnosis, however, of puerperal peritonitis often demands the most careful investigation. The formidable symptoms are exhibited by the pulse, which is generally very rapid; by the countenance, which is remarkably anxious and sunken; and by the nervous system, which is greatly agitated and depressed; low, muttering delirium being a common concomitant; and, after a short time from the inception, the tole- rance for blood-letting being extremely small, and the blood dark, and of loose coagulum. (Gooch.) Causes.—In addition to those laid down under ordinary acute peritonitis, there must be a peculiar condition of the frame, in association with the great change in the organs consequent on delivery, to induce puerperal fever, particularly the epidemic form. It has been contended, that the phenomena of puerperal fever originate in a vitiation of the fluids, the causes of which are especially rife after childbirth, and are seated in the uterus after delivery, from which the placenta has been separated. The bruised condition of the pelvic cavity; the abraded state of the mucous membrane of the uterus, where the placenta was attached; the gaping orifices of the veins and sinuses; the offensive lochial dis- charges, and the injurious effects of mechanical injury; retention of coagula, or of portions of placenta, or of dead and putrid chil- dren;—all, or any of these conditions, have been regarded as ready sources from which vitiated matters can be absorbed into the cir- OF THE PERITONEUM. 209 dilation. (Ferguson,Locock.) Arecent writer (Voillemier) regards the disease to be essentially general, and that the anatomical cha- racter consists in the existence of purulent matter in some part of the body. Where the disease affects numbers in a community at the same time, there must be a favourable constitution of the atmosphere, and, according to some, a contagious miasm, which emanates from the bodies of those labouring under the disease, and can even be conveyed by the practitioner to other parturient females, and affect them with the same disease. In many epi- demics of puerperal peritonitis, in the lying-in institutions of large cities, (Gordon.) woman after woman became attacked as they were delivered, especially where there had been close communica- tion with the patients labouring under the disease, or they had been attended by accoucheurs, who had previously attended others with- out making the necessary change in their dress. According to many observers, the miasm, presumed to arise from an individual labouring under puerperal fever, is more virulent than in almost any other disorder reputed to be contagious; and examples have occurred of all the patients of one partner in a medical firm having been successively attacked after delivery, when those of another partner have entirely escaped. Still, there are many, who deny that the spread of the disease occurs by contagion, and who refer it wholly to epidemic influences. Pathological characters.—These are essentially such as have been described under acute peritonitis. The fluid effused is usually whey-like, or milky in appearance, and contains pus, with flakes of coagulable lymph. The disease, it has been supposed, com- mences in the peritoneum forming the broad ligaments, (Mackin- tosh,) whence it spreads to a greater or less extent. The pleura is frequently found inflamed, as indicated by the existence of a similar sero-purulent effusion in the chest: there is sometimes evidence of inflammation of the brain; and, not unfrequently, the tissues of the uterus and ovaries are broken down and pulpy,—that of the uterus being soft, and often approaching to gangrene. Treatment.—Puerperal peritonitis is more severe and extensive than ordinary peritonitis, and, according to some, (Mackintosh,) is more frequently combined with venous congestion, which sup- presses the inflammation, and deceives the practitioner. It conse- quently requires a very early treatment, and if energetic means be not employed within twelve hours after the attack, and, at times, within six, all the efforts of the practitioner may prove futile. The inflammation must be subdued, and speedily, or the patient will die; and hence blood-letting, practised at as early a period as pos- sible, is one of the sheet-anchors of the therapeutist. Both in the well developed, and in the congestive forms,it must be mainly relied on. Eighteen or twenty ounces of blood should be drawn from the arm, as soon as possible after the inception of the disease, and the operation be repeated in four hours, should the symptoms appear to demand it, and the strength of the system permit. IS* 210 DISEASES OF THE ALIMENTARY CANAL. Leeches have been highly extolled by many practitioners. One hundred, one hundred and fifty, two hundred, and two hundred and fifty have been applied from first to last; but the number, to be advised in any case, must be left to the judgment of the prac- titioner. In the congestive form, whilst blood is drawn from the arm, or by means of leeches, it may be advisable to combine with it gentle stimulants, as wine-whey/placing the patient at the same time in a bath of 92°— 96° Fahrenheit; by these means the blood is solicited towards the surface, and the hyperaemia of the peritoneum consequently diminished. If meteorism exists, warm water thrown into the colon, or the common enema of spirit of turpentine, may afford relief. In all cases, stimulants, administered internally, must be pre- scribed with caution, and not unless the ordinary indications for their administration in other diseases should be present. Abstraction of blood and purgatives of calomel have been described as " the arms on which we have chiefly, if not solely to depend;" and both, it is added, should be employed decidedly, and to as great an extent as we dare, (Good); but cathartics ought not to be administered too freely; and it is, on the whole, better to keep the alimentary canal clear by laxatives and laxative enemata; and if the disease should not yield speedily to the sedatives recommended above, and to the various local applications advised for the forms of peritonitis already described, to endeavour to affect the system gently, by means of mercurials, administered either internally, or by means of friction with the mercurial ointment, (Decap,) dressing the blisters,if any have been applied, with the same ointment. Large quantities of mercurials have been given, and extolled by some. One patient took, in the course of treatment, an ounce of calomel! (Collins;) and twenty grains, every four hours, has not been an uncommon quantity; but the large doses of calomel have not proved so suc- cessful in the hands of others. (Locock.) As to the topical remedies and the general management, they have already been described under Acute and Chronic Peritonitis. It may be added, however, that injections of warm water have been recommended to be thrown into the vagina and uterus, three or four times a day. (Dance, Tonnelli, Lee, Campbell.) A recent writer (Churchill) says he has frequently syringed the vagina with warm water, with benefit, but he never threw the injections into the uterus. Such will be the plan of treatment usually, perhaps, found most successful. It is founded upon the best pathology; but great judg- ment is required on the part of the practitioner. It would appear to be incontestable, that, in certain epidemics, and cases of the same epidemic, which may require the general management detailed above, active treatment cannot be borne. The phenomena are, from the first, of an adynamic character; and the practitioner will soon find, that the same plan of treatment cannot apply to all. As OF THE PERITONEUM. 211 in all cases of the kind, it must be regulated by the character of the prevailing epidemic and the condition of the patient.' The disease, in spite of every care, is often most alarmingly fatal, and always regarded with terror by#the obstetrical practi- tioner. It is affirmed, indeed, to occasion seven-eighths of the total mortality in childbirth. (Ferguson.) II. DROPSY OF THE PERITONEUM. Synon. Ascites, Hydrops Abdominis, Askites, Hydroperitonia, Dropsy of the Lower Belly; Fr. Ascite, Hydropisie du bas-ventre; Ger. Bauchwassersucht, Wassersucht des Bauches. Diagnosis.—Dropsy of the peritoneum is known by enlarge- ment of the abdomen, commencing in the hypogastric region, and gradually ascending upwards, until the abdominal parietes are, at times, so distended as to be extremely thin, and almost transparent, with tortuous veins observable in various parts. Percussion, over the seat of the fluid, yields a sound, which has been regarded as intermediate between that afforded by percussion of the liver and of the small intestine. When the patient is in the upright posture, the distension of every portion of the umbilical and hypo- gastric regions is equable; but, if he lies on either side, or on ihe back, the position of the fluid being varied, the prominent portion of the abdomen is varied likewise. When the hand or extremities of the fingers are placed on one side of the abdomen, below the level of the surface of the fluid, and the opposite side of the abdomen is struck, a feeling of fluctuation is perceptible, which is more or less distinct, according to the greater or less distension of the parietes of the cavity. When it is not very distinct, it may be best detected by placing the pulps of one or two fingers on the iliac fossa, and tapping the opposite iliac region slightly, but briskly, with a finger of the other hand. The only inconvenience of which the patient complains is the feeling of weight in the lower part of the abdomen, until the accu- mulation of fluid becomes so great as to cause the abdominal viscera to press upon the diaphragm, and excite dyspnoea. The secretion of urine is generally scanty, and the cutaneous transpiration di- minished likewise. As ascites—like dropsy in general—is, in most cases, rather the evidence of a pathological condition than a pathological condition itself, the course of the disease is usually dependent greatly upon the visceral mischief, which gives rise to it. At times, the distension is so excessive, and the inconvenience sustained by the presence of the fluid so great, that it is necessary to perform the operation of paracentesis, and this may have to be repeated over and over again: the quantity of fluid, which has been abstracted in this way, is indeed enormous, and scarcely to be credited, did it not rest on unquestionable authority. Twelve gallons and a half have been removed at a single operation, (Storck;) and the operation has been repeated one hundred and forty-three times, and perhaps 212 DISEASES OF THE ALIMENTARY CANAL. oftener. In one case, it was performed ninety-six times within a few years, and the whole amount of fluid evacuated was two hundred and seventy-five gallons and a half; the first fifteen ope- rations yielding an average of twenty quarts. (Beall, of Missouri, Professor Gross, of Louisville.) Ascites may be confounded with encysted dropsy—as of the ovary—but a careful examination, with the history of the case, will exhibit the difference. Instead of the swelling being equable—as in ascites—it will be partial, and more prominent in some part of the abdomen than another—the intestines being pushed to the part opposite the tumour. It is possible, too, to confound it with pregnancy, where the ab- dominal distension is very great, owing to the quantity of liqour amnii, and the fluctuation is very manifest. A case of this kind occurred to Sir Astley Cooper and Dr. Haighton, of London, in which these gentlemen were so far deceived as to appoint a day for the operation of paracentesis, when fortunately, in the mean while, the lady was taken in labour, and delivered. The discharge of liquor amnii was enormous. . In rare cases, the ascitic effusion presses upon the recto-vaginal portion of the perineum so as to cause a tumour to form in perineo, in which fluctuation is manifest, a fact that ought to be borne in mind. Causes.—Ascites—like other dropsies—arises in consequence of a loss of balance between those vessels whose office it is to secrete the fluid that lubricates the peritoneum, and those which take it up. If the exhalents secrete too much, the absorbents remaining healthy; or if, on the other hand, the exhalents remain healthy, whilst the absorbents take up too little, accumulation of the serous fluid takes place, but under opposite circumstances. In the first case, the ascites may be active or sthenic, and may be the result of peritonitis; in the latter, passive or asthenic. The particular pathological condition must be discriminated by the accompany- ing symptoms. At times, we may have a difficulty in deciding as to its precise character; but if one case be accompanied by more or less febrile excitement, and another by evidences of the scor- butic or hemorrhagic diathesis, no obscurity can exist. Visceral disease is perhaps the most common of the causes of ascites; and frequently the effusion is owing to a mechanical im- pediment to the abdominal circulation; as where ascites occurs in one, who has been long habituated to over indulgence in spirituous potations. The liver becomes softened, indurated, hypertrophied, or so diseased, that the blood of the portal system cannot circu- late freely through it; engorgement of the abdominal venous system consequently supervenes, and transudation or increased secretion of the more watery parts of the blood takes place into the cavity of the peritoneum. Irregularity of circulation is likewise induced by the enlarge- ment of the spleen, so often observed as a sequel of intermittent OF THE PERITONEUM. 213 fever; by granular disease of the kidney, and by diseases of the central organ of the circulation. These are, of course, the most difficult of removal. At times, again, the loss of balance takes place without any adequate cause; sometimes after a debauch. When the disease is dependent upon serious mischief in other organs, the prognosis of the dropsy merges in that of those affec- tions, and as they often occur in persons of broken down consti- tutions, the issue will probably be unfavourable; and this is the cause, why the dropsical cases, that present themselves in our almshouses, are generally so unmanageable. The abstraction of the fluid by a surgical operation, can be regarded only as a pallia- tive, and the individual gradually sinks, worn out by the excessive secretion at the expense of the system, and the consequent irritative excitement. Commonly, stupor, and signs of cerebral oppression are the precursors of the fatal termination, which may be owing either to hypercrinia of the fluid of the arachnoid, or to the en- cephalic exhaustion. Pathological characters.—The fluid of ascites is transparent? and colourless, as a general rule; but occasionally, it is tinged yellow or green. Where it has long bathed the viscera, they exhibit the same appearance as if they had been immersed in fluid out of the body; and, in some cases, the tissues of the liver, spleen and intestines, seem as if they had been macerated. (Bouil- laud, Andral.) If the solid viscera are diseased, the evidences will be apparent. Treatment.—The treatment of ascites reposes upon the same principles as that of general dropsy. Great reliance must be placed upon blood-letting, if the disease be active, with brisk cathartics, diuretics, and local revulsives. Careful examination must be made to discover the pathological cause, and if this should appear to consist in disease of one of the solid viscera, the treat- ment must be directed to the removal of the cause, after which the effect may cease. Unless, however, the kidneys themselves be diseased, diuretics will generally, if not always, be proper. The dropsies, which are such common attendants or sequelae of intermittent fever, are often effectually removed by the sulphate of quinine, or by the sesquioxide of iron in large doses. (Levy, Gimon.) Whenever the distension becomes so great as to interfere mate- rially with the breathing, and to cause excessive abdominal dis- tension and uneasiness, the operation of paracentesis is indicated. As before observed, it can only be regarded as a palliative in any case; but it occasionally affords a chance for the successful employ- ment of appropriate anti-hydropics afterwards. Such a beneficial result can, however, be anticipated in those cases only, which are of an uncomplicated kind, or which have resulted from peritonitis. When the disease owes its origin to lesions of the heart, liver, spleen or kidney, the relief can only be temporary. Often, indeed, the patient sinks most rapidly after the fluid has been withdrawn; 214 DISEASES OF THE ALIMENTARY CANAL. generally from systemic irritation, as in cases where large quanti- ties of purulent matter have been evacuated; but, at times, owing to resulting peritonitis. From a fancied, but loose analogy with hydrocele, the rash prac- tice has been proposed of introducing the vapours of wine into the cavity of the peritoneum, (VHomme)-, yet nothing but evil, it would appear, could result from such a proposition. Peritonitis would generally follow; and the patient, who has submitted to the operation of paracentesis for ascites, which is rarely practised ex- cept in advanced cases, is little able to bear irritation of any kind. After the operation, opportunity is afforded for examining into the condition of the abdominal viscera, and every effort should be made, by appropriate revulsion, to prevent a re-accumulation of the fluid. Great advantage has accrued, in such cases, from change of air, as from one of the crowded cities to a watering place; where the individual can experience a thorough mutation of all the influ- ences surrounding him. The sulphur waters of the Virginia Springs, ^aken in moderation, have, along with the influences just men- tioned, exerted a salutary agency, by exciting the action of the kidneys and the bowels; but caution is necessary that they be not taken too freely. CHAPTER VI. MORBID PRODUCTIONS IN THE PERITONEUM AND INTESTINES. Various morbid productions occur in the peritoneum and intes- tines, besides those that have been already described. a. Tubercles.—These are met with in the peritoneum,—Perito- nistrumosie, (Piorry,)—sometimes accompanied by inflamma- tion, and at others not. They are in the form of granulations, more or less thickly dispersed over various parts. When they ac- company peritonitis, they may be suspected from the tubercular diathesis of the individual. From a comparison of 358 cases, of which 127 were in those who had died of phthisis, and 40 from other diseases, it was inferred, that tubercles never occur in any organ in the body, after the age of 15, except in cases in which they also exist in the lungs. (Louis.) Yet, they may be present to a great extent hi the peritoneum, without any being found in the lungs. In the case of peritonitis with tubercles, already referred to (p. 207), the surface of the intestine, as well as the omentum and peritoneum, was thickly studded with tubercles, varying in size from a pin's head, to a small pea, but the tubercles were by no means numerous in either lung. OF THE PERITONEUM AND INTESTINES. 215 Tubercles are likewise found in the intestinal canal, and most commonly towards the termination of the small intestine. They may exist without giving any evidence of their presence, or they may cause, or be accompanied by symptoms resembling those of chronic enteritis. b. Melanosis.—We have elsewhere spoken of melanosis having been met with in chronic peritonitis. The parts of the peritoneum, in which it is mostly observed, are the greater omentum and the epiploic appendages of the colon. At times, a nodulated variety is seen, the tumours, whether isolated or agglomerated, being generally adherent by small pedicles, and enveloped in cysts of fine cellular tissue, often furnished with delicate vessels. c. Fibrous, steatomatous,lipomatous, and encephaloid tumours. —Extremely large fibrous tumours sometimes form on, or rather under, the peritoneum, and occasionally augment so much as to fill the abdomen. An interesting case of this kind, connected with the peritoneal covering of the uterus, fell under the author's care, and subsequently under that of one of his colleagues in the Phila- delphia Hospital, (Pennock, of Philadelphia,) who has given a description of it accompanied by a drawing. (See the author's American Medical Intelligencer, Aug. 1, 1839.) Steatomatous and lipomatous tumours are but rarely met with. It has been asserted, indeed, that it is not very uncommon to see lipomata which have formed in the parietes of the intestines, with- out occasioning any disorder during life, (Andral,) but this is not the result of the author's observations. All these tumours, as well as encephalosis, manifest themselves, when of any size, by a swelling, which is perceptible on examina- tion; but they are devoid of pain; little sensible to pressure, and at first not marked by general symptoms; until they interfere with the abdominal circulation, and excite visceral irritation, under which the patient may succumb. The author attended, with a respectable physician of Baltimore, (Dr. Pue,) a case of encephalosis in a child, which almost filled the cavity of the abdomen. Its contents were distinctly encepha- loid in some parts; and in others, it contained a grumous fluid, of the general consistence of thin jelly; and, in others, a purulent secretion. A similar case is related by a recent pathological writer. (Professor Gross, of Louisville.) BOOK II. DISEASES OF THE RESPIRATORY ORGANS. The diseases of the air passages are of great interest to the therapeutist. The delicate organization of the lungs, their state of constant activity, and their being exposed to the contact of air of dif- ferent barometrical, thermometrical, and hygrometrical conditions, which contains various extraneous matters suspended in it, render them especially liable to diseases, and those of a most serious cha- racter. It has been affirmed, that thoracic diseases constitute, in England, nearly one-half of the fatal cases, and perhaps quite one- half of the slighter disorders; and many other diseases, both local and general, owe their serious or fatal character to secondary tho- racic lesions. (C. J. B. Williams.) In this country, the ratio is not so great, yet it is sufficiently considerable. Important as those diseases are, their diagnosis was in an ex- tremely imperfect state prior to the present century. Before this, indeed, attention, as will be seen, was paid to the physical signs afforded by listening to the sounds rendered on percussing the thorax; but still, it is to Laennec, that we are indebted for the introduction of the main improvements in the detection of thoracic diseases by audible evidences, in which he has been ably sup- ported by many living observers. To facilitate the understanding of the various diseases, which fall under consideration in this section, it will be requisite, as in other cases, to make a few preliminary observations on the anatomy and physiology of the apparatus, so far as is necessary; and like- wise on the principles and adaptation of the different plans, which have been devised, for accurately appreciating the physical signs of the different lesions. I. ANATOMICAL AND PHYSIOLOGICAL CONSIDERATIONS. The respiratory organs consist of the larynx/ the trachea, the bronchia, and the lungs; but besides these there are accessary or- gans, which require mention. The larynx is bounded anatomically, from above to below, by ANATOMICAL AND PHYSIOLOGICAL CONSIDERATIONS. 217 the epiglottis and the inferior ligaments of the glottis, in which voice is produced; and it is lined internally by a mucous membrane, which is a prolongation of that of the pharynx. On examining the interior of the larynx, two clefts are perceptible, one above the other; these are formed respectively by the superior and the inferior ligaments of the glottis; and, between them, are the ventricles of the larynx. The inferior ligaments of the glottis meet at a point behind the thyroid cartilage, which causes the projection in the neck,—the pomurn adami,—so as to form a triangular cleft—the glottis or rima glottidis, the posterior extremities of which are attached to the arytenoid cartilages; the cleft being diminished or enlarged by the contraction or relaxation of the arytenoid muscles, which pass from one arytenoid cartilage to the other. The thyro-aryte- noidei muscles form, with the ligamentous structure and mucous membrane, the lips of the glottis or inferior ligaments. These muscles have usually been esteemed dilators of the glottis. The intrinsic muscles of the larynx receive their nervous supply from the pneumogastric nerves. Shortly after the pneumogastric issues from the cranium, it gives off the superior laryngeal, which is distributed to the muscles that close the glottis; and after it has entered the thorax, it gives off a second, which ascends towards the larynx, and is hence called the recurrent or inferior laryngeal. It is distributed, in part, to the thyro-arytenoidei muscles,—no ramification, according to some, (Magendie, Cloquet, Ley,) going to the arytenoidei muscles. Others, however, maintain, that these last muscles receive a filament from each of the inferior laryn- geal. This difference of sentiment envelopes the precise func- tions of these different branches of the same great nerve—the pneumogastric—in obscurity. If the superior laryngeal had been distributed solely to the contractor muscles of the glottis, whilst the inferior laryngeal was distributed to the dilators solely, the anato- mical evidence would have been strong that the former are con- cerned in the dilatation ajjd the latter in the contraction of that aperture. Experiments have shown, that if both the recurrents and the superior laryngeal nerves be divided, complete aphonia is the re- sult; and it can be readily understood, that if either of these im- portant branches be injured, the voice may be affected; but much remains to be learned regarding their exact functions. Whenever any irritating substance reaches the larynx, it is at once closed by means of its contractor muscles. The action, in this case, is clearly excito-motory—in other words, the irritation is con- veyed with the rapidity of lightning along a sensitive nerve to the great nervous centres, and, with the like rapidity, the appropriate muscles are excited through a motor nerve. To this we have analogous phenomena in coughing and sneezing. In the case, abovementioned, of closure of the glottis under irritation, it has been believed, (J. Reid,) that the superior laryngeal is the sensi- vol. i.—19 218 DISEASES OF THE RESPIRATORY ORGANS. tive, and the inferior laryngeal the motor nerve. (On the subject of the nerves of the larynx, see the author's Human Physiology, 4th edit. vol. i, p. 411, Philad. 1841.) Every part of the larynx, with the exception of the inferior liga- ments, may be destroyed, and yet the voice may continue; and when the larynx is exposed in a living animal, the inferior liga- ments are distinctly observed to vibrate, whilst the superior appear to be unconcerned. (Bichat, Magendie.) The former are, conse- quently, the great organs by which voice is produced, although, for its perfection, the superior ligaments and the ventricles may be requisite. (Savart.) It can be readily understood, that any morbid state, which modi- fies the condition of the lips of the glottis, as inflammation, ulcera- tion, or oedema; or that interferes with the action of the intrinsic muscles, will modify the character of the voice; and that, if the lesion be considerable, it may induce total loss of voice—complete aphonia. As the intensity of the voice is dependent upon the force with which the air can be sent from the lungs, it will of course vary, according to the condition of those organs, and the general powers of the system. The trachea is continuous with the larynx, and is lined by a con- tinuation of the same mucous membrane. It divides into two large tubes—the bronchia—one of which goes to each lung, and these, after numerous subdivisions, become imperceptible in the lung. They are lined by a continuation of the laryngeal mucous mem- brane; and it is probable, that what are called the air cells of the lungs are only the blind extremities of myriads of bronchial tubes. Whether the mucous membrane proceeds as far as the ultimate radicles is a point that cannot be determined. In the trachea and larger bronchial tubes, the cartilages do not form an entire circuit:—in the trachea especially, an obvious mus- cular structure exists in the posterior third, where the cartilages are wanting. The use of these muscular fibres, doubtless, is to di- minish the calibre of the tube bjf their contraction, so that the air, being driven more rapidly through a narrower space, may more readily sweep away.i|p^ri* the mucous membrane the matter of expectoration. (Profe$soe,Phy sick, of Philadelphia, Cruveilhier.) These fibres cannot be detected in the smaller bronchial subdivi- sions, but many of the phenomena of asthma would seem to esta- blish their existence. (Laennec.) The position of the lungs at the sides of the chest and that of the heart must be borne in mind by the investigator of thoracic dis- ease. It has been already remarked, that the air cells—as they are termad— are probably but the minute terminations of the different bronchia. Each of these is associated with a radicle of the pul- monary artery, and of the pulmonary veins; and, in addition to these organic constituents, the lung has arteries—the bronchial— for its nutrition, with corresponding veins, and lymphatics. The nerves are from' the pneumogastric and the ganglionic. All these ANATOMICAL AND PHYSIOLOGICAL CONSIDERATIONS. 219 elements are bound together by interlobular cellular tissue, so as to constitute the lungs as we observe them when cut into. Each lung has a proper fibrous capsule, (Stokes,) and it is covered by the serous membrane—the pleura—in such manner, that there are two pleura, each of which is confined to its own half of the thorax, lining the cavity and covering the lung. Where the two pleurae approximate each other behind the sternum is the mediastinum, in which the heart is situate. As each pleura is re- flected over the lung—pleura pulmonalis—and lines the parietes of the thorax—pleura costalis;—when the lungs are distended with air, the two must be brought into contact. To prevent friction, a serous fluid constantly lubricates them in health; but, if this be- comes arrested from any cause, and morbid productions are formed on the pleura, the sound of friction becomes at times distinctly audible. No air is contained in the cavity of the pleura, as was at one time believed. (Galen, Hamberger, Hales.) In ordinary inspiration, when the ribs are raised by the appro- priate muscles, the pleura costalis is, of course, raised at the same time; and, hence, pain is experienced when the pleura is inflamed during inspiration. The pleura costalis and the pleura pulmonalis frequently, too, unite under such circumstances, and this is usually the case in phthisis pulmonalis, so that the affected side does not rise in inspiration like the other; and the same result occurs, if, owing to consolidation, the lung of one side is unable to receive its proper quantity of air. In inspiration, whilst the ribs are raised, the diaphragm is de- pressed; and, in cases of pleuritis, respiration is almost wholly effected in this manner, to avoid the pain consequent on the eleva- tion of the ribs. For the like reason, relief is obtained by tying a handkerchief firmly around the thorax. On the other hand, in cases of hepatitis, as the depression of the diaphragm cannot fail to add to the suffering, the breathing is almost entirely costal. During expiration, the muscles^ concerned in inspiration, are re- laxed; and, in full expiration, various muscles, that draw down the ribs, are thrown into action, which^re aided by the-active resiliency of the lungs themselves. (Jftagthdie, Carson.) The quantity of air, capable of being inspired and expired, must depend upon the capacity of the lungs and the strength of-the individual; so that it might seem important to test this at various periods of diseases, which involve the texture of the lungs, to enable us to infer as to the extent of lung impermeable to air; but the practical application of the method is environed with difficul- ties. It is always extremely distressing to the individual; and, as the powers of the patient simultaneously and progressively fail, there is less capability of full inspiration and expiration, and*, in- deed, of any effort,—so that the result, even if readily attained, would not be entitled to much consideration. The number of inspirations is worthy of attention. This varies 220 DISEASES OF THE RESPIRATORY ORGANS. in different individuals. Eighteen may, however, be regarded as an average. It varies according to age and sex. The child and the female breathe more rapidly than the adult male, and aged individuals appear to exceed the average. (Hourmann and De- chambre.) It must be borne in mind, however, that various cir- cumstances, exercise, moral emotions, distension of the stomach from food, &c. &c. increase the number materially. Thus much as regards the mechanical phenomena of respira- tion.—In diseases of the lungs, the chemical phenomena have, likewise, to be regarded. For plenary health, and even for exist- ence, it is necessary that air should be received into the lungs, con- taining one part of oxygen to four parts of azote. The contact between air thus constituted, and the venous blood sent to the lungs by the pulmonary artery, is essential, in order that haematosis —or the conversion of venous into arterial blood—may be accom- plished.—If such conversion does not occur at all, stasis of the blood—as will be seen under Asphyxia—takes place in the vessels of the lungs, and death. The atmospheric air passes with facility from the ultimate bronchial radicle into the minute pulmonary blood-vessel by imbibition, and the refuse gases are readily exhaled through the coats of the blood-vessel and of the bronchium into the latter tube. The blood, at the same time, loses its venous cha- racters and assumes the arterial. Lastly;—the various respiratory phenomena—mechanical as well as chemical—are largely under the nervous influence. Ex- periments show, that the pneumogastric nerves contribute to the change of the venous into .arterial blood, (Sir A. Cooper, J. Reid,) and that their division gives occasion to great dyspnoea, and death. (Magendie.) When the phrenic nerves are tied, the most deter- mined asthma is produced; breathing goes on by means of the intercostal muscles; the chest is elevated by them to the utmost; and, in expiration, the chest is as remarkably drawn in. The animals do not live an hour. The lungs have appeared healthy, but the chest contained more than its natural exhalation. (Sir A. Cooper.) When the great sympathetic has been tied, but little effect was induced on the animal; but when the pneumogastric, phrenic, and great sympathetic were tied together, the animal lived little more than a quarter of an hour, and died of dyspnoea. The pneumogastric and phrenic nerves form part of the respi- ratory system of nerves of Sir Charles Bell. (See the author's Physiology, 4th edition, i, 68.) This system is considered by Sir Charles to be distributed to the multitude of muscles, that are associated in the respiratory functions, in a voluntary or involuntary manner; and are especially concerned in forced or hurried respira- tion, coughing, sneezing, &c. As a distinct system, it is by no means universally admitted by anatomists and physiologists. Many are of opinion, that there is ho special column of the spinal marrow destined for respiration, and PHYSICAL EXAMINATION OF THE CHEST. 221 that there appears to be nothing so peculiar in the action of the respiratory muscles, as to require a distinct set of nerves. (/. Reid.) II. PHYSICAL EXAMINATION OF THE CHEST. By the "physical signs" of the healthy or diseased condition of the contents of the thorax, we mean the evidences that are afforded to the senses, uninfluenced by the vital properties of those contents; in contradistinction to "symptoms," which are the evi- dences afforded by the living contents in action. Surrounded, as the different viscera of the thorax are, by a bony frame-work, which prevents information from being obtained in the case of the deeper seated, by any of the senses, the diseases of those viscera were comparatively obscure, before it occurred to Auen- brugger to employ percussion; and to the distinguished proposer of auscultation, (Laennec,) to endeavour to detect their varying conditions by the sense of hearing. It is scarcely an exaggeration, indeed, to remark, that "the diseases of the respiratory system could scarcely be said to be understood, until the era at which Laennec's incomparable work appeared. The combination of auscultation and percussion constitutes the basis of the diagnosis; and the pathology is scarcely less indebted to that extraordinary man." (M. Hall.) 1. Percussion. Percussion was introduced by Auenbrugger, of Vienna, in the year 1761; but it remained almost neglected for forty-seven years, when a translation of the work was made by Corvisart, which drew the attention of the profession to the method. The object of percussion, as a means of diagnosis, is to appreciate the sounds rendered by various parts of the chest, when struck, both in the healthy and the diseased condition. As the lungs always contain a large quantity of residuary air, and the parietes are possessed of a certain degree of elastic tension, if they be struck or percussed, a liollow and somewhat tympanitic sound or resonance is elicited; the intensity of which is diminished by whatever interferes with the elasticity of the parietes, or by any adipous or other soft deposition, if in considerable quantity in the integuments. It will hence follow,fhat the resonance of the chest will be greatest over those parts, in which there is nothing but lung, and where the parietes are thinnest, and their tension greatest; and, on the other hand, if any disease has solidified the lung, so that it does not receive the air, or if any effusion has taken place within the chest, the resonance, instead of being hollow, as in health, be- comes dull; and, again, if the amount of air be augmented, as in pulmonary emphysema, the natural resonance may be largely in- creased. The following tables (Laennec, Williams,) will exhibit the sounds rendered by percussing the various regions in health. Where \ 19* 222 DISEASES OF THE RESPIRATORY ORGANS. any solid viscus interferes—as the heart on the left side, or the liver on the right—the sound is, of course, more dull. INTERNAL ORGANS. Clavicular, (Subclavian, Laennec.) Infraclavian," (anterior supe- rior, Laennec). Mammary. Clavicles. Apices of lungs. Between the clavicles and 4th ribs. Between the 4th and 8th -^ ribs. Inframam- mary. r Between the 8th ribs and the ■I margin of the<< cartilages of the Ualse ribs. Superior ster- nal. Upper part of sternum. Superior lobes of lungs; large bronchia near the sternum. Middle lobes of1 lungs; large bronchia in the upper part, near the sternum; the heart generally co- vered by the lungs in lower part of left Lregion. ■ The liver on the- right, and the sto- mach on the left side, covered only on the upper part by the thin margin of the anterior inferior lobes (j)f the lungs. Large bronchia. SOUND ON PERCUSSION. ^ Very clear towards the sternum; clear in the middle; dull close to the humerus. Very clear. Very clear; in wo- men, a clear sound "only by mediate per- cussion. Dull on right side; irregularly dull on **the left, or unnatu- rally resonant. Middle sternal. £MiddIe Part ofS, Margins of middle ? below, at times, more | ia„e | sometimes the sto- dull; at others, tym- Lmach. J panitic. Upper part of the^) lateral lobes of the > Very clear. .lungs. J Axillary. Lateral. Inferior lateral. In the axillae, i above the 4th- ribs. i Between the 4th and 8th ribs at the sides. Middle of the late- ? 3. 5 Very clear. Same as inframam- mary. Acromial. Scapular. ral lobes of the lungs. {Margin of lateral" lobes of lungs; the liver on right side, \- the stomach and spleen on the left. _ Dull by direct per- cussion; a somewhat clear sound by me- diate percussion, es- pecially near the cla- vicles. The scapulae^ r The pectoral reso- and muscular I Middle posterior J nance can be elicited ridge below (lobes of the lungs, i only by mediate per- J l_cussion. {Between the clavicles and upper margin of the scapulae. Superior lobes of >the lungs, and larger bronchia. [ me tand ridge them. PHYSICAL EXAMINATION OF THE CHEST. 223 INTERNAL ORGANS. SOUND ON PERCUSSION. Tolerably clear by mediate percussion, r Between the' Interscapular. < inner margins (_o( the scapulae. i The roots and in -ner parts of posterior-* llobes of the lungs. Infrascapular. C Base of the lungs; From the in- the liver encroaches ferior angle. of< on the right, and the. .the scapulae. | stomach on the left Lside. or when the arms are crossed, and the head bowed forwards: the spinous processes of the vertebrae sound Lwell. >- Clear in the upper portion, by striking on the angles of the ribs, or by mediate percussion; below, often dull on the right, and unnatu- | rally resonant on the Ueft side. Percussion may be mediate or immediate; that is, it may be made through some medium termed a pleximeter; or by the fingers themselves, the tips being placed on a level. The fingers of the left hand, with their inner surfaces towards the chest, are the best pleximeter. They must be laid fiat and transversely over the part to be percussed, and then struck with the tips of the fin- gers of the right hand, or with the stethoscope. The shirt may be drawn tightly over the part to be percussed; or percussion, where delicacy will permit, may be made over the exposed surface. The sounds rendered will be more distinct if the patient holds his mouth open whilst the chest is struck. In all cases, percussion must be practised over the corresponding parts of each side, and the results be compared. It may be effected, either when the individual is in the horizontal posture, or when erect. In the latter case, if the object be to examine the anterior part, the chest should be thrown forwards, by causing the pa- tient to sit perfectly erect, with the head raised, and the arms carried backwards. To examine the posterior part, the head must be bent forwards, the spine slightly inclined forwards, and the arms crossed. 3. Auscultation. Percussion is in reality a form of auscultation, but the latter term is commonly restricted to the audible evidences afforded by listening, either with the ear applied to the chest, or through an instrument called the stethoscope. In the former case, the auscul- tation is said to be immediate; in the latter, mediate. The stethoscope is the invention of Laennec; for although we have various forms, adapted for convenience or fancy, his original instrument was made upon principles that have been the guide to all subsequent inventors. It is a simple acoustic instrument, consisting of a cylinder with a tube running through it, which is funnel-shaped at one extremity, in order that the sonorous vibra- 224 DISEASES OF THE RESPIRATORY ORGANS. tions, that fall within it, may, after various reflections, as in the case of the common ear trumpet, be concentrated and pass into the meatus auditorius. The sounds, produced in the thorax, can therefore be conveyed to the ear in two ways;—first, by the solid parietes of the instrument, and secondly, by means of the air in its interior. Any of the stethoscopes, offered for sale, will answer the purpose of the auscultator, provided the ear part can be easily adapted to his ear, and on this account he ought to select one that is suitable for him. It is proper, however, to observe, that the author has found those, which are wholly conical, or which, in other words, consist of the funnel part only, the least satisfactory, in consequence of the confusion of sounds, resembling, in some measure, those that are heard when a hollow shell is applied to the ear. The instrument should always have, in addition to the funnel-shaped portion, space enough for an inch or two of tube which is perfectly cylindrical, in order that, by the concentration of vibrations, this source of inconvenience may be obviated. The length of the original instru- ment of Laennec rendered it extremely inconvenient of applica- tion in many cases, and it was by no means easy to place the end of the instrument entirely flat on the chest, whilst the other was put in apposition with the ear. A flexible instrument, like the flexible ear-trumpet, has been devised, by which, without changing from one side of the patient to the other, the sounds of respiration may be heard with the same ear; and this form of stethoscope answers useful purposes, but it has not been much employed. It is scarcely necessary to say, that in order to understand the abnormous or unhealthy evidences afforded by auscultation, we ought to be familiar with the sounds rendered in health, and, hence, the young auscultator, should practise on the healthy subject, and especially on children, in whom some of the sounds are well developed. With this view, he may employ either mediate or immediate auscultation. The author is in the habit of employing the latter where circumstances will admit; but there are cases in which either delicacy, or adaptation, or both, render the employ- ment of the stethoscope indispensable. When any part of the chest opposite the lungs is auscultated, a murmur is heard, which has been called the respiratory murmur, vesicular murmur, murmur of the expansion of the lungs, murmur of pulmonary expansion, (Andral,) or respiration of the cells. The murmur is more marked during inspiration, and it is presumed to be owing to the gradual expansion and contraction of the vesicles of the lungs, and the friction of the air against them. This vesicular murmur is louder during infancy and early youth— hence termed puerile—and in females than in males. The respiratory murmur, is not the same in all persons of the same sex, nor in every part of the chest. Many persons have the respiration naturally very feeble, without any lesion of the lungs, PHYSICAL EXAMINATION OF THE CHEST. 225 whilst others have it very loud, and almost puerile. (Laennec.) When the lungs are situate contiguous to the parietes of the chest, it is heard most distinctly,-1-for example, in the axilla; in the space between the clavicle and the anterior edge of the trapezius muscle; the space between the clavicle and nipple, and between the spine and inner edge of the scapula. When the murmur is not heard distinctly in any of these places, and especially if not audible on one side, whilst it is distinctly so on the other, it is an evidence of disease. It is important, however, to bear in mind, that a difference of sentiment exists as to the inspiratory murmurs of the two sides under the clavicles, which is the common seat of tubercular forma- tions. It has been asserted by one observer, (Gerhard, of Phila- delphia,) that " the bronchial respiration is decidedly more distinct in the right lung than the left, especially at the summit," and he accounts for it,- by " the greater diameter and straighter course of the tubes, at the summit of the right lung, which are not lengthened and curved, as on the left side, by the presence of the arch of the aorta." On the other hand, another observer, (Fournet,) has satisfied him- self, that in persons presenting all the characteristics of healthy lungs, the sounds of inspiration and expiration are precisely identical in all corresponding points; in the few persons in whom he detected a slightly greater development of the expiration under the right than the left clavicle, there were some motives for a doubtful opinion respecting the state of the lungs. M. Fournet, indeed, is of opinion, from the physical condition of the two lungs, that there is no reason, why they should furnish different respiratory sounds. Again, another practised auscultator, (Stokes), particularly dwells on the importance of the discovery made by him, that in many individuals, there is a natural difference between the intensity of the murmur in either lung, and in such cases, " with scarcely an exception, the murmur of the left is distinctly louder than that of the right lung." It would appear, consequently, and such is the result of the author's observation, that at times there is no marked difference between the two sides; that at others, the intensity of the inspiratory murmur is greater on the right side; and at others again, on the left. When we listen over the interscapular region, the respiration is more " blowing" or soujflante, as the French term it; this is owing to the bronchia at the root of the lungs being of considerable calibre. Of this souffle or " blowing sound," the trachea, in consequence of its size, affords an excellent type. # When the sound is heard over the parts mentioned, it is an evidence of the healthy condition; but if it takes the place of the respiratory murmur, it is a sign of dis- ease; and denotes that the respiration is tracheal or bronchial, or, as it is more frequently termed, tubal,—so called in consequence of the sound of respiration being formed altogether in the tubes. If a large portion of the lungs be impervious to air, the act of 226 DISEASES OF THE RESPIRATORY ORGANS. respiration is of course accomplished by the remainder. The air, in such cases, passes in and out of the tubes with great energy and noise, and the respiration has been termed supplementary. (An- dral.) When the ear is placed over the chest, at its anterior inferior or posterior inferior part, a gurgling noise (gargouillement) is some- times heard, which must not be mistaken for the gurgling sound occasioned by purulent matter in a cavity. It is produced by the movements of the contents of the stomach or intestines. Mention has been made before, of the friction of the pleura costalis with the pleura pulmonalis. This friction (frottement) does not produce any distinct sound in health, but becomes well marked in certain cases of disease. If the bronchial tubes be entirely free from disease, the sounds rendered will be of the kind described; but it will be readily under- stood, that if they be inflamed, or obstructed by mucus, pus, or blood, various sounds—rhonchi, rdles or rattles—will be heard, the character of which will be mentioned under the individual diseases. Thus far, we have considered the auscultation of healthy respira- tion. The voice, likewise, affords physical signs of great moment. At present, we shall speak of those only that are heard in health, and which are the basis of all our diagnosis in disease. When the voice is produced in the inferior ligaments of the larynx, the sonorous vibrations not only pass out by the vocal tube, but they proceed downwards along the trachea; and the resonance is distinctly heard when the ear or the stethoscope is applied to the chest. When the instrument is placed over the larynx or trachea at the time the individual speaks, the voice appears to pass immediately up to the ear of the auscultator, and is louder than that heard by the other ear. This phenomenon is termed the laryngeal or tracheal voice, or laryngophony, or tracheophony. It is the sound of health; but we meet with a similar physical sign in disease;— the voice, when a cavity exists in the lungs, and is at the same time empty, seeming also to pass immediately through the stetho- scope to the ear of the observer, and constituting the cavernous voice or pectoriloquy. When the stethoscope is applied over the sternum and subjacent trachea, or between the spine and the scapulae, in the middle of the back, over the subjacent large bronchial tubes, the voice is heard to resound very strongly, but it does not pass up to the ear, in adults, like the tracheal or laryngeal voice. In children, how- ever, this bronchial resonance, bronchial voice, or bronchophony, cannot be easily, if at all, distinguished from laryngophony. It can be readily understood,~that if any of the bronchial tubes be dilated, these sounds may become greatly developed. This resonance of the voice can be felt by applying the hand to PHYSICAL EXAMINATION OF THE CHEST. 227 the chest. An obscure, diffused fremitus is perceptible, which has been called the pectoral fremitus or vibration. (C. J. B. Williams.) In the minute ramifications of the bronchial tubes, the resonance of the voice is not heard; the vesicular texture of the lungs is a bad conductor of sound; and, consequently, it prevents the resonance of the voice in the bronchia from being transmitted to the parietes of the chest, excepting where bronchia, of a certain size, pass close to the surface. But, if the vesicular structure becomes consolidated from any cause—as by the formation of tubercles—then the bron- chophony or bronchial resonance becomes very distinct, and aids us materially in our diagnosis. Again, if fluid exist in the chest, so as to modify the transmission of the vocal resonance to the ear of the auscultator, it may become a physical sign of disease,—as is presumed to be the case with egophony, to be hereafter mentioned. When consolidation of the lung exists, if the tips of the fingers be placed over the part when the patient speaks, the thrill may be distinctly felt, running at times up the arm; whilst, in the portions of the lung that are free from disease, no such sensation is expe- rienced. It is very different, at least, from the gentle vibration felt in the opposite lung, if the latter be healthy. All these phenomena are better appreciated in thin persons. In those, whose chests are well covered with muscle and fat, and whose voices are deep-bass, the natural resonance of the voice is obscure, and of limited extent. It has been recently proposed to associate auscultation with per- cussion;—that is, to listen with the common stethoscope, or with one modified for the purpose, whilst a part is struck in the ordinary method of mediate percussion; and value has been assigned to auscultatory percussion—acouophonia or cophonia, (Donnd)— thus practised; (G. P. Cammann and A. Clark, of New York;) but it has not been much used, and is affirmed to be deceptive— the p-erceived sound bearing no precise relation to the condensa- tion or rarefaction of the subjacent parts. (Fournet.) 3. Inspection, Succussion, Palpation, $rc. of the Chest. Lastly;—among the physical signs may be reckoned those afforded by inspection of the chest—the rising of the ribs, the extent of costal respiration, &c.; by succussion and palpation—to detect fluctuation; by mensuration of the chest—to discover the difference of capacity between the side of the chest, which con- tains a lung more or less deprived of function from disease, and one which, in consequence of the morbid condition of its fellow, is perhaps executing more duty. All these methods will be referred to, where it may be necessary, under the particular diseases. Such are the chief means for the physical exploration of the chest. It affords valuable evidence in regard to the nature and 228 DISEASES OF THE RESPIRATORY ORGANS. amount of organic disease,—more than any assemblage of general symptoms. (C. J. B. Williams.) Still, the physical signs can only be regarded as valuable adjuvants, and not to be trusted to impli- citly. Certain organic affections of the chest afford nearly the same physical signs; but the general and special symptoms indicate the difference. It has been asserted, indeed, that auscultation is of no practical utility; and there are still a few,—dwindled, it is true, to units,- who ridicule the whole doctrine of physical signs as worse than useless. The author has, thus far, known no one who understands and has practised this method, who does not esteem it as a valuable aid in diagnosis. It is troublesome, however, to acquire the know- ledge, and, therefore, easier to decry its usefulness; as it is easier to decry productions of the press, which we have never perused, than to read them, and appreciate by study their usefulness. The stethoscope enables us to distinguish between diseases, whose gene- ral symptoms are alike; to pronounce on the existence of tubercu- losis, and whether the tubercles have gone on to softening, when otherwise doubt might exist; and thus to encourage or to discou- rage—according to the evidence afforded—subjecting the patient to the inconveniences of a migration to another and more genial clime;—in the former case, enabling us to support the drooping spirits with well founded expectations of benefit from the expatria- tion; and, in the latter, preventing all the unrequited misery and privation, which could not fail to attend upon so hopeless an expe- dition. Unquestionably, too exclusive attention has often been directed to the study of the physical signs of thoracic disease: dependent, moreover, as these signs are upon careful observation, it was to be expected, that unnecessary refinement might be introduced in th« detail of the sounds afforded. These, it will be seen, have become extremely numerous; and many of the subdivisions so minute and needless, as to excite ridicule from those even who place great confi- dence in auscultation. " To tell the truth," observes, recently, a dis- tinguished practitioner, (Trousseau,)" I have much greater pleasure in meeting with a man who will teach me the best mode of making a poultice, than with him who professes to instruct me in the differ- ences between the rale souflant and the rale sonore, or how to distinguish the rdle sibilant from the souffiant rdle, or this latter from the turturin rdle, or this again from the roucoulant rdle, or the caverneux from the cavernuleux rdle, and all such petty dis- tinctions." " The greatest error that has been committed in regard to auscul- tation," says another distinguished auscultator, (Raciborski,) "is in having attached too exclusive importance to it, and in having esteemed it, as it were, a science of sounds, (bruits,) each of which must indicate a different morbid condition. This much is certain, —and we are desirous of insisting upon it particularly,—-there is DISEASES OF THE RESPIRATORY ORGANS. 229 no rdle which has a very determinate and invariable value;- and that any one rdle being given, it is almost impossible to tell, from it alone, the name of the disease to which it corresponds. I defy any one whatever to distinguish in all cases, with his eyes shut, and without interrogating the patient, the majority of cases of in- cipient tubercular pneumonia in the first degree, cedema of the lung, haemoptysis, or even pulmonary emphysema. The sibilant rhonchus, or the bass-string rhonchus, does not indicate the exist- ence of simple bronchitis more than of pulmonary emphysema or of tubercles, for they may both be heard equally in the three dis- eases. The bronchial souffle no more indicates hepatization of the pulmonary parenchyma than it proves the existence of pleuritic effusion. The rhonchi even, which seem to belong more especially to a particular affection, have not such a determinate value as to enable us to pronounce positively the name of the disease when they are present. The gurgling, which is in some measure regarded as a pathognomonic sign of tuberculous cavities, may really be the result of pulmonary abscesses, or the effect of the dilatation of the bronchia; and the metallic tinkling itself may either be the result of pleurisy with effusion, of a pulmono-pleural fistula, or of a sim- ple pulmonary excavation." It is to be regretted, that many practitioners are accustomed to observe, or to listen, more than to reflect. As has been well remarked, (Stokes,) it is the art of reasoning justly upon the physical signs rather than inquiring into the characters of the phy- sical signs themselves, to which attention ought to be directed, and on which most observers fail." " It cannot be too often repeated," adds Dr. Stokes, " that physical signs only reveal mechanical con- ditions, which may proceed from the most different causes; and that the latter are to be determined by a process of reasoning on their connection and succession, on their relation to time, and their asso- ciation with symptoms: it is in this that the medical mind is seen. Without this power, I have no hesitation in saying, that it would be safer to wholly neglect the physical signs, and to trust, in prac- tice, to symptoms alone." VOL. i.—-20 • 230 DISEASES OF THE RESPIRATORY ORGANS. CHAPTER I. DISEASES OF THE LARYNX AND TRACHEA. I. INFLAMMATION OF THE EPIGLOTTIS. Synon. Epiglottitis, Inflammatio Epiglottidis, Angina epiglottidea; Fr. Epi- glottite, Inflammation de I'Epiglotte; Ger. Kehldeckelentzundung, Entzundung des Kehldeckels. Inflammation of the epiglottis is considered to be midway be- tween pharyngitis and laryngitis. (Most.) The office of the organ is inservient to both deglutition and respiration, and, consequently, both functions participate in the disorder. The epiglottis is not as important an organ as was at one time supposed. It was formerly universally believed to be the sole agent in preventing substances from passing into the larynx. This, however, appears to be the combined effect of the motions of the larynx, by which it is drawn upwards during deglutition, and of the muscles whose office it is to close the glottis; so that, if the laryngeal and recurrent nerves be divided in an animal, and the epiglottis be left in a state of in- tegrity, deglutition is rendered extremely difficult,—the principal cause that prevented the introduction of aliments into the glottis having been removed by the section. (Magendie.) Cases have been related, (Magendie, Trousseau and Belloq,) of persons, who were devoid of epiglottis, and yet who swallowed without any difficulty. (See the author's Human Physiology, 4th edit. i. 517, Philada. 1841.) Diagnosis.—It can rarely, if ever, happen, that inflammation of the epiglottis occurs without symptoms denoting that other parts in the vicinity are implicated; and hence it is, that the disease has usually been described under Laryngitis or Pharyngitis. Arecent writer (Dezeimeris) has collected several examples of this nature. In some of the cases of epiglottitis, the epiglottis has been seen of a red colour, enlarged, and, on drawing the tongue forward, erect, as it were, (Maimvaring, Sir E. Home,) or covered with false membranes, (N. Hill;) and, to the touch, it has been swollen, hard and prominent. In all cases, there has been great difficulty in deglutition, which appears to be of two kinds—one, which has been termed pharyngeal, the other laryngeal; the former, at times, altogether mechanical in its character, and owing to the narrow- ness of the passage for the food into the pharynx; at others, owing to the excessive sensibility of the epiglottis, and to the sort of con- vulsive effort, occasioned by the pain during the contraction of the pharynx;—the latter, or the laryngeal dysphagia, being dependent upon a small portion of liquid passing, during deglutition, into the larynx, and occasioning a convulsive cough for its expulsion. This difficulty, or impracticability of swallowing, when it coincides with OF THE LARYNX AND TRACHEA. 231 the absence of active inflammation and great swelling of the tonsils, is considered to indicate inflammation of the epiglottis. (Dezei- meris.) Taken alone, it may merely indicate the existence of in- flammation of the upper part of the larynx, in which, however, the epiglottis is frequently involved. At times, a sensation, as if an extraneous body were in the fauces, is experienced, with pain at the anterior and superior part of the neck, above the larynx. There is always, too, considerable pain in moving, and especially in protruding the tongue; and as the root of the epiglottis is studded with glands or follicles, the inflammatory irritation stimulates them to an increased secretion of mucus, which is detached with difficulty, giving rise to constant efforts, which greatly harass the patient, producing paroxysms of dyspnoea, and preventing sleep. (H Marsh.) Causes, and Treatment.—These are essentially the same as in pharyngitis, amygdalitis, and laryngitis. In addition to other means, stress has been laid on the application of a solution of nitrate of silver to the inflamed epiglottis. R.—Argent, nitr. gr. x. Aquae distillat. Ji. It may be readily applied by sewing a dossil of lint to the end of the finger of a glove, and placing it on the forefinger. (Cusack, H. Marsh, Dezeimeris.) The tenacious mucus, which collects about the top of the larynx, in this and other diseases, may often be re- moved by the same agency. II. INFLAMMATION OF THE LARYNX. Synon. Laryngitis, Inflammatio Laryngis, Cynanche Laryngea, Angina La- ryngea; Fr. Laryngite, Catarrhe Laryngien, Angine Laryngee; Ger. Entzundung des Kehlkopfs. Inflammation of the larynx, not many years ago, was scarcely studied as a distinct disease. In the Nosology of Good, the term laryngitis is not to be met with; but the disease is evidently comprised under the head of EmpresmaBronchitis, along with Cynanche tra- chealis,Cynanche stridula, Cynanche laryngea, Angina polyposa, Expectoratio solida, Cauma bronchitis, Angina canina and Croup. Yet it will be seen that, although inflammation of the lining mem- brane of the larynx, the trachea and the bronchia, may greatly resemble each other, there is room for a well founded distinction. Another division (Andral), is into,—1. Laryngitis, with simple redness of the mucous membrane, or Erythematous laryngitis. 2. Laryngitis, with tumefaction of the mucous membrane. 3. La- ryngitis, with copious secretion of mucus. 4. Laryngitis, with copious secretion of pus. 5. Laryngitis, with production of false membranes; and, 6. (Edematous laryngitis. There are these objections, however, to this classification—that no great advantage arises from the distinct consideration of the three first varieties; that the fourth is the chronic form of laryngitis, or laryngeal phthisis; and the fifth, laryngo-tracheitis or croup. The last, which 232 DISEASES OF THE RESPIRATORY ORGANS. is generally designated " oedema of the glottis," although usually, perhaps, originating in inflammation, may not always have it as a cause. Still, it may be well to consider it under the head of La- ryngitis. Another distinguished pathologist (Cruveilhier) divides laryngitis into two varieties, according as the diseased action is more conspicuous upon the surface of the mucous membrane of the larynx, or upon the submucous cellular tissue—designating the former mucous laryngitis; the latter, submucous laryngitis, which is oedema of the glottis. (Bayle.) Perhaps as convenient a division, in all respects, as any, is into the acute, the chronic, and the oedematous,—referring the fifth variety of Andral to a distinct head. a. Acute Inflammation of the Larynx. Synon. Acute Laryngitis. Diagnosis.—The first onset of acute laryngitis rarely differs from that of ordinary sore throat; but, sooner or later, there is a sense of constriction, heat, or pricking in the region of the larynx, which is, at times, very severe when the patient speaks or coughs, or when pressure is made on the larynx. At the same time, and even before the occurrence of these symptoms, there is more or less fever. The voice, as well as the cough, is hoarse, and, at first, dry; but subsequently, an expectoration of mucus takes place, and, at times, the sputa are mixed with blood. This secretion of mucus is of little moment in the case of the adult, but becomes serious in infants. Deglutition is, at times, difficult, or effected with incon- venience, and the inspirations are long and laborious, but by no means to the same extent as in croup or oedema of the glottis. In very severe cases, the dyspnoea recurs at short intervals with spasmodic force, and there is danger of suffocation, with great dis- tress, restlessness, and starting of the eyes, followed up, if the disease be not removed, by evident sinking of the vital powers, and death. In all cases of disease of the respiratory organs, the symptoms are liable to spasmodic exacerbations, and death would appear to arise occasionally from this cause, before the obstruction from the inflammation could be sufficient to induce fatal results. Owing to these various causes, hajmatosis is imperfectly executed, and this may be the cause of the comatose condition, which generally pre- cedes dissolution. Where the laryngitis is to a slight extent,—as the author knows from repeated experience in his own person,—the general incon- venience may be slight; but where very severe, the " great disor- der of innervation may mask the symptoms of local mischief." (Andral.) On inspecting the throat, there may be no evidence of pharyngeal inflammation, but generally, perhaps, the mucous membrane exhi- bits more or less injection. The duration of the disease, where it terminates fatally, varies OF THE LARYNX AND TRACHEA. 233 of course according to the constitution of the patient, the extent of the lesion, and the effects of remedies. The usual duration is from three to five days, yet it has proved fatal in less than twenty- four hours. It would seem to be the disease of which the illustrious Wash- ington died; and the cases of two distinguished members of the medical profession, Dr. David Pitcairn and Sir John Macnamara Hays, have been detailed by an eminent pathologist, (M. Baillie.) Before Baillie's time, this formidable kind of laryngitis, if known, had not been accurately described, but since that period, many examples have been placed upon record. Causes.—Exposure to cold, as in every other case of internal inflammation, has been assigned as a cause, and there is no ques- tion, that the irregularity, induced by exposure of a part of the body to the action of cold and moisture, may excite acute inflam- mation of the larynx as it does inflammation of the pharynx, and of other parts of the respiratory apparatus. It is probable, too, that those, who are liable to attacks of amygdalitis, may be more sub- ject to acute laryngitis, (Ryland;) but the author is unable to state this, as the result of any numerical estimate. It is also said to occur sympathetically, in cases of acute gastroenteritis. (Andral.) As a consequence of the major exanthemata, it is met with along with inflammation of the air passages in general, and the complication renders those diseases more formidable. Acute laryngitis may occur at all ages. It has been observed in the new-born; but it is extremely rare in childhood; whilst inflam- mation of the larynx and trachea with the production of false membranes is common in childhood, and rare in the adult age. There are very few cases on record, in which acute laryngitis, of the kind now described, has attacked persons under the age of twenty. Of twenty-four cases collected, (Ryland,) two only were under the age of 20; four between 20 and 30; six between 30 and 40; five between 40 and 50; three between 50 and 60; and four between 60 and 70. We have no exact data in regard to the influence of age as pre- disposing to this disease. Of 28 cases, taken indiscriminately from various works, 22 occurred in males, and only 6 in females. This may be owing to the former being more liable to irregular expo- sure, and to the more powerful exertion of the vocal organs; for this has been assigned as a cause of acute laryngitis as well as of the chronic form. Pathological characters.—The common appearances presented in acute laryngitis are, an inflamed and thickened state ,of the epiglottis, which is, at times, observed standing erect, so as to leave the larynx entirely uncovered. This enlargement is owing chiefly to submucous infiltration. The mucous membrane lining the larynx exhibits the ordinary signs of inflammation, with more or less of the same kind of infiltration; and if the disease has not 20* 234 DISEASES OF THE RESPIRATORY ORGANS. been rapidly fatal, ulceration may be met with; and pus has been observed, in the ventricles of the larynx. The condition of the epiglottis would of itself account for the difficulty of deglutition, which is sometimes considerable. Treatment.—The lighter forms of erythematous laryngitis re- quire but little treatment. Perfect rest in bed, with gentle cathartics, and warm diluents, so as to equalize the circulation over the whole surface, are generally sufficient. The severer forms, however, require the most energetic mea- sures, and even these are too often unsuccessful. In the early period of the disease, when the circulation is active, and the pain and constriction of the larynx are considerable, blood-letting should be employed so as to make a decided impression on the system, and it must be repeated should the symptoms demand it. Leeches should also be applied freely over the upper and front part of the neck, and a warm poultice, if it can be borne, over the leech bites. When blood has been copiously drawn, more or less reaction usually succeeds, which must be met by contra-stimulant doses of the tartrate of antimony and potassa,1 pediluvia, simple or sinapized, mucilaginous drinks, as gum-water,2 or the infusion of benne, or of the slippery elm; and catharties,3 and simple or cathartic enemata. 1 R.—Antim. etpotass. tart. gr. iv.— 3 R.—Infus. sennae, §ij. xij. Magnes. sulphat. giij. Mucilag. acac. sjiij. 01. menthae pip. gtt. vj.—M. Aquae, ;§vj.—M. Dose, one half, and in two hours the Dose, a tablespoonful, every two or remainder, unless the first should three hours. take effect. 2 R.—Acac. gum. ^j. Aquae, Oij.—M. The patient should be forbidden to speak, and the recommendation, that the air of the chamber should be preserved at an equable and mild temperature, is judicious. Should these means not prove efficacious, a revellent treatment should be immediately adopted, which may consist in the free ad- ministration of mercurials,1 so as to induce pytalism. 1 R.—PH. Hydrarg. gr. xx—in pil, by rubbing on the inner side of the iv. thigh a drachm of the unguentum fey- Dose, two night and morning. drargyrii and dressing the incisions Or, Hydrarg. chlorid. mit. gr. i. made by the scarificator with the same Conserv. rosar. q.s.—utfiatpilula. ointment, so as to induce ptyalism,if Dose, one night and morning; aided practicable. Should all these means fail, the practitioner must be prepared for the operation of tracheotomy, but it is of no use, unless per- formed early, and before the patient is evidently sinking. In some cases, in which it has been practised, the exhaustion has been so great, that reaction and recovery could not take place even when the respiration was rendered free by the operation. It gives time for the action of remedies, and all the writers on this subject have urged the importance of employing it early in the disease, and OF THE LARYNX AND TRACHEA. 235 as soon as the attacks of threatening suffocation seize the patient. (Louis, Lawrence, Porter, Ryland, Trousseau.) Where the spasms have supervened, and tracheotomy is not practicable from any cause, full doses of opium, or its preparations are indicated, (3 grains of soft opium in pill, or the equivalent in the prepara- tions of opium or salts of morphia). A full dose of the opiate is a valuable sedative, and not only allays the spasm, but diminishes the over action of the circulatory system. In six of the twenty-eight cases'before referred to, tracheotomy was performed, and in four a cure was effected; in the remaining two, temporary relief only resulted. (Ryland.) It has been recently urged, (Trousseau,) that the operation fre- quently fails, owing to the too small size of the canula employed. M. Trousseau uses a middle sized canula at first, and gradually increases the size, until the air ceases to make almost any noise in passing through it during a deep inspiration. b. Chronic Inflammation of the Larynx. Synon. Chronic Laryngitis. This term has been used synonymously with Laryngeal phthisis, Phthisis laryngea; Fr. Laryngite chronique, Phthisic laryngie, Laryngite avec sicrilion de Pus, (Andral); whilst laryngeal phthisis itself (Ger. Kehlkopfschwindsucht,Halsschwind- sucht,) has been employed so as to include " any chronic altera- tion of the larynx, which may bring on consumption or death in anyway." (Trousseau and Belloq.) It has been used, indeed, to include all chronic diseases of the larynx. In this work, the epithet " chronic" is employed in regard to laryngitis, in the same manner in which it is applied to other inflammations of mucous membranes:—to signify inflammation of the lining membrane of the larynx, or of the subjacent parts, the duration of which is long, or whose symptoms proceed slowly. Diagnosis.—The commencement of chronic inflammation of the various structures composing the larynx, is often extremely insidi- ous, and its progress so tardy, that much, and often irreparable, mischief is accomplished before any alarm is taken by the patient, and he applies for medical assistance. Pain is felt in the larynx, but its precise situation may vary; at times, it extends over the larynx; but, at others, is restricted to a small space, and generally to the region of the thyroid cartilage. Commonly, a kind of tickling sensation exists, which provokes coughing. The pain, too, is exasperated by coughing, speaking and deglutition, especially when ulcerations exist, and they are situate above the ventricles of the larynx. The breathing of cold air, and pressure upon the larynx likewise augment it. The voice is almost always changed, being hoarse, and, at times, so much enfeebled, as to be inaudible. The aphonia may supervene sud- denly or gradually, and ultimately be complete. Cough is a constant concomitant, and when the mucous mem- 236 DISEASES OF THE RESPIRATORY ORGANS. brane is much swollen, it becomes hoarse and even croupy. In the first instance it is dry, but subsequently it is accompanied with the expectoration of mucus, mixed occasionally with pus or blood. At other times, a membraniform matter is expectorated for months; and at others a considerable quantity of false membrane is thrown off, after which the patient rapidly recovers. Occasionally, por- tions of cartilage are mixed with the mucous or bloody sputa, and, in such cases, there is always accompanying hectic. Chronic laryngitis has, indeed, been divided into two heads;—the first com- prising that which affects the mucous membrane and the sub- mucous tissue; and the second, that which implicates the cartilages; the latter—it has been conceived—having perhaps the best claim to the name phthisis laryngea, from the incurable nature of the affection, and the hectic and emaciation, which invariably accom- pany its latter stages. (Ryland.) When chronic laryngitis is slight, and there is not much narrow- ness, the difficulty of breathing may not be great; but if it be at-' tended with much tumefaction of the lining membrane, the dyspnoea is considerable, and the sound rendered on inspiration sonorous and peculiar. It is evidently, too, augmented by paroxysms. The air of inspiration, likewise gives rise to a snoring (ronjlement) or whistling, (sifflement,) which may be continuous, or recur in paroxysms. These local symptoms may be so slight, that the general health does not suffer to any great degree. Commonly, however, more or less sympathetic febrile disorder is apparent, under which nutri- tion falls off, and atrophy supervenes. The disease now merits the term " Laryngeal Phthisis," which, is however, in the immense majority of cases, connected with the presence of pulmonary tuber- cles. (Andral.) Chronic laryngitis may be primary, or it may succeed to acute laryngitis; and when apparently terminating in health, it is readily reproduced by exposure to cold, errors in diet, &c. &c. Its dura- tion varies from a few months to several years. When the fauces are inspected, but little evidence of disease may be perceptible; at other times, however, the mucous mem- brane is injected, and the follicles are so large as to resemble split peas. Whether this enlargement of the follicles is the cause or effect, may admit of a question. The enlarged follicles probably exist lower down, where they cannot be inspected. This form of laryn- gitis is the one often known under the name " Clergymen's sore throat." Chronic laryngitis may terminate in health; but it is more likely to end fatally; and this may occur in different modes,—either by the lungs becoming implicated, or by the extent of the laryngeal lesions themselves, which may excite severe irritative fever, or interfere with the entrance of air into the lungs, and thus induce asphyxia. In almost all cases of phthisis laryngea, the disease is complicated with pulmonary tubercle. (Andral, Louis, Stokes.) OF THE LARYNX AND TRACHEA. 237 Dr. Stokes, indeed, asserts, that after ten years of hospital and private practice, he never saw a case presenting the symptoms of laryngeal cough, purulent or muco-purulent expectoration, semi- stridulous breathing, hoarseness, or aphonia, hectic, and emaciation, in which the patient did not die with cavities in his lungs. In some, the laryngeal affection appeared to be primary; but, in the great majority, symptoms of pulmonary disease existed previous to its appearance. Such, also, is the result of the author's obser- vation. In many cases of pulmonary phthisis,—sore throat, hoarseness, or aphonia, with cough, occur; but the case is different, when the laryngeal symptoms have been primary. (Graves.) Causes.—The same causes, that give rise to acute laryngitis, may induce the chronic form also. It may be caused, like the acute, by the inspiration of acrid substances, or by extraneous bodies received into the larynx. The habitual and intemperate use of ardent spirits has likewise been esteemed a cause, as well as the effect of mercury. These act either as predisposing or exciting causes. It is often the result of phthisis pulmonalis; whilst, on the other hand, the pulmonary irritation, induced by it, may occasion the development, and augment the course of tuberculosis of the lungs in those who are predisposed to pulmonary consumption. (Ryland.) The coexistence of ulceration of the lungs, and of suppurated pulmonary tubercles, has often been proved. In one-fourth of the cases of phthisis, ulceration of the larynx has been observed; in one-sixth, ulceration of the epiglottis; and ulceration of the trachea was met with more frequently than either of the other lesions. (Louis.) It is probable, however, that idiopathic chronic laryn- gitis rarely produces the symptoms of phthisis; but the. two dis- eases are frequent concomitants. (Andral.) Amongst the exciting causes are mentioned—prolonged action of the vocal organs;—hence the disease is said to be frequent among actors, singers, lawyers, preachers, &c. It has already been re- marked, that it is so common amongst the last, as to have received the name of the "clergymen's sore throat;" yet why it should pre- vail among them more than among lawyers, professors, &c. who use their vocal organs more, is not clear. It has, indeed, been sug- gested, that the clergymen, as a class, are of feebler constitutions, which circumstance may have originally led them to embrace their useful avocation; and, hence, that they are more liable to such derangements than more healthy individuals; (Professor Chapman, of Philadelphia;) but this does not seem sufficient to account for the difference. Another explanation has been offered, (Stokes)—that the clergyman begins to exercise his vocal organs at a much earlier period than the lawyer, for example. The young clergyman, often of a feeble and nervous constitution, and acting under conscientious motives, to the neglect of bodily health, not 238 DISEASES OF THE RESPIRATORY ORGANS. only reads the service, and preaches once or twice, or even more frequently, in the week, but. is exposed to night air and the in- clemency of the weather. He is compelled to do so, while both the larynx and constitution of the lawyer have generally full time for maturity, before he need employ the one or expend the other in the duties of his profession. Syphilis would appear to be a frequent cause of chronic laryn- gitis, and especially of the ulcerative form,—the ulcers extending, at times, from the throat by continuity of surface. (Carmichael.) As to age, the disease has certainly been observed most com- monly between twenty and forty; but, as to sex, discrepancy of sentiment exists;—some affirming, that the number of females, attacked by it, is infinitely greater than that of males; (Ryland;) others, that males are more frequently affected than females. (Andral.) Pathological characters.—Chronic inflammation induces the same changes in the laryngeal mucous membrane as in other membranes of the class; for example, redness, increased thick- ness, and alteration of consistency, over a greater or less extent of surface. Occasionally, too, vegetations of considerable size, and white and hard granulations, are perceptible. Pus, too, is gene- rally found covering its surface. The mucous follicles, both of the lining membrane of the pharynx and larynx, are frequently en- larged, especially in that form of the disease to which clergymen are subject, and they seem filled with a yellowish matter. Ulcera- tions are likewise very common, so as even to destroy the vocal cords. The submucous cellular tissue is often infiltrated by a thin fluid; and, at times, collections of pus exist in it; at others, it is indurated, and tubercles are found in different stages of develop- ment. The instrinsic muscles of the larynx have been found much re- duced in size, softened, and occasionally destroyed. At other times, they have been hypertrophied. The epiglottis may be thickened, ulcerated, carious, and even completely destroyed; yet the patient may have been able to swallow to the last. Experi- ment and observation have, indeed, shown, that the epiglottis is not the agent that prevents the entrance of the food into the larynx during deglutition. (See p. 230.) Of the cartilages of the larynx, the cricoid and the arytenoid are most frequently diseased-the thyroid least so. Occasionally, they are ossified, or ossific points are deposited on the mucous membrane. In broken down consti- tutions, in which large quantities of mercury have been used, it has been remarked, that chronic larvngitis is very apt to terminate in ulceration of the cartilages. (Graves, Stokes.) Treatment.—In the treatment of chronic laryngitis, at all stages, rest of the vocal organs is indispensable; but it is extremely difficult to have it rigorously enforced. In the early periods, blood-letting from the arm is sometimes demanded, and in almost every case, it OF THE LARYNX AND TRACHEA. 239 will be advisable to apply cups to the nape of the neck, or top of the chest; or, what is better, leeches freely over the seat of the disease. Emollient fomentations and poultices, likewise afford relief, but they have been objected to—probably altogether on hypothetical considerations—under the idea that they solicit an increased flow of blood towards the throat, and thus aggravate the disease. (Trousseau andBelloq.) Revellents are, however, the most important remedies. A blister may be applied to the top of the sternum, or over the trachea, and as soon as it heals, another should be applied, so as to keep up an intermittent irritation, which #is preferable to a permanent one. Hence blisters, thus employed, are better than setons; and the oint- ment of the tartrate of antimony and potassa,1 or the croton oil,2 is, perhaps, preferable to either. 1 R.—Ant. et potass, tart. p. j. 2 ]J,—01. tiglii, p. j. Adipis, p. vij.—M. 01. oliv. p. ij.—iij.—M. A piece, the size of a hazelnut, to A few drops to be rubbed in at a time. be rubbed on the region of the larynx, night and morning. With the view of procuring rest, opium and its preparations may be given. They are useful, likewise, in allaying the cough.1 The salts of morphia may also be employed endermically,2 and ad- vantage has been derived from frictions over the larynx, with the extract of belladonna.3 1 R.—Tinct. opii, 2 R.—Morphias acet. vel Tinct. digital, aa gtt. xl. Morphiae sulphat. gr. ss___ Mucilag. acacise, gr. i.—sprinkled over a blis- Syrup. aa giij. tered surface. Aquas, !§vj.—M. s R—Ext. belladonna, gj. Dose, two tablespoonfuls, three or Cerat. commun. ^xi.—M. four times a day. Where the affection of the larynx has lost its inflammatory cha- racters, and any of its terminations remain, topical remedies may be employed. These have, indeed, been regarded as the most effica- cious of all. (Trousseau and Belloq.) They may be made to come into immediate contact with the diseased surface "itself. At an early period of the disease, inhalations of the steam of warm water may be employed with advantage, but subsequently more excitant applications are needed, to induce a new action in the diseased surface. Inhalations, however, are liable to the inconvenience, that they cannot be restricted to the larynx; and, consequently, no agents are administered, in this manner, in cases of chronic laryngi- tis, except such as do not over-excite the mucous membrane of the lungs. The vapour of hot water, to which one of the essential oils has been added, may be used in the way of inhalation, with safety and occasional benefit. Various forms of apparatus have been devised for this purpose. (Cottereau, Gannal, Richard.) But MM. Trousseau and Belloq frankly confess, that a simple teapot is as well adapted to the purpose as the most complicated machines. 240 DISEASES OF THE RESPIRATORY ORGANS. In this way, chlorine, creasote, and iodine, may be inhaled under the circumstances laid down under Phthisis Pulmonalis. Topical remedies, in solution, are more to be relied on. Of these, nitrate of silver, corrosive sublimate, sulphate of copper, nitrate of mercury, and Lugol's caustic solution of iodine, (see the author's New Remedies, 3d edition, Philad. 1841,) have been employed, but the nitrate of silver is to be preferred, on account of its rapidity of action and harmlessness. (Trousseau and Belloq.) It may be used in the proportion of ten or fifteen grains to the ounce of water, (Graves, Stokes,) and it has been prescribed as strong as one part of the nitrate to two pasts of water. (Trousseau and Belloq.) Various plans have been adopted for applying it. The author uses a mop of rag at the extremity of a piece of whalebone. Others attach a piece of sponge to the end of a quill, dip it in the solution, and having slightly squeezed it to prevent the fluid from dropping., they touch the posterior fauces; raise the outer extremity of the qtiill so that the sponge may touch the epiglottis and superior part of the larynx, and draw it gently out in this manner. Thus, the solution is made to come into immediate contact with the in- flarried surface. By others, it has been advised to take up a drop of the strong solution on the bent extremity of a piece of firmly rolled paper, or whalebone, and to cause this to touch the lining membrane of the larynx. (Trousseau and Belloq.) A plan,—before mentioned—suggested by Mr. Cusack, of Dublin, has been regarded by a competent witness (Stokes,) as the best of all. A brush of lint, of the requisite size, is sewed on the end of the fin- ger of a glove, which is then drawn on the index finger of the right hand. The patient is made to gargle with warm water, and the lint being dipped, in the solution, can be readily applied to the larynx. It has been suggested, that the solution may be thrown, in the form of a shower, into the larynx, from a small silver syringe, like Anel's, (Trousseau and Belloq,) but the plans, already recom- mended, have the merit of being more easy of application. When the disease is dependent upon any syphilitic vice, it may be necessary to administer mercury, or some other revulsive agent —iodine, for example. When mercury is pushed so as to affect the mouth, it will sometimes break in upon the morbid chain where no vice is suspected, or present. It should be given, under such circumstances, so as to exert its ordinary influence slightly on the mouth. When, however, pulmonary tubercles are coexistent, care must be taken in the administration of this potent remedy, as the dyscrasy, induced by it, is apt to cause their development. Where the disease is dependent upon the use of mercury, it should, of course, be carefully abstained from, and an appropriate treatment, in which rest and the free use of iodine are combined, should be prescribed. In many cases, the spasmodic exacerbations are very severe and OF THE LARYNX AND TRACHEA. 241 distressing; they may be assuaged by opiates, or by the application of the emplastrum belladonnas or emplastrum opii. Lastly,—a question may arise as to the necessity for the operation of tracheotomy. Although frequently demanded in acute laryngitis, and not to be postponed, it is rarely necessary in cases of chronic laryngitis; but should symptoms, similar to those of acute laryngitis, which demand the operation, arise, it must be unhesitatingly per- formed. It is probable, however, that in such a case, the operation could be o( but transient benefit; so much disorganization must have occurred as to render ultimate recovery almost wholly, if not wholly, hopeless. c. QSdematous Inflammation of the Larynx. Synon. (Edematous laryngitis, (Edema of the glottis, (Edema glottidis, Hy- drops glottidis, Submucous laryngitis, (Edematous angina, Cynanche laryngea; Fr. Laryngite cedemateuse, (Edeme de la glotte. The oedematous condition of the larynx has been considered by most pathologists to be dependent upon previous inflammation; yet a similar state has been observed as an accompaniment of the leucophlegmatic habit; so that some have been disposed to admit an oedema of the glottis of an idiopathic character, in which the submucous infiltration is wholly serous; and another—symptomatic or inflammatory—in which the fluid in the submucous tissue is sero-purulent. (Andral.) The character of the secreted fluid can- not, however, be regarded as a sufficient ground of difference in pathology. Diagnosis.—The very first symptoms resemble those of ordinary laryngitis. There is pain, or uneasiness, at the upper part of the larynx, which gives occasion to the sensation of a foreign body lodged there. Cases, indeed, it is affirmed, have occurred, in which broncholomy has been resorted to, for the removal of the suspected foreign body; yet nothing of the kind could be discovered after the most careful examination; and it has been suggested, (Quai?i,s Martinet,) that such a mistake may occur from the close resem- blance that exists between the symptoms of oedematous laryngitis and those caused by the presence of a foreign body. In case of the presence of the latter, however, both inspiration and expiration are sibilant and difficult; whilst, in oedematous laryngitis, the in- spiration alone is sonorous or sibilant, whilst expiration is free and easy. This is owing to the oedematous mucous membrane being drawn into the aperture of the glottis during inspiration, and to the passage, during expiration, being left entirely clear. The voice is raucous, base, and discordant; and, occasionally, altogether suppressed. From the very commencement of the disease, the breathing is extremely difficult, especially in paroxysms, which threaten imme- diate suffocation. These become more and more severe. Sleep cannot be indulged; or, if the patient falls into a nap, he is awoke by violent attacks of suffocation. The severity of the symptoms vol. i.—21 242 DISEASES OF THE RESPIRATORY ORGANS. gradually increases, and death closes the scene, either suddenly, or after the most horrible suffering. Percussion and auscultation afford only negative signs; but this circumstance, in the absence of other diseases of the larynx and trachea, ought to cause the suspicion of oedema of the glottis. (Ros- tan.) If the finger can be carried along the tongue as far as the glottis, or even the upper extremity of the larynx, a soft projecting ring or cushion may be felt protruding into the tube, which has been esteemed a pathognomonic sign of the disease. (Thuillier, Rostan, Lisfranc, Cruveilhier.) In order to accomplish this, the mouth should be propped open by means of a piece of wood, introduced between the upper and under molar teeth, and the root of the tongue must be drawn for- wards by means of the handle of a spoon. The finger may then— and especially in females in whom the space between the mouth and the larynx is shorter—be able to attain the lips of the glottis. In males, however, the plan has failed. (Ryland.) The age of the patient is a principal means of diagnosis between oedematous laryngitis and croup. The latter disease is rare in the adult, whilst oedema of the glottis has only been observed at that age. It has been elsewhere remarked, that aneurism of the aorta has been mistaken for laryngitis, and it may be confounded with this form of the disease, the pressure of the tumour giving occasion to the sibilant inspiration, and paroxysms of suffocation, which are known to exist in the disease under description, but careful atten- tion to the signs afforded by auscultation willsufficiently diagnos- ticate the two affections. The progress of oedematous laryngitis is commonly very rapid, and it is almost always fatal. Of seventeen cases, one only reco- vered. (Bayle.) Causes.—These are usually not appreciable. It is said to have been owing, in some cases, to rheumatic metastasis. (Legroux.) Pathological characters.—The sides of the larynx, and espe- cially of the glottis, are thickened, so as to form a soft ring or cushion, caused by a serous or sero-purulent fluid, which gives it a yellowish or grayish appearance. This generally closes almost entirely the aperture of the glottis. Treatment.—The treatment, to be adopted in this disease, may have to vary according to the accompanying condition of the sys- tem. Generally, the inflammatory evidences are by no means marked;—the pulse and heat of skin being perhaps unmodified, so that the disease appears to be wholly local. It cannot often hap- pen, therefore, that general blood-letting is needed. Leeches may be applied over the neck, and, lower down, a blister; every revel- lent agency must, indeed, be had recourse to, to divert the local mischief from the larynx. Emetics and cathartics should be ad- ministered,—the former every few hours so as to cause vomiting, (ant. et potass, tart. gr. ij.—iij;) and, even if vomiting should not OF THE LARYNX AND TRACHEA. 243 be induced, the contra-stimulant agency of the antimonial may be beneficial. Any of the ordinary cathartics may be administered;1 stimulant enemata may be thrown into the rectum every few hours, and sinapisms be applied to the legs, feet, or arms. ' R.—Pulv. jalap, vel Pulv. rhei, gr. xv. Hydrarg. chlorid. mit. Zingib. pulv. aa gr. v.—M. It has been suggested, that large doses of calomel (gr. v.—x. omni hora) should be administered, which, either by their purgative effect, or by their revellent action on the general system, may tend to check the inflammation of the glottis, and to promote the absorp- tion of the effused fluids. (Ryland.) Should these remedies have been employed, and attacks of im- pending suffocation be urgent, the operation of bronchotomy must be practised; but, as in cases of ordinary laryngitis, it must not be postponed too long, otherwise it also must fail. It has been pro- posed, that, the moment the nature of the disease is known, the operation should be practised, and that it should be followed up by the revellent treatment just recommended; (Vavasseur;) or that, in its place—and the plan is preferred by some—an elastic gum tube, open at both extremities, and of a proper size, should be introduced into the larynx from the mouth, so as to keep the passage open. (Bayle, Thuillier.) It is scarcely possible, how- ever, to conceive, that any benefit could accrue from the presence of an extraneous body in such a condition of the parietes of the larynx. Another plan—scarcely, if at all, more feasible—is to pass the finger into the glottis, and to make pressure on the infil- trated parts, so as to diminish their volume; (Thuillier;) and, lastly, it has been proposed to scarify the engorged parts, (Lisfranc,) so as to permit the escape of the fluid. Both these plans have been characterized as fantastic, very difficult, if not impossible, of accom- plishment, and more likely to increase than diminish the existing evil. (Ryland.) The last is undoubtedly extremely difficult of execution; but, if it could be carried satisfactorily into effect, it would offer great probability of benefit. The danger of the disease is, in some measure, proportioned to the extent of the tumefaction, and any method, that would abstract the effused fluid, could not fail to afford essential relief. II. INFLAMMATION OF THE LARYNX AND TRACHEA. Synon. Cynanche Trachealis, Cynanche vel Angina Laryngea of some, A. Membranacea, A. Strepitosa, A. Exsudatoria, A. Polyposa, A. Trachealis, A. Humida, A. SutTocativa, Suffocatio Stridula, Laryngitis et Tracheitis Infantilis, Empresma Baronchlemmitis, Orthopnoea Cynanchica, Paedanchone, Trachitis, Tracheitis, Diphtheritis Trachealis, Laryngo-Tracheitis, Laryngo-Tracheitis with Diphtheritic Exudation, Laryngitis with production of False Membranes, Plastic or Pellicular Inflammation of the Larynx,.Croup, Roup, Hives, Choak, Stuffing, Rising of the Lights, &c; Fr. Croup, Angine Laryngee et Tracheale, Laryn«rite avec production de Fausses Membranes (Andral), L. Pseudomem- braneuse; Ger. Croup, Hautige Braune, Entzundung des Luftrohrenkopfes. 244 DISEASES OF THE RESPIRATORY ORGANS. Diagnosis.— This disease is a combination of laryngitis and tracheitis; which last does not differ materially from laryngitis, except by its seat, and, therefore, does not require a distinct con- sideration. The disease, about to' be investigated, is not, however, a simple laryngo-tracheitis, but an inflammation often accompanied with the production of false membranes—differing, consequently, from the inflammatory affections of the larynx that have been thus far considered. Of late years, it has been maintained, (Bretonneau,) to be identical with the diphtheritic inflammation of the supra- diaphragmatic portions of the alimentary canal, which have been described collectively under the name Diphtherites; and a recent writer (H. Bell) has observed, that the ideas of Bretonneau on croup are, at the present day, generally admitted, " supported, as they have been, by the anatomo-pathologists. who have made their observations since him, the question turning no longer on the exist- ence of the diphtheritis, but on its nature." It is not accurate, however, to ascribe such sentiments to the generality of pathologists. Almost all admit, that the essential character of croup, in the child, is a violent inflammation, accom- panied by an exudation of plastic lymph; but the. generality of American and British practitioners regard this idiopathic inflam- mation of the larynx and trachea, or rather of the latter—for the larynx is generally but little implicated—as very different from the diphtheritic inflammation that occurs in diphtheritic stomatitis and pharyngitis, in which, as has been shown, there is always precedent fever, and the formation of false membranes in the mouth and pharynx, which may extend down the windpipe, and give rise to symptoms of croup in the advanced stage of another and totally different disease. (Stokes.) It is extremely doubtful, indeed, whether the mild cases of croup —which are relieved by simple treatment, are unaccompanied by fever, and form, perhaps, a large proportion of the cases ordinarily classed as croup,—have any tendency to the formation of false membranes. They have been considered as cases of simple laryngo- tracheitis, and have been classed, by a recent writer, (Berton,) amongst the false croups—;faux croups. The inflammatory idiopathic croup, in which the accompanying fever is symptomatic, Dr. Stokes has termed "primary croup." It is that which we meet with in childhood; whilst "secondary croup" comprises the symptomatic affection just described, and is the croup of the adult—the Diphtherite of Bretonneau. Between these two forms of croup, Dr. Stokes has pointed out the following differences, which are so well shown in tabular form, that we borrow his observations. PRIMARY CROUP. ' SECONDARY CROUP. 1. The air passages primarily en- 1. The laryngeal affection secondary oa£ed« to disease of the pharynx and mouth. OF THE LARYNX AND TRACHEA. 245 PRIMARY CROUP. SECONDARY CROUP. 2. The fever symptomatic of the lo- 2. The local disease arising in the cal disease. course of another affection, which is generally accompanied by fever. 3. The fever inflammatory. 3. The fever typhoid. 4. Necessity for antiphlogistic treat- 4. Incapability of bearing antiphlo- ment, and the frequent success of such gistic treatment; necessity for the tonic, treatment. revulsive and stimulating modes. 5. The disease sporadic, and, in cer- 5. The disease constantly epidemic, tain situations, endemic, but never and contagious. [?] contagious. 6. A disease principally of child- 6. Adults commonly affected. hood. 7. The exudation of lymph spreading 7. The exudation spreading to the to the glottis, from below upwards. glottis from above downwards. 8. The pharynx healthy. 8. The pharynx diseased. 9. Dysphagia either absent or very 9. Dysphagia common and severe. slight. 10. Catarrhal symptoms often pre- 10. Laryngeal symptoms superven- cursory to the laryngeal. ing without the pre-existence of ca- tarrh. 11. Complication with acute pulmo- 11. Complication with such changes nary inflammation common. rare. 12. Absence of any characteristic 12. Breath often characteristically odour of the breath. foetid. The symptoms of the idiopathic croup of childhood are suffi- ciently distinctive. The onset of the disease is various. At times, with all the signs of health, the child is suddenly attacked with pain in the throat, hoarse cough, of the peculiar kind to be mentioned presently, and difficulty of breathing, soon followed by fever, of greater or less severity; the disease, in such case, arrives at its greatest intensity in a very short period; at other times, precursory symptoms exist for a longer or shorter period, occasionally for days, —such as cough and hoarseness, but without any fever; after which the symptoms of croup become declared. Most commonly, the attacks occur in the night, and often after the child has been unu- sually active during the day. The danger of the disease, when neglected, is so well known, that parents are familiar with the cough of croup, and on the alert, should the child cough as if the sound passed through a brazen trumpet, or resembled the barking of a dog. In such case, the child, when the affection is slight, may awake without much evidence of disease; the cough may persist through the night, but gradually lose the croupy character before morning, and there may be no accompanying fever. In more severe cases, however, on awaking, the voice, also, may be sharp and stridulous; the inspiration distinctly audible and laboured, and, often, of a crowing character, when the narrowness of the air pas- sage is considerable; the child is evidently distressed; the face more or less swollen and suffused; the skin hot, and the pulse frequent and hard. After the disease, if left to itself, or if obstinate, has been thus active, there may be—as in other diseases of the respiratory apparatus—alternations of exacerbation and remission; but the 21* 246 DISEASES OF THE RESPIRATORY ORGANS. disease makes progress; the hoarseness and dyspnoea augment; the voice is lost, and lividity of countenance indicates the imperfect haematosis, under which the child gradually sinks; or, what is more common, dies in a paroxysm of suffocation, even when the appearances, on dissection, may not exhibit sufficient narrowness of the air passages to account for death. In younger children, the expectoration, where any exists, is swallowed, so that it cannot be regarded in the diagnosis; but in older children, in the latter stages, pus is occasionally expectorated; with portions of a whitish membraniform substance. When this exudation has taken place, the difficulty of breathing is often most distressing; the head being forcibly thrown back, so as to stretch the trachea, and this may be the only posture in which temporary relief is obtained. The ordinary period of termination, is from the third to the fifth day; but it is asserted, (Golis, Albers,) that the disease may become chronic, and continue for two or three weeks. The author has not met with a case of the kind. The physical signs in croup, although not as important as in diseases of the lungs, cannot be regarded with a distinguished ob- server (M. Laennec) as useless. Very commonly, indeed, the case is complicated with pulmonary disease, which cannot be overlooked either in the diagnosis, or prognosis. If the disease be confined to the larynx and trachea, there will be no dulness on percussing the chest; and hence this negative sign is of moment. Where there is any complication of bronchitis, or pneumonia, they can be detected, also, by the signs afforded by those diseases on auscultation. It is important, how- ever, to bear in mind, that the sounds may be masked by the stridulous breathing. (Stokes.) When the false membrane is par- tially detached, we may have, it is asserted, a clapper or valve-like sound on inspiration, when the upper extremity of the membrane is partially detached; and on expiration, when the lower extremity is detached, and moved by the passage of the air through the larynx. (Maunsell.) Causes.—Although we -are not well informed as to the causes of croup, there are a few points which merit mention. Age unquestionably has a decided influence. After the first year, and up to puberty, -is the period most liable to it. After puberty it is extremely rare, and the cases that have generally been so regarded belong rather to the division of secondary croup. From the experience of several writers, who have published the results of their observations, (Van Bergen, Home, Crawford, Rosen, Cheyne, Michulis, Zobel, Pinel, Barthez, Caillau,) it would appear, that the croup has been observed only once at the age of seven months, and never at any antecedent period; that it never occurred at a later age than twelve; and that from two to ten was the common age at which it was observed. It certainly is extremely unfrequent in children at the breast, (Billard,) yet it is OF THE LARYNX AND TRACHEA. 247 stated to have been seen in an infant a few days old. (Dugls.) Diphtheritic inflammation of the mouth and throat is very common at this early age, but that affection—as we have seen—is different from primary or idiopathic croup, to which the older child is subject. Sex, unquestionably, also affords a predisposition. (Jurine, Golis, Ramsey, Guersent.) Of 543 cases of true and false croup, collected by M. Guersent, 293 were of the male sex, and only 218 of the female. This may be mainly owing to the greater exposure to vicissitudes of the former than the latter. There can be no doubt, that irregular application of cold and moisture to the frame must be regarded as a cause of croup. It prevails more in cold and damp regions, than in those that are dry and warm. In like manner, it is more common during the spring, autumn, and winter seasons, than during the summer. The author has had an opportunity of observing croup on the banks of the Firth of Forth, on the margins ofthe English lakes of Cumberland; in London, Paris, the interior of Virginia, Baltimore, and Phila- delphia; and the disease has certainly not been equally severe in all these places. The cases were more generally rapid in their course, and destructive in the second of those situations, in which, unless very active measures were taken within the first twelve hours, they were too often beyond the efforts of art. In the other localities, the disease has generally been readily subdued, if it were treated sufficiently early, and appropriate remedies were employed. In certain families, owing to favouring organization, in which almost all the children have participated, scarcely any have escaped the disease. The subsequent attacks commonly, however, are more and more mild, until ultimately, before or near the age of puberty, they altogether disappear, owing to the fresh evolution at that epoch. Croup is generally, perhaps always, a sporadic disease. It is said, however, to have prevailed epidemically, and as many as thirty-seven epidemics have been recorded. It is extremely ques- tionable whether any one of those was the primary or idiopathic croup of children. The same may be said of the croups, that have been esteemed contagious. (Rosen, Golis, Lobstein, Bretonneau, Guersent, Trousseau.) When it has appeared epidemically, it has generally been complicated with diphtheritic pharyngitis, measles scarlatina, &c; and—as has been already remarked—belongs to an essentially different affection, being—in the first of these diseases- altogether secondary, the diphtheritis spreading from the mouth and pharynx into the larynx and trachea. There appears to be no reason for believing, that the primary idiopathic croup is ever communicable by contagion. The disease is of an extremely dangerous character, but the re- sults of our own observation have by no means corresponded with those of many pathologists, as to its mortality. It has been already remarked, that it is more rapid and fatal in some situations than in others; and there can be no doubt, that extensively fatal diphtheritic affections have been confounded with primary croup, so as to swell 248 DISEASES OF THE RESPIRATORY ORGANS. up the mortality of the latter. Thus, the mortality has been esti- mated at two-thirds of those attacked, (Caillau, Double;) whilst others have estimated it at one-tenth, (Jurine, Vieusseux;) another observer, (J. Frank,) cured 39 cases, and lost 27; and a recent writer,—who avowedly regards croup as in all cases a diphtheritis— regards the estimate of Caillau as nearest the truth, if it be not in- deed too favourable. (H Bell.) No such mortality attends the disease in this country, or indeed in any place where the author has practised, or seen it. On the contrary, when the practitioner is called sufficiently early, it is usually very manageable. Still, it is a disease in which the prognosis must be extremely guarded. Too often, indeed, in consequence of the very slight suffering, the child, although breathing and cough- ing in the peculiar manner of croup, is able to play about, so that no alarm is taken until too late, and many deaths occur from this cause, which might probably have been prevented. Pathological characters.—The mucous membrane of the larynx and trachea, but especially of the latter, in a fatal case of croup, is found to exhibit the ordinary signs of inflammation. These may extend down into the larger and even into the smaller divisions of the bronchia. The essential character of the disease, however, is, that the tube, especially below the inferior ligaments of the larynx, is lined by a false membrane, of a pale yellow or grayish colour, the thickness of which is dependent upon the intensity of the in- flammation, that gives rise to it. This false membrane extends into the larger bronchial divisions, and may exist in the larynx; but it is more readily expectorated, as it forms, from the larynx, whilst the narrowness, formed by the inferior ligaments, prevents the ready escape of that which is thrown out in the trachea. The false mem- brane may either form an adventitious tube, or be in detached por- tions, blended with mucus or flocculi of albuminous matter. At times, it is separated from the mucous membrane by a purulent or mucopurulent secretion, whilst at others it is intimately adherent to the mucous membrane. When the disease has been rapid in its course, the pseudo-membrane is usually confined to the trachea, showing that the disease is essentially tracheitis. In many cases, the under surface of the epiglottis is coated by the false membrane, and the rima glottidis is obstructed by it. It is affirmed, that cases have occurred in which the mucous membrane of the air passages was covered only by a viscid secretion or by pus, yet death took place as speedily, and precisely with the same symptoms as mark the progress of the disease in those in whom the false membranes existed. (Martinet.) Generally, in those who die of croup, more or less evidence exists of bronchitis or pneumonia. The false membrane has been considered by some, (Van Bergen, Bohmer,) to be organized, but it is generally esteemed to be an- organic. There can be no doubt, however, that, like other plastic productions, it is capable of becoming organized. (Albers, Blache, Skiers.) The chemical composition does not differ from the pseudo- OF THE LARYNX AND TRACHEA. 249 membrane of serous surfaces. (Bretonneau, SchwilguL) It is insoluble in cold and in hot water, hardens by the action of acids, and dissolves in alkalies. Treatment.—In mild cases of croup, not preceded by bronchitic or pulmonic disease, in which the child is suddenly attacked with croupy cough and breathing at night, but where there is little or no fever, and the disease appears to be more spasmodic than in- flammatory, it is generally readily managed. An emetic should be immediately exhibited, and, for this purpose, one of the indirect emetics, or one whose emetic operation is preceded by nausea, had better be employed. • R.—Antim. et potass, tartrat. gr. iv. Sacchar. alb. 3j. Aquae, gj. Dose, a teaspoonful every quarter of an hour, until it produces vomiting; or a teaspoonful of the vinum antimonii or vinum ipecacuanhae, or five grains of the pulvis ipecacuanhae may be administered in the same manner. The sedative effect of the nausea, and the equalizing and revel- lent agency of the emesis, frequently put a stop to the disease at once. The warm bath may be afterwards employed, and the child be placed between blankets; but, often, this inconvenient, though salutary agent, may be dispensed with. Warm diluents may be freely allowed. In this country, the " Hive or Croup Syrup" of Dr. J. R. Coxe has been much used in cases of croup, and is kept by many families as a regular domestic remedy for such cases. It is the mel scillse compositum of the dispensatory of the United States, and is com- posed of squill, seneka, tartrate of antimony and potassa, clarified honey and water. Dose, as an emetic for children, ten drops to a drachm, repeated every fifteen or twenty minutes, until vomiting is induced. It is, however, a nauseous emetic, and possesses no advantage, perhaps, over the emetic articles abovementioned. It contains one grain of tartar emetic in every ounce of the mixture. The bowels may, at the same time, be acted upon by calomel, (gr. ij.—vj.) or by any of the other cathartics. The calomel, how- ever, has been administered not only as a cathartic, but as a revel- lent, and great reliance has been placed upon it by many practi- tioners. (Professor Rush, of Philadelphia, J. Hamilton, jun.) With this view, it is given in the dose of from one to four grains, every hour or two, until some impression is made upon the system, when it must be gradually discontinued, prescribing it at longer and longer intervals. Usually, after it has been given for a day, and, at times, for a shorter period, its effect upon the secretions is exhibited by the appearance of the alvine discharges, which are of a green colour, and resemble chopped spinach. As soon as this appearance occurs, the revellent effect of the mercury upon the constitution has been obtained, as far perhaps as is practicable, and it may be discon- tinued altogether, or the intervals between the doses be made pro- 250 DISEASES OF THE RESPIRATORY ORGANS. gressively longer. The only danger is salivation, which is, at times, uncontrollable, and produces serious local mischief, and, occasion- ally, death. The evils from this cause, in a few instances, induced a distinguished teacher, (J. Hamilton, jun.) to discountenance the employment of calomel, in the latter periods of his life, although, when the author attended his lectures, he was one of its strongest advocates. If the disease occurs in a child under two years of age, much apprehension need not be entertained on this head, as it is extremely difficult to salivate at that age; but if the child be older than this, the effects of mercury on the system are exerted with great facility, especially if the inflammation be not very violent. In this, as in many other cases of inflammatory disease, as soon as the revellent operation of the mercury is apparent, the progress of the disease is generally arrested, and it has been inferred, that could the subject of inflammatory croup be brought under the influence of mercury, before suffocation takes place from oedema of the glottis, or before the rima is plugged up by false membrane, the disease would almost invariably be cured. (Ryland.) On the other hand, the mercurial treatment of croup has been characterized as insufficient and un- necessary. (Stokes.) It is assuredly uncertain, and liable to the occasional inconveniences that have been pointed out, but its revellent action may unquestionably be efficacious. Still, it should be employed with caution, and not in the profusion advised by many authors. Should the symptoms not yield to the emetic and warm bath,— and the difficult and peculiar breathing and cough remain the same, and especially if there be concomitant fever,—blood must be drawn either from the arm or jugular vein, or by means of leeches. There is perhaps no real advantage—as regards the removal of the disease—from bleeding in the jugular. It is the effect on the sys- tem to which we have to look; and blood should be drawn, until the pulse exhibits the effect of the agency, but short of inducing syncope. In all inflammatory diseases, this result should be avoided, as the reaction is generally proportionate to the preceding depression; but, in young children, still more caution is needed, as they sometimes do not rally after the operation. After blood has been drawn from the arm, should the case still be urgent, leeches may be applied around the neck, and their application be repeated, according to the nature of the case, and the strength of the individual. Along with the blood-letting may be conjoined the various reme- dies already recommended. This plan of treatment is, indeed, the one usually adopted, and found to be successful. General and local blood-letting have, however, been looked upon by an emi- nent practitioner and teacher, (Stokes,) as merely assistants to the "principal remedy," which he considers to be the tartarized anti- mony. This he advises to be given so as to produce free vomitins, at least once in every three quarters of hour. Others have advised OF THE LARYNX AND TRACHEA. 251 the same agent to be given so as to keep up a state of nausea, or of sedation, without vomiting. (Porter.) Both plans are unques- tionably efficacious;—the equalizing and revellent agency of the emetic appearing to operate as beneficially as the sedative agency of the nauseant. Blisters are frequently applied to the throat in the early periods of croup: but the practice is not generally esteemed to be judicious. Some, indeed, have considered it to be fraught with danger. (Stokes, Porter.) When applied to the throat, owing to their proximity, they may add to the irritation in the larynx, whilst no revellent agency can be expected from them. The application of a soothing cataplasm, where it can be employed, is a more philo- sophical and successful remedy. It is asserted, however, that sponging the throat and chest, with water as hot as can be borne, has been found, in many instances, capable of arresting at once all the threatening symptoms of croup. (Graves.) It has also been advised to apply pounded ice to the throat; but the author is unable to say anything respecting its value from his own observation. In the impressible frame of the infant, caution ought, however, to be exerted in the use of cold and moisture, especially where the lining membrane of the respiratory apparatus already labours under more or less inflammation. (Andral.) A recent writer (C. Wilson) speaks in high terms of the success he has obtained from the use of the tartrate of antimony and potassa as a contra-stimulant. He generally commences the treat- ment with the application of leeches to the larynx, which are fol- lowed by warm poultices, frequently renewed; and simultaneously with the leeches the tartrate is begun with, in doses of one-fourth or one-third of a grain;—at first, generally, every hour, until a de- cided impression is made, and afterwards every two hours, until the patient is considered in safety. It is usually given in the form of mixture, with a little mucilage; and, occasionally, in older chil- dren, half a minim or a minim of .the tinctura opii was added to each dose, which appeared to have a marked effect in insuring the tolerance of the medicine, without diminishing its usefulness. Along with this remedy, others—as blisters—which are generally employed, were not neglected. In the croup of children, as in that of the adult, it has been re- commended to apply the stick nitrate of silver, by means of a bent port-caustic, so as to cauterize the pharynx freely; (F. Ha.'in;) but the recommendation has not experienced much favour. M Hatin found it of no use after the false membrane had formed. Such are the main agencies to be invoked in the treatment of the first stage of croup. A period too often arrives, when the vigorous employment of antiphlogistics can be productive of no good, and may be prejudicial. Occasionally, too, the practitioner is not consulted until there is reason to believe that the morbid for- mations within the larynx and trachea have actually taken place 252 DISEASES OF THE RESPIRATORY ORGANS. In these cases, although leeches may be occasionally advisable, it must be borne in mind, that the abstraction of blood may enfeeble the patient without arresting the inflammation, so that he may die exhausted from the recuperative action necessary for removing the false membrane or other termination of the inflammation. The use of mercury, in the manner already pointed out, has been sug- gested, under the idea, that it has the power of diminishing the plasticity of the blood, and, therefore, of modifying the secretion from the lining membrane of the larynx and trachea. Its whole agency, however, is probably revellent. Liquid ammonia has been administered with the same view;1 and it has been proposed to introduce a certain quantity of water into the vessels, with the view of diminishing the plasticity of the fluid. This, however,— as well as various local applications to the fauces,—has been chiefly advised, in diphtheritic affections, to modify the condition of the fluid of the circulation. 1 R.—Aq. ammon. gtt. iv.; in Aquae cyatho ter die sumend. In this second stage of the disease, occasional emetics are neces- sary to remove the false membranes from the trachea, (Vieusseux, Porter); and along with mercurials they form the main part of the treatment. In addition, blisters may be applied to the top of the chest; and should the powers fail, it may be necessary to support the system by the ordinary excitants, and especially by those of a more permanent character; of these wine-whey is perhaps the best. Hot turpentine stupes may likewise be applied to the chest and extremities, "and now and then the reward of the nil desperan- dum[practice may be unexpectedly obtained." (Stokes.) With regard to the operation of tracheotomy, in cases of primary or idiopathic croup, it is generally disapproved of by authors. (Cheyne, Porter, Royer Collard,Bricheteau, Vieusseux, Double, Albers, Jurine, Maunsell, Stokes.) The operation, in extremely rare cases, has been successful, but, in almost all, it has been un- successful, and when we bear in mind, that fatal cases never occur without the bronchial tubes' lower down being affected with the malady, we can see the reason why it is so rarely attended with success. It is likewise a serious objection to the operation, that the struggles of the patient, the constant motion of the larvnx up- wards and downwards, and the hemorrhage, apt to take place from the hyperamnc condition of the thyroideal veins, render it extremely difficult. It is now, indeed, rarely thought of. In a discission which took place at the Academie Royale de Medecine, he following was given as the ratio of success with the different celebrated operators, whose names are mentioned:- OF THE LARYNX AND TRACHEA. 253 Operations. Cures. Deaths. M. Amussat, G 0 6 Baudelocque, 15 0 15 Dlandin, 5 0 5 Bretonneau, 18 4 14 Gerdy, 6 4 2 Roux, 4 0 4 Trousseau, 80 20 60 Velpeau, 6 0 6 140 28 112 A few words are necessary as to the treatment of the Croup of the Adult, which, as has been seen, is secondary in its character, and connected with the same diphtheritic habit that gives occasion to diphtheritic stomatitis and diphtheritic gastritis. The remarks as to pathology and therapeutics, made under the latter disease, are equally applicable to diphtheritic laryngo-tracheitis. Mercury, administered so as to affect the system, has been given with the same views as in primary croup—that is, to diminish the plastic tendency in the blood, and cases are on record, in which very severe cases of diphtheritis of the air passages appear to have been cured by it. (Bretonneau, Louis.) Great reliance has, however, been placed on the topical applica- tions recommended in diphtheritic pharyngitis, and especially on the muriatic acid, nitrate of silver, alum, the sulphuret of potassa, and the muriate of ammonia, applied in the manner directed under Chronic Laryngitis. Tracheotomy has likewise been advised in cases of diphtheritic laryngo-tracheitis, when urgent symptoms arise, which threaten suffocation. Perhaps, in such case, it might be more serviceable than in cases of primary croup, in which there is so frequently a combination of bronchial and pulmonary in- flammation. It has been proposed, with another view likewise,— to introduce through the aperture the local applications that have been found so useful in diphtheritic pharyngitis. (Bretonneau.) Fragments of the membraniform exudation are occasionally ex- pelled through the opening, and through it agents, as calomel, have been introduced to act on the morbid surface. Eight grains of calomel, introduced in this way, appear to have afforded marked relief in one case. (Bretonneau.) Powdered sugar and powdered alum have been blown into the larynx through the aperture in the same manner. One of the great advisers of topical applications introduced into the larynx, (Trousseau,) appears to have less con- fidence in them than formerly. They are, indeed, not much em- ployed. III. SPASM OF THE GLOTTIS. a. In Children. Synon.—Laryngismus stridulus, Asthma spasticum Infantum, A. Infantum Bpasmodicum, A. Intermittens infantum, A. dentientium, A.periodicum acutum, Spasmus glottidis, Asthma Thymicum Koppii; Cynanche trachealis spasmodica, Asthma acutum Millari, Crouplike inspiration of infants, Child crowintr, Spas- VOL. i.—22 v 254 DISEASES OF THE RESPIRATORY ORGANS. modic croup, Pseudo-croup, Spurious croup, Millar's asthma, Cerebral croup, Suffocating nervous catarrh, Thymic asthma, Koppian asthma; Fr. Asthme aigu de Millar, Pseudo-croup; Ger. Millar's hitziges Krampfasthma. This disease was known to the older writers, but the first accu- rate description of it was given by Dr. J. Clarke, under the designa- tion of "a peculiar species of convulsion in infant children." Of late years, it has attracted more attention, (Ley, Pretty, H. Davics, North, Gooch, Marsh, Joy,) and by many of the German and other writers, (Kopp, Caspari, Hirsch, Most, Montgomery, Hood,) has been termed in consequence of their views of its pathology, Asthma thymicum, and Asthma thymicum Koppii. Diagnosis.— This affection is so alarming in its character, that it immediately excites the attention of parents. It consists, essen- tially, in a diminution of the aperture of the glottis, so that the respiration is occasionally arrested for a moment; and after violent efforts, the child alternately succeeds in drawing in its breath, with a sound approximating to that of croup or hooping-cough, and occasioned by the very narrow chink through which the air passes. After a time, the attack ceases, and the child remains in its ordi- nary health; but sooner or later, the disease returns;—at first, the child waking out of sleep in one of them, but, subsequently, this may occur whilst it is awake. The intervals between the pa- roxysms are at first considerable, but they become less and less, until frequently the child scarcely recovers from one, before it is attacked with another. During the paroxysm, the face often be- comes swollen and livid, and the veins filled with black blood. At various intervals, from a few seconds up to a minute, or at times nearly two minutes, air is at length admitted through the glottis, passing through the contracted rima glottidis, and giving occa- sion to the peculiar crowing sound. " To these symptoms not unfrequently succeed a fit of coughing or crying, which terminates the scene; or, if the glottis be not even thus partially open, the child at the end of from two to three minutes, at the utmost, will die of asphyxia; pallid and exhausted, it falls lifeless upon the nurse's arm, and it is then that the child is generally said to have died in a fit." (Ley.) Either just before, or for some time after, a paroxysm, the noise of the patient's breathing is that which an increased secretion of mucus in the air passages would produce. (North.) The symptom is rarely absent, and communicates to the affection the appearance of catarrh, and especially of the catarrhus suffocativus, by which name it has been known by some. (Ley.) Sooner or later in the disease, the hands and feet become slightly swelled, and the fingers and toes rigid, the thumb being frequently drawn forcibly into the palm of the clenched hand. It is not, how- ever, the flexor muscles that are alone affected. The spasm has been observed in the extensors, producing a permanent spreading and extension of the fingers, which has been considered to denote a less serious lesion of the nervous system than the opposite con- \ OF THE LARYNX AND TRACHEA. 255 dition. (Maunsell.) The presence of these symptoms has given occasion to the names Carpopedalspasm, (James Johnson,) Cere- bral spasmodic croup, and a spasmodic affection of the chest and larynx in young children, accompanied by general or partial convulsions. (North.) By the generality of writers, it is conceived, that there is a natural association of the disease with the convul- sions, but it may exist without them. (Marsh, Ley.) As to the prognosis, great variety of sentiment has existed. Whilst some have esteemed it an affection of the most serious nature, (Simpson, J. Hamilton, Jun., Clarke, W. Griffin,) it has been maintained that it is rarely fatal, (North,) whilst others think it will generally yield to proper remedies. (Millar, Rush, Under- wood, Marsh.) It is certainly an alarming affection, and very frequently proves fatal. We have known several children in the same family die in succession when they attained the same age. Causes.—The fact just mentioned shows, that a predisposition to this affection is laid in organization, a circumstance which has been proved by other observers. (Pretty, North, H. Davies, and Ley.) Age offers another predisposition. Although the disease has been met with at a later period, the large majority of cases occur before the termination of the first dentition. It would seem, Jikewise, to be a complaint of damp situations and seasons. It this country, it is very rare. Almost all writers, again, agree, that it occurs generally in those of the strumous habit. Among the exciting causes, must be ranked powerful mental emo- tions, and anything that can over-excite the nervous system or any part of it. In one case, a paroxysm was induced, whenever the child was brought back to a newly painted house. (Marsh.) Pathological characters.—We have much still to learn on this interesting subject; and the proof of this is, that, even at the present day, different opinions exist as to its nature. It has been thought to be, in the first instance, a spasmodic affection of the muscles of the glottis; and that it is not until the disease has increased in severity, and general convulsions have arisen, that the brain or its meninges become the seat of disease. The seat of the primary lesion has been presumed to be at the origin of the pneumogastric nerve. (Marsh.) By others, it has been supposed to be in the brain. (Clarke, Cheyne.) By others, it has been referred to hyper- trophy of the thymus gland, producing pressure upon the heart, lungs, and great vessels; (Kopp, Hirsch, Most, &c.;) and, lastly, it has been maintained to be owing to enlargement of the bronchial or deep-seated lymphatic ganglions of the neck, pressing on the re- current nerves, and inducing paralysis of the muscles supplied bv them. (Ley.) rr J Dr. Ley's view, consequently, differs from those usually em- braced, m regarding the affection to be more allied to paralysis than to convulsive movement. Before his work appeared, it was generally believed to be spasmodic; and, in the opinion of most writers, the spasm of the muscles of the larynx was owing to 256 DISEASES OF THE RESPIRATORY ORGANS. the existence of cerebral disease, usually of an inflammatory cha- racter. As a general rule, however, when the affection of the glottis has occasioned death at an early stage, no pathological appearances have been perceptible in the brain or its meninges; and when such appearances have existed, numerous attacks of spasm have occurred, so that the cerebral lesions have often, cer- tainly, been secondary. Treatment.—This has varied according to the pathological views of the practitioner. Where the disease has seemed to be complicated with difficult dentition, derangement of the digestive apparatus, and with marks of a strumous habit; (Marsh, Maunsell;) the gums, if a tooth be pressing forward, must be freely divided; the diet regulated; and free exposure to pure air be recommended, with the various agents advised, when dentition is accompanied by morbid derange- ment. The head affection—should it exhibit itself—must be treated by the rules laid down under diseases of the encephalon. The exciting causes, too, must be removed whenever this is prac- ticable. Such would seem to be an outline of the general principles applicable to most cases of this disease;—an outline, which will have to be filled up by the practitioner, according to the indica- tions presented by the individual case. Should enlargement of the thoracic or cervical lymphatic gan- glions exist, which, we are told by one writer, (Ley,) is the fact in nineteen cases in twenty; the cause of the enlargement must be investigated, and, if it be owing to bronchitis, cutaneous affections of the scalp, or scrofulosis, they must be first removed, if practicable. If the glandular enlargement be active, and there is a tendency to suppuration, it must be encouraged, and the abscess be opened as early as possible; on the other hand, if it be indolent, its absorption must be attempted by iodine, or its salts, administered internally , or externally, or both. The neck and upper part of the sternum may be rubbed, morning and evening, with an ointment of iodine1 and the solution of iodide of potassium, (gtt. iij. ter die,) or of the iodide of iron, (gtt. iv.—vj.), which is generally preferable, in con- sequence of the defective nutrition, that always accompanies, or rather forms scrofulosis, may be given, gradually increasing the dose. 1 R.—Potass, iodid. p. j. Cerat. simpl. p. viij. The two great remedies, relied upon by one respectable writer, (Merriman,) in this malady, are soda and burnt sponge—the latter of which owes its main efficacy to the iodine which it contains. The soda prevents the predominance of acidity, so fruitful a source of the bowel complaints of children, and the burnt sponge is one of our best agents for inducing a modified condition of the function j of nutrition. The believers in the existence of hypertrophy of the thymus, as OF THE LARYNX AND TRACHEA. 257 € a cause of this disease, advise that all undue congestion and nervous excitement in the heart and lungs should be diminished, and pre- vented by low diet, large and frequent local bleedings every four or eight days; blisters and issues on the chest, constant active cathartics, &c, and that the hypertrophy of the thymus should be diminished by mercury, iodine, &c. (Hirsch.) The practitioner should, however, be careful in a disease, un- questionably associated, in most cases, with scrofulosis, not to reduce the system so far -as is inculcated by this view of the pathology of the disease. Great advantage has arisen from the revulsion afforded by a change of air in chronic cases, especially by a removal from a cold and moist to a warm and dry air. Such, at least, is the general belief; and it is a result which might be anticipated. It has been deprecated, however, by one writer, (Mackintosh,) who exhibits, in his works, too many evidences of a desire to be singular in his sentiments. He remarks, that change of air is said to have worked wonders;—that he has seen it beneficial when the child was re- moved from a cold, bleak situation, to a milder and more sheltered spot, but that he has "more frequently observed change of air hurtful." As regards the treatment during the paroxysm, little need be said, as it is commonly ended before the practitioner can be called. Nothing more can be done than to place the child in the erect or sitting posture; to use friction along the spine; to sprinkle cold water on the face, and apply ammonia to the nose, so as to induce crying, or sneezing, or some strong form of expiration, during which the glottis is exposed, and the paroxysm terminates. If the fit does not yield to these remedies, vomiting may be excited, and friction used over the body, or the child may be placed in the warm bath. The case of a child, two years old, has been narrated, (Marsh,) in which very frequent attacks, complicated with general convulsions, were stopped, and suspended for a month, after the administration of a tobacco enema, (five grains of the leaves to an ounce of water.) Should none of these agents succeed, the operation of tracheo- tomy has been suggested; but this ought scarcely to be performed, unless the child is in a state of asphyxia, when every effort should be made to inflate the lungs, and restore the breathing. Among the agencies, in this view, tracheotomy is one of the most im- portant. (Porter.) The child, that is liable to such attacks, should be warmly clad, and protected, as far as practicable, from vicissitudes. The diet, too, should be the breast milk, whilst the child is at the breast; and, if not, cow's milk, diluted with two-thirds of sweetened water, or with weak arrowroot. b. In Adults. Spasm of the glottis, occurring in the adult, owing to pressure on 22* 258 DISEASES OF THE RESPIRATORY ORGANS. the larynx and trachea, or on their nerves, has been separated from the spasm of the glottis of children, (Ryland), although the symp- toms, causes, &c. are much the same. In the adult, however, the affection is secondary; whilst in the child, this is doubted by many, although maintained, as has been seen, by some. The disease, in such cases, may arise either from irritation of an inflammatory nature, in the immediate vicinity of the larynx, (Fletcher); from foreign bodies in the oesophagus, (Pelletan); from bronchocele, (Fletcher); from aneurism of the arteria innominata, (Lawrence.) &c. &c, all of which must be diagnosticated by the appropriate rules. The prognosis is of course, unfavourable, inasmuch as it merges in that of the original affection, which is often irremediable. The great object is, by every care to prevent the recurrence of the paroxysms of suffocation, by avoiding every source of mental and corporeal agitation. Perfect quiet, an inclination of the body forwards so as to favour the respiratory efforts, the warm bath, with opiates, have been recommended during the continuance of the paroxysm. (Ryland.) In hysterical females, a spasmodic affection of the laryngeal muscles is by no means unfrequent, giving rise to what has been termed " hysteric croup." The paroxysms consist of a long pro- tracted, loud and convulsive cough, followed, at times, by the crowing inspiration, and by dyspnoea so great as to threaten suffoca- tion. This state may continue for two or three hours, until the patient faints, or a decided hysterical attack supervenes. The treatment is that recommended for hysteria. During the paroxysm, new impressions must be excited by cold water thrown over the face and neck; or by the douche from the spout of an ordinary teapot. The compound spirit,or the carbonate,of ammonia, must be held to the nostrils; and when the patient is able to swallow, the various remedies advised for hysteria must be administered. In one case the creasote1 was used with much benefit as an inhalation. (Dr. Herndon, of Virginia.) 1 R.—Creasot. gtt. xxx. Aq. fervent. Oij.—M. \ IV. MORBID PRODUCTIONS IN THE LARYNX AND TRACHEA. a. Hypertrophy of the Cartilages.—The different cartilages of the larynx and trachea may become hypertrophied, but no incon- venience results from this, provided the mischief does not proceed too far; but if it occasions narrowness of the larynx, all the signs of suffocation may ensue. During life, there is a constant sense of constriction in the larynx, and progressively increasing dyspnoea; and, on dissection, the cause of the symptoms is apparent. (An- dral.) If the hypertrophy be accompanied by tenderness on pressure, leeches may be applied over the affected part, and an ointment of iodine1 may be rubbed in, night and morning. OF THE LARYNX AND TRACHEA. 259 ' R.—Iodin. gr. v. Adipis, 3ij.—M. Quantity for each friction, a half drachm. b. Ossification of the Cartilages.—This is a physiological result in the aged, in whom the various cartilages of the larynx are always found more or less ossified—a change which does not produce any inconvenience, unless they become hypertrophied, when the phe- nomena may occur, which have been described abovei When entirely ossified, they are said to have caused death by occasioning total dysphagia. (M. Baillie, Travers;) but this must be a very rare case. The arytenoid cartilages are seldom ossified, (Andral;) but they have been found so. (Travers.) The cartilages of the trachea are likewise often ossified in the progress of life without any evident symptoms arising. c. Tubercles.—These are sometimes met with in the mucous membrane, but scarcely ever except where the individual is, at the same time, affected with phthisis. When they occur primarily in the larynx, they may undergo softening, and give rise to all the phenomena of chronic laryngitis. d. Polypoid and other Tumours, &c. &c.—The polypoid tumours, which form in the larynx and trachea, are similar to those of other mucous membranes. Their presence is not indicated by any pa- thognomonic signs, and, therefore, they are not detected until after death. They are generally found above the inferior ligaments of the larynx, and are attached by a pedicle either to the ventricles of the larynx, or to the ligaments. Tumours of various kinds have likewise been found, on dissec- tion, in the larynx, and calculous concretions and hydatids in the ventricles. V. FOREIGN BODIES IN THE LARYNX AND TRACHEA. When any foreign substance passes into the larynx of an adult, there is rarely difficulty in the diagnosis, inasmuch as the history of the case is sufficiently known; but in children, there is not the same facility; and cases of foreign bodies, impacted in some part of the air passages, have, doubtless, often been mistaken for spasm of the glottis and croup. Diagnosis.—As soon as the extraneous substance has passed into the larynx, it gives rise to a train of symptoms extremely like those of croup, but differing somewhat, according to the size and character of the substance, and the part of the air tubes, in which it may be situate; whether, for example, it be in the larynx, the trachea, or bronchial tubes. In the majority of cases, where it is met with in the last situation, it is in the right bronchium, either owing to the greater size of that tube, or to the anatomical arrange- ment of the trachea at its bifurcation directing the substance into the right bronchium, or to both. The projection or septum, which divides the right and left bronchium, is not in the mesian line, but to 260 DISEASES OF THE RESPIRATORY ORGANS. the left of it, so that this direction is naturally taken by the extra- neous body. (Stokes.) As soon as the foreign body has reached the larynx, and espe- cially if it remains there, the symptoms are violent and distressing, this part of the windpipe being possessed of more irritability than lower down. The child is suddenly attacked with violent spas- modic cough, croupy breathing, pain in the region of the larynx, and paroxysms of suffocation, in which the dyspnoea has been observed to be greater during expiration than during inspiration. (M'Namara.) The case may terminate fatally from mechanical obstruction, or the substance may pass through the rima glottidis into the trachea, after which relief is obtained, which is, however, but temporary, and is generally followed by inflammation of the bronchial tubes or of the pulmonary tissue, of an acute or chronic character. The most favourable event is the expulsion of the extraneous body from the mouth, after which the symptoms speedily yield, except where its presence has given rise to serious bronchial or pulmonary mis- chief, under which the patient may succumb. If a child has been previously in perfect health, and has been playing with some small article, after which it is attacked with the violent symptoms described above, the presumption will be great, that the article has passed into the windpipe. The physical signs, which throw light on the case, will be as follows:—If the extraneous body be still in the larynx, and no dis- ease have supervened in the lung, the sound rendered on percussion and auscultation of the chest will be as in health; the respiratory or vesicular murmur may be everywhere clearly distinguishable. When the extraneous substance is movable in the trachea, its motion up and down the trachea may be occasionally heard, as well as a valve-like sound, produced by its being violently driven, in expiration, against the rima glottidis. (Maunsell.) This, how- ever, is not included by all among the physical signs, farther obser- vations being considered necessary to establish it. (Stokes.) If the foreign body has passed down into one of the bronchia,the physical signs are more valuable. In such case, it may either have obstructed the bronchium completely, or imperfectly. Hence, the respiratory murmur in the corresponding lung, is either greatly diminished or altogether gone, whilst the sound on percussion re- mains the same; and the opposite lung—into which the whole of the air must now pass—exhibits the puerile respiration. When the foreign body passes up from the bronchium into the trachea, the respiratory murmur will be again heard in the affected lung. Treatment.—Emetics have been advised, with the view of causing the expulsion of the foreign body, and where it is small, they may be of service. As it is the mechanical succussion, which is needed in such cases, the direct emetics are capable of accom- plishing all that the others can effect, whilst they operate much OF THE BRONCHIA AND LUNGS. 261 more speedily. The sulphate of zinc may, therefore, be given, (gr. vj, dissolved in water, to a child,) or the throat may be tickled with a feather. Should this fail, recourse should be had to bronchotomy, and it mnst be borne in mind, that the earlier it is practised, the greater will be the safety of the patient. CHAPTER II. DISEASES OF THE BRONCHIA AND LUNGS. I. INFLAMMATION OF THE BRONCHIAL TUBES. Synon.—Bronchitis, Inflammatio bronchiorum, Angina bronchialis, Catarrhus rulmonum, Pleuritis humida, P. bronchialis, Pulmonary catarrh; Fr. Bronchite, nrlammation des Bronches; Ger. Entzundung der Luftrohrenaste, Bronchial- entzundung. Inflammation of the bronchial tubes, like other inflammatory affections, admits of two well founded divisions, the acute and the chronic; and the former may be subdivided into the ordinary acute and the epidemic form. a. Acute Bronchitis. 1. Ordinary Acute Bronchitis. Not many years ago, bronchitis and catarrh, or pulmonary catarrh were generally separated from each other; but by most modern pathologists, they are usually classed together, although the latter may not be confined to the mucous membrane of the bronchial tubes, but extend along that of the trachea, larynx, and indeed, along that of the pharynx and nose; constituting, in the nose, a cold in the head, coryza or nasal catarrh; which, when confined there, it need scarcely be said, cannot be regarded as bronchitis, by any forced extension of the term. The French, again, and, in certain cases, the British pathologists also, have usually separated " catarrh" from the " pulmonary catarrh," applying the former term, to an increased secretion from any mucous membrane;—thus, a defluxion of mucus from the intes- tines, has been termed catarrhus intestinorum—from the bladder, catarrhus vesicce, &c. It is of great moment, however, to abolish terms, which are employed with different significations, and hence there is advantage in considering the pulmonary catarrh, as synonymous with bronchitis. The milder forms of bronchitis, constituting what is commonly called a catarrh, are familiar to all, and no one passes through life without being affected by them. They are generally, however, easily managed, and commonly receive no medical attention what- ever. 262 DISEASES OF THE RESPIRATORY ORGANS. Diagnosis.—As inflammatoryjor other irritation of the lining membrane of the nose is indicated by sneezing, so is that of the bronchial tubes by cough; both being owing to the reflex nervous action, which gives occasion to a convulsive respiratory effort on the part of certain muscles, to drive the air rapidly through the air passages, and thus to sweep away from the mucous membrane any source of irritation that may exist there. Cough, consequently, in these affections, is a mere symptom, although of old it was re- garded as a distinct morbid condition. In the first instance, the cough of bronchitis is dry, in conse- quence of the first effect of inflammation of mucous membranes, being to diminish or arrest the discharge from them; but this state soon passes away, and the mucous follicles secrete a larger quantity than in health, and a fluid of an abnormous character; the patholo- gical state resembling, again, the common cold in the head, in which the nasal mucous membrane is first of all devoid of its ordi- nary secretion, but soon secretes an unusual quantity of a thin mucus. It is this condition, when accompanied by more or less hurry and oppression of breathing, and some degree of febrile movement, which we understand by the term "common catarrh." When the inflammation of the bronchia is to a greater degree than this, a deep-seated pain is experienced in the thorax, with a sense of heat under the sternum; frequent cough, at first dry; diffi- culty of breathing, and excitement of the circulatory function in a ratio with the degree of the inflammatory action. More or less headache is generally experienced, especially after the fits of coughing; and if the inflammation is considerable, the face is red and tumid; the appetite gone; there is more or less thirst; the tongue is white; and the mouth clammy. At times, the fits of coughing occasion vomiting, and there is commonly, as in most febrile and inflammatory affections, an in- crease of the symptoms towards evening. Occasionally, too, the bronchitis is accompanied by phlegmasia of other mucous mem- branes, and there is a protracted febrile indisposition, to which the name "Catarrhal Fever," has been given, although the term is often used synonymously with acute bronchitis. In severe cases, the cough is violent, and recurs in paroxysms occasioning a severe pain and sense of laceration, which is often referred to the lower portion of the sternum. The pain shoots with violence from the ensiform cartilage to the back; and, owing to the exertion in coughing, the various muscles of the chest and abdomen are painful on pressure. About the second or third day of the disease, the cough, which had been previously dry, becomes more moist, and a thin, frothy secretion is expectorated, with more or less difficulty;—the sputa gradually become more copious and consistent, viscid and ropy; and, at length, are thicker, more opaque, and less in quantity. Towards the termination of the disease in health, they become OF THE BRONCHIA AND LUNGS. 263 white, yellow, or, more frequently, of a gosling-green colour; and, if expectorated into water, they are suspended at or near the sur- face. Occasionally, pus is united with the mucus of bronchitis, especially in cases of measles. The author had a case of this nature under his charge, a short time ago, in which the quantity of pus, secreted by the bronchial mucous membrane, was surprising; the physical signs showed satisfactorily, that there was no cavity. At times, also, the matter of expectoration is streaked with blood; and cases have occurred in which it has been found tinged with bile. (Andral.) In other cases, a pseudomembranous secretion is expectorated, which has the shape of the bronchial tubes, and generally requires violent efforts of coughing to separate and expel it. To this form of the disease, the names Bronchitis membra- nacea, Plastic bronchitis, and Bronchial polypus, have been given. (J. North, Corrigan, Cane.) The physical signs of bronchitis are more negative than positive. Percussion renders a clear sound over every part of the thorax, indicating that there is nothing like morbid deposition or consolida- tion. Auscultation indicates a sibilant or whistling, dry rhonchus or rdle, exhibiting thickening of the mucous membrane, and conse- quent narrowness of the tubes; and, at a later period, when the mucous secretion has become increased, the mucous rdle is heard. The respiratory murmur is commonly heard everywhere; but, on careful examination, it may be found momentarily absent in certain parts, which is attributable to the bronchial ramifications being obstructed by the secreted mucus, or by a plastic secretion; and, as soon as this is expectorated, the respiratory murmur is ob- served to return. The duration of the disease varies; but the average may be reckoned at from one to two weeks. Mild cases of bronchitis—those commonly classed under the head of Catarrh—almost always terminate favourably. The same may be said of the majority of cases of active bronchitis; but, occa- sionally, owing to the extension of the inflammation to the small bronchial subdivisions, and to its narrowing the tubes and filling them with mucus, death takes place from asphyxia. The disease may likewise pass into the chronic form, or may become compli- cated with pneumonia; and there would seem to be no doubt, that tubercles may form, and pass through their various stages, so that death may result from phthisis. (Andral.) It is proper to remark, that simple bronchitis almost invariably oommences in the lower and posterior portions of the lungs, usually attacking both sides, and advancing from below upwards, whilst the opposite is the case in phthisis. (Louis.) Causes.—These are the same as those of the inflammatory affec- tions of the respiratory apparatus in general. It may likewise be induced by the inhalation of irritating gases and extraneous bodies contained in the atmosphere—as in the operations of the miller, the glass-cutter, &c. &c. It forms a part, as it were, of one of the 264 DISEASES OF THE RESPIRATORY ORGANS. eruptive fevers—measles; and, not unfrequently, supervenes on other diseases—as variola, scarlatina, and hooping-cough. Pathological characters.—The bronchial mucous membrane is generally red; at times, in patches; at others, universally. Some- times, the inflammation is confined to one lung, and even to one lobe of a lung. The redness of the mucous membrane is usually deeper in the smaller bronchial ramifications, and gradually be- comes less so on ascending towards.the larynx. The membrane is not uncommonly thickened; and when this is the case in the larger tubes, no great inconvenience may have been experienced; but if it exists in the smaller tubes, so as to diminish their calibre materially, dyspnoea, with the sibilant rhonchus, may be the result. At times, the bronchial tubes are found lined with a membraniform or plastic secretion, and there is always in the bronchial subdivi- sions a greater or less quantity of the fluid that was expectorated during life. Treatment.—The treatment of a mild case of bronchitis, consti- tuting ordinary catarrh, is extremely simple. It is generally suffi- cient to recommend rest in bed, the equalizing influence of the temperature being most salutary. At the same time, the patient must abstain from animal food, and subsist chiefly on gruel or arrowroot, or tea; and, if the cough be severe, seek to allay it by means of jujube paste, simple gum lozenges, or any mucilaginous mixture or oily emulsion. R.—Mucilag. acaciae, |iss. Or, R—Mistur. amygdal. gv. Syrup, papav. ^j. Liq. morphiae sulphat. 3j.—M. Aquae, Sjiiiss.—M. Dose, a tablespoonful, when the cough Dose, a tablespoonful, when the cough is troublesome. is troublesome. Before the patient goes to bed, the feet may be put into a mixture of warm salt and water, or water in which flour of mustard has been stirred, constituting the sinapized pediluvium of the French writers. Warm wine whey, also, acts favourably as a gentle stimulating diaphoretic; but caution is needed, where there is danger of the supervention of acute inflammation of the bronchial tubes or of other tissues. Where the febrile irritation is considerable, the sense of heat and pain in the chest great, with much dyspnoea, and violent and frequent cough, blood may be taken, and the operation may have to be repeated, when the patient is young and vigorous, more than once or twice. In the very severe forms, indeed, the safety of the patient reposes on the vigorous employment of general blood- letting, followed by the application of cups or leeches to the chest, and, subsequently, of blisters, and the contrastimulant use of the tartrate of antimony and potassa,—on all the means, in short, which are demanded in acute laryngitis. Emetics, by their equalizing and revellent action, are especially advisable. Expectorants and diaphoretics—so much prescribed—are de- clared by a recent writer, (Mackintosh,) to be more injurious than OF THE BRONCHIA AND LUNGS. 265 beneficial, except perhaps in chronic affections; and he deplores the loss of much valuable time by trusting to their action. The remark is just, but the common error consists in the belief that there is any agent, that can act either as an expectorant or as a diapho- retic in all states of the system. Where it is necessary to encourage expectoration, or diaphoresis, the pathological cause of the obstruc- tion must be inquired into, and, where practicable, removed; but in acute bronchitis, no expectorant or diaphoretic, which is indebted for its properties to its excitant agency, is admissible, whilst in chronic bronchitis these same agents may be employed with great advantage. In cases of plastic bronchitis, mercury, given so as to affect the mouth, has been regarded as a certain remedy. (Cane, Corrigan.) It need scarcely be said, that in acute bronchitis the regimen should be that of other highly inflammatory diseases. 2. Epidemic Acute Bronchitis. Synon. Influenza, I. Europaea, Catarrhus epidemicus, Febris catarrhalis epidemica, Catarrhus a contagio, Kheuma epidemicum. The names given to epidemic catarrh, in various countries, and in the same country, have been various. In Germany, it has been called Spanischer Ziep, Pips, (epidemic of 15S0,) Schafhusten, (Sheepcough,) Modekrankheit, (fashionable disease,) Morbus ver- vecinus, M. Arietis, Hiinerweh, Cephalalgia contagiosa, (epide- mics of the 16th and 17th centuries,) and it is now usually called Injlucnz, Nordische Influenz, Russische Katarrh, Blitzkatarrh, epidemische Schnupfenfieber, &c. In France, it has been termed Tac, (a stroke,) Ladendo, Quinte, (used also for hooping-cough,) Florion, (a violent stroke,) Coque- luche, (until into the 16th century, after which it meant hooping- cough,) Baraquette, Generate, Grippe, (the common name in France at this time,) Follette, Grenade, Coquette, Petite Poste, Petit Courier, and Allure. In Italy, 77 Cortesivo Coculuco, (until into the 16th century,) Mai del castrone, Moutone, (so called from the tone of the voice,) Mazuchi, and Morbo Russo. In Spain, Catarrho epidemico. In England and America, Influenza, (in the 18th century, Hux- ham,) and Epidemic Catarrh. The Italians have employed the word Influenza for other epi- demics, and this is the reason why, in the chronology of one of their authors, (Zeviani,) it appears to have recurred more fre- quently than in that of other historians. The following dates of the recurrence of the influenza, to the commencement of this cen- tury, are on the authority of four different chronologists. Most. 1712, 1729, 1732, 1743, 1762, 1782, 1800. Saillant. 1510, 1557, 1558, 1574, 1580, 165S, 1669, 1676,1729, 1732, 1733, 1734, 1735, 1736, 1737, 1741, 1742, 1743,1761, 1775, 1780. Webster. 1510, 1557, 1580, 1587, 1591, 1597,1602,1610,1647, 1650, 1655, 1658, 1675, 1679, 1680, 1688, 1693, 1697, 1698,1708, vol. I.—23 266 DISEASES OF THE RESPIRATORY ORGANS. 1709, 1712, 1729, 1730, 1733, 1737, 1743, 1747, 1755, 1757,1762, 1767, 1772, 1775, 1781, 1782, 1788, 1789, 1790, 1795, 1797. Zeviani. 1239, 1311, 1323, 1327, 135s, 1387, 1400, 1410, 1414, 1438, 14S2, 1505, 1510, 1543, 1557, 1562, 1574, 1578, 1580, 1591, 1593, 1597, 1617, 1622, 1658, 1663, 1669, 1675, 1679, 1691, 1709, 1711, 1729, 1733, 1737, 1743, 1762, 1782, 1788. A modern writer, (Kluge.) from his investigation of this matter, considers, that the following is the chronological order of the return of the true influenza: 14th century—1323, 1326. 15lh do. ' 1410, 1411, 1414. 16th do. 1510, 1557, 1562, 1574, 15S0, 1593. 17th do. 1658, 1669, 1675, 1693. 18th do. 1708, 1712, 1729, 1732, 1733, 1742, 1743, 1761, 1762, 1775, 1776. 19th do. 1800, 1803, 1831, 1833. And to these may be added the well marked epidemic of 1837. (Blakiston, Graves, Broussais, Andral.) The most remarkable, perhaps, of the influenzas, was that of 1782, although those pf the last ten years were sufficiently striking in their general phenomena and peculiarities. The one of 1782 began in Europe in the far north, and in December, 1781, reached St. Petersburg, where it attacked, with electrical rapidity, 40,000 people in a single day, whence it got from the French the name of La Russe, and from other nations the appellation " Russian." From St. Petersburg, it spread to Poland, Denmark, and Germany; and in June and July of 1S34, had reached France, Spain, England, and Scotland; and in September of the same year was rife in the British American colonies. In the epidemic of 1831, 30,000 people, it was asserted, were suffering at the same time in Berlin; and, at a later period, 45,000 in Paris. (Most.) Of the European epidemics of 1831, 1833, and 1837, the two first were less severe, and attacked fewer individuals than the last. (Andral, Graves.) From a general view of various influenzas, M. Andral has deduced:—First. They differ as to the extent of their sphere of action—some appearing only in certain countries, whilst others invade the whole earth. Secondly. Almost all have travelled rapidly, commencing in the north, and extending towards the south,—at times, like a vast torrent, spreading from neighbourhood to neighbourhood; at others, bounding from countries to countries, sparing whole regions to rage in others more distant. Thirdly. As regards the number attacked;—at times, but few have been affected at first; at others, numbers. Fourthly. In regard to seve- rity;—some have been devoid of danger, whilst others have been fatal, and have destroyed especially children and old persons. Fifthly. As regards symptoms,—each epidemic has presented some special phenomenon; every form has constituted, as it were, a sort of morbid individuality, which, after its manner, ran through OF THE BRONCHIA AND LUNGS. 267 phases of increase and decrease, always commencing in the same way, and being invariably like unto itself. Sixthly. As to the parts affected;—some have been limited to the bronchia, but most commonly the disease invaded other mucous membranes, when the reaction was generally violent, and the affection assumed the inflammatory form; in one case, the nervous system predominated, and its influence was exhibited by an ataxic or adynamic form of the disease; in other cases, it was accompanied by haemoptysis or an exhalation of blood from other mucous membranes; at times, much sweating accompanied the disease; and, occasionally, the fluid of perspiration was extremely fetid. Lastly,—in certain cases, an effusion of serous fluid occurred into the abdomen. It has been remarked, that severe as the disease is, it is not one of danger, the bills of mortality seldom indicating any notable in- crease in the proportion of deaths during the existence of such an epidemic. (Geo. Gregory.) This, however, can only apply to certain epidemics: others have proved extremely fatal. The mor- tality of the epidemic of 1837, in Europe, was greater than that from cholera, although the disease was by no means so severe, or so rapidly fatal. This was owing to its attacking almost every person in society, whilst the ravages of cholera were comparatively limited. (Graves.) It has been estimated, indeed, that in Dublin alone, 4,000 persons died of the influenza of 1837. (Graves.) From the returns of a single cemetery—the Prospect cemetery, Glasnevin, probably the largest in Ireland—the increase of burials, during four months, in which the influenza prevailed, was 747. In December, 1835, - - - - 355 In December, 1836, - - - - 413 January, 1836, - - - - 392 January, 1837, - - - - 821 February, 1836, - - - - 362 February, 1837, - - - - 537 March, 1836,.....392 March, 1837,.....477 Total for four months, - - - 1501 2248 Increase, during influenza, 747. In Hamburg, there died in January, 1836, 466 persons; in De- cember, 1836, 364 persons; and in January, 1837, whilst the in- fluenza was raging, 836 persons. The mortality was extremely great among the aged. (Assing.) Ages. Jan. 1836. Dec. 1836. Jan. 1837. Between 20 and 30 - - - 35 - - - 28 - - - 48 30 " 40 - - - 35 * - - 45 - - - 68 40 " 50 - - - 36 - - - 29 - - - 58 50 " 60 - - - 36 - - - 38 - - - 90 60 « 70 - - - 55 - - - 36 - - - 128 70 " 80 - - - 37 - - - 36 - - - 117 80 " 90 - - - 12 - - - 10 - - - 37 90 " 100 - - - 4 - - - 2 - - - 3 102...........1 Diseases. Apoplexy, 33 41 67 Inflammation of lungs and pleura, 24 - 8 165 Catarrhus suflbcativus, --11 -- 9 --38 Phthisis pulmonalis, - - 64 - - 57 - 151 Marasmus senilis, 48 44 101 268 DISEASES OF THE RESPIRATORY ORGANS. Causes.—As to the causes of influenza, we know no more than we do of those of other epidemic diseases. It has appeared in all countries, and has raged with equal severity in all seasons, and, so far as can be observed, in all conditions of the atmosphere. Hence it has been conceived that it may depend chiefly on telluric in- fluence, or upon some agency connected with variations in the physical conditions which operate on the external surface of the earth, (Graves); but it is obvious that the supposition only indicates the little knowledge we have of the subject. The influenza of 1833-4, was by no means so generally fatal as that of 1837. Both were characterized by considerable irritation of the lining membrane of the air passages, but that of 1837 was attended by severe bronchitis and pneumonia, which were not as frequently seen in the epidemic of 1833-4: the accompanying fever of the latter was likewise more acute. In regard to the nature of the disease, various opinions have been entertained. Essentially, it consists of the catenation of symp- toms, to which the term catarrh or bronchitis is appropriated; but along with this, especially in the epidemic of 1837, the nervous system was greatly affected. By one of the writers (Blakiston) on the influenza of 1S37, it has been designated "an affection of the nervous system, with its concomitant derangement in the organs of digestion, circulation, &c, commonly known under the name ' nervous fever,' accompanied throughout its ivhole course • by irritation of the pulmonary mucous membrane;" and this view • appears to have been embraced essentially by other writers on the subject. (Graves, Andral.) Andral, however, concludes that it is a general affection, the nature and cause of which are as unknown as those of the greater part of epidemics, which appear at irregular epochs. Treatment.—If such be the diversity of phenomena in influenza, and such the uncertainty that hangs over it, it need scarcely be said that no fixed rules of treatment can be laid down. In simple, uncomplicated cases, very little management has been required. Keeping the patient in bed, and treating him as if affected with ordinary catarrh, has usually proved sufficient. By some, blood-letting was always considered to be counter-indicated, (Blakiston,) and especially if it were not employed within the first twelve or twenty-four hours, (Graves); but when used very early, it has often proved efficacious. Where any doubt, however, exists, ten or twenty leeches may be applied over the sternum, or from five to ten ounces of blood be taken by cupping. When tlie mouth is clammy, or bitter, and the tongue coated, with inappetency for food, and a sense of weight at the epigas- trium, an emetic1 may be given with advantage. (Andral.) 1 R.—Pulv. ipecac, gr. xv—xx.—or Antim. et potass, tart. gr. ij. The tartrate of antimony and potassa has also been administered as a nauseant, and in large doses as a contra-stimulant, but it has OF THE BRONCHIA AND LUNGS. 269 not exhibited the efficacy which it exerts in highly inflammatory diseases—as pneumonia and pleurisy, in which, when conjoined with the lancet, it has been regarded by one writer, (Cartwright, of Natchez,) as almost a specific. The lobelia inflata has been suggested by the same gentleman in influenza, under the notion that '• in those diseases affecting the mucous lining of the bronchial tubes, the lobelia inflata comes as near being a specific [?] as tartar emetic and the lancet in pneumonia and pleurisy." The lobelia is certainly a valuable sedative, but not deserving of the elevated rank that has been assigned to it. The diseases of the bronchial tubes differ, and no one remedy can be applicable to every patho- logical condition. When there was more than usual inflammation of the bronchia, in the epidemic of 1837, large doses of the ethereal tincture of lobelia, repeated at short intervals, with counter-irrita- tion, " seemed" useful. (Blakiston.) Should the cough be dry, and harassing, opiates may be ad- ministered, with mucilages or emulsions. R.—Emuls. amygd. ^vj. Or, R.—Mucilag. acaciae, ^j. Liq. morphiae sulphat. £ij.—M. Syrup, tolut. 3iij. Dose, a tablespoonful occasionally. 01. oliv. §ss. Aquae, ^ivss.—M. Dose, the same as the last. As to the particular form of counter-irritation, some difference of sentiment has existed. In the epidemic of 1837, blisters were not found as serviceable in all cases, as had been anticipated:— fomenting the neck and chest with very hot water appeared to be much more serviceable. (Graves.) At the commencement of the attack, it was often found neces- sary to have recourse to diffusible excitants, and to administer tonics at an early stage, (Blakiston); and during the convalescence, it was generally requisite to prescribe tonics, to restore the languish- ing functions of the stomach. (Andral.) b. Chronic Bronchitis. Synon.—Tussis senilis, Catarrhus senilis, Rheuma catarrhale, Peripneumo- nia notha, Bronchorrhoea acuta, Winter cough, Chronic catarrh. Chronic bronchitis is one of the* most common diseases of the temperate regions of the globe; yet—strange to say—it is only within the present century, that its pathology has been clearly understood. Neither acute nor chronic bronchitis was compre- hended in its true relations, until in 1808 an interesting treatise on bronchitis first appeared, (Badham); which was followed, not long after, by another on the chronic forms of the disease. (Hast- ings.) Since then, the inflammatory affections of the lining mem- brane of the bronchial tubes have received great attention from pathologists. Diagnosis.—It may be proper to observe before detailing the symptoms, that the trachea itself may be affected with chronic inflammation—constituting chronic tracheitis—independently of 23* 270 DISEASES OF THE RESPIRATORY ORGANS. any affection of the laryngeal and bronchial mucous membrane; commonly, however, the inflammation extends, so that either the larvnx or the bronchia become implicated. When the trachea is affected alone,—the disease is denoted by cough,—slight perhaps at first, but subsequently violent, with mucous expectoration, streaked at times with blood, and occasion- ally purulent. The pain is sometimes severe, and is felt from the base of the cricoid cartilage, to behind the last portion of the ster- num. When the mucous membrane is ulcerated, and greatly tumefied, a whistling sound is heard during respiration, which may give rise to the idea, that there is a tumour within the trachea. This state of the mucous membrane is accompanied by dyspnoea. The voice is rough, but not extinguished or veiled, unless the in- flammation implicates the inferior ligaments of the larynx. (Jin- dral.) The general symptoms are the same as in chronic laryngitis; and, as in the latter we have phthisis laryngea, so, in the former, we may have phthisis trachealis. (German writers.) Chronic bronchitis may be the termination of the acute; but, in other cases, it exists where there have been none of the evidences of the latter. The symptoms vary very materially, but in every case there is cough, differing, however, in its character and inten- sity, but always more marked, perhaps, than in other diseases of the respiratory organs. The expectoration, too, differs greatly. At times, it is clear and transparent; at others, very frothy; or, on the other hand, viscid, adhesive, and containing small white grains, which adhere to the vessel. These particles have been mistaken for portions of pulmonary tubercle, and, therefore, have been sup- posed to be indicative of phthisis; but if there be any doubt as to their nature and origin, the doubt may be dissolved by placing some of them on a piece of paper, and exposing them to heat. If they are merely sebaceous matter from the mucous follicles of the fauces and pharynx, they will leave on the paper a greasy stain, which will not be the case, provided they are tubercular matter from the lungs. In other cases, the sputa consist of a greenish yellow puriform mucus, which may either form a homogeneous mass, or the matter of each expectoration may remain distinct. Commonly, they are devoid of smell, but, at times, they are in- supportably fetid. Cases of this kind have fallen under the author s care, which have ultimately recovered, and many such are on record, on the authority of others. (Bricheteau, Stokes, Cook, of Buskirk's Bridge, New York.) The quantity of the expectorated matter varies, likewise, mate- rially. At times, it is so great as to exhaust; in other cases, the cough is severe and fatiguing; whilst the expectoration may be so trifling, that the disease has been called dry catarrh or dry bron- chitis, the catarrhe sec, of the French writers. The respiration may not be much affected; but, commonly, it is more or less oppressed, and, at times, seems to be complicated, OF THE BRONCHIA AND LUNGS. 271 as it were, with asthma—the difficulty of breathing recurring in paroxysms. Commonly, there is not much pain attendant upon it, unless the paroxysms of coughing are frequent, and severe. Nor are the general symptoms usually marked. At times, there is no accompanying fever; but, in other cases, the febrile movement is considerable; the inflammatory affection passing to the subacute form. When this is the case, the nutrition of the system is affected; emaciation takes place, with evident febrile exacerbations towards evening, and all the signs of hectic, under which the individual is gradually worn away. These are the severe forms of the affection, which approximate, in their symptoms, to phthisis pulmonalis. In the milder cases, individuals may be affected for years with chronic cough and ex- pectoration, without the general health suffering materially, if at all. Generally, the disease disappears, or is decidedly improved, during the summer,—returning every winter, so as to give occa- sion to the name " Winter cough." It has been already remarked, that the patient ma.y die, worn out by hectic fever: it would seem, likewise, that death may occur, in old people especially, owing to the copious secretion of mucus into the small bronchial ramifications interfering with haematosis, so that the nutrition of the frame is, in this way, modified, and asthenia induced; giving rise to the Bronchitis asthenica of authors, or to simple gleet or Bronchorrhoea, under which—especially on the supervention of inflammatory or other irritation in any other part of the economy—the patient succumbs. Occasionally, chronic bronchitis is accompanied by some affec- tion of the lungs or pleura, or some chronic cardiac affection, which must be appreciated, in order to form a sound prognosis, and to establish proper indications of therapeutics. The physical signs of chronic bronchitis are, like those of the acute, purely negative. The resonance of the chest may exist throughout. The different rhonchi or rales are heard as in acute bronchitis;—for example, the mucous rdle, which never occupies the whole extent of the chest, is not constant, and scarcely ever masks the vesicular murmur; sibilant rdles of different character, which have been compared, in certain cases, to the clacking of a small valve, or to the pronunciation of the word tic; gurglings, like those of phthisis, heard in parts where dilatations of the bronchial tubes exist; and cavernous respiration, pectoriloquy, or diffuse bronchophony with humid rdle, where the bronchial dilatations are considerable, and implicate a great number of the bronchia. The diagnosis of chronic bronchitis is generally easy; but, at times, marked difficulties exist. Thus, incipient phthisis, when it has not induced much engorgement of the lung, and when the tubercles are not present in sufficient number to yield a dull sound, may be taken for simple chronic bronchitis; and, again, when the latter is accompanied by dilatation of the bronchia, it may present the least equivocal physical signs of phthisis. 272 DISEASES OF THE RESPIRATORY ORGANS. By careful observation, however, the error may most commonly be avoided. Without taking into consideration the general symp- toms, the mucous rhonchi or rdles will be found to occupy different situations in the two diseases. The modification of the respiratory murmur, which precedes the establishment of those rdles, is heard at the summit of the lung in phthisis; the physical signs are con- stant over the same part; whilst, in chronic bronchitis, the rdles are heard generally over the lungs, and vary in their character at different periods. As regards the dilatation of the bronchia, which may give rise to obscurity in the diagnosis, it is rarely accompanied by induration of the lung, sufficiently great to give occasion to any marked dimi- nution of the sound on percussion, as is the case in phthisis around the tubercular excavations. The dilatation, moreover, does not always exist at the apices of the lungs; more commonly, it occu- pies the middle portion, and it continues for a long time without inducing any rapid and constantly augmenting effects. (Videcoq.) Causes.—Chronic bronchitis is often a sequel of the acute form; but, as has been seen, it occurs as a primary disease. It is very common in advanced life, and especially in those ^rhose constitu- tions have been injured by excesses. At times, it is observed in children, especially after hooping-cough. Occasionally, too, it is associated with another affection,—as some organic disease of the heart, or tubercles of the lungs. Like acute bronchitis, it may be also occasioned by irritating substances floating about in the atmos- phere. It is said, likewise, to have succeeded to the repercussion of acute or chronic cutaneous eruptions, and the suppression of some habitual flux or hemorrhage. (Laennec.) Pathological characters.—The mucous membrane, which is of a vivid red colour in acute bronchitis, is of various shades of red in the chronic form. When the inflammatory stage has wholly passed away, and the discharge has become a true gleet of the bronchial mucous membrane or a bronchorrhoza, the membrane may be found very pale, or of a yellowish hue. (Andral.) The bronchial ramifications contain mucus and other secretions, similar to those expectorated; and, at times, there is a true fibrinous secretion, which clogs up the tubes, and extends, like the branches of a tree, into their various subdivisions. This plastic bronchitis is often associated with the presence of tubercles and tubercular cavities in the lungs. In a case, which recently fell under the author's care, the quantity of membraniform arborizations expec- torated vyas very great; and both the general and the physical signs indicated the coexistence of bronchitis and phthisis. On dis- section, many of the bronchial tubes of the right lung were found to contain the fibrinous secretion, and others were dilated; whilst, in both lungs, tubercles were found both quiescent and in a state of softening, or already softened. The nutrition of the mucous membrane itself, is generally more or less affected. It may be indurated, or softened, or, here and OF THE BRONCHIA AND LUNGS. 273 there, ulcerated; and this is most frequently the case in the Asthma puluerulentum, A. gypseum, A. montanum, or Staubasthma of the Germans, which is produced by pulverulent particles passing in with the air of inspiration, and exciting inflammation and its consequences in the bronchial tubes. The mucous membrane is more frequently thickened, occasionally to such an extent as to obliterate the smaller bronchial ramifications, and to diminish the calibre of those of larger size. One of the most interesting of the lesions, is the dilatation of one or more of the bronchial tubes—bronchiectasie. (Piorry.) Some- times, this is uniform; at others, it is a sudden dilatation, forming a considerable cavity in one of the tubes; and, at others, again, a bron- chium is observed to present several successive strictures and dilata- tions. The solitary dilatations vary in size, sometimes being no larger than a hempseed; at others, able to contain an almond or a walnut. Treatment.—This must be regulated by circumstances. When there is much febrile and inflammatory excitement, the disease must be treated as a case of acute bronchitis, no matter how long it may have persisted; but when the active inflammatory symptoms have passed away, an opposite course may be demanded, and one which combines a gently excitant with a revellent agency; watching carefully, however, and having recourse to antiphlogistics, when- ever there is any appearance of fresh inflammation, or of a renewal of the old. Perhaps the best of all remedies, employed in chronic bronchitis, belong to the class of revellents. Intermittent counter-irritation, effected by successive blisters, or by the application of the tartarized antimony ointment, or by croton oil, proves extremely serviceable; and it is by the new action, induced on the surface, that flannel, worn next the skin, is so salutary a remedy in such cases. With the same view, a large portion of the chest may be sponged daily with a liniment, composed of spirit of turpentine and the acetic acid, so as to keep up an erythematous state of the surface.1 This is recommended as an easily manageable and efficacious remedy, (Stokes); and it is affirmed to be an imitation of the celebrated liniment of St. John Long, the famous empiric. (Graves.) 1 R.—Ol. terebinth. ^iij. Acid, acetic, fort. ^ss. Vitell. ovi. Aquae rosar. ^iiss. 01. limon. 3j___M. The beneficial agency of emetics, is, perhaps, chiefly revellent. Almost all therapeutists (Laennec, Stokes, Giovanni de Vittis,&.c.) depose to their value, not only in aiding, mechanically, the expul- sion of the secretion from the tubes, but interfering with its too copious reproduction. The ordinary emetics of ipecacuanha and tartarized antimony, or of both combined, are the most advisable, 274 DISEASES OF THE RESPIRATORY ORGANS. owing to the powerful revulsion effected by them through the state of nausea, and the subsequent emesis. The bronchial tubes being cleared, in this manner, of the great quantity of mucus, haematosis is more readily accomplished, and if lividity of the countenance have previously existed, it disappears. They have been esteemed most serviceable at night, taken immediately before the hour of rest, and in the morning, especially after a tolerably long sleep, when time has been afforded for a great accumulation of secretion in the bronchial tubes. (Mackintosh.) It is in these cases of bronchorrhoea, that the various substances belonging fo the class of reputed expectorants have been adminis- tered largely, although it is not always easy to understand the precise object which the prescriber has had in view. In these asthenic forms of bronchitis, the expectoration is generally too copious, and the powers too slight to expel it with facility; a remedy, consequently, which is possessed of gently excitant proper- ties, by arousing those powers, may favour expectoration; but there is no reason for believing that we are possessed of any medicinal substance, which has the faculty of promoting the expulsion of fluid from the lungs by any specific action, which it is capable of exerting on the parts concerned. (Paris. See, also, the author's Therapeutics, p. 313, Philad. 1836.) The expectorants, commonly advised, are squill, ammoniacum, myrrh, the polygala senega, &c, alone, or in combination; but although the author has prescribed them frequently, and carefully watched their effects, he has never been able to observe any result, except what might be ascribed to their excitant impression on the stomach, and its extension to other parts of the system. Every one, affected with ordinary catarrh, in which the secretion of mucus has been considerable, must have observed the comparative facility with which he has expectorated, even after an ordinary meal, through the impression it has made primarily on the stomach. "Expectorants," says a modern writer, (Mackintosh,) "appear to be somewhat serviceable, and the best is squills. But I have seen expectorants used for a considerable time without any benefit, till after the application of a blister, or the use of the inhaler, when the discharge has become free and easy." Dr. Mackintosh's opinion of the virtues of expectorants does not seem to exceed that of the author. Where the cough, however, is severe, and the bronchial irritation great, relief may be obtained by any of the ordinary saccharine, mucilaginous or oily mixtures, with or without the addition of anodynes, which produce their beneficial effects in the mode elsewhere explained. Among the various excitant substances, prescribed in chronic bronchitis, the balsams have been ranked highly. Their efficacy in diseases of the mucous membrane of the intestinal canal, (Arm- strong, La Roche, of Philadelphia,) led to the belief, that they might be serviceable in affections of the pulmonary mucous mem- OF THE BRONCHIA AND LUNGS. 275 brane likewise; and, accordingly, they have been much employed, especially the copaiba, and the terebinthinate preparations; but the testimony in their favour has not been uniform. Our own expe- rience has not been more favourable than that of some others, (Chomel, Mackintosh;) and when benefit has resulted from their employment, it has seemed to be owing to the excitant effects of the remedies, rather than to any special action, which they exerted on the pulmonary mucous membrane. In many cases of chronic bronchitis, the patient is doomed to suffer during the whole of winter, and to improve on the approach of summer; time is, therefore, an important element in any improvement that may take place, and many agents doubtless frequently rob it of the credit to which it is entitled. By a similar kind of reasoning to that employed in the case of the copaiba, the strychnia has been suggested in chronic bronchitis. From its efficacy in analogous affections of the digestive mucous membrane, good reason, it was conceived, existed for the .hope, that it would prove effective here. (Stokes.) The author has never employed it, nor is he aware of any successful results from its ad- ministration. In Germany, the tops of the galeopsis grandiflora, a plant which is ranked there as a " bitter resolvent," and which is supposed to be the basis of a nostrum, celebrated in pectoral diseases und^r the name of "Blankenheimer tea," (Blankenheimer Thee,) or " LiebecZs pectoral and phthisical herbs," (Liebersche Brust oder JIuszehrungskrauter,) have enjoyed great repute. R.—Summitat. galeops. grandiflor. • Rad. althaeas, aa ^j. Rad. glycyrrhiz. 3ij.—M. A fourth part of this to be boiled in a pint and a half of water, and to be taken daily. Tar water was at one time highly extolled in pulmonary affec- tions, and amongst the rest in pulmonary catarrh and chronic bron- chitis, and since the discovery of creasote, which is its main active ingredient, fresh trials have been instituted with it. (PUrequin.) The author has administered it freely, and, in cases in which the ordinary excitant expectorants are found to be serviceable, it has afforded relief; but farther than this no advantage has appeared to accrue from its administration. It is easily prepared. R.—Picis liquid, ^j. Digere in aquae Oij. per dies octo et cola. Dose, from 3 viij. to ^xij. in the day, mixed with milk. Creasote itself has been administered in the same cases;1 but it does not appear to possess more virtues than the tar water. 1 R.—Creosat. gtt. v. Mucilag. acaciae, ^iij. Syrup, tolut. 3j.—M. Dose, a tablespoonful every four hours. Recently, the acetate of lead has been brought forward as a 276 DISEASES OF THE RESPIRATORY ORGANS. remedy by far the most worthy of reliance in bronchitis attended with profuse secretion. (W.Henderson.) Its administration was limited to the period of the disease, in which the evidences of abun- dant secretion were apparent. The dose for children was gr. $, gr. ss. to gr. j. eight or ten times a day; and from one to three grains for the adult, so as not to exceed 12 grains in the day. The most important plan of exhibiting many agents, so as to act effectively on the mucous membrane, is by inhalation. Where the secretion is readily accomplished, and the affection belongs to the form of catarrh denominated "dry," the inhalations may be of the steam of water; on the other hand, should it be advisable to stimu- late the mucous membrane, the vapour from the infusion of chamo- mile flowers, or of some other excitant, whose properties are dependent upon volatile oil, may be inhaled. Tar vapour, which was at one time so highly extolled in phthisis, appears rather adapted for the disease under consideration, and many of the cases of reputed phthisis, recorded in the books as cured by it, were doubtless chronic bronchitis. The inhalation of chlorine has been serviceable in like cases. (Corrigan.) It may be inhaled from a common dish, or inhaling vessel, or from a well contrived apparatus proposed by Dr. Corrigan, of Dublin, (Dublin Journal of Medical Science, March, 1839, p. 94, and the author's New Remedies, p. 126,) by dropping any of the acids on a mixture of chloride of lime, so that the acid may be disengaged slowly; and, in the same manner, creasote may be inhaled; five, ten, or fifteen drops, according to the degree of tolerance of the lungs, being dropped into hot water, and the vapour received into them. Iodine has been administered in the same way; at times, alone; at others, associated with conium, in the manner advised under phthisis; but whilst some extol it highly, others have not been able to observe the least benefit from it. (Pereira.) The conium and other narcotics have likewise been administered by inhalation, twelve or fifteen grains of the extract of conium being diffused in an inhaling apparatus, and the vapour drawn into the lungs for a quarter of an hour, once or twice a day. (Stokes.) There are many cases, in which the internal administration of narcotics, acronarcotics, and sedatives, must be serviceable. If the cough be extremely troublesome, the various preparations of opium, hyoscyamus, hemlock, or belladonna, may be administered with much advantage. The colchicum1 has been recommended by many, (Armstrong, Hastings;) and by others, (Granville, Ma- gendie, Heller, Elwert, Behr, Roch,) the hydrocyanic acid.2 1 R.—Tinct. colchic. gss. Sp. aether, nitric. 3j. Dose, twenty drops three times a day on sugar. 2 R.—Acid, hydrocyanic, gtt. xv. Mucilag. acac. Syrupi, aa^ss. Aquae, gv.—M. Dose, a tablespoonful five or six times a day. OF THE BRONCHIA AND LUNGS. 277 Where persons are liable to attacks of chronic bronchitis, it be- comes important that they should be avoided by a change of air, especially from a cold and moist climate to one that is warm and dry. The West India islands, especially Santa Cruz, offer the best situations for this purpose, all the American and European climates being proverbially liable to great vicissitudes. In cases of phthisis, as will be shown, these vicissitudes, provided they are only within certain limits, are not to be deprecated; but in those who are pre- disposed to chronic bronchitis, they are injurious. Still, a mere change of air to countries, which are themselves exposed to cold and disagreeable winds—for example, to southern France and Italy —is often decidedly serviceable under the new impressions excited; and there are places in the Mediterranean, such as Hieres, which are well sheltered, and, therefore, not liable to the objections that may be brought against some of the other localities frequented by invalids. In the United States, Pensacola offers perhaps as many advantages as any other southern situation; possessing, as it does, a comparatively genial climate, and accommodations—the presence or absence of which must always be taken into consideration—for the valetudinarian. In this way, the winter may be escaped, and the habit be occasionally broken in upon. There are but few in- valids, who are subject to bronchitis, who can bear with impunity the contact of very cold air with the pulmonary mucous mem- brane; hence, they are compelled to breathe through folds of gauze, or to hold a handkerchief to the mouth, whenever they are exposed to it. An instrument has been invented, (Jeffrey,) called a " Respi- rator," which consists of several strata of fine wire, through which the air can pass with facility, and, in its passage, has its tempera- ture modified, so that no irritation is produced in the lungs. It is an ingenious and successful invention, but is somewhat expensive, and not much used. The bronchitic individual should be careful to protect himself against irregular exposure, by casing himself in flannel. He should be especially careful not to expose himself to the night air, or to go abroad in cold damp weather, particularly during the prevalence of one of our northeast winds. By these precautions, with the use of the flesh brush, and ordinary attention in other respects, the disease may be warded off; but should they fail, change of climate becomes essential. a. Summer Bronchitis. Synon. Summer catarrh, Catarrhus aestivus, Hay-asthma, Hay-fever, Rose catarrh; Ger. Sommerkatarrh, Heufieber, Heuasthma. A singular variety of chronic bronchitis is met with in the sum- mer season, both in this country and in Europe, which has received various names, indicative of the period of the year at which it oc- curs, or of the causes which are supposed to give rise to it. It has been well described of late years only, and chiefly by British wri- ters. (Bostock, Gordon, Elliotson, &c.) vol. i.—24 278 DISEASES OF THE RESPIRATORY ORGANS. Diagnosis.—The most constant symptoms are itching of the eyelids, and, at times, of the inner canthi of the eyes, with irregular attacks of violent sneezing, sense of weight on inspiration, and, at times, considerable dyspnoea, copious discharge from the Schneide- rian membrane, redness of the conjunctiva and sense of weight in the forehead, with suspension—partial or entire—of smell and taste, during the continuance of the disease. The exacerbations have commonly been observed to supervene in the morning, a short time after rising; but frequently they appear several times in the course of the day. The following letters from intelligent individuals, themselves sufferers under the malady, will best exhibit its course and charac- ter. The first is from a practitioner of Bristol, England, to Dr. Elliotson. " 1 knew nothing," he remarks, " about hay-fever as any definite disease; but your description of it is, with little exception, a very accurate description of what I suffered, every June, for several years. Were I not, at the present time, annoyed by this trouble- some affection, I should probably not have found leisure to give you the trouble of reading anything on this subject. " The attack generally begins, with me, at the latter end of May, with great itching of the eyelids, particularly at the inner canthi, from which I regularly, during this month, extract some cilia, which grow very near the cornea, and increase the irritation. My most troublesome symptom is sneezing. It is of a violent kind, and often continues eight or ten times. The defluxion from the nostrils is most copious at these periods of the day, while, in the intervals, I have no catarrhal symptoms. Expectoration of clear mucus is also considerable. My sneezing attacks are sure to come on while I am visiting my patients, to my great annoyance. This comfortless state generally continues five or six weeks, but is never sufficient to interrupt any of my employments, or render any con- finement necessary, though I am always free from it when in the house. How far grass or hay has any thing to do with this affec- tion, I cannot satisfactorily determine. There certainly are several hay-fields within a quarter of a mile of my house. The air seems to make me worse, and an open window is my abhorrence, while I am thus indisposed. Last week I spent an hour or two in a friend's hay-field, with a party of ladies, but the syllabub, the ladies, and the pastoral sports, had no amusement for me; and I was glad to get to a corner of the park, where my streaming eyes and nostrils, and noisy sternutations might escape both remark and commiseration. Certainly, during that afternoon, in the hay-field, was the worst attack I have had; but whether it was the air which was cooler than usual, or the hay, I could not tell. I must how- ever confess that my fancy on the subject has always leaned more to the effect of some subtile particles of an irritating nature, than to the ordinary causes of catarrhal affections. My lungs are rather OF THE BRONCHIA AND LUNGS. 279 asthmatic; formerly I had a good deal of asthma. I have never found time to try any remedies." The following letter is from a patient of the author, who has been long a sufferer under this disagreeable affection, and who kindly furnished the particulars of his case, but whose modesty shrinks from the publicity of having his name attached to it. Had it pleased him so to do, it would have been found to be that of a gentleman whose intelligence and sterling worth are known and appreciated far from the locality in which he resides. " Baltimore, June 30th, 1840. "My dear Sir, " Lwill very cheerfully endeavour to give you, in terms as few, and at the same time as full, as circumstances allow, my recollec- tions of the catarrh with which I am periodically visited, establish- ing one only condition most explicitly, that my name is in no wise to be referred to. Of this I should have great horror. " My impression is, that the first attack was late in the summer of 1823, which followed the summer (1822) in which I had under- gone an operation for the removal of hemorrhoidal tumours. These I had suffered from, since my boyhood, and they were wont to bleed freely. I had made a voyage during the same season. The operation arrested the discharge. The attack, which has generally occurred after the middle of July, (but not always on the same day of the month, as was the case with Mr.----, Mr.----, Dr.----, I believe, and others,) was always sudden, and without any appa- rent predisposing cause. It is sensibly aggravated by fruits gene- rally, and by peaches in particular, and it never was as bad, or lasting, as during the season in which I resolved to persevere in a cooling diet, eating fruit freely—for which there is an inordinate demand—and drinking ice water. It is accompanied by two or three paroxysms in a day of violent sneezing, and most copious flow, from the nostrils, of a limpid secretion, like tears; and, with me, the sympathy between the eyes and throat does not appear until some weeks, and is not violent. The affection is mainly of the head. I can arrest it by inhaling laudanum through the nos- trils, but suffer much from the experiment, and am glad, by means of snuff, to bring it on again. It gradually wears out,—in general in the course of October,—and in the latter stages the secretion assumes the appearance of the effects of a common cold. It leaves me liable to chills in the night, which awake me from a sound sleep, and it also leaves a liability to a nervous sensation, which creeps over me like an approaching faintness. This is apt to come on almost at the moment after taking coffee in the morning, and at other times. " I have tried countless remedies, regular and irregular, and nothing cures: some things aggravate; few mitigate. The Prussic acid with black drop, three times a day in small doses, have gene-. 280 diseases of the respiratory organs. rally been useful. Rowand's tonic mixture is a good preparation, and, I think, palliates the symptoms in their course. Fatigue, ex- posure, excitement, all aggravate. Moderation, quiet, comfortable diet, the sofa, not the bed, riding rather than walking, suit me in the season. "The effect on the nerves is terrible, but on the constitution eventually slight. I am convinced it ought not to be cured, and Dr. Physick, of Philadelphia, told me, that he had utterly failed in the several cases that had come under his care. I have been told more than once that it is gouty, and there was gout in my family. "It has been commencing earlier for some few years than for- merly, but is not continual until the stated season, and then the dripping from the nostrils is almost ceaseless. Tepid bathing, I think, aggravates the symptoms. When badly managed, it has lingered on, with intermissions, until mid-winter. It is a mighty trial of faith, patience, good nature, &c; and if I were on a jury before whom one was tried for murder, who could prove that at the alleged season he was afflicted with this catarrh, I should suspect him the more grievously, but deal with him much more leniently. " Among the symptoms I failed to remark, that it causes a writer to be very clumsy and confused. From this, and the history, which you have above, you will immediately infer the fact, that I am suffering from it already. Add to this the hour—12 P.M.—and you will not be surprised at the style of the drawing." It is obvious from these ample details, that the disease does not belong to asthma—as we now define it—that is, to nervous or spasmodic asthma, but that it consists essentially of inflammatory irritation of the mucous membrane of the eyes, nose, and the whole of the respiratory apparatus,—the dyspnoea originating in this cause. It is rather a form of chronic bronchitis, and can scarcely be regarded as a combination of catarrh and asthma, as it has been by some. (Elliotson and others.) Causes.—The prevalent idea is, that it arises from vegetable matter diffused in the atmosphere, that it is derived from the flowers of some plants, and that in a great number of instances it comes from grass. (Elliotson.) Dr. Elliotson asserts, that a lady, who had suffered from the disease for many years, told him, that being once away from home at an inn, where she conceived there was no danger whatever of being affected by the flowers of grass, she was suddenly seized with violent dyspnosa, and great irritation, and on looking out of a window, she saw that a cart-load of hay had just been brought into the inn-yard. She told him, also, as another proof, that the affection arose from this source, that her children once came into the room after having been playing with hay, and instantly her breathing became affected. It is, however, against the idea of the effluvia from hay being a common exciting cause, that the haymakers themselves are said to be entirely free OF THE BRONCHIA AND LUNGS. 281 from it, and that it is often met with in towns, where such effluvia, if they exist at all, cannot be in any great quantity. The rarity with which the disease is met with sufficiently proves, that the predisposition lies in some idiosyncrasy, which is, at times, derived from progenitors. In a letter from Mr. Poyser, of Wirks- worth, England, to Dr. Elliotson, he speaks of the mother of a large family, who had been afflicted with this malady for many years. " This lady decidedly considers the cause of her complaint to be an emanation from the flowers of grass. It begins when grass comes into flower. There is a perceptible increase or paroxysm, when she is exposed to these effluvia, and when the flowering time is over, she can go into a hay-field with impunity, which she could not previously do. " The father of this lady is immediately seized with violent and continual sneezing, and inflammation of the nose and eyes, when he goes into, or approaches, a hay-field; but the symptoms go off when he is removed from the smell of hay. He, therefore, carefully avoids the exciting cause, and escapes the disease. Three of the sons of Mrs. A. are also subject to this disease, and their symptoms are similar to her's, though less severe. One of these young gen- tlemen is now at Geneva, and had the complaint there this sum- mer." When a predisposition is laid in idiosyncrasy, the smell of hay may act as an excitant cause; but in other instances it may be an emanation of a different kind. The odour of ipecacuanha is one of the most frequent excitants. The author knew a young gentleman who could not touch powdered ipecacuanha without the immediate supervention of every symptom of " hay asthma." With others, the same effect is induced by the smell of the rose, the bean-flower, &c. &c. In one of the sons of the lady, whose case is described by Mr. Poyser, all the symptoms of the disease are produced by the smell of the Guinea pig; and an English nobleman is affected with sneez- ing and asthmatic symptoms, if he comes in contact with a hare, or rather with the fur of a hare, and he remains ill for several days afterwards. He experiences great suffering, whether the hare be dead or alive. (Elliotson.) Treatment.—From the cases that have been detailed, it would not seem that any great advantage is to be derived from medicine. It has been affirmed, that the best prophylactic, before the period of expected recurrence, is the cold shower bath, accompanied by the internal use of the sulphate of quinia and the sulphate of iron. R.—Quiniae sulphat. gr. ij.—iij. Ferri sulphat. gr. j.—f. pil. Dose, one, three times a day. This plan has been found so effective, that two persons, who had previously been most severely afflicted," were able to walk through a rich meadow without suffering in the slightest degree; although formerly, if they had ventured out into such a situation, they would 24* 282 DISEASES OF THE RESPIRATORY ORGANS. have brought upon themselves all the agonies of spasmodic asthma." (Gordon.) It has been advised, likewise, that the person should visit the seacoast during the period at which he is usually attacked, and the change, as might be presumed, whatever may be the cause, has often proved very beneficial. It is proper to remark, however, that the only instance said to be on record, in which the disease attacked a patient before the usual period, was when he was re- siding, for a few days, in an airy house, situate on a cliff overhang- ing the ocean. (Bulman.) In one case, the patient almost entirely escaped the disease, by merely commencing, some time previous to the expected period of attack, to anoint the eyelids at bed time with the unguentum hydrargyri nitratis properly reduced,1 and by bathing the eyes occasionally during the day with a coilyrium composed of rose water and acetate of zinc;2 and after this had dried, smearing them with simple spermaceti ointment to remove the stiffness left by the coilyrium. 1 R.—Ung. hydrarg. nitrat. p. i. 2 R.—Plumbi acet. Adipis, p. ix.—M. Zinci sulphat. aa gr. vi. Aquae rosae, ^iv.—M. When the disease has fairly set in, its course is not much modi- fied by remedies. Being chronic in its character, it does not well bear depletion. Almost all the sufferers have experienced incon- venience from too rigid a diet, and from too free exposure to air. These facts must be borne in mind, as well as the circumstance, that the affection wears itself out in the progress of time, and with- out materially affecting the constitution. The practitioner should, therefore, avoid being too officious. Under the idea that the cause was the effluvia from grasses—the pollen in all probability—and that such effluvia might be destroyed by the chlorides, Dr. Elliotson requested a gentleman, who had the disease, to sprinkle the chloride of soda around the chamber, and he did so with the most perfect success. In another case saucers of a solution of one of the chlo- rides were placed about the bedroom: rags were dipped in the solution, and hung upon the backs of chairs; the hands and face were washed with it, night and morning; and the patient was directed to carry a small bottle of it about with him, and to smell it repeatedly in the course of the day. The result, in this case, was likewise satisfactory. (Elliotson.) In other cases, however, the plan has been by no means as beneficial; and even if it had been, the result would not be a sufficient proof, that the cause was the one assigned by Dr. Elliotson. No matter what might be the effluvium in the air, the chlorine could not fail to modify the con- dition of the latter, and thus to obviate, more or less, the morbific influence. It is clear, therefore, from the whole history of the affection, that the efforts of the practitioner can lead only to the palliation of the more urgent symptoms, and that, even in this respect, his powew are extremely limited, and his attempts to afford relief too fre- OF THE BRONCHIA AND LUNGS. 283 quently either altogether nugatory, or productive of unexpected aggravation of the symptoms. II. HOOPING-COUGH. Synon. Bex convulsiva, B. theriodes, Tussis convulsiva, T. asinina, T. canina, T. clamosa, T. clangosa, T. ferina, T. spasmodica, T. pueros strangulans, T. quinta, T. stomachalis, Pertussis, Pneusis pertussis, Amphimerina, Orthopnoea tussiculosa, Bechorthopnoea, Morbus cucullaris, M. cuculus, Chincough, Kink- cough, Kincough, Kindcough; Fr. Coqueluche, Catarrhe ou Bronchite convul- sive; Ger. Keuchhusten, Keichhusten, Krampfhusten, Stickhusten, Eselshusten, Schlafhusten, Brechhusten, Kielhusten, Blaue Husten, Consulsivische Katarrh, Epidemische Kinderhusten. A variety of " nervous cough" is at times met with, in nervous and hysterical persons, which is dry, sonorous, returns in paroxysms, and requires to be treated by revellents and narcotics, so as to excite a new impression in the nervous system. It is different, however, from the neurosis,—if we may so term it,—of the respiratory organs, which we have now to consider, and which has something special, and specific, in its character. By the ancients, hooping-cough was confounded with other affec- tions, unless we presume that it was unknown to them, and made its appearance, like some other diseases, at an after period. It seems to have been first satisfactorily described in the latter period of the 17th century, (Willis, in 1682,) although it was a disease appa- rently well known. (Sydenham.) Diagnosis.—Hooping-cough may be conveniently divided, as it has been by many writers, into three stages, although, it need scarcely be said, every such division must be artificial and arbi- trary. The first—the "catarrhal stage" of some, essentially resembles ordinary bronchitis or catarrh. There is more or less indisposition, chilliness, depression, suffusion of the face and eyes, increased se- cretion of tears, sneezing, and discharge from the nose, along with a dry fatiguing cough, which returns by fits or quintes. During this stage, there is more or less febrile indisposition, with exacer- bations during the night. This stage is very variable in its duration; at times, lasting for a few days; but, at others, for weeks. It does not often, however, exceed a fortaight. The second—the " nervous, and spasmodic or convulsive stage," of some—is known by the occurrence of the characteristic symp- toms of the disease. The cough is now excessively violent and convulsive, and so distressing, that the patient, feeling its approach, runs to lay hold of, and support himself by some object, until the paroxysm is ended. These come on more frequently during the night, and consist of a series of forced, quick, and unequal expira- tions, which follow each other so rapidly, that inspiration is im- practicable. The return of blood is accordingly interfered with, and the face becomes swollen and livid; the tears are discharged copiously; the veins of the neck are prominent; a copious perspi- 284 DISEASES OF THE RESPIRATORY ORGANS. ration breaks out, and suffocation appears imminent. In a short time, however, small imperfect inspirations are effected, and then a slow, long, and distressing inspiration, accompanied by a pecu- liar noise, which has been compared to a " whoop,"—hence the name " whooping-cough or hooping-cough;" and, by others, to the braying of an ass, or the crowing of a cock; to which, however, it bears but little resemblance, although names, descriptive of the notion, have been assigned to it, especially by the Germans. The cough sometimes ceases after this peculiar inspiration, but a second or a third may succeed, and the paroxysm may not wholly terminate until a viscid, ropy, colourless secretion is expelled with difficulty by expectoration, and often accompanied by vomiting. The sonorous inspiration is owing to the entrance of the air into the trachea through the glottis, the opening of which is spasmodi- cally contracted. It is not uncommon for a tensive pain to be felt in the forehead; and it is a symptom which requires attention. Some, indeed, im- pressed by this encephalic affection, have placed the site of the pathological condition, which characterizes the disease, in the brain. (Webster, Desruelles, Geo. Gregory.) The duration of the paroxysms is from one to four or five mi- nutes, and their recurrence is equally various,—at times, every five or ten minutes, but, at others, not oftener than six or eight times in the 24 hours. When the paroxysms are not very long, or frequently repeated, the child resumes his play immediately afterwards; but when they return with great violence and frequency, dyspnoea, pain in the chest, and general indisposition remain. Their recurrence is imme- diately excited by mental emotion—as fright, crying—or by rapid running. They are commonly, also, more frequent, after excitants of any kind have been taken; and where more than one in a family suffer, the occurrence of a paroxysm in one is very apt to excite it in another. It is not an uncommon occurrence for blood to flow from the nose, and occasionally from the mouth and ears, during the paroxysm; and for infiltrations to take place under the conjunctiva. In ex- cessively severe fits of coughing, the urine and faeces are discharged involuntarily; and where there is a liability to prolapsus of the rectum, or to hernia, these protrusions may occur under like cir- cumstances. Between the fits, there is little or no general indisposition, unless some complication exists. The duration of this period is very variable. On an average, it may be estimated at from a fortnight to a month, but it may con- tinue for months. The third stage or the "stage of decrement or decline," is indicated by the diminution of the spasmodic phenomena; the paroxysms of coughing becoming shorter and shorter, and less violent and frequent; the peculiar inspiratory noise, by which they OF THE BRONCHIA AND LUNGS. 285 terminate, diminishes, and ultimately disappears. The liquid ex- pectorated becomes opaque, thicker, of a greenish hue generally, and sometimes puriform. The cough at length does not differ from that of ordinary catarrh, and gradually ceases, especially if the dis- ease has existed during the spring; if during the autumn, it may remain severe the whole of the subsequent winter. The duration of hooping-cough is uncertain; on the average, it may be estimated at from six weeks to three months; but it may continue much longer. If the ear be applied to the chest during a fit of coughing, no respiratory murmur is heard, because the air does not enter the chest; but the moment the pathognomonic inspiration takes place, the air is heard rushing into the ultimate bronchial ramifications, and the respiration becomes louder than natural. As there is no consolidation, percussion renders a clear sound, both during the paroxysms and in the intervals between them. Hooping-cough is often complicated with other affections, as with bronchitis and pneumonia. Of 3S cases of complications of hooping- cough, 12 were of pneumonia, (Blache;) and of 28 cases, observed in 1836, in the Hbpital des Enfans of Paris, ten were of pneumo- nia. (Constant.) As a sequel of hooping-cough, tubercles are at times formed or developed, and, not unfrequently, serious ence- phalic affections ensue,—encephalitis, hyperemia, and convulsions, which accompany every paroxysm of coughing, and are difficult of removal owing to the persistence of their cause. In the winter season, epidemics of hooping-cough are apt to be accompanied with inflammatory affections of the air passages; in summer, with affections of the alimentary canal, especially inflammation of the lining membrane. Causes.—But little is known of the causes of hooping-cough. It is one of the diseases that reign epidemically; and, as has been more than once observed, we know but little of any of the diseases that occur under epidemic influences. The disease is rarely sporadic; and, as a general rule, it attacks individuals but once; but to this rule there are many exceptions. A recent writer, (W. England,) states, that he had, at the time of writing, (May, 1840,) under his care, a boy, five years of age, labouring under hooping-cough, who had the same disease when about a year old. It is farther stated, that a maternal aunt and uncle of this child were twice affected with the disease—first when infants but a few months old; the aunt a second time, when seven years of age; and the uncle a second time when forty-five years of age. It prevails at all seasons and in all climates, and attacks every age and condition; but chil- dren are more liable to it than adults; and children, under the age of the second dentition, are affected in greater numbers than the older. Of 130 recorded cases, 106 were under 7 years of age; 24 between 8 and 14. (Blache.) When hooping-cough prevails extensively, the mortality from it is occasionally considerable. In Glasgow, the deaths have been 286 DISEASES OF THE RESPIRATORY ORGANS. pretty nearly 5h per cent, of the whole number of deaths; and in one year, they amounted to \\\ per cent. (Watt.) The disease differs from some other epidemics—as the influenza— in not affecting any great belt of country. It is commonly, indeed, restricted to a small sphere, and this is one reason why it has been conceived by some to spread rather by contagious than by strictly epidemic influence. Whether it be ever produced by contagion has, however, given rise to much discussion. Many deny it alto- gether, (Stoll, Sprengel, Laennec, Professor Dewees, of Philadel- phia;) but the large mass of observers do not hesitate to admit it, (Rosen, Cullen, Hufeland, Jahn, C. A. Tott, Duges, Blache.) With those who believe in its being a contagious disease, a ques- tion frequently arises as to the precise period at which it becomes, and ceases to be so. The author, who is rather disposed to be a contagionist, has had no reason for believing that it has been com- municated until the disease has been fully formed, or after the cessation of the whoop. Pathological characters.—It is difficult to affirm positively what are the anatomical characters of this disease. It never terminates fatally, without inducing some other affection, whose traces are perceptible on dissection. This circumstance, with the phenomena during life, has caused the disease to be classed by distinguished pathological writers, (Cullen, Andral,) amongst the "lesions of innervation of the bronchia." In the great majority of cases, however, more or less redness is observable in the mucous lining of the bronchial tubes. This is at times general, but at others restricted in extent; and although by some it has been said to have been wanting, it has been maintained by others to be an invariable appearance. (Mackintosh, Alcock.) The small bronchial ramifications have been found filled with a mucous or muco-purulent matter; and where the inflammation has extended to the lungs or pleura, or complications of disease of other parts have existed, their characteristic lesions have been seen on dissection. A very common necroscopic appearance is dilatation of the bronchia, (Jadelot, Laennec, Dubreuil, Guersent, Blache, Bertin, Bell;) and, along with this, pulmonary emphysema is not uncom- monly found, especially where the disease has existed for a long time. The bronchial ganglions or glands would seem to have been as often (diseased as the bronchial mucous membrane. They hate been red. swollen, or tubercular. Some have affirmed, that the pneumogastric nerves have exhi- bited evidences of inflammation, (Autenrieth, Breschet, Kilian;) whilst by others no appearance of the kind has been met with. (Marcus, Albers, Copland.) With regard to the precise nature of the disease, much difference of opinion has existed, and still exists; but it is not advisable to dwell on points, which, in the existing state of science, appear in- OF THE BRONCHIA AND LUNGS. 287 appreciable. The view, most in accordance, we think, with all the phenomena, is, that the disease consists in erethism of the nerves distributed to the bronchial mucous membrane, accompanied gene- rally, if not always, with bronchitis. It has been found, that when the pneumogastric nerves were bruised and pinched in a living animal, so as to break down their structure, convulsive cough was excited like that of hooping-cough; and, again, it is well known, that if extraneous bodies be received into the air passages, a spas- modic contraction of the glottis may occur with a hooping sound on inspiration. Treatment.—This is generally palliative; for it rarely happens, that we are able to cut short the disease. The number of remedies, which have been brought forward, is immense, but the true plan is to treat the disease according to general principles; for neither in this, nor in any other disease, has a specific been discovered. The treatment may be divided into that which is applicable in the first or forming stage, according to the division of the symptoms laid down;—in the second, or convulsive stage, or stage in which the disease is fully formed; and in the third, or stage of decrement or decline. The first stage requires the treatment that is demanded in sub- acute bronchitis. It is rarely necessary to take away blood from the general system, but should the symptoms seem to demand de- pletion, the application of leeches to the chest may be of service. In the second stage, a great variety of medicines has been pre- scribed; and perhaps the most efficacious of these are emetics. They may be given every three or four days, and even oftener, unless their administration should seem to be productive of bad effects. By some, they are given every day or two, for the first two weeks. (Laennec.) Either the tartrate of antimony and potassa, or ipecacuanha may be administered; the nausea dislodges the mucus from the bronchial tubes; and the immediately succeed- ing efforts at vomiting expel it. It has long, indeed been observed, that those children, who vomit readily during the paroxysm, suffer the least; and this has been a great incentive to the administration of emetics. Purgatives are of no essential use, and are only prescribed under the general principles, which point out the necessity for their use in other cases. Narcotics have been greatly extolled, but some more than other*'. The belladonna has been preferred by many; so much so, indeed, that certain writers, (Wiedeman, Hufeland,) have regarded it as a specific in the disease. This is not the fact; but when pushed to the extent of affecting the brain—as indicated by vertigo, dimness of sight, dilatation of the pupils, &c—it has arrested the'violence of the paroxysms. Some, however, (Hufeland, Alibert, Maun- sell,) administer it in smaller doses, and are not desirous of pro- ducing narcosis. 288 DISEASES OF THE RESPIRATORY ORGANS. R.—Ext. Belladon. gr. ss. Sachar. alb. 3j.—M. et divide in part viij aequales. Dose, one, night and morning, for a child from two to four years old. The effect of belladonna is, however, somewhat uncertain; in a very small dose, it occasions symptoms of narcosis, and it is apt to lose its effect speedily, so that the disease continues stationary. The various other narcotics, as opium, and its preparations, hyoscyamus, conium, lactucarium, tobacco, &c, have been admin- istered with advantage in particular cases; but all—and especially the last—require care in their administration. The hydrocyanic acid, in the opinion of some, is almost entitled to the rank of a specific. (A. T. Thomson, Roe.) By Professor Thomson, it is regarded as the sheet-anchor of the practitioner. After emptying the stomach with an emetic, and purging the patient briskly, he commences with the use of the acid, and never alters the prescription except to increase the dose; and Dr. Roe found its employment attended with such striking effects, that he could not entertain a doubt of its possessing "a specific power over hoop- ing cough." The result of all his trials convinced him, "that in warm weather it will cure almost any case of simple hooping. cough in a short time; that in all seasons it will abridge its duration; and in almost every instance, where it does not cure, that it will, at least, materially relieve the severity of the cough." It is proper to remark, however, that Dr. Roe always combined it with other agents, that have been recommended in the disease. R.—Acid, hydrocyanic. (Scheele's), tn_xij. Liquor, antim. tartaris. sjj. Tinct. opii. camphorat. Jijss. Mist, camphor, ^vijss.—M. Dose, a tablespoonful, every four hours in some warm drink: " the child to remain in a warm room, and to live upon light pudding and broth." Thi9 pre- scription was for a delicate hoy, four years old. For a healthy looking female child, five years of age, Dr. Roe ordered the following mixture: R.—Acid, hydrocyanic. (Scheele's), TT|xx. Liq. antim. tartaris. ^iss. Vini. ipecac. 3iss. Aquae, ^xiij.—M. Dose, a teaspoonful, every two hours. It need scarcely be said, that it is not easy to deduce satisfactory inferences, as to the action of any one ingredient of a compound ,j formula, every article of which, it is presumable, has been added to effect some definite object. Narcotics have likewise been administered endermically with advantage, (Meyer, Glede;) but unpleasant accidents have resulted from them, so that, even in this form, they must be employed with caution. Various reputed antispasmodics—assafcetida, musk, valerian, castor—have been administered by some practitioners, and lauded —but the author has seen no effect from them, except what could be ascribed to their excitant agency,—or in other words, to the OF THE BRONCHIA AND LUNGS. 289 new impression made by them upon the nerves of the organs of taste, and of the stomach. By some recent observers, (Steymann, Lombard,) the sesqui- oxide of iron—the precipitated carbonate—has been regarded as the best antispasmodic in hooping-cough. Dr. Lombard gave it in the quantity of 24, and even 36 grains to young children, either in water or syrup, or mixed with a cough mixture. He never found it produce any inconvenience; on the contrary, he found that all the children, treated after this method, recovered faster than with other remedies, and he considers himself justified in affirming, that it enjoys the property of making the paroxysms less violent, diminishing their number, and after a certain time of entirely curing the disease. The good effects of the iron are ascribed to its anti- periodic and antineuralgic properties; and these effects are con- sidered to favour the idea, that hooping-cough resembles a true neuralgic, or at all events nervous disease. (Lombard.) Of late, the lobelia inflata—which is an acro-narcotic—has been much recommended in spasmodic diseases of the air passages, and, therefore, in hooping-cough. R.—Tinct. lobeliae, gtt. xxx—xl. Mucilag. acac. Syrup, papav. aa 3jj. Aquae, 5[vj.—M. Dose, a teaspoonful, every two or three hours. It has been regarded as infallible as the hydrocyanic acid has been by its supporters. (Andrew.) Revellents have been much employed; but the more severe have generally been laid aside,—partly, because they are not more serviceable than the milder; and partly, also, because, in young children, blisters and issues are apt to be followed by unpleasant consequences. In their stead, the ointment of tartarized antimony may be rubbed on the chest or epigastrium, but care must be taken that the pustulation is not too extensive, as troublesome ulcera- tions have been known to result from it. (Bell.) The croton oil has, likewise, been used in the way of friction. R.—01. tiglii, — oliv. aa. partes aequales.—M. A few drops to be rubbed on the chest night and morning. Various embrocations have also been advised, to be rubbed on the chest, epigastrium, and along the spine. They all act on the same principle. Roche's embrocation for the hooping-cough has been much used. R—01. oliv. ^xvi. — succini, ^viij. — caryoph. q. s.—M. The oil of cloves is added merely as a scent, but it is not tetter than any of the ordinary excitant liniments, as the Linimentum ammonias, or the Linimentum camphorae compositum of the Phar- macopoeias. At the meeting of the Medical Section of the British Association, vol. i.—25 290 DISEASES OF THE RESPIRATORY ORGANS. in 1840, it was stated, that rubbing the chest with cold water, repeated two or three times a day, with so much activity as to pro- duce a rubefacient effect, was frequently of great use in hooping- cough. (Hannay.) The warm bath is occasionally found serviceable in allaying the violence of the paroxysms. Remedies have likewise been administered in the way of inhala- tion. Sulphuric ether, thrown upon the bed or on the clothes of the patient, speedily vaporizes, and has been conceived to diminish the violence and duration of the cough. The smoke of tobacco; the inhalation of the vapour from a hot decoction of belladonna, of the cherry laurel water, and of different aromatic substances, of the vapour of tar, and of nitrous acid, have likewise been advised, but their efficacy is so little marked, that they are scarcely ever em- ployed. When tensive pain exists in the forehead, a few leeches may be applied with marked advantage. It has been presumed, indeed, that the severity of the whoop may be, in this way, diminished; and that the fact is in accordance with the acknowledged influence of certain states of the brain upon the respiratory organs. (Webster, Geo. Gregory.) Lastly,—vaccination has been proposed as a method for curing hooping-cough; and there are many cases on record, which would seem to show the marked influence exerted by this new affection, artificially excited, on that which had possession of the economy. At the same time, it must be remarked, that it has often failed altogether. It may be well, however, to seize the opportunity for vaccinating, provided it has not been previously practised. In the third stage or the period of decrement, advantage may be derived from the use of gentle tonics, as the cold infusion of cinchona, the infusion of gentian or colomba; and at this period, the excitant remedies—external and internal—advised in chronic bronchitis, may be employed with as much prospect of success as in that disease. Change of air is, at this period, most important, and it is not essential, that the change should be from a worse air to a better. The inhabitants of Edinburgh frequently send their children from the airy parts of the town into the Cowgate,—-a filthy street, which runs at right angles under one of the largest thoroughfares in the old town, and in which, at a certain hour of the night, the inhabi- tants eject all the offensive accumulations from their houses, to be washed away by the water of the reservoirs let on for the purpose; yet the change is often most salutary. Even the change from one room of the house to another, has been found of benefit. (See the author's Elements of Hygilne, p. 151, and the article, "Atmos- pherm," by the author, in the American Cyclopedia of Medicine and Surgery, p. x.) The patients should be warmly clad, if the season requires it, and wear flannel next the skin, whatever may be the season; and OF THE BRONCHIA AND LUNGS. 291 they should take moderate exercise, and food easy of digestion, and not in two great quantity. Should the convalescence be tedious, and the cough and other signs of pulmonary disorder persist, change of air, society and scenery; and, where practicable, if the winter is approaching, removal to a more genial climate, should be strongly recommended. In the summer season, the climate of the United States is amply adequate to all useful purposes, and, several of its mineral springs afford localities that are very favourable for the complete restoration of the valetudinarian. The springs at Warrenton in Virginia, afford an excellent sani- tarium for such cases. It need scarcely be said, that the different complications, which present themselves in the course of the disease, must be met by the modes of treatment recommended under their respective heads,— the circumstance being always borne in mind, that after the com- plication has been removed, strength is necessary for the support of the patient through a long and a tedious malady, and that, there- fore, all copious abstractions of blood, should be made with a wise caution. III. HEMORRHAGE INTO THE BRONCHIA AND LUNGS. a. Hemorrhage into the Bronchia. Svnon.—Haemoptysis, Haemorrhagia Pulmonum, Bronchorrhagia, Pneumor- rhagia, Haemoptismus, Haemoptoe, Emptoe, Emptoys, Sputum cruentum, Haemor- rhagia haemoptysis, Spitting of blood; Fr. Hemoptysie, Crachement de Sang; Ger. Blutung aus den Lungen, Bluthusten, Blutspeien, Blutausfluss, Lungen- blutfluss. Hemorrhage from the bronchial tubes, is by no means of com- mon occurrence; and although always an alarming disease, inas- much as it is so often the announcement of the existence of pul- monary tubercles; yet, when it is a simple exhalation of blood from the bronchial mucous membrane, it is comparatively of little danger. Spitting of blood is always an alarming symptom to the patient, no matter, whether it proceeds from the bronchial arteries, or from some of the vessels in or near the pharynx; although, in the latter case, the exhalation is of no greater consequence than in epistaxis in the same individual; hence the number of cases of " spitting of blood,"—meaning, by that term, haemoptysis, which are of no serious consequence. It is not generally difficult to diagnosticate these cases, and, con- sequently, to separate an affection, which is of little or no conse- quence, from one that merits the greatest consideration. A prac- titioner boasted to the author of the great success, which attended his practice in haemoptysis; but on inquiring closely into the cases, they were all examples of venous hemorrhage—and to a small extent only—from the pharynx. Diagnosis.—An attack of haemoptysis is commonly preceded by more or less indisposition, and especially by a sense of weight, or heat, or an indescribable feeling of uneasiness about the chest, with oppression in the breathing and cough—signs indicating hyperas- 292 DISEASES OF THE RESPIRATORY ORGANS. mia or congestion of the lungs—and a sweetish taste, or the taste of blood in"the mouth. With these local, are commonly associated general symptoms; the extremities and surface of the body are cool; irregular chills are experienced, especially in the back; the face is alternately pale and flushed, and there is palpitation, with an accelerated, and at times vibratory, full and hard pulse. A dis- tressing sense of ebullition is also experienced in the chest, which is a certain sign of blood being effused into the bronchial divisions. (Rostan, Andral.) The constraint in respiration augments; and a sense of tickling and pricking is referred to the bifurcation of the bronchia. The expectoration of mucus, streaked with blood, or of pure blood in greater or less quantity, now commences; and when the blood is examined, it is found to be of a florid vermilion colour, and frothy; unless it has remained some time in the bronchia, when it may be black. Such is the case, when the exudation of blood is ceasing; the portions which transude, instead of being thrown off immediately, may remain there for hours, and be ultimately expectorated of a very dark colour. Cases have been often seen, where extraordinary quantities of blood have been discharged; and the patient has sunk immediately—but they are rare. (Andral.) The expectoration resembles red currant jelly; but, at times, is not so much tinged: the quantity of blood evacuated varies; it is sometimes so great, that it almost amounts to vomiting—mouthful after mouthful being expectorated; the feelings of indisposition then gradually cease, but they may recur, and be followed by a similar hemorrhage. The quantity lost is, at times, astonishing, especially when it is vicarious, as in cases of suppression of the catamenia; in these cases, it may return monthly. After a copious discharge, cough usually continues with the ex- pectoration of a slight quantity of dark liquid, or coagulated blood, which ceases gradually. When the chest is percussed, it emits its natural sound, because the blood is expectorated as fast as it transudes: for the same reason, on auscultation, no sound may be heard except the mucous rdk with large bubbles, (rdle muqueux a grosses bulles.) Difficulty may occasionally arise in discriminating the blood of haemoptysis,- from that of haematemesis and epistaxis. In the last disease, the blood may flow by the posterior nares into the pharynx, and be expectorated along with the mucus of those parts. The colour of the blood is strikingly different, however, from that of active haemoptysis; it is never florid and frothy, as in the latter dis- ease. The blood of haemoptysis may be distinguished from that of haematemesis by the same signs, as well as by the accompany- ing symptoms. In the former disease, as we have seen, there is cough and dyspnoea; in the latter, nausea, weight at the epigastrium, and vomiting: on inspection, too, the blood evacuated, may be found mixed with the contents of the stomach or small intestine. The blood in haemoptysis may proceed from the rupture of an OF THE BRONCHIA AND LUNGS. 293 aneurism of the aorta; but, in such case, there is not much time for doubt, as the case speedily terminates fatally. As it very rarely happens, that haemoptysis is a primary disease, and as it is almost always symptomatic of some internal lesion, it becomes important to determine the nature of such lesion, and especially, whether it consist in deposition of tubercles. In the latter case, the prognosis merges in that of phthisis pulmonalis, and the existence of tuberculosis must be determined by the signs and symptoms to be hereafter described. Even where tubercles are not present, it may lay the foundation for them in one predisposed to them. It has been affirmed by a distinguished pathologist, (Andral,) that he has found less than one-fifth of those, who have laboured under haemoptysis, exhibit tubercles on dissection. There are many, again, who have been haemoptoic in their youth, who have attained a good old age, remaining delicate for a longer or shorter period, or entirely re- covering. It is unquestionable, however, that in the majority of cases, haemoptysis is either preceded or followed by phthisis pul- monalis. Causes.—The predisposing causes of haemoptysis are numerous; the phthisical habit—to be described hereafter—and any organiza- tion, in which the vessels are loosely protected by the parts in which they creep, offer a predisposition. This is apt to be the case in that organization, which has been esteemed markedly stru- mous, in which the hair is fair; the eyes blue, and the pulse rapid. Age is, likewise, a predisposition. In infancy and advanced life, the disease is rare; but soon after puberty, when, owing to the different evolution of organs, the disposition to epistaxis has ceased, the tendency is much greater; and again, after the age of 35, when the evolution takes place that favours cerebral hemorrhage, the liability to haemoptysis is greatly lessened. Between the ages of 15 and 40, may be regarded as the period most subject to the disease. Women, it is affirmed, are more liable to the affection than men. (Andral.) Any sudden changes of atmospheric pressure may, likewise, have some influence; that is, a change from a denser to a rarer condition, provided it be considerable. We might suppose, therefore, that persons, who live in elevated regions; as on the mountains of South America and Thibet, would be subject to haemoptysis. The system soon, however, becomes accustomed to the altered circumstances, and we have no reason for believing, that, ultimately, such persons are more liable to haemoptysis and other affections of the pulmonary apparatus, than those who reside on the level of the ocean. It has been affirmed, that attacks of spitting of blood are more frequent in spring and autumn, when the days are warm, and the mornings and evenings cool, than at other seasons, (Andral;) but the author is not able to say, that he has observed any in- 25* 294 DISEASES OF THE RESPIRATORY ORGANS. fluence exerted by seasons. The same may be said of the hour of the day. His observation has not led him to infer, that most of the attacks occur in the night or morning. (Most.) The exciting causes are very numerous. Any violent corporeal exertion, either of the lungs or of the body generally, may induce it, especially ifanyofthe predisponent influences, already described, are in action; or if there is either vascular fulness, or mechanical impediment to the circulation, owing to the presence of tubercles in the lungs. One of the most severe cases of haemoptysis, which the author has attended, occurred in the act of sexual intercourse. In the advanced stages of pulmonary consumption, haemoptysis may be a symptom of the existence of abscess in the lungs. The inhalation of fine mechanical particles, borne about in the air, in certain occupations, or of acrid vapours, may also be an ex- citing cause. Pneumonia is attended with some exhalation of blood, but this is generally to a slight extent. Inflammation, therefore, of the pulmonary parenchyma may be regarded as a cause of haemopty- sis, and any induration, or hypertrophy, or dilatation, or protracted palpitation of the heart, or organic disease of any of the viscera may interfere with the due circulation of the blood, and give rise to hyperaemia in the lungs, which may terminate in the exhalation of blood into the bronchial tubes. In like manner, pregnancy, or the improper pressure exerted on the female by corsets too tightly applied, may induce it. It succeeds, at times, to the suppression of accustomed evacuations, as of the haemorrhoidal or menstrual flux, and recurs periodically at the times when the others have been expected. The condition of the blood has likewise its effect in favouring hemorrhage, and this, we shall see, has to be borne in mind in the treatment. If the blood is thin,—that is, contains a larger propor- tion of serum than of red globules or fibrine,—it will more readily transude through the parietes of the vessels; hence, haemoptysis is occasionally seen in scorbutus, and in chlorosis. Some singular cases are recorded, in which unusual agencies have acted in the way of causes. Thus, music, it is affirmed, has induced it in many persons affected with phthisis. In other cases, it has supervened on the application of leeches, or of a blister or sinapism, and, on the other hand, these means will frequently arrest it. The author had a case recently under his charge, in which the patient felt the sensation as if blood were drawn internally towards the part of the chest to which any form of counter-irritant was applied, and spitting of blood invariably followed. We are told, again, of persons who could not partake of particular articles of diet, or inhale particular odours, without this affection supervening. (Andral.) Such, however, are rare cases—exceptions to the gene- ral rule. It has been asserted, that haemoptysis may be caused by a pro- longed mercurial treatment, or after the long use of the preparations OF THE BRONCHIA AND LUNGS. 295 of iodine; but although the author has had ample opportunities for seeing both these therapeutical agents used to a great extent, he has never witnessed this result. Pathological characters.—In a case of simple exhalation from the lining membrane of the bronchial tubes, the membrane may or may not present signs of a pathological condition. It has been found more or less red, livid, and tumefied, and, at other times, pale, and exanguious. Commonly, it is covered with blood, and, on its surface, a number of red points may be observed on careful examination; but there is usually no trace of ulceration or of any rupture. The flow of blood takes place by transudation or diape- desis; not by rhexis or rupture of vessels, as was at one time universally believed; and we still constantly hear of a haemoptoic individual having broken a blood-vessel in his lungs. The mucous membrane is usually a little softened, and impregnated or tinged with blood throughout its substance. (Laennec.) This softened condition is the main cause, perhaps, of the sanguineous exhalation. Treatment.—When the haemoptysis is slight, and occurs in one enjoying good health, and is merely limited to sputa, tinged more or less with blood, the simplest means are sufficient for its removal. It is but necessary to inculcate mental and corporeal quietude, silence, a restricted diet, the occasional use of a brisk cathartic,1 and, if much plethora, or sense of tightness about the chest exists, general or local blood-letting. 1 R.—P. jalap, gr. xv. Hydrarg. chlorid. mit. Pulv. zingib. aa gr. v.—M. It was at one time the belief with the profession, and still is with the vulgar, that in all cases of haemoptysis, as of other hemorrhages, astringents should be employed; but the case is not so simple. The pathological cause of the hemorrhage has to be inquired into, and the disease treated in accordance therewith. If the hemoptysis be attended with symptoms of vascular fulness or activity, blood- letting, and the agents belonging to the classes of sedatives and refrigerants, are chiefly indicated. Usually, when a person is attacked with hemorrhage from the lungs, the greatest alarm is felt, and, in all cases, it is expected that the practitioner should have recourse to blood-letting, to arrest the flow. The fact, how- ever, is, that the loss of blood may be arrested at a less expense of fluid, when due attention is paid to ventilation, posture, &c. than when the lancet is used. A coagulum soon forms around the transuding vessel, and the hemorrhage ceases. Whether blood- letting has to be practised must depend upon other grounds—upon the results of an inquiry into the state of the circulation, general and capillary, connected with the hemorrhage; and should there be evidences of plethora, or of hyperaemia, the quantity of the cir- culating fluid should be diminished, otherwise, the hemorrhage may recur—care being had, as in every case of hemorrhage, not to allow too much fluid, but rather advising that a small piece of ice 296 DISEASES OF THE RESPIRATORY ORGANS. should be taken into the mouth occasionally, for the purpose of allaying thirst and undue excitement. Blood-letting is one of the most powerful sorbefacients we pos- sess; and if, immediately after it has been practised, fluid be freely allowed, it will pass at once into the blood-vessels, so that the quantity of blood circulating in the vessels may be as great, soon after the operation, as it was before it; but it will be blood con- taining a larger proportion of watery contents, and, therefore, better adapted for transuding through the parietes of the vessels. If such be the case after a single bleeding, it can be readily seen that re- peated bleedings, under similar circumstances,cannot fail to increase the evil, by laying the foundation for repeated returns of the hemorrhage. The symptoms that precede, accompany, or follow the hemor- rhage, must be the guides to the abstraction, and should it be ac- companied by a sense of heat or pain in the chest, constant or frequent cough, dyspnoea, and the pulse be, at the same time, full and hard, blood-letting may be practised, and repeated at the dis- cretion of the practitioner. In this country, during the haemoptysis, it is very common for the patient to be directed to take common salt into the mouth, un- der the idea that it possesses haemastatic virtues. (Rush.) The author has never had the slightest reason for believing, that it has been productive of any advantage, nor can he see under what principle it has been recommended. It has been already remarked, that, after a time, the hemorrhage ceases, whether salt has been employed or not; and hence it has probably happened, that the result has been ascribed to the salt, when it may have exerted no agency. By some of the European writers, it is referred to as a remedy employed in Philadelphia. (Andral.) In cases of active hemorrhage, where the loss of blood, and the use of ice, with the other means above recommended, are insuffi- cient to reduce the vascular action, the tartarized antimony and ipecacuanha have been used, with the view of inducing the seda- tion that accompanies nausea. The digitalis has, likewise, been recommended for the same purpose. It may be given alone,1 or in combination with the hydrocyanic acid.2 1 Pulv. digit, gr. j. vel 2 R.—Tinct. digit, gtt. x\. Tinct. digit, gtt. x. ter die. Acid, hydrocyanic, gttvj.' Mucilag. acaciae, giij. Aquae, ^iiiss.—M. Dose, a fourth part every four or five hours. The objection to the digitalis is, that its effects are not immediate; still, there are many cases in which ample time is allowed for them to be elicited. Amongst the most valuable of the remedial agents in haemoptysis are revellents, of which there are various kinds. Dry frictions may be made over the surface; and, as the recession of the vital activity OF THE BRONCHIA AND LUNGS. 297 from the extremities is one of the common precursors of an attack of hemorrhage, it is important to solicit the blood towards them, by siuapised pediluvia, or by sinapisms to the feet, calves of the legs, arms, &c. Dry cupping over the surface of the body has, like- wise, been recommended; and, when the hemorrhage has taken place, some have advised, that ligatures should be put round the limbs, with the view of modifying the circulation. The plan is not, however, much employed, although we are satisfied it has occa- sionally been of advantage. Flying blisters, applied here and there, have been advised, (Stoll;) but they have been thought contra- indicated, where bleeding had been pushed to a great extent, in consequence of the irritability thereby engendered. (Andral.) There can be no question, indeed,—as the author has else- where pointed out,—(General Therapeutics, Philada. 1836,) that excessive loss of blood develops the nervous irritability, and that mischief is apt to be induced from this cause. When blood-letting is practised, whilst the hemorrhage is taking place from the lungs, it belongs to what were formerly termed "revulsive bleedings,"— the flow of blood being solicited towards the open vein, and, there- fore, deriving from the "determination" towards the bronchial mucous membrane. On the principle of revulsion, the application of leeches to the anus has been strongly advised, (Andral;) and, for the same reason, it has been recommended not to apply them, or the scarificator, or blisters, over the chest. The writer, just referred to, inculcates the necessity of applying them not on the chest, but to the anus. Although the equalizing and revulsive operation of emetics might be of service in haemoptysis, it has been conceived, that the activity they occasion in the vascular movements might do more harm than their other operations might do good. Yet it has not*been found, that haemoptysis, symptomatic of phthisis, has been increased at sea, during the retching of sea sickness. (Professor Morton, of Philadelphia. See also, the author's Elements of Hygiene, p. 183.) The revulsion, excited by cathartics, may be invoked beneficially, after the hemorrhage has ceased. During the attack, their operation might be injurious, in consequence of the corporeal disquiet they induce. The saline cathartics, which operate on the different tracts of ilie intestinal canal, and augment the secretion from the mucous membrane, ought perhaps to be chosen. R.—Magnes. sulphat. 3iij. Potass, bitart. gss. Aquae menthae, §iij.—M. Dose, one half, to be repeated in three or four hours, if necessary. Where blood is flowing copiously from a vessel, the idea would at once present itself, that astringents should be employed; and, before philosophical views of pathology were entertained, these were the agents universally had recourse to. Whenever haemoptysis is attended with symptoms of vascular fulness or activity, 'the agents, already described, act as indirect 29S DISEASES OF THE RESPIRATORY ORGANS. astringents, and but little reliance is placed upon any of the articles of the materia medica, which are regarded as direct astringents, as none of them can be made to come in contact—except in a very dilute sta,te—with the vessel whence the blood proceeds. Most of the astringents are, however, tonics, and, in cases of asthenic he- morrhage, may be serviceable in this way, from the improvement they produce in the general system; whilst others have the power, at the same time, of modifying the condition of the blood, and ren- dering it less fitted for ready transudation through the parietes of the vessels. Almost all the agents that belong to the class of astringents have been given in haemoptysis. The sulphuric acid, in a dilute state, or in the form of the elixir of vitriol, (gtt. viij.—x. in a glass of water,) is a common remedy; or a lemonade, made of dilute sul- phuric acid, lemon peel, sugar, and water; but, if the experiments of a distinguished physiologist, (Magendie,) are to be relied on, the sulphuric acid does not favour the coagulation of the blood, but the contrary. Alum, kino, the extract of the krameria, &c. &c. have likewise been favourites with some. In regard to the acetate of lead, much difference of opinion has existed. Some have regarded it as the most potent of all remedies, (gr. ij. iij. iv. in pill, every three or four hours,) after plethora has been considerably reduced. Tannin has been highly extolled.1 The tannin occasions con- stipation, which may be removed by enemata. 1 R.—Tannin, pur. gr. iv. Pulv. acaciae gum. gr. xvj. Syrup, simpl. q. s. ut fiant pilulae viij. Dose, one, every three hours. From the powers of creasote as a haemastatic, it was certain to be employed in haemoptysis; and testimony of its efficacy has been adduced. (Santini, Schmalz.) In the hands of some, however, (Guitti,) it has proved of little avail. The author has used it on one or two occasions, and he thinks with advantage.1 1 R.—Creasot. gtt. v. Mucilag. acac. giij. Syrup, gj.—M. Dose, a spoonful, every three hours. From the effect which it exerts on the coagulability of the blood,it seems well adapted for all cases in which there is too great tenuity of that fluid. The same may be said of the iodide of iron, which the author has prescribed with the very best effects. Its property of coagulating the blood, and, therefore, of inspissating it, renders it especially valuable in hemorrhage, occurring in pathological con- ditions of the system, in which there is paucity of red globules of the blood, and too great a proportion of serum, (gr. ij. or iij. in solution in water, three or four times a day.) Haemoptysis has occasionally recurred in an intermittent manner, and has been arrested by the sulphate of quinia. (Vavasseur.) Both this, and the iodide of iron, as well as other tonics, may be OF THE BRONCHIA AND LUNGS. 299 administered, whenever the hemorrhage is of an asthenic character, and when the catenation of symptoms resembles those of scurvy. During the whole course of active haemoptysis, the diet should be that of any febrile affection, except that fluid should be less freely allowed. The diet ought, indeed, to be as dry as possible; and, to allay thirst, small pieces of ice may be taken into the mouth, or iced lemonade may be sucked through a rag. When the fever has abated or disappeared, more nourishing aliment may be allowed; but everything must be taken cold. Farinaceous vegetables with milk—as arrowroot, sago, rice, &c. should form the main diet, and every care be taken to avoid mental or corporeal agitation. All unusual exertion of voice or of body must be avoided; and the effects of vicissitudes of temperature and of consequent irregu- larity of circulation be obviated by flannel next the skin, and if this should fail, removal to a milder climate may be advisable. (Andral.) b. Hemorrhage into the Lungs. Synon. Apoplexia Pulmonalis, A. Pulmonum, Pneumorrhagia, Pulmonary Apoplexy; Fr. Apoplexie Pulmonaire; Ger. Lungenschlagfluss. By many, pulmonary apoplexy is reckoned as a form of hae- moptysis, and is considered under that head. There is, however, pathologically, a well marked difference; in the latter cases, the blood is exhaled from the bronchial mucous surface, whilst, in the former, it is effused essentially into the pulmonary parenchyma itself. The affections are, however, so congenerous* that it may be advisable to consider hemorrhage into the lungs immediately after hemorrhage from the bronchial tubes. Hemorrhage into the lungs is not an uncommon affection. It has been affirmed, indeed, to be very common, (Rostan,) but the author of the assertion remarks, in another place, that it is some- what rare! In some cases, it has destroyed instantaneously by asphyxia, but generally, it is announced by a train of symptoms, which may indicate its existence. Diagnosis.—The attack is commonly very sudden, and is marked by great dyspnoea, amounting, at times, to a threatening of suffo- cation. The movements of the thorax are hurried and unequal, exhibiting, indeed, the greatest possible irregularity; and the accom- panying anxiety is intense. The characteristic physical signs have been considered to be:— absence of the respiratory murmur over a portion of the lung of no great extent, and a crepitant rhonchus around the part. (Laennec.) But these signs would not appear to be constant, and, in many cases, it would seem, percussion and auscultation have afforded no in- formation. (Andral.) The expectoration of a black fluid, devoid of fcetor, and resembling a solution of liquorice juice, has been esteemed a more positive sign, as indicating a collection of blood, which has undergone some change prior to its expulsion. (Andral.) Where the blood is, at the same time, poured out into the air 300 DISEASES OF THE RESPIRATORY ORGANS. cells, the quantity expectorated may be enormous. As much as ten pounds have been lost in. forty-eight hours. (Laennec.) Causes.—In the generality of observed cases, the hemorrhage has occurred in persons labouring under heart disease, or pulmonary consumption. One of the most rapid cases which the author has seen, was that of a young gentleman who was travelling for his health, and was, at the time, affected with manifest tuberculosis of the lungs, which had gone on to softening. Pathological characters.—Portions of the lung,usually restricted to a few inches in extent, are found of a deep red colour, and having a density similar to that of the lung when hepatized by inflammation—appearances which are not modified by ablution. When these portions are divided by the knife, coagulated blood is generally found in the centre, which is, of course, entirely devoid of organization. The parts of the lung, surrounding the seat of the apoplexy, are crepitant, and separated fro.m the apoplectic por- tions by a well marked line of demarcation. Careful examination will often exhibit laceration in the pulmonary tissue. The hardness of the affected portions is owing to the absorption of the more liquid portions of the blood. Treatment.—The plan of treatment, laid down by almost all, is to bleed copiously, and not to be prevented from this course by apparent debility, or feebleness of pulse. It has been properly remarked, however, that "the plan of bleeding, in every case of bloody discharge from the lungs, is very bad;- because it is bleeding for a name, •without pathological considerations." (Mackintosh.) The objects with which bleeding should be practised, may be to diminish the quantity of the circulating fluid; or, by inducing syncope, to arrest the flow; or to change the direction of the blood towards the artificial outlet. A more remote object may be—to favour the absorption of the blood already effused. In plethoric individuals, there can be no doubt of the propriety of this course, pushed as far as the symptoms, in the individual case, may indicate; but where the disease occurs in oligaemic indi- viduals, the caution which was advised under Haemoptysis, and the various revellents and other agents, recommended under the same head, are equally appropriate here. IV. INFLAMMATION OF THE LUNGS. Svnon. Inflammatio pulmonum, Pneumonia, Empresma pneumonitis, Perip- neumonia, Pneumonia peripneumonia, Pneumonitis, Peripneumony; Fr. Pneo- monie, Peripneumonie, Fluxion de poitrine, Inflammation du parenchyme pul- monaire; Ger. Lungenentzundung, Entzundung der Lunge. The definition of pneumonia, given of late years, by some of the best observers, is—inflammation of the parietes of the pulmonary vesicles or air cells, or of the intervesicular cellular tissue, or of both combined, (Broussais, Bouillaud, Andral, Raciborski;) % however, we regard the vesicles or air cells to consist of the termi- nal extremities of the bronchial tubes, it is difficult to separate OF THE BRONCHIA AND LUNGS. 301 pneumonia from bronchitis, which, as we have seen, is an inflam- mation of the mucous membrane of the bronchia. It is presumed, however, that the small tubes are not lined by a mucous membrane, and hence it may be supposed, that pneumonia is an inflammation of the cells and minute tubes, (Stokes;) and the writer, just cited, believes, that " it differs from bronchitis in the ordinary acceptation of the term, merely in the occurrence of a parenchymatous inflam- mation, such as solidification, suppuration, and abscess, phenomena not proceeding from any inherent difference in the diseases, but a result of anatomical structure." He elsewhere remarks, that "he who would call pneumonia a bronchitis of the terminal tubes, would be hardly guilty of a misnomer." Inflammation of the lungs may admit of three divisions for con- venience of description; a. the acute; b. the chronic; and c. the typhoid. a. Acute Inflammation of the Lungs. Inflammation of the lungs has received various epithets, accord- ing to the part of the lungs implicated. When the air vesicles are presumed to be affected alone, or chiefly, it has been termed vesi- cular pneumonia. When the inflammation implicates all the vesicles of a lobule, it is termed lobular pneumonia; and when the whole of a lobe or all the lobes of a lung are concerned, it is termed lobar pneumonia. Double pneumonia is when both lungs participate in the inflammation, as is commonly the case in children; and pleuropneumonia is the term applied to the disease, when the inflammation affects, at the same time, both the lungs and pleura. Lobar pneumonia occurs more frequently in the inferior, than in the superior lobes. Of 88 cases, the inferior lobe was inflamed in 47; the superior in 30; and in 11 cases, the whole lung was impli- cated. (Andral.) From the combined observations of several distinguished pathologists, (Andral, Chomel, Lombard,) it would appear, that in 1131 cases, the right lung was concerned in 562- the left in 333; and in 236 the disease was double. (Forbes.) It is probable, however, as has been suggested, (Stokes,) that the pro- portion of cases of double pneumonia is underrated in the estimate It is very much more common in young children and old persons than in adults. Of 128 cases observed in infancy, (Valleix Ver- nois,) the disease occurred in the right lung in 17 cases; in the left Jung in no case; and the pneumonia was double in 111 cases. Of these 111 cases, the disease predominated on the right side, 59 times- on the left, 10 times; and it was equal on both sides, 42 times Pneumonia is often associated with bronchitis, so that the former may be masked by the latter. This is especially the case in children in whom no information from the sputa is attainable; and at the same time the sounds afforded by percussion may be alike on both sides, as the affection is rarely confined to one lung. (Maunsell.) 302 DISEASES OF THE RESPIRATORY ORGANS. Previous to six years Of age, the symptoms and progress of the disease differ somewhat from those of a later period; it would seem then to occur mostly as a secondary lesion, (Gerhard, of Philadel- phia, Rilliet and Barthez;) and has been conceived to be owing to a stagnation of blood in the lungs, which acts, as it were, as a foreign body, and concurs in producing an alteration in the pulmo- nary tissue, with which it combines, and becomes identified, so as to form what is called hepatization of the lungs, (Billard:) although, however, in very young children, the disease is generally secondary, in other cases it runs its course in a brief space of time, sometimes in forty-eight hours, and attacks those in perfect health. Howsoever this may be, it is certain, that in children, the diagnosis between pneumonia and bronchitis is not easy. Diagnosis.—The essential symptoms of pneumonia are—febrile excitement, cough,—viscid, bloody or purulent expectoration, and shortness and difficulty of breathing; yet these are not pathogno- monic; and it is only by associating them with the physical signs, and carefully observing the latter, that we are enabled to pronounce positively; for although, as has been well remarked, (Stokes,) any of the physical signs taken singly may occur in other affections, in pneumonia their mode of succession is characteristic; still, the diag- nosis is not as easy as some have imagined, (Bright and Addison,) as is exhibited by the fact, that the respectable pathologists, just cited, consider pungent heat of the surface as the most invaria- ble and conclusive diagnostic, and that where inflammation is con- fined to the chest, however various may be the tissues implicated, the presence of this symptom may be esteemed a certain indication of pneumonia in nineteen cases out of twenty. First, as regards the symptoms that are referable to the lungs themselves:— One of the most important of these is the expectoration. At the commencement of the inflammation, the cough is dry, and by no means in a ratio with the degree of the inflammation. If some degree of bronchitis has preceded the attack of pneumonia, the sputa may be mucous; about the second or third day of the disease, however, the matter of expectoration becomes characteristic, con- sisting of mucus intimately mixed with blood; yet this appearance is by no means constant. (Stokes.) The disease may, indeed, occur without any characteristic expectoration; and where the bloody and viscid sputa are present, their appearance may vary from yellow, or rusty, to florid red in the course of the same day. (Andral.) As the disease proceeds, the density of the sputa augments, and they become viscid, transparent, and so tenacious as to adhere to the sides of the vessel. In this state, they may remain until the disease is about to terminate, when they vary according to the nature of such termination. If the disease is about to end by reso- lution, they lose their red colour and great viscidity, but resume them on the occasion of any exacerbation; on the other hand, if the disease grows very serious, they become small in quantity, are OF THE BRONCHIA AND LUNGS. 303 expectorated with difficulty, and, at times, are wholly suppressed. This suppression may be real, or the sputa, owing to their viscidity and the feebleness of the patient, may accumulate in the bronchial tubes, and induce death by asphyxia. Although the rusty sputa—crachats rouilUs, of the French pa- thologists—are found in the more active cases of pneumonia, occurring in persons of robust habit, yet in a large proportion of hospital cases, in which the disease occurs in feeble constitutions, in the child, and as a sequel to fever, the appearance of the sputa has been esteemed of little value. (Stokes.) It is certain, that there are many cases, which run their course both to a happy and fatal termination, in which tbe matter of expectoration is similar to that of simple bronchitis. In cases of intercurrent pneumonia, or such as occurs in the course of another disease, the absence of the charac- teristic expectoration is noticed. (Andral.) When the pneumonia has terminated in suppuration, the expec- toration presents itself in two forms:—either in that of pus, or of a purplish-red muco-puriform fluid, having the consistence of gum water, and the appearance of liquorice or prune juice—the latter form of expectoration, occurring generally when the pneumonia is of a lower grade, and in broken-down constitutions, whilst the for- mer is a consequence of active pneumonia in a healthy individual. Dyspnoea is a symptom, which exists to a greater or less degree in pneumonia, but to a less extent than in bronchitis or pleurisy: the extent of obstruction cannot certainly be estimated by the amount of difficulty of breathing. Occasionally, however, great oppression is experienced at the chest, with anxiety, lividity of face, and sense of suffocation. These cases not uncommonly terminate fatally. On the other hand, especially after antiphlogistic remedies have been used, the breathing is singularly easy, even although a large portion of lung is solidified. (Stokes.) Pain does not exist in pneumonia, unless the pleura is involved, which, however, as already remarked, is generally the case. The pain may be felt in various parts of the chest, and is most severe at the commencement. It is usually augmented by coughing, in- spiration, change of posture, percussion, and by lying on the affected side. It is maintained by some pathologists, that inflammation of the pleura rarely complicates the pneumonia of children. ( Valleix, and Gerhard, of Philadelphia.) By others, however, the complication has been found to be common, the pleura having been unaffected in ten cases only. (Rilliet and Barthez.) Evidences of acute pleurisy existed even in one-third of the children from two to five years of age. When the pleura is unaffected, a feeling of constraint, a kind of weight and sensation of heat, is experienced in the chest. (An- dral.) It has been often said, that the patients constantly lie on the side 304 DISEASES OF THE RESPIRATORY ORGANS. affected, but such is certainly not the fact; the decebitus, indeed, is generally on the back. (Andral.) Three stages of pneumonia have usually been pointed out. (Laennec.) In the first, the lung is engorged with blood, and a crepitating rhonchus is heard; in the second, solidification takes place, with its physical signs: and in the third, interstitial suppu- ration of the lung, or the condition, which precedes the formation of abscess, supervenes. It has been suggested, however, (Stokes,) that a stage, prior to the first of Laennec, exists, and, consequently, that Laennec's first is really the second stage of the disease, and there can be no doubt, we think, that a stage of irritation, if not of inflam- mation, exists, previous to the secretion or effusion, which causes the crepitant rhonchus. Dr. Stokes affirms, that he has repeatedly seen a condition of the lung, which seems to be the first stage, and in which the pulmonary tissue is drier than usual, not at all engorged as in Laennec's first stage, and of a bright vermilion colour, from intense arterial injection. This condition was found in the upper portions of lungs, in the middle and lower parts of which Laennec's first and second stages existed. Dr. Stokes, consequently, enume- rates the stages of pneumonia as follows:—First. The lung drier than natural, with intense arterial injection, no effusion of blood into the cells. Second, (Laennec's first.) The cells engorged with blood; no change of structure. Third, (Laennec's second.) Solidity and softening, (Ramollissement rouge, of Andral.) Fourth. Inter- stitial suppuration. And Fifth. Abscess. In the first of these stages, the principal phenomenon is local puerility of respiration, which may be esteemed diagnostic, if it occurs along with fever and excitement of the respiratory system, (Stokes,) especially if there be clearness of sound on percussion, indicating that no extensive organic modification has yet occurred. Nor does the sound on percussion become obscured, until about the second or third day, and sometimes later. In the second stage of Stokes—the first of Laennec—the crepi- tating rhonchus is heard along with a gradually diminishing respi- ratory murmur. This crepitating rhonchus has been compared to the sound produced by rubbing a lock of hair close to the ear. (C. J. B. Williams.) As a physical sign, it points out a secretion or effusion into the vesicles, but to determine that it is pneumonic,the increasing dulness and gradual obliteration of the respiratory mur- mur must be combined with comparative dulness of sound on per- cussion. (Stokes.) It may be proper to remark, that in some cases the crepitant is united with the mucous rhonchus. In other cases, the crepi- tant rhonchus is heard, where there is simple bronchitis without any inflammation, perhaps, of the pulmonary parenchyma, and hence it has been inferred, that, like other rhonchi, the crepitant rhonchus results from a mixture of air and liquid, and that the differences, which the rhonchi present, are owing to the difference in the size of the cavities in which they are produced. (Andral) OF THE BRONCHIA AND LUNGS. 305 In cases, for example, of extensive excavations in the lungs, gar- gouillement or gurgling is heard; in the larger bronchia, the mucous rhonchus; in the bronchia of medium size, a mixture of the mucous and crepitant rhonchi; and in the smallest bronchia and pulmonary vesicles, the pure crepitant rhonchus. These different rhonchi An- dral designates, respectively—the "cavernous," the "bronchial," and the "vesicular." In the third stage—the second of Laennec—there is solidity with softening; the cbIIs are obliterated, whilst the large tubes remain pervious; there is, therefore dulness of sound, with bronchial or tubal respiration, and a loud resonance of the voice—bronchophony; signs which sufficiently indicate solidification. Occasionally, rapid solidification occurs without being preceded by the usual signs—the lung passing, in the course of a few hours, from apparent health, according to every physical sign, to solidifi- cation. Signs of sudden solidification, without preceding crepitating rhonchus, have been regarded pathognomonic of pleurisy with effu- sion, (Andral,) yet they are equally indicative of the condition just described. The principal physical diagnosis between this " typhoid solidity" and a pleural effusion is, that with the dulness and absence of respiration of a considerable effusion, the signs of excentric dis- placement are wanting; the heart is not displaced; the epigastrium and hypochondria are concave, and the intercostal muscles unaf- fected. (Stokes.) When pneumonia is about to end by resolution, and to pass from the third stage to the second, the crepitating rhonchus returns. This has been called the " returning crepitating rale"—Rhonchus crepi- tans redux, Rdle crepitant de retour; the tubal respiration dimi- nishes; the bronchophony gradually disappears; the crepitating rhonchus fades away, by little and little, until, ultimately, only the normal sound of respiration can be heard. In many parts of the lungs, however, different physical signs may be elicited, indicating that these parts are in different stages of inflammation; and, at times, after the other signs have ceased, a crepitant rhonchus may remain. This circumstance should keep the physician on his guard against a relapse, or some disorganization of the lung, which may result insidiously from the existing phlegmasia. (Laennec, An- dral.) It was the opinion of Laennec, that as solidification of the lung disappears, the fact is invariably announced by a return of the crepitating rhonchus; but this would not appear to be an absolute rule: the change, indeed, from complete dulness of sound, and tubal respiration, to clearness and return of respiratory murmur, has been often observed, without any "crepitus of resolution." (Stokes.) The signs of the fourth and fifth stages of Stokes, are the follow- ing:—If there be tubal respiration, along with a sharp and peculiar muco-purulent rhonchus, these signs, taken along with the previous history of the disease, and the existing symptoms, will lead to the inference that there is interstitial suppuration. 26* 306 DISEASES OF THE RESPIRATORY ORGANS. The signs of pneumonic abscess do not differ from those of tu- berculous cavities; the former are generally, however, at the inferior portion, or about the root of the lung, and are not so slow in their formation as tubercular abscesses. (Stokes.) When pneumonia is deeply seated towards the base, the centre, or the root of the lung, percussion may yield but little information, and the same remark applies to auscultation. In like manner, when some isolated lobule is inflamed, the physical signs may yield no information as to the existing lesion. When inflammation affects both the lungs and pleura—pleuro- pneumonia—the signs of the pneumonia may be modified by those of solid,fluid,or aeriform secretions into the pleura; notwithstanding, however, the frequency of adhesions, the friction sound—bruit de frottement—is rarely observed in pneumonia. The secretion of air into the pleura is indicated by the sudden appearance of tympanitic resonance over the affected portion of the lungs, which may be distinguished from the "cracked vessel sound"—bruit depot file —of caverns, and differs, also, from the clear sound rendered by percussing the lower portions of the lungs over the stomach dis- tended with air. (Stokes.) Lastly, during pneumonia, a bellows sound—bruit desoufflet— of the heart has been observed; and, also, a throbbing of a large portion of the chest, synchronous with the systole of the heart, during the earlier stage of the disease. (Graves.) The bellows' t sound has been supposed to be owing to inflammation, either of the pericardium or endocardium, accompanying the pneumonia; and the throbbing has been presumed to be owing to the semi-fluid condition of the lungs, the pulsations of the heart being propagated I through these organs, and occasioning phenomena analogous to 1 those of aneurism. (Graves, Stokes.) < The average duration of pneumonia is from twelve to twenty- four days. At times, it continues only two or three days; at others, it may go on for thirty or forty. It is always a serious disease. I Of seventy-eight cases, observed at La Charite between the years 1821 and 1827, twenty-eight proved fatal. (Louis.) Acute pneu- monia may, likewise, pass into the chronic form, or it may give occasion to the formation or development of pulmonary tubercles. Many varieties are observed in the disease. For example,— intense pneumonia may exist, without giving rise to dyspnoea, cough, or the characteristic sputa; and it would appear, that aus- cultation may afford no sign of it. (Andral.) In this form, the disease has been termed " Latent pneumonia." It is rarely primary, and commonly occurs in the course of other diseases. (Andral, Stokes.) Of the differences presented by pneumonia, when it occurs in children, we have already spoken. In them, the disease frequently terminates fatally, before it reaches the third stage; the appear- ances on dissection being principally those of engorgement of the lungs. OF THE BRONCHIA AND LUNGS. 307 In old persons, a more rapid prostration is induced than in adults, and hence the term Peripneumonia notha, which has been applied to pneumonia in them, as well as to chronic bron- chitis; which latter affection is indeed very apt to be complicated with pneumonia, giving occasion to intense dyspnoea. It has been properly remarked, that great practical difficulty exists in diagnosticating the symptoms of pneumonia, when it occurs in the course of serious fevers, pleurisies, pericarditis, arach- nitis, gastroenteritis, pulmonary tubercles, aneurism of the heart, &c. (Andral.) Of the catenation of symptoms, which constitute the bilious and typhoid forms of pneumonia, special mention will be made here- after. Causes.—Pneumonia is a disease of all climates, although, like other inflammatory diseases, less frequent perhaps in Australia. It would seem to be not so common where the climate is warm and equable; and, in the temperate regions, some countries are more affected by it thau others. In the United States, it is a very common disease; and, according to the statistics that have been taken, it is here, also, more frequent in some places than in others. The following table, prepared by an accurate medical statistician, (Emerson, of Philadelphia,) exhibits this fact as regards some of the principal cities of the United States. It gives the average mortality from consumption, and acute diseases of the lungs in those places. New York. Boston. Philada. Baltimore, j Average annual proportion of the general mortality to the population, one in 39.36 44.93 47.86 39.17 Average of the mortality from consumption alone, to the general mortality, one in 5.23 5.54 6.38 6.21 Average of consumption and acute diseases of the lungs, one in 4.07 4.47 4.90 5.33 It would appear, that situations in cold and variable climates, in which the hygrometric state of the atmosphere varies considerably, and which are open to cold winds from the ocean, are less fitted for those who are liable to affections of the pulmonary organs. (See the author's Elements of Hygiene, p. 201.) In like manner, pneumonia is more likely to occur in cold and moist seasons. Recently, the attention of the army medical officers of the United States has been drawn to this subject; and the following table presents, in a condensed shape, so far as regards the catarrhal form of pulmonary lesions, the result of the quarterly sick reports of 45 permanent posts, arranged in classes, and comprising a period of ten years, and of 31 temporary posts in Florida. It is based on an aggregate mean strength of 47,220 men, and the period of observa- tion extended from 1829 to 1838 inclusive. It exhibits the con- densation of about 1500 quarterly reports of sick, and the mean strength of each post, computed from monthly returns in the adju- tant general's office. (Forry.) 308 DISEASES OF THE RESPIRATORY ORGANS. Ratio of Catarrhal Diseases. "g^S Ratio treated per 1000 mean SYSTEMS OF CLIMATE. © ■° Q> 3 E 2 " S°2a strength. 0 .2 '> s ■a 3 Diflferei tween t temperi winter i mer. 0) » c ■3 2 u u 'i = ss = p "3 . '1st class. Posts on the coast of New England. 43° 18' 38° 61 63 49 3G 8o 233 2d class. Posts on northern Northern. -. chain of Lakes. 3d class. Posts north of lat. 39°, and remote from 46° 27' 43° 00 90 62 50 96 300 the ocean and inland seas. 44° 53' 55° 84 175 120 86 169 552 r 1st class. From Delaware Middle. - Bay to Savannah. 37° 02' 32° 99 102 45 23 97 271 2d class. Southwestern ■ . stations. 35° 47' 36° 83 122 61 33 78 290 1st class. Posts on lower Southern. < Mississippi. 2d class. Posts in Penin- 30° 10' 24° 39 92 34 26 60 218 _ sula of East Florida. 24° 33' 11° 34 45 24 40 33 143 Total, 689 395 294 616 • In the French hospitals, three times as many cases of pneumonia have been observed in the last six months of the year as in the first. (J. Pellet an, Briquet.) It has been already remarked, that pneumonia often occurs in the course of other diseases: it would seem, indeed, that chronic inflammation in any organ has a tendency to predispose to it; so that, after a chronic disease has persisted for a long time, the patient may be carried off by an attack of acute pneumonia. It is apt, too, to occur in connection with, or as a consequence of, sur- gical operations and injuries. From a table of forty-one deaths, occurring from various injuries and diseases in the surgical wards of University College Hospital, London, in which an account of the state of the lungs was kept, these viscera were found in twenty- three cases to be in the first or second stages of pneumonia. (/. E. Erichsen.) On this account, it has been suggested to defer opera- tions during very severe weather, or during the prevalence of an epidemic pneumonia. The great dyspnoea, which precedes dissolution in most cases, has been regarded as pneumonia, and has received the epithets Pneumonie des agonisants, (Laennec,) and Hypostatic pneu- monia, (Piorry;) but there is little reason for the opinion, that the condition is inflammation. It appears rather to be a state of hyperaemia, dependent upon the difficult transmission of blood through the lungs. (Andral.) Pneumonia occurs at all ages. It has been found even in the still-born, and is, consequently, an intra-uterine disease also. It attacks both sexes indiscriminately, although it is affirmed, that OF THE BRONCHIA AND LUNGS. 309 • men are more subject to it than women. This may be owing to their greater exposure to its exciting causes. At times, it occurs epidemically, when its characters are so far modified as to de- mand a very different treatment at one time from that which is required at another. Pathological characters.—In accordance with the different stages of the disease, of engorgement of the lung, solidification, and interstitial absorption, laid down by Laennec, he adopts three de- grees in which the pulmonary parenchyma may be found affected on dissection. 1. Simple engorgement. 2. Red hepatization; and 3. Gray hepatization. The word "hepatization" has, however, been objected to, as not expressive of the changes that are induced either in the second or third stages of Laennec. It has been observed, (Andral,) that an inflamed lung differs from liver in consistence especially,—being most commonly soft- ened and friable; but, at the same time, in certain, and much more rare, cases it is harder than natural. On these accounts, Andral pro- posed that the terms "red" and "gray ramollissement" should be substituted for the "red" and "gray hepatization," of Laennec. Andral's own observations, however, show, that the term ramol- lissement, which signifies "mollescence or softening," can only apply to a portion of the cases, and, accordingly, the word " solidi- fication" is usually given by pathologists to any of the conditions of the lungs, in which their vesicular structure becomes filled with any secretion, that prevents the reception of air into them. If a patient dies in the early stages of pneumonia, when the lung is simply engorged, the crepitation of the lung may still exist, but it will be more feeble than in the natural state, and pressure on the lung will show, that the pulmonary vesicles contain fluid, as well as air. The parts, which are affected with inflammation, are of a brown or vermilion colour, which contrasts with the appearance of the healthy lung. When the affected part is cut into, a frothy and bloody fluid exudes, and if the engorged parts be well washed, their colour is restored as well as their crepitation, and they float high in water. (Andral.) If the inflammation is more intense than this, the consistence of the parenchyma of the lungs is diminished; it becomes friable, and breaks down readily when pressed between the fingers. In this state, it resembles the tissue of the spleen, and the condition of the lung has accordingly been termed, by some, splenization. When cut into, the fluid, that exudes, is less copious and frothy; and this condition has been esteemed the transition from engorgement to solidification. (Andral.) In the second stage of Laennec—the third of Stokes—the pul- monary vesicles become impervious to air; the lung is greatly engorged with blood, uniformly red, and resembling the liver in appearance. It is no longer crepjtant, and when the solidified por- tion is thrown into water it sinks. A recent pathological writer, indeed, (Professor Gross, of Cincinnati,) affirms, that although he • 310 DISEASES OF THE RESPIRATORY ORGANS. has frequently tried the experiment, he has never witnessed this last circumstance, and he feels inclined, therefore, to regard it rather as an exception, than as a general event. The observation of the author does not accord with his; and the difference may have origi- nated in the circumstance, that the portions of lungs, with which Dr. Gross experimented, may not have been wholly solidified, but may have contained sufficient air to render them buoyant. It is clear, indeed, that the substance of the lungs themselves, and the fluids that give rise to the solidification, must be heavier than water, and, therefore, unless buoyed up by air, that they must inevitably sink in water. If the lung be cut into, a red, but not frothy, fluid exudes, less in quantity than in the preceding stages, and the pulmonary tissue appears to be composed of a multitude of red granulations of very small size, which are pressed against each other; white spots are likewise observed, which are caused by the pulmonary vessels and bronchial tubes that are unaltered. In this stage, the pulmonary tissue is so much softened, that it can be crushed readily under the finger, and reduced into a reddish pulp; hence, the name Ra- mollissement rouge, which was given to it. (Andral.) The weight and size of the lung are manifestly augmented; accordingly, it presses against the ribs, which leave indentations in it; but this cannot happen, unless the increase of size is considerable. If the inflammation of the lung has proceeded still farther, inter- stitial suppuration is established, constituting the Hepatisation grise, (Laennec,) or Ramollissement grise. (Andral.) The colour of the affected portion of the pulmonary tissue is now^ grayish; and, on making an incision into it, a grayish purulent fluid exudes, which may exist in the lung either in the state of infiltration or of abscess; in the former case, the granular appearance of the lung may be very marked; and the pus may be readily pressed out, if the parenchyma of the lung has been cut or torn. The substance of the lung is, in such case, so friable, that if the finger be pressed lightly on any point, small cavities filled with pus may be made, which may be readily taken for recently formed abscesses. (Andral.) Occasionally, the pus may be traced into the small divisions of the pulmonary artery. The formation of pus commonly takes place from the twelfth to the fifteenth day, but cases have occurred in which it has been found as early as the fourth day. The formation of abscesses in the lungs is extremely uncommon. On this point all observers agree. Of several hundred examinations, made of persons who had died of pneumonitis, in not more than five or six was the pus collected into an abscess. (Laennec.) On the other hand, tubercular cavities are very common, and, doubtless, have often been enumerated amongst abscesses following inflammation of the pulmonary paren- chyma. Of abscesses, perforating the lung from without, and of gangrene of the lungs, mention will be made under separate heads. OF THE BRONCHIA AND LUNGS. 311 In children, lobular pneumonia is very common; and instead of its being confined to a single lobule, it often extends over many, constituting what has been termed, " lobular pneumonia general- ized." (Rilliet and Barthez.) As in the pneumonia of the adult, the morbid appearances may be divided into three stages. * In the first, the cut surface of the lung is marbled with spots of a grayish rose and red colour; these spots are more or less circumscribed, and are more readily torn than the healthy tissue; but they float in water, and yield, when pressed, liquid mixed with air, and still crepitate. The second stage is thte one most commonly met with, and resembles the hepatization of the adult: the third, or that of suppuration, requires careful ex- amination to detect it—the substance of the lung having regained the grayish colour, which belongs to its healthy state; but, by careful attention, some lobules are observed more prominent than the rest; they are not flaccid like those around them, and, on press- ing them, they discharge a purulent fluid. (Rilliet and Barthez.) Treatment.—The importance of early and active treatment in pneumonia has been generally, if not universally, admitted. Under such circumstances, it can usually be controlled. It has, indeed, been esteemed the most manageable of all parenchymatous inflam- mations, when judicious treatment is adopted at an early period. Of the advantage of general blood-letting at an early stage, but little difference of opinion has existed. It is only when the lung has passed to a state of solidification, that a question has often arisen as to its advantages or appropriateness. The extent, to which the abstraction of blood should be carried, has, however, given rise to much diversity of opinion. Of late years, one observer (Bouillaud,) has advised bleeding coup sur coup, and fixed the medium quantity necessary to be taken, at from 16 to 20 cups (palettes,) of six ounces each, in three days; and he affirms, that of one hundred and two cases, ninety were cured, and only twelve died. More recently, the results of M. Bouillaud's plan of treatment have been laid before the Academie Royale de Medecine, of Paris. (Pelletan.) Seventy-five cases were treated by repeated bleedings, the amount of blood taken varying from ten to seventeen palettes, which was drawn in the first three or four days after the patient's reception into the hospital. In pneumonia of one lung, only two cases in fifty-five terminated fatally. In double pneumonia, eleven cases of sixteen recovered. The average duration of the disease under this system, was only from nine to thirteen days; whilst in fifty cases, treated by M. Louis less actively, the average duration was fifteen days. Almost all practitioners, however, agree, that this copious and repeated abstraction of blood, is generally neither necessary nor advisable. The author has not found it often requisite to bleed more than 312 DISEASES OF THE RESPIRATORY ORGANS. twice or thrice at the farthest; and a recent and excellent pathological writer (Stokes) has affirmed, that of many hundred cases, he has had only one in which it was necessary to bleed oftener than twice, and in this instance, there was a complication with hypertrophy of the heart. The .true principle seems to be—in his opinion—that general bleeding is to be considered only as" a preparative for other treat. ment, and not the chief means of removing the disease. On the other hand, it has been maintained, from the results of numerical observations, that the influence of bleeding, when per- formed even within the two first days of pneumonia, is less than has been supposed, and that, in general, its power is very limited; that its effect, however, on the progress of the disease is found to be happy, and that patients, who were bled during the first four days of the disease, recovered—other things being equal—four or five days sooner than those bled at a later period. (Louis.) The researches of M. Louis, gave occasion to numerical investigations, as to the effect of blood-letting in pneumonia, on this side the Atlantic. Of thirty-one cases, treated at the Massachusetts general hospital,—in three, blood-letting was practised on the first day of the disease. The average duration was 13§ days. The number of bleedings, in each case, was four; and the average quantity of blood, abstracted in each, 61$ ounces. In fifteen cases, which were bled, for the first time, on the first, second or third day, the average duration was 12$ days. The same thing was true, with a slight difference, of twenty-one cases in which bleeding was practised on or before*the fourth day. In five cases, bled for the first time after the fourth day, the average period of convalescence was 13^ days. In these 26 cases, the average duration of the dis- ease was 125 days. In five cases, blood-letting was not employed, except in one, in which six leeches were applied. The mean duration of the disease was 14§ days. So far, consequently, as these cases go, it would seem, that the effect of bleeding, on or before the fourth day of pneumonia, is to shorten its course by nearly one day, when com- pared with the cases in which it was not employed till after that period:—compared with those who were not bled, it was shortened a little more than 2i days. These results, obtained by an accurate and careful observer, (Professor James Jackson, of Boston,) are confirmatory of those of Louis, which led him to infer, that bleeding does not exert so powerful an effect on pneumonia as is generally believed; but they are not sufficient to induce us to discard this important remedy, oi to place as little reliance upon it as has been done by some. (Laen- nec.) It is doubtful, whether it ever succeeds in cutting the disease short: the remarks of Louis, indeed, on this point, are very explicit. His conclusion is, " that we cannot cut short pneumonia by blood- letting, at least during the first days of the disease; and if the con- trary has been believed to occur, it is, doubtless, owing to the dis- ease having been confounded with others; or because, in some rare OF THE BRONCHIA AND LUNGS. 313 cases, the general symptoms rapidly diminish after the first bleed- ing; still, the local phenomena, crepitation, &c. for the most part, continue to advance with no less certainty." It must be admitted, however, from the testimony of most ob- servers, that in strong and vigorous subjects, general bleeding is an important remedy; yet, it must be equally admitted, from the same testimony, that it ought not to be practised at all periods; and that after the stage of engorgement has passed into that of solidification, and a fortiori, when it has entered that of interstitial suppuration, it may be a very questionable agent. When the practitioner is called during the first stage of Stokes, or even during the second, a copious bleeding, which will exhibit its effects upon the system, or upon the morbid manifestations, but short of inducing syncope, may be sufficient. One single venesec- tion of this kind, carried to the extent of relieving the pain in the chest, of permitting the patient to take in a deep inspiration, and of converting the small, rapid and oppressed pulse, into one that is large and full—has been found more efficacious than four, practised at a later period. Of 180 cases, it was found necessary in two only to repeat the blood-letting on the same day, or at the next exacer- bation. (Most.) It is scarcely necessary to say, that circumspection should be used in regard to blood-letting, when, along with smallness and feebleness of pulse, a state of depression or exhaustion exists; or when the disease—as previously remarked—has passed beyond the first stage of solidification. In cases where doubt exists as to the repetition of blood-letting, the local abstraction of blood may still be very advisable. It has, indeed, been considered, on high authority, (Stokes,) as the prin- cipal remedy. The application of cups with the scarificator is preferable to leeches, but if the latter be employed, cups may be applied over them; and the abstraction of blood, in this way, may be repeated as the case may require. Where bleeding alone has not proved successful, the tartrate of antimony and potassa, given in large doses, has exerted a favour- able action, and appeared to diminish the mortality of the disease. (Louis.) It is now, indeed, generally combined with general and local bleeding, and is usually considered secondary to them, not as a chief remedy, as it has been regarded by some. (Laennec.) In order that the tartrate of antimony and potassa may produce its full effects on pneumonia, it is not necessary, or even desirable, that it shall induce vomiting or purging. Its contra-stimulant effects are, indeed, best exhibited, when it produces no evacuation; or, in other words, when a tolerance is established. Where blood- letting cannot be practised, either owing to the individual, or the epidemic, influence, this remedy is, at times, extremely beneficial; or, if the patient is exhausted by age or other causes, or appears too weak to bear the loss of blood, or obstinately refuses to submit to it. It may, likewise, be a valuable agent, and of convenient vol. i.—21 314 DISEASES OF THE RESPIRATORY ORGANS. employment in the country, where the physician can seldom make closely repeated visits to his patients. The signs, which promise success, are the tolerance or absence of evacuations, observable after the second or third dose,1 dimin- ished frequency of the pulse, and a feeling of improvement. (Brich- eteau.) 1 R.—Antim. et potass, tartr. gr. vj. Aquae cinnam. §vj. Acet. opii, gtt. xij.—M. Dose, half an ounce, every two hours. It would seem, that as there are medical constitutions, which do not admit of blood-letting, so there are some, so eminently phlo- gistic, that they interdict the use of tartarized antimony. For instance, after having employed it successfully in 1831, in the Hospital Necker, it could not be used advantageously at the end of 1832, and even at the commencement of 1833. (Bricheteau.) If the dose of the tartarized antimony, as in the formula given above, be six grains the first day, the quantity may be increased by one or two grains daily, until ten, twelve, or fifteen grains are given in the twenty-four hours; but it is rarely necessary to exceed this dose. Should the first doses produce vomiting, or purging, or both, these effects do not continue, but generally subside after the first twenty-four hours. As the disease yields, the remedy must not be suddenly discontinued. It is advisable to diminish the dose at the rate of a grain or two daily, until it is ultimately left off; but it should not be abandoned as long as the crepitant rhonchus is heard. It has been conceived, that good effects have resulted from its use, even where a great part of the lung has been infiltrated with pus. (Laennec, Trousseau.) As tartarized antimony probably acts as a revellent, and by the derivative influence which it exerts upon the lining membrane of the first passages, it will necessarily be contra-indicated where gastritis is present. Where this remedy is inadmissible, another revellent agency may be had recourse to with advantage, after blood-letting has been used as freely as has been deemed advisable. This is exerted by the use of mercury, both internally and externally. The object is to induce a new action as speedily as possible. With this view, it is well, that the intervals between the doses of the remedy should be considerable, as the system sooner feels the impression under such circumstances, than when it is given at short intervals. R.—Hydrarg. chlorid. mit. gr. iv. Conserv. rosar. gr. xij.—f. massa in pil. iv. dividenda. Dose, one pill, every six hours. Along with these pills, blistered surfaces, if such there be, may be dressed with the strong mercurial ointment;'and, as soon as evi- dences of the peculiar action of mercury on the system exist, the mercurials must be discontinued. It must be borne in mind, that—as has been more than once OF THE BRONCHIA AND LUNGS. 315 observed—it is not easy to affect the system by mercurials, when the organic actions are greatly excited. It is necessary, therefore, to reduce these to the appropriate point first; and frequently, when mercury has been given freely, and without any sensible effects, a slight abstraction of blood will speedily develop them. The pre- vious exhibition of tartarized antimony has been found to facilitate the mercurial action, and conversely; and, moreover, both plans of treatment are by no means incompatible. (Stokes.) Very recently, the author has had under his care a severe case of typhoid pneumonia, which remained stationary for days, but ultimately yielded to a grain of calomel, given night and morning, and to a blister dressed with mercurial ointment, although none of the ordinary signs of mercurial action were induced. Where solidification exists, after the ordinary signs of pneumonia have passed away, the cautious use of mercurials, with repeated local bleedings and revellents to the surface, afford the best pros- pect of success. The seton has often been employed, in such cases, with benefit, (Stokes;) but it does not possess the advantage of counter-irritation effected in an intermittent manner, as by succes- sive blisters. Attention ought, in all these cases, to be paid to position; the patient being directed to lie on the sound side to avoid hypostatic engorgement; or, where the posterior part of the lung is engorged, to lie on the face for a certain time every day. (Stokes, Gerdy.) With regard to blisters, much difference of sentiment has existed as to whether they are advisable during the early stages, especially of acute pneumonia. Sinapisms to the inferior extremities are said to have been serviceable in some cases; but many advise, that blisters to the chest should be employed with caution, affirming, that they are rather a torment than a relief to patients. It is only after the febrile symptoms have been reduced, that much advantage can be expected from them. It has been affirmed, indeed, on high authority, (Louis,) " that blisters have no evident action on the progress of pneumonia; and that without any loss, they may be banished from the treatment of those cases of pleurisy and pericar- ditis, which occur in healthy subjects." The remark appears to be too sweeping, but there can be little doubt, that their employment is unadvisable in the acute stage of the disease; and as little, that at a subsequent period, as well as in typhoid pneumonia, they are most efficacious agents. (Stokes, Gigon, Pelletan.) Weak sinapisms, and emollient and narcotic cataplasms to the chest, have been found useful, especially in children. The bowels, too, must be attended to, and, occasionally, the engorgement of the lungs has been found to disappear under the revellent action of a brisk cathartic. (Andral.) Throughout the whole period of the disease, mucilaginous or gummy drinks may be allowed,—as gum-water, barley-water, &c. &c; and if the cough be troublesome, it may be alleviated by any of the expectorants advised in bronchitis. It must be recollected, 316 DISEASES OF THE RESPIRATORY ORGANS. however, that the cough is but a symptom, and will yield with the pathological condition, which induced it. The air of the chamber should be kept at a comfortable temperature, (Professor J. Jackson, of Boston,) and especially during the night, and mental and corpo- real quietude be strictly enjoined. When the inflammation has been removed, milk, with the farinaceous preparations, as arrow- root, sago, &c. may be allowed, but great circumspection must be used to avoid errors in diet, which may be of extremely injurious tendency. b. Chronic Inflammation of the Lungs. Chronic pneumonia is undoubtedly a rare disease,—that is, sim- ple chronic pneumonia, regarded as an original affection. This is the opinion of most pathologists. (Laennec, Andral, Chomel, Stokes, Forbes.) Some, however, are disposed to think that it occurs more frequently than has been imagined, (Andral); whilst others think, that it is more rare than is generally believed. We have stated, that simple chronic pneumonia is uncommon; but the scrofulous or tuberculous inflammation, which is chronic in its character, and accompanies the softening of tubercles—if it can "be regarded as chronic pneumonia—is extremely frequent. This form of the disease may be primarily chronic in its charac- ter; or it may be a sequel of the acute form; it may, also, occur in the course of chronic bronchitis, or—as remarked above—be a complication of tuberculosis of the lungs. Diagnosis.—The symptoms resemble those of chronic bronchitis, except that the dyspnoea is more considerable. Percussion yields a dull sound, but if the indurations are small, the evidence it affords may not lead to any positive knowledge. By auscultation, the crepitant rhonchus is heard disseminated; and, at times, there is bronchial respiration; and, at others, complete absence of respira- tion. Both the symptoms and physical signs resemble, therefore, those of the acute form of the disease. The general symptoms have a great similarity to those of phthisis pulmonalis—emaciation, fever, and sometimes night sweats. (An- dral.) Pathological characters.—The lung is generally found to present more or less of the red and gray indurations, with atrophy. The colour, however, varies; at times, it is pale yellow, iron gray, or even black, and different portions of the inflamed lung may present different tints, so as to exhibit a mottled appearance. It is singular, that the upper lobes of the lungs are more frequently affected with chronic pneumonia than the inferior, which is the opposite to what holds in acute pneumonia. (Andral.) When the disease is limited to the state of red induration, it may terminate favourably; but if it should extend beyond this, the issue is unfavourable, either owing to the disorganization occasioned by the primary affection, or to its giving rise to tubercles. (Andral.) Treatment.—It is essentially that of chronic inflammation.— OF THE BRONCHIA AND LUNGS. 317 Revellents—as cupping, blistering, the tartarized antimony oint- ment, and mercurials, given so as to affect the system slightly. c. Typhoid Inflammation of the Lungs. Synon. Pneumonia Typhoidcs seuTyphodes, Putrid, Typhoid or Erysipelatous Pneumonia; Ger. Bosartige Lungenentzundung. Under this denomination, nosologists generally include inflam- mation of the lungs, often more or less latent, and accompanied by great prostration, and this, perhaps, dependent either upon the low state of the constitution, the complication with other diseases, or owing to the pulmonary affection being secondary to a general morbid condition. (Stokes.) This form of pneumonia is met with everywhere. It is said to be, at times, so frequent in Dublin, as to be almost epidemic; and it is very common in this country. South of the Potomac, it is said to be seldom so inflammatory as it is along the shores of New Jersey, Delaware and Maryland; and the farther south, the more it is said to assume a middle typhoid complexion, (Prof. Potter, of Baltimore;) but there is no regularity in its history in this respect. In all these situations, and elsewhere in the United States, unless the symptoms of prostration areverygreat.it bears the name of "bilious pneumonia," or " bilious pleurisy." This term has been given, however, to different affections. The bilious pneumonia of Stoll is considered to have been pulmonary catarrh with disorder of the stomach or intestines; and, in other cases, the name has been assigned to inflammation of the lungs, presenting some symptoms of embarras gastrique, and accompanied by a yellowish expecto- ration, which was supposed to be bile, but was really produced by a mixture of blood and mucus. (Andral.) Typhoid pneumonia has been seen as a complication of gastro- enteritis, of true typhus, of malignant erysipelas, of diffuse cellular inflammation, of delirium tremens, of phlebitis; and, occasionally, it is apparently the sole disease. (Stokes.) Diagnosis.—Typhoid pneumonia is often masked by the disease with which it may be complicated. Thus, the main evidences of the disease may be those of common gastric or bilious fever; but if attention be paid, more or less dyspnoea and cough may generally be observed. The disease is often, however, extremely insidious in its progress, and is not suspected; the dyspnoea may suddenly become aggravated, the motions of the chest are irregular, and death takes place in a very brief space of time from engorgement of the lungs. (Carhoright, of Natchez.) At times, the symptoms are wholly absent, but the physical signs may reveal the true nature of the case. A trifling cough, with or without expectoration, slight dyspnoea, and hurry of breathing may occur; yet the patient may not complain of his chest, although extensive and fatal disease may be present. It has, indeed, been affirmed that, in this disease, the stethoscopist will over and over 27* 318 DISEASES OF THE RESPIRATORY ORGANS. again detect inflammation of the lung, when there has been no preceding cough, pain, dyspnoea or expectoration. (Stokes.) In this form of pneumonia, extensive engorgement of the lung and solidification often take place most rapidly; but, although this is the fact, the progress towards resolution is generally ex- ceedingly slow; chronic hepatizations, with or without hectic fever, or a lurking congestion, may continue for weeks; and although, under appropriate management, the disease may be ultimately removed, atrophy of the lung, with or without ulcerative disease, is often established. (Stokes.) In certain cases, months may elapse before the respiratory murmur is heard, and, in many instances, it is never re-established. On the other hand, typhoid pneumonia has been known to cease in a single day, on the supervention of an attack of gastritis or enteritis. (Stokes.) Typhoid pneumonia may terminate in rapid and fatal hepatiza- tion, in gangrenous abscess, or it may induce chronic solidification or induration of the lung, which may end in the tubercular con- dition. Treatment.—As the disease partakes of the characters of typhus and pneumonia, the mode of treatment must vary, according to circumstances. In all cases, however, general blood-letting will have to be used with caution. It certainly can only be practised— if practised at all—in the very commencement of the attack. In robust individuals, where the bilious or gastric symptoms are more marked than the typhoid, it may be necessary; or, if it may seem to be counter-indicated, the joint depletory and revellent action of cupping may be employed with advantage. Revellents may be used here at an earlier stage, and with deci- dedly more advantage than in acute pneumonia. Mercury—with this view—may be given, as elsewhere directed, until the system is brought slightly under its influence; blisters may likewise be used much earlier, and with decided benefit; the patient should be clothed in flannel next the skin, and the warmth of his extremities be supported by adventitious aid, if necessary. In cases in which the gastric or bilious complication is consider- able, and especially if there be marked signs of gastroenteritis, leeches may be applied over the region of the stomach, and a warm bread and milk, or flaxseed, poultice over the leech-bites. Emol- lient or anodyne enemata may also be prescribed, and caution should be employed in the use of cathartic remedies. In the debility, that attends the lowest forms and stages of this disease, it may become necessary to support the system; but, as in all similar instances, agents, belonging to the class of tonics or of gentle excitants, are preferable to the more powerful. Wine whey, and the cold infusion of bark with acids, or any of the vegetable tonics, may be administered with good effects. The decoetion of senega, with carbonate of ammonia, has, likewise, been extolled, when the patient becomes hectic, with copious expectoration (Stokes.) OF THE BRONCHIA AND LUNGS. 319 The mild farinaceous articles of diet—as arrow-root, sago, or tapioca—may be given throughout the whole period of the disease; and, in the latter stages, wine may be added. Should the disease linger, and convalescence be tedious, change of air may be very advisable. V. GANGRENE OF THE LUNG. Svnon. Gangraena Pulmonum, Necropneumonia; Fr. Gangrene du Poumon; Ger. Lungenbrand. Gangrene of the lung, being always, perhaps, the result of in- flammation, might have been considered under Pneumonia; there is convenience, however, in separating it. The disease is not so unfrequent as is usually imagined. It does not often occur in private practice, but in eleemosynary institutions, into which those of broken-down constitutions are freely admitted, it is often seen. In the Philadelphia Hospital, a few cases are annually observed: in the nine months prior to August, 1838, four cases were admitted, all of which terminated fatally. It is a disease, observes a recent writer, (Craigie,) "the presence of which it is difficult to distinguish in the early stages from that of other dis- eases of the lungs; its determining causes are totally unknown; and it is not known that, in any genuine instance of it, the patient has made a recovery." The two following cases, which fell under the author's care, and were reported by intelligent resident physi- cians, (Drs. Vedder and J. B. Cottman,) will illustrate the affec- tion better than any general description. Case 1.—A woman, aged thirty-three years,—who had been a patient in the Lunatic asylum for about one year, and whose health was good until two months before her admission into the medical ward, since which period she was affected with severe cough,—complained, at her entrance, of considerable fever and dyspnoea, with paroxysms of coughing so violent as to threaten suffocation. She was bled to six' ounces, which relieved the dyspnoea, and suspended the paroxysms of coughing. R.—Syrup, ipecac. Tinct. opii camphor, aa §ss. Mucilag. lini, ^v.—M. Dose, a tablespoonful, every two hours. On the 6th of July, the expectoration and breath became fetid. On the 8th, she presented the following condition:—Emaciation evi- dent, but moderate; lies with her head elevated; expression of anxiety; nostrils dilate during inspiration; face slightly flushed; tongue red at the centre, white at the edges; respiration 60 per minute; breath extremely fetid; cough loose, and frequent; sputa dark coloured and of a gangrenoid odour; pulse 138, small, and quick; oedema of both feet. Physical signs.—Chest, anteriorly on the left side;—respiration cavernous under the clavicle at its internal margin; bronchial, ex- ternally; inferiorly, abundant sibilant and sonorous rhonchi, with 320 DISEASES OF THE RESPIRATORY ORGANS. sounds of bubbles of mucus; vesicular murmur feeble; pectoriloquy in the infra-clavicular space. Anteriorly, right side.—Respiration cavernous, with gurgling under the clavicle; pectoriloquy marked; inferiorly, sibilant and sonorous rhonchi. Percussion, on the left side anteriorly, yielded a flat sound below the clavicle to the second rib, rather dull below; on the right side, a flat sound to the third rib, dull below. Posteriorly—the respiration on the left side, at the summit, bronchial, with resonance of the voice; throughout the remainder of this side feeble. On the right side, respiration cavernous, with gurgling,—on coughing, the air seeming to pass through a constricted orifice; the splashing of the fluid can be heard against the walls of the "cavity. This character of respiration extends to the middle of the chest; it is rude below this. In the corresponding part, there is intense pectoriloquy. On percussion, the sound is flat in the superior half of the right side, clear below. On the left side, it is dull at the summit, and nearly natural below. (Addatur misturae liquoris sodse chlorin. 3ss.—Nutritious diet, with six ounces of wine to be made into whey.) On the 10th of July, there was more oppression; the strength had diminished; the skin was above the natural temperature; pulse 150, and feeble; respiration 56 in the minute, laboured, and interrupted by cough- ing; sputa of the same fetid character. On the morning of the 11th, at the visit of the author, she was evidently moribund; breathing extremely difficult, and abdominal; skin covered with a cold, clammy sweat; extremities cold; pulse scarcely perceptible at the wrist; countenance anxious; yet her mind was active, and the amount of intellectual manifestations as usual. She died about one o'clock, P. M. Unfortunately, permission could not be ob- tained to examine the body. Case 2.—The last case was one of gangrene of the lungs super- vening on phthisis. The following is one of pleuropneumonia fol- lowed by the same results:— A man, aged 38, had always enjoyed good health until about seven years ago; his parents were healthy, and there was no here- ditary disease in the family. About the period mentioned, he had an attack of intermittent fever, of which he recovered in about nine months, and remained healthy until the first of August, 1839, when he was attacked with cough; had no pain in the chest; be- came very weak in a short time, and was compelled to give up labour; had been at work for six or eight months in a tunnel; was often wet all day, and frequently, during the winter, his shirt would freeze to his back. He gradually grew worse, until the 11th of June, when he was admitted into the hospital affected with bron- chitis. He remained there until the 2d of July, when he was discharged, cured of his affection; there still, however, remained some cough, with slight dulness on percussion under the right clavicle, and a difference in the respiration of the two sides of the chest. He went on the farm to work, and caught cold, when he was again admitted into the hospital, and fell under the care of the OF THE BRONCHIA AND LUNGS. 321 author. He was emaciated; face flushed; general appearance very much attenuated since he left the hospital; respiration laboured; cough troublesome; complains of no pain; skin hot and dry; pulse 100, weak and feeble. On the chest there was an elevation as large as a goose's egg, where the fifth and sixth cartilages on the right side join the ribs, for which he could give no satisfactory reason. Percussion anteriorly, on the right side, gave a flat sound in the upper portion; a. clear sound in the middle, and a dull one in the lower. Anteriorly, on the left side, the sound is flat through- out. Respiration, anteriorly on the right side, bronchial in the upper portion; vesicular in the middle; feebly vesicular in the lower. Anteriorly, on the left side, rude at the summit; feebly vesicular throughout the remainder. Posteriorly, the physical signs correspond to those anteriorly, except that the respiration at the summit of the left lung is heard more distinctly than anteriorly. Impulse of heart greater than natural. (Four cups were directed to be applied to the chest, with a mucilaginous mixture for the cough; farinaceous diet and ice.) On the 12th the fever still continued, the skin being hot and dry, and the thirst very great; respiration much oppressed. (The cupping was repeated.) On the 14th the respiration was easier; face flushed; skin hot and dry; pulse 120, quick and feeble. On the 18th, the emaciation had advanced; cough troublesome; expectoration very abundant, and excessively fetid, consisting mostly, however, of mucus; face pale; skin cold and moist; respjra- tion oppressed; complains much of weakness; (Calcis. chlorin. gr. iv. every three hours; dry cupping to the chest; continue the pecto- ral mixture, and let the patient have four ounces of wine in the twenty-four hours.) On the 19th, he was very much emaciated. He had vomited frequently; was unable, indeed, to retain anything on his stomach; expectoration about two pints in the twenty-four hours; breath of a gangrenous odour, and so unpleasant, that it was loathsome to examine the chest. On the 21st the patient was evidently sinking fast, and the odour, exhaled by him, was so disagreeable, that no one would go near him. He died on the morning of the 22d of August. On opening the chest, no particular lesion was found correspond- ing to the prominence on the right side. The pleura costalis was adherent throughout to the pleura pulmonalis. On the left side, the adhesions could not be separated, until the lung was removed from the chest. On the right side, the pleurae were adherent about half-way up from the base of the lung; the remainder of their sur- faces was bound together by bands of lymph. One-third of the upper lobe of the right lung was slightly emphysematous; a few miliary tubercles were scattered through it; the remainder was of a purple or greenish tint externally; when cut into, the tissue was softened, engorged with bloody serum, and presented numerous 322 DISEASES OF THE RESPIRATORY ORGANS. cavities of different sizes, some as large as a ten cent piece, filled with a purulent matter, and very fetid. Some of these cavities were lined by a distinct false membrane; others were proceeding to ulceration; many of the smaller cavities did not appear dishnct, but merely distended vesicles, filled, however, with a matter similar to that contained in the larger; the middle and lower lobes exhibited the same appearance; the bronchial tubes on the right side were very much enlarged, of twice the natural size; the larger of a pale pink colour; the smaller of a deep red, terminating in a distinct cul-de-sac. The bronchial glands were enlarged; colour natural; consistence soft. The summit of the upper lobe of the left lung was emphysema- tous, the remainder healthy, except in a few spots at the lower portion, where gangrene had commenced, and the lung presented the same appearance as already described. The middle and lower lobes were in the same state as on the right side; the bronchial tubes were enlarged; their lining membrane slightly roughened, and of a rose colour. Such were the chief pathological appear- ances. (American Medical Intelligencer, August 1, 1838, and October 15, 1839.) Gangrene of the lungs may be diffused or circumscribed, and where recovery takes place it is of the latter class. In all cases, that have fallen under the author's observation, the subjects were addicted to spirituous liquors. The only pathognomonic symptom, as has been correctly ob- served, (Stokes,) is the extraordinary and disgusting odour of the breath and expectoration, which is generally constant; but, in some cases,, it may not be readily appreciated, unless the patient be made to cough. The treatment consists in the employment of chlorides internally, or of chlorine by inhalation; in allaying irritation by opium, and supporting the patient by wine whey and nourishing diet. VI. EDEMA OF THE LUNGS. Synon. Hydrops Pulmonum, Hydropneumonia, Anasarca Pulmonum; Fr. OEdeme du Ponmon; Ger. Lungenwassersucht. This affection is said to be somewhat common, (Laennec, An- dral,) but it certainly is not readily diagnosticated. Diagnosis.—It is described as occurring under three different forms. 1. The super-acute. In this, the patient, at the time in perfect health, or in the course of an acute disease, is suddenly seized with symptoms of suffocation, which end in death by asphyxia. This may be the result in two or three hours, or not for as many days. 2. The acute, likewise characterized by considerable dyspnoea, which augments for from four to twelve days, and ends in complete prostration, during which the fatal termination occurs. 3. The chronic. In this form, the dysp- noea may be slight or null for months, whilst the patient is in a state of rest, but it may appear with more or less intensity OF THE BRONCHIA AND LUNGS. 323 during exercise, coughing and expectoration. In all these forms, percussion affords a more or less obscure sound, according to the degree of the disease. Auscultation, too, exhibits, that the vesicu- lar murmur is much more feeble than in the natural state, and that it is accompanied by a subcrepitant rhonchus, less in degree than that of pneumonia in the first degree, and with moister and more bulky bubbles. (Andral) " It must, however, be acknowledged," says the best describer of this disease, (Laennec,) " that it is some- times difficult to distinguish these two diseases from each other, by the signs alone, that are furnished by the cylinder, and that it is requisite to associate with them the comparison of the general symptoms. When the oedema is very extensive, and very intense, the sonorousness of the chest diminishes in a sufficiently marked manner; and a slight bronchophony is manifested in such cases, especially at the root of the lung; but the long persistence of the crepitant rhonchus, and the absence of the general signs of inflam- mation almost always permit osdema of the lungs to be distinguish- ed from pneumonia in the first degree, even in cases where these affections are united." CEdema of the lungs may be a primary affection, or it may de- velop itself in the course of different diseases—as acute bronchitis, acute pneumonia, diseases of the heart; and those of the brain, such as cerebral hemorrhage, softening of the eighth pair of nerves, or pressure upon them by serum. It is said to supervene, also, under the influence of general dropsy, and in the course of all chronic maladies, which require decubitus on the back. (Andral.) Pathological characters.—The tissue of the lung, which is of a pale grayish or yellowish colour, is more dense and heavy than in its natural state; it crepitates, and if, by compression, it be freed from the liquid it contains, it preserves the impression of the finger. The lung is gorged with a colourless, transparent, frothy fluid, but the air-cells retain their natural texture. Treatment.—As the disease is induced by such different condi- tions of the system, it is difficult to lay down any precise plan of treatment. The practitioner must be guided by the particular indications that present themselves. VII. EMPHYSEMA OF THE LUNGS. Synon. Pulmonary Emphysema, Asthma aereum ab Emphysemate Pulmo- num, Pneumoectasie, Dilatation of the air-cells; Fr. Emphyseme du Poumon; Ger. Lungenemphysems. Emphysema of the lungs was first described by Laennec, but it was not much regarded, until the attention of pathologists was re- directed to it by the investigations of another distinguished observer, (Louis). Yet it is by no means an uncommon affection. The writer, last cited, describes it, indeed, as " one of the most frequent and remarkable affections to be found in the whole catalogue of nosology." Two forms of emphysema of the lungs have been described; one 324 DISEASES OF THE RESPIRATORY ORGANS. in which the disease is confined to the vesicles or air-cells—hence called Vesicular emphysema; and the other in which infiltration of air has taken place into the cellular tissue, connecting and separat- ing the lobules of the lungs;—hence termed Interlobular emphy- sema. To this last form of the disease, the term "Emphysema of the Lungs," appears more appropriate; inasmuch as the other con- cerns the terminal extremities of the bronchial tubes, in the opinion of many excellent observers; a recent writer, however, (Lombard,) who divides emphysema of the lungs into three forms—the vesicu- lar, lobular, and lobar, discards the interlobular, because it is ex- ternal to the pulmonary tissue, and therefore not " a lesion of the organs of respiration"! The term "Emphysema" has, indeed, been regarded as altogether improper, inasmuch as it is not the principal characteristic of the disease, and although a frequent, by no means a constant, complication. " Indeed it seems certain, that even if we admit the existence of the pleural vesicles of Laennec, to have been produced by rupture of the cells, yet that this may exist without true general emphysema of the lung, and it is difficult to conceive how emphysema could exist in the lung without being diffused over the body." (Stokes.) a. Vesicular Emphysema. This affection consists essentially in dilatation of the air-cells: the lung, consequently, becomes increased in size, and the quantity of air within the chest, as well as the capacity of the chest itself, augmented. Diagnosis.—One of the best descriptions of this disease, is that by Louis, (translated by T Stewardson, Jun., M. D., of Phila- delphia.) It is a disease unattended by fever, and of long duration, commencing frequently in early youth, and very rarely after fifty years of age. The first symptom is slight dyspnoea, which gene- rally continues, without aggravation, for a number of years, when it dates from infancy; and afterwards becomes more and more marked, occurring in paroxysms, during which the patient appears at times to be threatened with suffocation. The dyspnoea is often preceded by cough, and is almost always accompanied, at some period or other of its course, by bronchitis, which, when aggravated, would seem to be one of the most common causes of the paroxysms of dyspnoea. The disease is, indeed, considered by some, (Laennec, Stokes,) to be the result of bronchitis,—the mucous secretion of which cannot be readily expectorated, and therefore dilates the vesicles; but this is denied, (Louis,) because, in the cases which he has observed, the emphysema was rarely preceded by bronchitis, and the bronchial tubes, in the vicinity of the dilated vesicles, have been found empty, containing neither mucus nor false membrane. Connected with the symptoms above described is an alteration of the form of the chest, generally of limited extent, implicating both the ribs and intercostal spaces, and the common seat of which is the anterior part of the thorax, and the supra-clavicular regions. OF THE BRONCHIA AND LUNGS. 325 The shoulders are elevated and brought forward', and the patient stoops habitually, owing to the relief which he has found from bending the body forwards. To such an extent does the habit of stooping alter the configuration of the chest, that the acromial, in- terscapular, supraspinous and subspinous surfaces may become nearly horizontal. In some cases, the heart is displaced by the dilated lung, which pushes it downwards, so that its impulses become manifest in the epigastric region. (Stokes.) The chief physical signs in this disease, are the greater sonorous- ness of the elevated portions of the chest on percussion, and the diminution of the sound of respiration on auscultation. A sibilant or subcrepitant rdle is often mixed with the respiratory murmur; and, in some patients, at a more or less advanced stage of the dis- ease, there is palpitation with oedema of the lower extremities. (Louis.) The dyspnoea is regarded as almost pathognomonic of emphy- sema, if we take into consideration its commencement at an early age; its duration; its being continuous, although paroxysmal; and its being unattended by, or separable from, the other symptoms of , diseases of the heart. It cannot easily be mistaken for chronic bron- chitis, as the latter does not give rise to paroxysms of dyspnoea, to prominence of the chest, and to constant diminution of the respira- tory murmur. From dilatation of the bronchia, it is known by the respiration in the latter, instead of being weaker, being stronger, • throughout a certain extent, than in the natural condition, and the voice being more resonant. From tuberculosis of the lungs, it is known by the circumstance, that there is flatness on percussion in some part, in the latter; whilst in emphysema the sound is clearer than common, and there is, in general, neither emaciation nor fever. From aneurism of the aorta, or any tumour, which might compress the trachea, or a large bronchial tube, it is distinguished by the dyspnoea, in these cases, being more severe and more constant, and generally accompanied by a whizzing sound, which does not occur in emphysema. (Louis.) The physiognomy of an individual labouring under this disease, has been esteemed almost characteristic; the complexion being of a dusky hue, and the countenance, although with an anxious and melancholy expression, having, in several cases, a degree of fulness, which contrasts greatly with the condition of the rest of the body. This has been supposed to result from hypertrophy of the cellular membrane, and respiratory muscles of the face; the first produced by repetitions of venous obstruction, and the second by the violent exertion of the whole system of respiratory muscles. The nostrils are dilated, thickened, and vascular; the lower lip is enlarged, and its mucous membrane everted and livid, so as to give a peculiar expression of anxiety, melancholy and disease to the countenance. (Stokes.) The following modes have been pointed out for distinguishing vol. i.—28 & 326 DISEASES OF THE RESPIRATORY ORGANS. emphysema of the upper and lower lobes—conditions which, how- ever, are seldom absolutely distinct. (Stokes, Cowan.) Emphysema without displacement of the Emphysema with displacement of tht diaphragm. diaphragm. 1. The shoulders greatly elevated, 1. The shoulders not affected; the and the upper part of the chest convex, upper part of the chest flat, and the convexity only evident inferiorly. 2. The sound on percussion of the 2. The reverse. upper portions morbidly clear; of the lower, little altered. 3. The stethoscopic signs of the dis- 3. These signs predominating in the eases manifest in the upper portions. lower lobes, and audible below the usual level of the diaphragm. 4. The epigastrium collapsed, and 4. The epigastrium full and resist- the heart and liver in their natural ing; the right hypochondrium dull on situations. percussion, and the heart downwards. 5. The distress in breathing much 5. The dyspnoea much more per- less, except during an exacerbation of manent, and less affected by treatment bronchitis. calculated to relieve bronchitis. The course of the disease is chronic, yet it is subject to variations. In many cases, it continues for years in a mild form, with but little change. In other cases, it has come on with some degree of vio- lence, yet the subjects have attained considerable age. In rare cases, its progress has been more rapid. Causes.—With regard to the causes of vesicular emphysema, it has been already remarked, that it probably is not always depend- ent upon bronchitis, as is believed by some; the same may be said of pneumonia, as a cause, notwithstanding it is accompanied by dilatation of the vesicles. The immediate cause of the dilatation we are unable to appreciate; nor is it explained by the assertion, that both in this form of dilatation, and in that of the larger bronchial tubes, " we must admit, at least in a great number of cases, a force analogous to that, which presides over the extension of hollow organs, and in virtue of which these latter enlarge, without our being able to account for it by means of any obstacle or mechanical cause." (Louis.) A recent writer (G. Budd), ascribes it to a want of elasticity in the lung, or, in other words, to absence of its natural tendency to collapse. The powerful muscles of inspiration are continually acting to dilate the chest, and thence, by virtue of atmospheric pressure, the air-cells. "This agency is not counteracted as it should be by the natural elasticity of the lung, and the air-cells, as well as the cavity of the chest, are, in consequence, permanently dilated." (G. Budd.) The disease has been observed to supervene after a powerful moral emotion. The question as to its hereditary character was closely and ably investigated by a young American physician, too soon lost to science, (J. Jackson, Jr., of Boston,) who was a worthy pupil of a distinguished master, (Louis,) and the following are the results at which he arrived: OF THE BRONCHIA AND LUNGS. 327 1. Of twenty-eight patients, affected with pulmonary emphy- sema, eighteen were the offspring of parents, one of whom had been attacked with the same affection, and several of whom had died in the course of it. In some cases, the same was true of the brothers and sisters. 2. Of fifty individuals not affected with emphysema, three only were descended of parents, who laboured under the disease; whence it would follow, that emphysema is frequently an hereditary affection. It would seem, too, that hereditary influence is much more marked, where the emphysema dates from early infancy, than in those in whom it commences immediately before, or subsequent to the age of twenty. It was found, for instance, that of fourteen individuals, whose dyspnoea was traced to early youth, fourteen had asthmatic parents; whilst of fourteen attacked later in life, two only were the offspring of parents who had died of the same disease. Pathological characters.—On opening the thorax, the lungs do not collapse, and are more bulky than in health; the vesicles are dilated, and this dilatation is always more marked at the free border than in other parts of the lung; and, along the free border, peculiar appendices are met with, which result from the laceration of the pulmonary vesicles, and the form, size, and structure of which are very variable. The dilatation rarely implicates the bronchial tubes. (Andral, Louis.) The extent of the emphysema differs in different cases, but it seems to affect both lungs nearly alike. Of 43 cases, it was found on the left side in 23; on the right, in 20. (Louis.) It would appear to affect the upper lobe more frequently than the lower. In most of the cases, the heart was larger than natural; and this circumstance has given rise to the idea, with some, that emphysema is a secondary disease in all cases; and hence, that it is important to seek out the primary lesion. (Rostan.) It is extremely pro- bable, that this may be the case in many instances; and yet it is equally, if not more, probable, that the emphysema itself may have reacted on the heart, and given rise to morbid conditions of that viscus. In many of the patients, observed by Louis, adhesions were found between the lungs and the pleura, and tubercles were, like- wise, met with not unfrequently in the lungs, but there was no reason for believing, that they were in any respect concerned in the causation of the emphysema. Treatment.—When the disease has existed from an early age, it would not seem probable, that any remedial agency could do more than palliate the symptoms. It has, indeed, been affirmed, that, under treatment calculated to remove bronchial irritation, the vesicular murmur may return, and the volume of the lung be diminished. (Stokes, Osborne.) The disease is certainly susceptible of alleviation; but, except in very recent cases, it can scarcely be cured. All mental and corporeal agitation—as well as every- 328 DISEASES OF THE RESPIRATORY ORGANS. thing that can irritate the lungs in particular—must be carefally avoided; and if the patient experiences relief in one place rather than in another, or by change of air, this course may be recom- mended to him, where his circumstances will admit of it. The various means, that have been advised under bronchitis, for allay. ing bronchial irritation and cough, may be used here, and great advantage is said, by some, (Stokes,) to have resulted from their employment. On the other hand, their use has not been found productive of much benefit in the hands of others. Opium is the therapeutical agent, which has exerted the greatest effect on the dyspnoea. (Laennec, Louis.) Almost all those to whom Louis gave it were remarkably relieved, and the symptoms resumed their former violence as soon as its use was suspended, unless they had been relieved for a certain length of time. When the affection is accompanied by disease of the heart, the treatment will have to vary according to the nature of the disease, and to the rules laid down elsewhere. Hypertrophy with dilata- tion of the cavities of the heart is the most frequent complication; but it must be borne in mind, that the dyspnoea, which the patient experiences, is owing, in a great measure, to the emphysema, and % that it is not sensibly influenced by blood-letting, in the majority of cases certainly; and, hence, this remedy should be used with caution. (Louis.) The diet and regimen must be so regulated as to keep down any acceleration of the circulation, which could not fail to augment the dyspnoea. b. Interlobular Emphysema. This variety of emphysema—as before remarked—is owing to the infiltration of air into the interlobular cellular tissue. It is said to be an exceedingly common affection in the Western States, (Professor Gross, of Louisville,) which is singular, if correct. Diagnosis.—Dyspnoea is here also the main symptom, and it is proportionate to the extent of the mischief. If it be slight, neither percussion nor auscultation may throw any light upon it; but if to a greater extent, the resonance may be louder on percussion over the seat of the lesion, and the dry, crepitant rhonchus with large bubbles may be more especially manifest during inspiration. Along with these signs, a sound of friction during both inspiration and expiration has been described, (Laennec;) but it has been properly remarked, (Stokes,) that this point of diagnosis requires farther investigation. When healthy serous membranes rub against each other, they give rise to no friction sound; but if, owing to in- flammation, they become dry, or the seat of morbid exudations and changes, such a sound may be elicited as in pericarditis, pleurisy, and peritonitis. It is, therefore, probable that, when the friction sound is heard in interlobular emphysema, it is owing rather to slight pleurisy than to the existence of the subpleural vesicles of Laennec. (Meriadec, Laennec, Stokes.) OF THE BRONCHIA AND LUNGS. 329 Another diagnostic sign of pulmonary emphysema—in both the vesicular and interlobular form-is the difficulty of breathing out, which has been attributed by some to obstruction of the minute bronchial tubes; by others—and more properly perhaps—to the diminished elasticity of the lung itself. (Magendie.) Causes.—-It has been affirmed, (Andral,) that the disease may occur spontaneously, owing to a simple exhalation of air into the interlobular cellular tissue, but this is probably not often the case. Generally, the air vesicles give way, and infiltration takes place, under some mechanical injury or violent effort. Of nineteen cases of the disease, of which a record was kept, (Professor Gross, of Louis- ville,) six occurred in association with bilious and typhoid fever, four with dysentery, three with hooping-cough, one with acute inflammation of the lungs, four with tubercular phthisis, and one with cholera infantum. In twelve of these cases, the emphysema affected both lungs, though not to the same extent. In five, it was confined exclusively to the right lung; in two, to the left. Pathological characters.—The cellular tissue between the lobules of the lungs is infiltrated with air, and the surface of those organs presents small vesicles or ampullas, arranged in transparent strips or bands, which penetrate more or less deeply into the pul- monary tissue. These bubbles of air have likewise been observed frequently in the course of the vessels, which traverse the lungs, and along those that run on its surface. (Laennec.) Emphysema does not occur frequently at the base of the lung. When it does so, it is apt to pass to the mediastinum, and thence to the cellular tissue of other parts of the body, so as to cause ge- neral emphysema. In such cases, if the ordinary symptoms and signs of pulmonary emphysema be present, there can be no diffi- culty in the diagnosis. The following is a case of this kind:— A child four years old, labouring under hooping-cough, was found lying in a state of coma consequent on convulsions, with emphysema above the left clavicle, which, in a few days, extended through the cellular texture of the whole body, and was so exten- sive over the abdomen and ribs as to raise the skin at least one inch. From the puffed appearance of the child's face, his friends could not recognize him. The main treatment consisted in keeping the child as quiet as possible, giving a solution of tartarized anti- mony with tincture of digitalis, in frequently repeated doses, to reduce the circulation and respiration to the lowest possible ebb, and regulating the bowels daily by a gentle cathartic. The diet was restricted to a pint and a half of asses' milk per diem. After about a fortnight, the crepitus began to subside, and ultimately disappeared. (Lilburn.) Treatment.—This does not differ from that of vesicular emphy- sema. It can rarely be necessary to treat any case so actively as the one just described. The cares, recommended under the head of vesicular emphysema, are equally demanded in the interlobular form. The disease, although tedious, is not of grave prognosis. 28* 330 DISEASES OF THE RESPIRATORY ORGANS. The air in the cellular membrane is gradually absorbed, and the dyspnoea becomes greatly diminished, and more frequently wholly removed, than in the vesicular form, in which the dilatation of the vesicles remains generally, if not always, permanent. VIII. ASTHMA. Svnon. Asthma convulsivum, A. spasticum adultorum, A. seniorum, A. spas- ticum intermittens, Dyspnoea et Orthopnoea convulsiva, Brokenwindedness, Nervous asthma, Convulsive asthma; Fr. Asthme, A. nerveux; Ger. Engbrus- tigkeit, krampfhafte Engbrustigkeit, Convulsivisches Asthma, Brustkrampf. The terms dyspnoBa, asthma, and orthopnoea, were formerly em- ployed to designate different degrees of difficulty of breathing; but their signification is now more precise;—dyspnoea being appropria- ted to difficulty of breathing in general; asthma to the disease now to be described; and orthopnoea to that great difficulty of breathing, in which the patient is incapable of respiring, except in the erect posture. It has not been unusual to divide asthma into two varieties; the one constituting the essential or idiopathic disease; and the other the secondary or consecutive; the former not being depending, so far as can be detected, upon disease of any other organ, whilst the latter may be clearly associated with, and is perhaps dependent upon appreciable affections of the lungs, heart, great vessels, &c. The former of these will alone engage us here. It has been a question, however, whether any essential nervous asthma exists, or whether there is not always some organic lesion. Many of the best ob- servers have had their attention directed to this point, but they have been totally unable to discover any morbid appearances sufficient to account for the disease. (Laennec, Ferrus, Andral, Guersent, Lefevre, Sue.) Hence it is, that Andral always uses the term " nervous asthma" for the affection under consideration, and he adduces, in support of his view, arguments drawn from physio- logy, which have great force; the effects, for example, of compress- ing, tying, or dividing the pneumogastric nerves, and of disease at the encephalic origin of those nerves, or of the nerves themselves; the fact, that the attack is often brought on by nervous agitation; that the patient is in perfect health between the paroxysms, &c. &c; but to this point of pathology reference will be made hereafter. Diagnosis.—The paroxysms of asthma come on, at times, with- out any premonition, and instantaneously; at other times, there is a sensation of oppression or df fulness at the pit of the stomach— which is commonly owing to the presence of flatus in that organ— with a feeling of irritation in the air passages. These premoni- tory symptoms are, however, extremely uncertain. The paroxysms themselves usually commence at night, and be- tween the hours often and two, they rarely occur during the day. If the patient be lying down, he immediately rises, and remains sitting up, experiencing a sense of violent constriction over the whole chest; the arms are thrown back to facilitate inspiration; the OF THE BRONCHIA AND LUNGS. 331 shoulders are raised, and the head is often violently straightened on the neck; the patient lays hold of any object that may afford him support; all the inspiratory muscles are in full action; the in- spirations are quick, suddenly interrupted, and repeated at short intervals; the patient demands that more cool air should be ad- mitted into the apartment, and feels as if he were about to be suffocated. The respiration is sibilant, and sometimes sonorous. Along with these symptoms, there is, usually, a small, frequent, broken and dry cough; the face is pale, sometimes livid; the eyes anxious and projecting; and the surface of the body covered with a cold and copious perspiration. The stomach is frequently more or less disordered, and vomiting is not an uncommon attendant; the condition of the pulse, as to force, frequency and fulness, varies; it is commonly, perhaps, frequent, small, and contracted. During a paroxysm of asthma, the chest does not sound well on percussion, and the respiratory murmur is indistinct, even on the most full inspiration. But if the patient, after holding his breath a little, be requested to breathe again quietly, the spasm will be over- come, "as it were by surprise," (C. J. B. Williams,) and the entry of the air into the cells will be heard in a clear, and, at times, puerile manner. This may be done by desiring the patient to read aloud, or speak as many words as he conveniently can without taking breath, and then to breathe at his ease. But after one or two inspirations, the spasm returns, and the respiration is as dull as ever. (Laennec.) The usual duration of a paroxysm of nervous or spasmodic asthma is three or four hours; after this, the symptoms generally become mitigated. When the paroxysm has attained its height, the cough usually becomes more free, and the expectoration more easy and copious; the sputa are transparent, colourless, and viscid; and, occasionally, of a sweetish, but oftener of a salt taste; and towards the termination they are ropy and similar to a solution of gum tragacanth. (P. Frank.) At times, they have been observed as if moulded to the bronchia, (Lefevre,) but in such cases, there is doubtless inflammation of the lining membrane of the tubes, of which this plastic secretion is one of the evidences. Whilst the respiration and expectoration are becoming more free, eructations of gas generally take place from the stomach; the pulse becomes more full and free: the countenance resumes its natural expression; the urine, which was at first perhaps pale, watery, limpid and copious, becomes of a darker colour, less copious, and at times altogether suppressed, (Broussais,) and at length the patient, exhausted, sinks to sleep. On awaking, he may find himself entirely restored, but, almost always, there is more or less pain in the region of the diaphragm, with dyspnoea, which—if the paroxysm is about to return on the following night—may con- tinue through the whole day. Towards midnight, there may be a return of the paroxysm, and this may be the case for three or four nights, after which the individual may be restored to his accustomed 332 DISEASES OF THE RESPIRATORY ORGANS. health. This succession of paroxysms, constitutes an attack of asthma. (Sestier.) Asthma is very rarely fatal. The most violent attacks, which seem to threaten instant suffocation, almost always terminate favourably. The author has never seen a fatal case during the paroxysm; but should such an event occur, we are told it will be immediately preceded by a most distressing anhelation, frothing of the mouth, livid countenance, weak, tremulous pulse, or total failure of pulse; great depression of general strength, and, sometimes, more or less paralysis of the upper extremities, (Professor Chapman, of Philadelphia;) yet, most of these symptoms are often present, and the patient recovers. The great danger consists in the repeated recurrence of the paroxysms, which may give rise to other affec- tions, and especially of the heart and great vessels. It may happen, also, that death may occur during a paroxysm, owing to cerebral hemorrhage, or to the rupture of some important vessel or viscus; but these are collateral dangers. The recurrence of the attacks of asthma is extremely irregular. Cases are on record, in which it would seem to have observed regular periods, but this is not common. The varieties of asthma, usually described—by the German writers especially—are numerous. Under the name Asthma with puerile respiration, dyspnoea has been understood, which is dependent upon an increase of the desire to respire, the respira- tion being, in other respects, perfect. (Laennec.) The respiratory murmur is found to have resumed all the intensity, which it pos- sessed in early infancy, and yet the patient is oppressed, especially on taking the least exercise. This form of dyspnoea, is chiefly observed in the course of chronic bronchitis; and its precise nature is not readily appreciable. Nervous asthma itself has been usually divided into two forms; in the one, commonly regarded as Nervous asthma, properly so called, there is no expectoration after the paroxysm. It has been termed Asthma siccum, Asthma spasticum siccum. This variety is, however, of rare occurrence; in the other, the Catarrhal asth- ma, Asthma humidum, A. aquosum, A. pituitosum; Fr. Asthme humide; Ger. feuchtes Asthma, Schleimasthma, the pa- roxysm is usually followed by a copious expectoration of mucus. When asthma is accompanied by pain in the epigastrium, flatus, eructations, vomiting, &c, it has been termed by some, Gastric asthma, A. abdominale, A. flatulentum, A. ab acrimonid, &c. Causes.—It is not easy to state in what the predisposition con- sists. It is generally believed, that a peculiar conformation, derived from progenitors, predisposes to it, but this probably applies rather to emphysema of the lungs, than to asthma: and many of the cases, that are recorded of asthma in young children, belong unquestion- ably to emphysema. Among the causes, that give rise to the paroxysms, atmospheric variations have been generally enumerated. In general, a cold OF THE BRONCHIA AND LUNGS. 333 and dry air suits the asthmatic, but there are most singular differ- ences in this respect. With some, closing the door of a room will bring on a paroxysm; with others, darkness greatly increases the violence of the attacks. (Leflvre.) A recent writer of eminence, (Graves,) has given the following example in elucidation of this singular feature of the disease. In December, 1839, he attended two gentlemen residing in the same street, and each about forty-five years old. Neither was liable to any other disease, and they were both short and stout. On a very cold morning Dr. Graves found one of them very ill. He had not slept at all during the night, and had every moment been on the point of smothering from asthmatic dyspnoea. The extreme violence of the paroxysm he attributed to the fact, that his bedroom chimney had smoked occasionally during the night, and the weather was so cold, that he was afraid to open the windows to let out the smoke. Dr. Graves ordered him to change his room, and then proceeded to visit his neighbour, and found him sitting in a room full of smoke. The patient apologized to the doctor for introducing him into so disagreeable an atmosphere, and explained, that when the fit of asthma became very bad, the only sure means for obtaining relief, which he knew of, was to get a good coal fire lighted in the grate, which being done, he made-his servant occasionally obstruct the progress of the smoke up the chimney, and thus maintain a certain density of smoke in the room. This never failed to afford him relief. This gentleman was of very active habits; was agent to several large properties, and, consequently, obliged to travel much about the country; experience had proved to him, that he could derive no benefit from turf smoke, and, therefore, he never stopped at any inn, where they had no other fuel but turf, as he felt him- self insecure, unless he could procure coal smoke, in case of an asthmatic attack. (Graves.) Various odours—agreeable or disagreeable—smoke; dust; irrita- ting gases; metallic and other particles floating in the air, unques- tionably act as exciting causes: and to these has been added—air surcharged with electricity, as well as different lunar phases, (Ses- tier,) but the author has not had the slightest reason for believing in the influence of the latter. Some asthmatics are so sensible of atmospheric changes, that they are aware of the presence of a cloud in the sky, and can pre- dict storms from the increase of their dyspnoea. (Broussais.) . In like manner, it can be understood, that irregularities of diet, especially when food in too great quantity, or improper in quality, has been taken: the abuse of alcoholic liquors; the suppression of any accustomed discharge, and the transference of irritation thereby engendered; too great exertion of any kind, and mental emotions— in short, undue moral or physical excitement of any kind, may induce the return of the paroxysms. There is something extremely inexplicable in the fact, that the air of contiguous localities, and even of different parts of the same 334 DISEASES OF THE RESPIRATORY ORGANS. house, may affect the asthmatic very differently. As a general rule, perhaps, the air of the crowded city is more congenial, than that of rural and elevated situations. A friend of the author—one of the most respectable inhabitants of Baltimore—is unable to sleep at his country house, which is not more than a mile and a half from the centre of the town. He has tried the experiment frequently, and the result has always been identical. The author knows another gentleman, who cannot sleep with impunity in the town: others, again, prefer a dry, whilst many breathe more freely in a moist, atmosphere; and the same thing applies to medicinal agents, that are administered in the way of inhalation. An interesting case has been related, in which the air of different parts of the same house produced very different effects. (Professor Chapman, of Philadelphia.) Called to visit a young lady from the south of the United States, who was labouring under a violent paroxysm of the disease, Dr. Chapman was told that she had de- rived immunity from it during a previous and recent residence in Paris, by selecting the middle story of an hotel in a particular por- tion of that city; and that, whenever she quitted the apartment, a paroxysm soon came on, from which she was as speedily relieved on returning to it. Curious to make the experiment, Dr. Chapman was seconded by the patient's own desire, owing to her anxiety to change her lodgings, where she had suffered severely, and in a very short time she went to another house in the vicinity, in which she entirely escaped the disease for several months. Being compelled, however, to leave it, she took up her residence at the distance of a few hundred yards, in a street no less thickly built; and here she had scarcely any exemption for weeks. On moving to a different quarter of the city, Dr. Chapman witnessed a complete verification of the statement she had made him. As long as she occupied the chamber on the second floor, she was harassed almost nightly by renewals of attacks, which were prevented by sleeping in the room above. Even by dining below, her respiration was, on several occasions, seriously affected. Pathological characters.—It has been already remarked, that the researches of the most eminent pathologists, have failed in de- tecting any morbid appearances, that throw light on the essence of asthma; and that all the phenomena indicate it to be a neurosis of the chest. The spasmodic nature of the disease is now admitted by almost all; the spasm being seated—as it always is—in the nerves, that are distributed to muscular fibres, in this case surrounding the small bronchial ramifications; that such fibres exist, has been demon- strated by the observation of distinguished anatomists, (Reisseisen, Sommering, Cruveilhier;) and even had they not, the phenomena of asthma would have been sufficient proof of their presence. (Laennec.) It has been supposed, indeed, that the bronchial spasm is consecutive on irritation or inflammation of the pulmonary urn- OF THE BRONCHIA AND LUNGS. 335 cous membrane, (Bricheteau, Professor Geddings, of Charleston;) but this can scarcely be the case in those asthmatics who are affected by slight changes of air in the manner already described. Others, again, in the apparent obscurity of the subject, have sup- posed either that the disease is owing to a spasmodic condition of the heart, which prevents the blood from being distributed to the lungs, (Broussais,) or that it is always a symptomatic affection of some lesion of the heart or great vessels, (Rostan,) whilst others, again, are of opinion that the cause of the phenomena ought to be sought for in the brain and spinal marrow, and not in the heart or lungs. (Georget.) All the phenomena of asthma establish, that the disease is de- pendent upon some special condition of the nerves, that are dis- tributed to the bronchial mucous membrane, and that through them the different nerves connected with the respiratory function become implicated. Under the spasm of the muscular fibres of the bronchia, thus induced, the functions of the membrane itself become disturbed; and, after repeated paroxysms, modifications in the texture of the membrane may be perceptible. The good effects of the narcotic or anti-spasmodic treatment of asthma, are strongly in favour of its neuropathic character. Treatment.—The treatment of asthma—as of every other pa- roxysmal disease—resolves itself into that which is proper during the paroxysm, and that which is advisable afterwards. a. During the paroxysm.—The patient should be propped up in bed, and every ligature or article of clothing that could interfere with the circulation, be removed. Air, too, should be freely ad- mitted into the chamber. The great difficulty of breathing, and the apparent urgency of the symptoms, would naturally suggest the use of blood-letting; and when the patient is vigorous and plethoric, the operation may be practised with advantage. It can only be employed, however, as an antispasmodic. There is no inflammation, it must be recol- lected, to be subdued; and, therefore, should the practitioner deter- mine upon employing it, he will not consider it advisable to repeat the operation, but will rather have recourse to other agents, which are found to be effectual, as far as any remedies are so, in the paroxysm. Therapeutical agents, which act by inducing a new impression on the nervous system, or by allaying nervous erethism, are those which prove most beneficial. To the first class belong emetics, which have been advised by most therapeutists. As the object is revulsion, those emetics are preferable, which induce nausea, followed by full vomiting; and there is no one more advisable than the tartarized antimony,1 singly, or in combination with ipecacuanha.2 lJ&.—Antim. et potass, tart. gr. iv. * R.—Antim. et potass, tart. gr. ij. Aquae ^iij.-M. Pulv. ipecac, gr. xv—M. Dose, one half, to be repeated in twenty minutes, should the first half not operate. 336 DISEASES OF THE RESPIRATORY ORGANS. The various articles belonging to the class of emetics, have been advised, but none of them possess virtues beyond those of the articles first mentioned. The sulphate of zinc was largely pre- scribed by an extensive practitioner, (Prof. Kuhn, of Philadelphia,) who believed it to be possessed of superior " antispasmodic" proper- ties in this, as well as every other affection of the air passages, of a spasmodic nature; but his view has not been embraced by others. It is obviously, indeed, less adapted for such cases, in consequence of its revellent action being less energetic, by reason of its action as a direct emetic, or one that does not induce much preceding nausea. The revulsion, effected by stimulating manuluvia and pediluvia, or by sinapisms applied to the wrists, lower extremities, and to the anterior or posterior part of the thorax, has, likewise, yielded relief. The same may be said of the revulsion from dry cups applied over the chest; and, as the modification in the circula- tion, produced by a ligature round the lower limbs, and the new condition thereby engendered, has prevented an attack of epilepsy, the same course has been advised in asthma, (Jolly;) cold affusions and aspersions have been used with a similar view by some^and are said to have been of benefit. Galvanism is a remedy, which has been much extolled, and whose operation must be esteemed essentially revellent. Resting on his views of the absolute identity between the nervous and the galvanic fluids, Dr. Wilson Philip employed galvanism in asthma. In a communication read by him before the Royal Society of Lon- don, in January, 1816, he details some experiments which he made on rabbits. The eighth pair or pneumogastric nerves were divided by incisions made in the neck. After the operation, the parsley, which the animals had eaten, remained unchanged in their sto- machs, and, after evincing much difficulty of breathing, they seemed to die of suffocation. But when on other animals, whose nerves had been divided, the galvanic agency was transmitted along the nerve, below its section, to a disc of silver, placed closely in con- tact with the skin of the animal, opposite its stomach, no difficulty of breathing occurred. The galvanic action being kept up for twenty-six hours, the rabbits were then killed, and the parsley was found digested. The removal of dyspnoea, in these cases, led Dr. Philip to em- ploy galvanism as a remedy for asthma; and by transmitting its influence from the nape of the neck to the pit of the stomach, he gave decided relief in every one of twenty-two cases, of which four were in private practice, and eighteen in the Worcester Infirmary The power employed varied from ten to twenty-five pairs of plates. Since that time, galvanism has been repeatedly used in such cases, but commonly the plates are employed for this pur- pose. The disease is unquestionably, in the majority of instances, dependent upon erethism of the pneumogastric nerves; all the phenomena exhibit that there is a spastic constriction of the small OF THE BRONCHIA AND LUNGS. 337 bronchial tubes, occasioned at the extremities, or in the course of the nerves. The new impression, made by the galvanic agency, breaks in upon the concentration of nervous action, by exciting other portions of the nervous system, in the same manner as we observe spasms or ordinary cramps relieved, or paroxysmal dis- eases warded off, by agents that are capable of suddenly impressing some part of the nervous system. (See the author's New Remedies, 3d edit. p. 511. Philada. 1841.) The magnet has been used in similar cases. (Laennec.) It was employed in the manner recommended by Halle;—that is, by establishing a magnetic current through the diseased parts, by means of several magnetised plates; and Laennec affirms, that he frequently found it diminish the oppression. Of the substances that act by allaying nervous erethism, nar- cotics hold the first rank; and of these, opiates would naturally first suggest themselves to relieve the paroxysm. Yet there has been much difference of opinion in regard to them;—some extolling them highly, whilst others have recommended caution in their employment, and some have thought them decidedly prejudicial. The truth is, that the efforts of the practitioner are not attended with very marked success during a paroxysm of asthma; but, still, much may be done to relieve; and, in this respect, the author has found opiates to hold an elevated rank, when given in full doses, and especially in combination with an agent, which, in appropriate doses, is a nauseant, and, therefore, a relaxant. The pulvis ipe- cacuanhas et opii is hence an excellent form; or the opiate may be administered along with a diffusible stimulant, and be repeated, unless its effects are perceptible. R.—Tinct. opii, 3j. jEtheris rectificat. gij.—M. Dose, sixty drops, every half hour, until relief is obtained. Belladonna, hyoscyamus, stramonium, conium, and other nar- cotics, have been substituted for opium; but, as in every other spasmodic disease, none of them can be relied upon as much. The hydrocyanic acid, even when the pulse was small, irregular, and often not readily distinguishable, is said to have acted in asthma almost like a charm, removing the oppressed breathing, and restoring the free play of the respiratory organs, (A. T. Thomson); but such has not been the result of our trials with iter It is certainly less efficacious than narcotics. (Laennec.) ▼ Both the nux vomica and its active principle, strychnia, have been administered in asthma, and, like other excitants of the nervous system, they may have rendered service, but they are not to be depended upon. The same may be said of the reputed antispas- modics—as assafoetida, castor, musk, valerian, &c,—which are mainly dependent for their virtues on the essential oil they contain, and therefore on the impression which they make on the gustatory nerves, as well as on those of the stomach. Next to narcotics, thev vol. i.—29 J 338 DISEASES OF THE RESPIRATORY ORGANS. are the remedies most frequently employed during a paroxysm, either alone, combined together, or associated with opium. R.—Mist, assafcetid. 3v. Tinct. opii camphorat. ^ss. Sp. setheris sulphuric, comp. ^iij.—M. Dose, a tablespoonful, every half hour. Towards the end of the paroxysm, it has been advised to admi- nister some of the reputed expectorants—as gum ammoniac, myrrh, the polygala senega, &c. Of the reality of any such class of medi- cinal agents, great doubts may be entertained; but there can be no question, that the demulcent agency of any of the ordinary syrups, combined with the slightly excitant properties, which some of them —as the syrupus or oxymel scillse, or the syrupus senegge—possess, may be employed beneficially. No great reliance, however, can be placed on them. The efforts of the practitioner must be directed to the removal of the pathological condition, and as that yields, the secretion from the bronchial mucous membrane will be restored. There is a mode of administering narcotic and other substances, so as to cause them to come in contact with the seat of the disease, and to afford marked relief in many cases—that is, by inhalation. In this way, aqueous and other vapours have been received into the air passages. Warm vapours, impregnated with narcotic or gently excitant substances, are administered in this mode. The leaves of belladonna, hyoscyamus, stramonium, &c. have been boiled in water, and the vapour inhaled into the lungs; but the probability is, that the effects did not differ from those of the vapour of simple water, as the narcotic properties of the plants are not volatile. Chlorine, iodine, the iodide of sulphur, tar, and various excitants, have likewise been inhaled in the form of vapour, but there can be few cases in which their employment could be suggested, especially as experience has shown that such striking benefits result from certain of the narcotics employed in the way of fumigation. The most important of these is the stramonium, which was at one time esteemed almost, if not wholly, a specific. It is not entitled to any such reputation, yet it affords eminent relief in many cases. The smoke of tobacco relieves some asthmatics, and aggravates the symptoms of others, but that of stramonium agrees with a large majority of persons, and, at times, affords marked relief. A friend, who suffers excessively under the disease, frequently makes mani- fest to his medical attendant the relief he derives from its inhalation. For this purpose, he employs the dried stalk. Others use the root; and others, again, the leaves only. A veteran asthmatic, in a letter to a distinguished physician, (Forbes,) thus expresses the results of his own experience:—" Smoking, I am able to say, after fifteen years' practice, and suffering as much as mortal can suffer and not die, is the best remedy for asthma, if it can be relieved by expecto- ration. I have been in the hands of all the doctors of ■------f01 fifteen years, and still I say, smoke." OF THE BRONCHIA AND LUNGS. 339 At the period when the inhalation of " factitious airs" was sup- posed to hold out a probable plan of cure for many serious diseases, oxygen was highly extolled in asthma, (Beddoes,) but no one thinks, at the present day, of employing it, and the same may be said of the proposition to force air into the lungs of the asthmatic through a common bellows. (Chiaraventi.) Upon the principle of revul- sion, it might be advantageous; but we cannot see how it could act upon any other. Such are the chief therapeutical agencies to be employed during an attack of asthma. b. Between the paroxysms.—In the intervals between the fits, care is demanded to prevent their recurrence. The therapeutical agents, that are advisable, will depend upon the accompanying symptoms. As a general rule, the remedies needed during the paroxysm will be indicated, under various modifications, in the intervals. Attention must be paid to the due maintenance of the functions of the skin, the kidneys, and the alimentary canal; to restore, where practicable, any cutaneous or other irritation, or any accustomed evacuation, provided such have been unduly or sud- denly arrested; and where the attacks observe anything like a regular intermission, to employ the various antiperiodics recom- mended in intermittents, especially the sulphate of quinia and arsenic. The main reliance, however, must be placed in hygienic precau- tions. The patient should breathe the air, that experience shows to be most congenial to him. Long journeys have often removed the disease; and sea voyages have been especially recommended. So beneficial is the result of travelling air and exercise, that even the exposure and hardships of military life have proved beneficial. During the late war, when the volunteers of Philadelphia were called out, and encamped for several months—part of the time in winter—individuals, who had been previously harassed dreadfully by the disease, escaped entirely, whilst thus employed, and have since been nearly exempt from it. (Professor Chapman, of Phila- delphia.) The diet should be properly regulated, so that excess in eating and drinking is avoided; regular and moderate exercise must be taken daily; vicissitudes of temperature be guarded against, by appropriate clothing, and flannel be always worn nextT the skin. Frictions with the flesh-brush should be frequently employed, and cold, tepid or warm bathing, where it is not contra-indicated. Frictions with various substances, as cold vinegar and water; the liquor ammoniae acetatis, &c. have been recommended, (Copland,) but we do not see on what principle. No advantage can assuredly be induced by the agent employed beyond what simple friction is capable of affording. No less attention should be paid to preserve perfect tranquillity of mind. By a strict observance of these rules, the paroxysms of asthma may be warded off, and comparative comfort be enjoyed even when the predisponent cause is powerful. ' 340 DISEASES OF THE RESPIRATORY ORGANS. IX. MORBID PRODUCTIONS IN THE LUNGS. The morbid productions met with in the lungs may be, as else- where, either " analogous,"—that is, similar to those met with in the healthy condition of the body,—or " heterologous,"—that is, having no analogy in the economy. Notwithstanding the advanced state of diagnosis in modern times, it is not easy,—indeed, often not practicable,—to distinguish them from each other. When they are of trifling size, they may give rise to no sign that can reveal their existence; and when more developed, although their presence may be detected, it is frequently impossible to discriminate as to the precise mode of production. For example, tubercles in the lungs, when disseminated, may give rise to no local phenomena; but if agglomerated, the signs, afforded by percussion and auscultation, may sufficiently diagnosticate their presence. The same remark is applicable to other morbid formations, yet it may be extremely difficult to detect the precise morbid production which gives rise to the phenomena. (Rostan.) a. Cancer of the Lung. Synon. Cancerous phthisis, (Bayle,) Medullary or Encephaloid Tumour of the Lung; Fr. Cancer du Poumon; Ger. Lungenkrebs. This disease is by no means common, yet it is occasionally met with, and, difficult as the task is, has been diagnosticated during life. Diagnosis.—If the patient presents signs of chronic disease of the lungs, with the general evidences of the cancerous diathesis, and especially if there be concomitant cancer of some other portion of the body, there can be but little doubt of the existence of cancer of the lung. It may be divided into those in which simple degeneration oc- curs without change of volume, and those in which tumours exist, that cause compression and displacement. (Stokes.) In the first class, the physical diagnosis is difficult, whilst in the second, the signs may be those only of some internal tumour. It has been properly remarked, however, that as intra-thoracic tumours are in general either aneurismal or cancerous, the diagnosis will be be- tween these forms of disease. There are no physical signs peculiar to this affection, but the evidences of gradual diminution, and ultimate subsidence of vesi- cular murmur, with the tracheal respiration, resonance of the voice, and complete dulness on percussion, without the precursory signs of pneumonia, pleurisy, or tubercle, will justify a suspicion of the existence of the cancerous degeneration without change of volume. On the other hand, where cancerous tumours exist, that cause compression and displacement, there may be, as in aneurism, localized dulness, double pulsation, with bellows' sound, difference of the radial pulses, tracheal breathing, dysphagia, palpitation and pain in the shoulder; but the feebleness of pulsation, connected OF THE BRONCHIA AND LUNGS. 341 with the extent of dulness, may assist in distinguishing the disease from aneurism. Such are the main diagnostic evidences laid down by one (Stokes) who has paid much attention to the subject. The author has not met with any case, and, therefore, cannot speak from experience. Dr. Stokes adds, that though the existence of external cancer may often aid in diagnosis, yet the disease may be altogether internal; or the visceral may precede the external cancer. Andral affirms, that he has never found cancer of the lung without its existing else- where at the same time. When the cancer has attained the stage of softening, it gives occasion to hectic fever and emaciation; and the straw—and, at times, livid—colour, is an index, so far as it goes, of the nature of the affection. Lancinating pains in the chest have been enumerated amongst the signs of cancer of the lung, (Rostan;) but, according to some, although they are regular concomitants of cancerous affections of certain parts, they have never been observed in cancer of the lung. (Andral.) In one case, a pain was experienced, similar to that induced by compressing the testicle. (Bayle.) Causes.—They are those of cancer in general. The lesion is gradually formed, and often without any evidences of bronchitis or pneumonia; and, frequently, the lung remains entirely healthy around the cancerous masses. The first symptoms appear, at times, after the removal of a can- cerous tumour. Time of life seems, as in cancer of other parts, to exert an influence. It has been generally observed between the ages of 25 and 70. Of nine cases in which the ages were noted, it was found to have occurred at the following ages:—25, 35, 37, 48, 49, 55, 57, 58, and 72. (Andral.) Pathological characters.—Two forms of cancer are found on dissection. In the first, one or more cancerous masses, of different size and shape, and enveloped or not in a cyst, are found in the substance of the lungs. These masses can be readily removed, when the pulmonary parenchyma surrounding them may be found unaffected. They are generally encephaloid in their character. In the second, a portion of the lung is transformed into a scirrhous formation. This may implicate one lobe of the lung only, or a whole lung. (Bouillaud.) Treatment.—-It is obvious, that if the disease be diagnosticated, no treatment can eradicate it. The efforts of the practitioner must be limited to palliation. b. Melanosis of the Lung. Synon. Nigritudo seu Carcinoma melanoticum seu Melanses pulmonum; Fr. Melanose pulmonaire. This black matter, which is not unfrequently met with in the lungs at an advanced period of life, either in the interlobular tissue or in the parietes of the vesicles, has attracted more attention from 29* 342 DISEASES OF THE RESPIRATORY ORGANS. the morbid anatomist than the therapeutist, or, to employ the lan- guage of a writer on diagnosis, (Rostan,) "its anatomical charac- ters have attracted the attention of pathologists much more than its functional expression." Diagnosis.—There are no symptoms that can diagnosticate this from other mofbid conditions of the lung, of a chronic character. They are affirmed, indeed, on good authority, (Andral,) to be identical with those of chronic pneumonia; and a form of phthisis has been described, and termed melanic. (Bayle.) Causes.—They are very obscure. It. has been affirmed, that it may be produced by breathing the vapour of oil and coal in.com- bustion, constituting, when it implicates the whole lung, what has .been called the " black lung of coal miners," and, recently, anthra- cosis. (Stratton.) Melanosis of the lung is observed, however, in all conditions and in every way of life, and in the country as well as in the city. (Andral.) It is often seen in the lungs of horses, and in white horses, it is affirmed, oftener than in others. (Dupuy.) Pathological characters.—Melanosis of the lung cannot be mis- taken. At an early period, it is liquid, and may infiltrate the paren- chyma of the lung, which may be healthy, or indurated. The melanotic formation may be isolated or encysted; and it generally exists, at the same time, in other organs,—as the liver, the spleen, the brain, &c. It is commonly found in irregular masses, in small nodules, in thin, irregular plates, or in minute points. The tube- riform variety,—Melanomyces [?] (Ritgen), Melanospongus— occurs in globular, oval or pyriform tumours, from the size of a currant to that of an egg or even a large apple. The surface of the tumours is either smooth, irregular, lobulated or studded with small tubercles, like a mulberry. Of this variety, two or three examples only have been seen by Dr. Gross. The author has met with several examples of the amorphous kind. A case is related of a man, fifty-nine years of age, in whom the left lung was wholly converted into a black, homogeneous sub- stance, of such density, that the scalpel could scarcely penetrate it. The whole appeared like a mass of extravasated black injection after it has cooled. (Andral.) Some writers have divided the different kinds of true melanosis— melanosis vera—into four classes;—Melanosis punctiformis, M. tuberiformis, M. slratiformis, and M. liquiformis, but all divi- sions, founded on form only, are of course arbitrary. Melanosis—it is affirmed, (Andral,)—may be confounded with the bronchial glands or ganglions. The latter are, however, small and close to the bronchia; their outer surface is very smooth, and their interior rarely presents a very uniform black colour. The fluid which oozes out from them, scarcely colours the finger, whilst melanosis always gives the skin the tint of Indian ink. Treatment.—As we have no means of diagnosticating this affec- tion, it is of course impracticable to lay down any precise rules of treatment. OF THE BRONCHIA AND LUNGS. 343 c. Serous Cysts and Hydatids in the Lung. Synon. Fr. Kystes sereux, et Hydatides du Poumon. A question may occasionally arise as to whether the cystiform productions found at times, although rarely, in the lungs, are of the acephalocystic kind, or mere serous cysts. The author has elsewhere, indeed, Stated, that the evidences of the animalcular nature of the former—wherever met with—are by no means overwhelming; and that, on the other hand, there is great reason for believing in their being nothing more than cysts containing a limpid fluid. Diagnosis.—If the cysts or hydatids be in small number, and they occupy but a limited space, or if they be accompanied by acute pneumonia, or any other pulmonary disease, the symptoms may be very obscure. The only pathognomonic symptom of the presence of acephalocysts in the lungs is their appearance in the expectoration; yetj in such cases, it is not easy to believe, that they were formed in the pulmonary parenchyma. It has been affirmed, indeed, that hydatids, formed in the liver, have been discharged by the lungs, and been tinged with bile. (Andral.) The physical signs are like those of other morbid growths. If the cysts be few in number, the sounds afforded by percussion and auscultation may be those of health; if more numerous, and there- fore occupying a larger surface of the lung, the sounds may indi- cate some extraneous deposition, but they can afford no informa- tion as to its precise character. In one case, in which a dull sound was rendered on percussing the inferior part of the chest, a large pouch was found in each inferior lobe of the lung, which was filled with hydatids. (Andral.) Pathological characters.—The seat of hydatids is generally in the parenchyma of one or both lungs. They have, however, been found in the pulmonary blood-vessels, as well as in pouches communicating with the bronchia, or with the cavity of the pleura. Their size varies. Generally, they are small, but, at times, as large as the fist, and occupying a whole lobe. They have been attributed to inflammation, but as has been properly remarked, (Andral,) this is altogether hypothetical, and explains nothing. Their cause is, indeed, wholly unknown. They have been supposed (Baron,) to be the source of all tubercular affections of the lungs, but this is liable to the same observations as the last hypothesis. Certain it is, that they are very rarely met with in the human subject. Of nearly 6000 patients, admitted into the wards of M. Lerminier in six years, hydatids were met with in the lungs only five times. In one of these instances, they were found in the pulmonary veins; but in all the others they were de- veloped in the pulmonary parenchyma. (Andral.) Treatment.—As we have rarely any pathognomonic evidence of the presence of serous cysts or hydatids in the lungs, we can rarely be called upon to treat the affection; were we, indeed, aware of their presence, it would not be easy to offer anything satisfactory 344 DISEASES OF THE RESPIRATORY ORGANS. In one case, the expectoration of the hydatids appeared to be pro- moted by the inhalation of the vapour of ether. (Simon.) * The practitioner will have to inquire into the condition of the general and local symptoms, and to lay down his indications ac- cordingly. d. Calcareous Concretions in the Lung. Synon. Fr. Calculs Pulmonaires; Ger. Steine in den Lungen. These are by no means uncommon. Every pathologist must have frequently met with them, and often on the dissection of those who have died of other diseases. A recent writer (C. RogSe,) affirms, that in the lungs of 100 old women, whom he examined, he found cretaceous or calcareous tubercles in 51. The author has frequently seen the lungs studded with them, yet there may not have been any signs, that indicated their presence during life, at least immediately preceding dissolution. Perhaps in all cases, they are degenerated tubercles, and certainly a degenera- tion the very opposite to that of softening. When analyzed, they are found to consist of three parts of animal, to ninety-seven parts of saline, matter, (M. Hall);—the saline matters consisting almost entirely of phosphate of lime, with some carbonate of lime, and carbonate of magnesia. They are of different degrees of consistence, sometimes hard and at others soft, like particles of plaster softened in water. Their colour, size and number likewise vary. When accompanied by the ordinary signs of pulmonary consumption, they constitute the calculous phthisis of Bayle. These concretions are almost always found at the top of the lung. Of fifty-one observed cases, in thirty-nine they were either at the apex of the lung exclusively—or in much greater number than in the rest of the organ; in six, they were equally distribnted over the whole lung; and in six, they were found in several parts of the lung, without any being at the top. Twenty-four times, they were found in both lungs simultaneously; seventeen times in the right lung, and ten times in the left. (C. Rogie.) Diagnosis.—The only certain evidence of the existence of pul- monary calculi, in any case, is their presence in the expectorated matters; yet, it has been properly remarked, that this circumstance is not sufficient to discriminate, whether they proceed from the lungs, the bronchia or the bronchial ganglions. Treatment.—The same remarks as those applied to the treat- ment of serous cysts and hydatids are equally applicable here. We have no pathognomonic signs of their presence in the lungs, and if we had, it is not easy to lay down any plan of management that would lead to their removal. e. Tubercles in the Lung. Synon. Tubercula Pulmonum; Fr. Tubercules Pulmonaires; Ger. Lungen- tuberkeln. The presence of tubercles in the lungs gives rise to pulmonary OF THE BRONCHIA AND LUNGS. 345 consumption; yet they cannot be regarded as synonymous, inas- much as tubercles may unquestionably exist there, and yet remain quiescent, so that no symptoms of pulmonary consumption may present themselves. Still, these latter cases must be regarded as exceptions, and therefore it may be convenient, with the generality of writers, to inquire, under this head, into the phenomena of pul- monary consumption. The word "phthisis," (from $0«o," I dry up," " I fade,") like " con- sumption," means emaciation and decline from any cause. Hence, in the older writers, and, indeed, in the more modern, we meet with laryngeal, pulmonary, gastric, hepatic, intestinal, splenal and renal phthisis, to designate, respectively, the marasmus, which is produced by diseases of the larynx, stomach, liver, spleen and kidney. In more modern periods, the term phthisis has been applied to diseases of the lungs only, and by one distinguished writer on this subject, (Bayle,) as many species of phthisis were laid down, as there were organic lesions, which, in his opinion, could, by their development, lead to wasting and death. Hence, he had the tu- bercular, the granular, the cancerous, the melanotic or melanic, the calculous, and the ulcerous. Since the period, however, of the distinguished proposer of stethoscopy, (Laennec,) pathologists have generally admitted but one species of phthisis, the tubercular, and have considered that the existence of tubercles of the lungs con- stitutes the proper character of phthisis. (Andral.) Perhaps it may be well to include under the term all those forms of disease of the lungs, which arise from the formation of tuberculous matter, or of depositions and indurations, which are allied to it, in the substance of the lung. (C. J. B. Williams.) To give a correct- view of this important morbid condition, it will be advisable to inquire, first of all, into the pathology of tubercle. 1. TUBERCLE. It has been properly remarked, that, after inflammation, tubercle is the most important of the subjects comprised in the theory of medicine or pathology. (M. Hall.) It is important, therefore, to inquire, briefly, into the pathological characters it presents in the lungs, which constitutes, essentially, the pathological anatomy of pulmonary consumption. Pulmonary tubercles present three distinct periods in their exist- ence—one of development or crudity; one of elimination or soften- ing; and one of excavation or cavern. (Andral.) 1. Period of development or crudity.—Tubercle, in the simplest and most common form, is a small, yellowish white body, of a round shape, firm consistence, and sufficiently hard to be crushed in many cases; in others, of the consistence of viscid pus, or cheese. It varies in size from that of a millet-seed, to that of a pea or a nut 346 DISEASES OF THE RESPIRATORY ORGANS. It is without any trace of organization or texture, is sometimes isolated; at others agglomerated in masses of greater or less dimen- sion; sometimes infiltrated into the parenchyma of the lungs, and occupying one or more lobules; at others, a lobe, or even the whole lung. Tubercles are very rarely single or solitary; and their number varies greatly. They are commonly situate at the top of the lung, and when they are met with in the inferior lobes, they are always in a less advanced stage of existence than those of the superior lobes. (Andral.) Various opinions have been entertained in regard to the primitive state of tubercle. It has been presumed to commence by small, transparent, shining grains or granulations, of variable size, from that of a millet-seed to that of a grain of hemp, which have been called miliary granulations. (Bayle.) Such is the opinion of different distinguished pathologists. (Laennec, Louis.) It has, however, been combated (Andral), on the ground that if the granu- lations were the first stage of tubercle, they ought to be met with wherever tubercles exist, which is not the case. They are seen only in the pulmonary tissue. (A. A. Sebastian.) Andral regards them to be formed of the pulmonary vesicles, indurated and hypertrophied, and constituting one of the anatomical forms of pneumonia—the vesicular. Others have considered the tubercle, at its commencement, to be nothing more than a particle of fibrine resulting from a trifling oozing of blood, (Donne"); whilst others, again, (Baron,) have assigned them an hydatid origin; but this opinion has been embraced by few, although, in animals, hydatids and tubercles have been found in the same organs, and even depots of tubercular matter are affirmed to have been found in animals in hydatid cysts. (Dupuy, Andral.) Whenever tubercle is met with, it is in the solid state. Yet it cannot be presumed to have been separated from the blood-vessels in this form. It is probably more fluid when first deposited, and afterwards the fluid portions are taken up by absorption; but how this is effected we know not. (Magendie, Cruveilhier, Andral.) Ordinary tubercles consist of about ninety-eight parts of animal, and two parts of saline, matter, comprising the chloride of sodium, and the phosphate and carbonate of lime. (Thenard.) Of the cal- careous tubercles mention has already been made, (p. 344.) It has been a great question among pathologists, and one on which difference of sentiment yet exists, as to the precise location of tubercle. Whilst some have believed them to be seated in the lymphatic system of the respiratory apparatus, (Broussais); others have referred them to the pulmonary vesicles, and minute bron- chial tubes. Some, again, have presumed them to be secreted from the bronchial mucous membrane, (Carswell); whilst others have referred them to the cellular membrane of organs principally. The author has frequently investigated this point, and has satisfied him- self, that the submucous seat of the tubercle was manifest in several cases. It is obvious, however, that other textures, besides the OF THE BRONCHIA AND LUNGS. 347 cellular membrane, may secrete tuberculous matter, for we find it deposited at the surface of the mucous lining of the air passages, in the bronchia; in the vesicles; in the cellular texture, which unites the different parts of the lungs; and in the lymphatic vessels of the lungs. (Andral, M. Hall.) When deposited, and as we ordinarily see it, it would appear to be, like the cuticle, completely anorganic, having at times, although very rarely, a cyst. Appearances of blood-vessels are sometimes seen; but these, it is affirmed, are owing to a portion of the pulmo- nary parenchyma having become incarcerated, when the tubercles, which were at first isolated, joined and became agglomerated, as no trace of a vessel has been met with in a simple tubercle. (An- dral.) It has likewise been a question with pathologists, as to the mode in which the tubercles become developed. Some have presumed, that the matter of tubercle is endowed with plastic properties, so that it increases from within, in the manner of organized and living bodies—that is, by intus-susception, (Bayle;) but the tubercles- whatever size they may attain—never exhibit any traces of organi- zation. The fresh deposition doubtless occurs in the same manner as that of the primary tubercle, and increase of size takes place by accre- tion. The tubercles gradually become agglomerated, so that the intervening tissues are incarcerated and compressed, and as vessels were distributed through these tissues, evidences of them appear on dissection. At times, however, they become confounded into one mass, in which nothing but tubercular matter is perceptible. 2. Period of elimination or softening.—After the tubercles have remained crude for a longer or shorter period, they undergo important changes, and ultimately become softened. The mode, in which the softening is effected, has been a matter of dispute; some believing, that they possess, within themselves, the power of softening, as they do of development, (Bayle, Laennec;) others attributing it to an inflammatory process, (Broussais, Bouillaud); but the most probable view is, that the tubercles act as foreign bodies, irritating the surrounding tissues, and occasioning a secre- tion of pus, which softens the tuberculous matter mechanically. (Lombard, Andral.) When the mollescence of the tubercles has taken place, the tuber- cular matter seeks to escape; this gives rise to the 3. Pjeriod of excavation or cavern;—the stage, in other words, of ulceration. The pus makes its way into the bronchial tubes in the same manner, as that of an ordinary abscess makes its way to the surface. The pulmonary parenchyma, surrounding the tuber- culous matter, as well as the bronchial tubes themselves, becomes destroyed; and a ready exit is thus afforded to the tuberculous matter, which is thrown out by expectoration. The excavations or caverns are owing to the simultaneous soft- ening of several tubercles agglomerated together, or of one large 348 DISEASES OF THE RESPIRATORY ORGANS. tubercle; as well as to the destruction of the pulmonary parenchyma by ulceration, and the expectoration of the softened tuberculous matter. The number of the cavities in the lung is extremely various. At times, there are several; at others, but one or two; these are always surrounded, in greater or less number, by tubercles in different stages of their progress, which, by becoming successively softened, add to the size of the cavities already existing, or form new ones. On the dissection of lungs that are largely tuberculated, sufficient evidence is afforded, that the cavities are formed in the manner described. They are usually found divided into compartments by extensions of the pulmonary parenchyma, forming bands or cords, which extend from one side of the cavity to the other, and which break at times, so that the divided extremities hang loose in the cavity. In other cases, as in one which the author has just ex- amined, large vessels are seen crossing the cavities, which do not appear, however, to be capable of conveying blood, but to have become obliterated; sometimes, before they are rendered impervious by disease, the vessels give way, and de.ath takes place by haemop. tysis; at times—but rarely—almost instantaneously, the hemor- rhage being so extensive. The seat of the excavations is generally in the superior lobe, where the tubercles are commonly most numerous. At limes, they so completely destroy the pulmonary parenchyma, that the exterior paries may be formed.by the pleura pulmonalis only. The contents of the cavities are various. They commonly consist of a mixture of pus, mucus, and tubercular matter, and, at times, blood; and, occasionally, portions of the pulmonary parenchyma are observed in the sputa. In a case, which the author had'under his care recently, this was manifestly the fact. In the case, before alluded to, the fluid was thin and sanious, and of an offensive cha- racter. At times, indeed, gangrenous sloughs form in the parietes of the caverns, so as to complicate the phthisis with gangrene of the lungs. Occasionally, the caverns are found quite empty, but this is uncommon. It is important, also, to bear in mind, that the cavern may contain a greater quantity of pus at one time than another, and, at times, may be so completely filled, that, as regards the physical signs afforded by the voice alone, no positive deduc- tion can be made, whilst, at other periods, and of the same day, especially in the morning, the caverns may be so far emptied by expectoration, that the vocal signs of a cavern may be very une- quivocal. The interior of the cavern may consist of the pulmonary paren- chyma indurated, red and infiltrated with tubercular matter, the surface being irregular, and projections and prolongations existing, which are formed either of condensed cellular substance, or of the remains of vessels as before described. In their shape—as has been correctly remarked—these small fasciculi or bundles bear a very close resemblance to the fleshy columns of the heart, and OF THE BRONCHIA AND LUNGS. 349 they are often incrusted with yellowish tubercular matter. (Pro- fessor Gross, of Louisville.) It rarely happens, that any remains of bronchial tubes exist in them. It would seem, indeed, that the slight pressure, made by these heterologous formations on the tubes, is sufficient to cause their absorption. Generally, however, bron- chial tubes are seen to terminate in them, through which the tu- bercular matter, pus, &c, are expectorated, and the presence of which affords signs of moment to the auscultator. Occasionally, a communication exists between the cavern and the cavity of the pleura, giving rise to pleuritis, or pneumothorax; or a fistulous opening may exist, by which the matter may make its exit by the parietes of the thorax. (Andral, Professor Morton, of Philadelphia.) Frequently, the excavations, especially if old, are lined by a whitish false membrane, thin, soft, and friable, or adherent, and formed of various layers. The following particulars of the necroscopy of a case of tubercu- lar phthisis, which fell under the author's care in the Philadelphia Hospital, and was reported (American Medical Intelligencer, 1838-39, p. 201,) by an intelligent resident physician, (Vedder, of Schenectady,) exhibit the characters frequently presented by tubercular caverns on the dissection of those who have died of phthisis:— The left lung was adherent throughout, and was removed with the greatest difficulty; on separating, it a large cavity was opened, which discharged about a pint of dark fluid blood. The pleura pulmonalis anteriorly was three-eighths of an inch in thickness, hard and almost cartilaginous. On cutting into it, the scalpel passed immediately into a large anfractuous cavity, occupying the whole of the superior, and about one-half of the lower, lobe: numerous firm bands traversed it in all directions, (obliterated blood-vessels;) two or three were of a light red colour, and—as it were—dissected out; they were still permeable; a probe could be passed into them. An imperfect, almost cartilaginous, septum existed, which could, with difficulty, be cut by the scissors: it was constituted apparently by the pleura, which dipped between the lobes. Numerous small ca- vities communicated with the large cavern: these varied in size from that of an almond to that of a pullet's egg. The large, and nearly all the small, cavities were lined by an old and polished membrane. Numerous bronchial tubes terminated abruptly in the cavity; these appeared as if cut off, and varied in size from that of a pipe stem to double the size. One was about half an inch in diameter. On the anterior surface of the lung was an opening, which communi- cated with the cavity. It was evidently old, from the character of its margins, which were smooth, rounded, firm and shining. The lung was, however, so firmly bound down in this place, as to have prevented the passage of air into the cavity of the pleura. One mass of tubercles was met with in the lung, of about the size of an vol. i.—30 350 DISEASES OF THE RESPIRATORY ORGANS. egg. A small portion of the base of the lung still preserved its vesicular texture, crepitated, and was engorged with blood. This was the only portion of the lung in which the vesicular structure was not destroyed. In the right Jung there were a few scattering nuclei of tuber- cles; and in the posterior part of the upper lobe there was a small cavity lined with a smooth membrane. The bronchial glands were tuberculous. It has been a prevalent opinion, that when once a cavern has formed in the lungs, it is incapable of cicatrization; and one of the most distinguished of modern pathologists, (Louis,) has affirmed, that, in the numerous dissections which he has made, he has never met with a single example. His negative experience has, however, been controverted by the positive observation of others. (Laennec, Andral, Forbes, Carsivell, C. RogSe.) The author has met with several cases, in which this change was unequivocally accom- plished; and the details of a case have been recently published of a distinguished medical practitioner in this city, (Dr. Parrish,) in whose lungs there were marked evidences of cicatrization. This probably occurred after he had long suffered under symptoms of phthisis, and exposed himself to a regimen, which will be men- tioned hereafter. (Professor Wood, of Philadelphia.) The mode, in which this cicatrization is accomplished, appears to be as follows:—At times, the cavern exists, but it becomes lined with a membrane of a cellulo-vascular character, approaching, in its nature and functions, the serous membranes. This may be re- garded as the completion of the process of reparation; for no more tubercular matter or pus is poured into the cavern. By degrees, this cavern diminishes in size, and, in process of time, may form a mere line with cellulo-fibrous parietes, in which large bronchi suddenly terminate. The contraction of the parietes of the cavern gives occasion to a puckering of the lung, which is often most strongly marked on the apex, where the contraction of the cellular parietes of the cavern have drawn it strongly downwards, and the pleura pulmonalis along with it. In the depressions, pseudo-membranous flakes are thrown out, which subsequently become converted into fibrous, or fibro-carti- laginous, tissue. A recent writer, (Fournet,) whilst he admits that pulmonary phthisis is, in extremely rare cases, susceptible of cure, in the stage of excavation, considers it to be by no means demonstrated, that the cure depends upon complete cicatrization of the excavations; nor is the mode—he maintains—in which the cure is effected, yet understood, although he thinks it more likely to be by conversion of the excavations into fistulse, than by their closure. That tubercles are capable of what may be esteemed a cure, in their period of crudity, is shown by the results of all observation. They may, under appropriate treatment, remain quiescent, or they may become converted into those calcareous concretions, which, as OF THE BRONCHIA AND LUNGS. 351 has been elsewhere shown, are met with in the lungs, in the dis- section of persons who have died of disease in other organs. It has been properly remarked, that the cicatrization of the lungs must not be confounded with the phenomena that result from dila- tation of the bronchia, or with the puckering and sinking down of , the lungs, observed in old people, in whom these organs tend to become atrophied. (Andral.) Whilst the tubercles are in the crude state, the pulmonary paren- chyma, surrounding them, commonly appears unchanged; but when the stage of softening is in progress, and especially when caverns have formed, it is subjected to material modifications. Generally, evidences of inflammatory action are perceptible around the tu- bercular masses, which may be acute, but more commonly it is chronic. At times, pneumonia exists along with tubercles, so as to give rise to the interesting question, whether the pneumonia gives origin to the tubercles, or conversely. Our view—as will be seen hereafter—is, that whilst the formation of tubercles may be excited by inflammation, they are not necessarily dependent upon it; and, consequently, as a general rule, if pneumonia is found, it must be esteemed either an accidental complication, or the result of the presence of tubercles. It had been long observed, that tubercles are often developed in many organs at the same time, and that, in the consumptive, especially, they are met with in other parts than the lungs. The numerical results have been obtained, however, in recent times only. Of 358 necroscopies of persons who had died of phthisis, the presence of tubercles, or of tubercular matter, was observed in The lungs, in all the cases except one. Small intestine, in nearly one-third. Large intestine, in one-ninth. Mesenteric glands, in one-fourth. Cervical glands, in one-tenth. Lumbar glands, in one-twelfth. Prostate, in one-thirteenth. Spleen, in one-twentieth. Ovaries, do. do. Kidneys, in one-fortieth. Uterus, ""j Brain, | Cerebellum, y In one only. Medulla oblongata, j Ureters, J It is, therefore, in the lungs only, that tubercles exist alone; and in not one of the 358 subjects were there tubercles in any organ without their being at the same time in the lungs. (Louis.) In the report made to the Academie Royale de Medecine of Pans, on M. Louis' Researches on Phthisis, M. Chomel the re- porter, asks whether these numerical results will apply to'infants? To establish this, investigations have been instituted, which have led to the following observations. In 100 adult subjects, who had died of phthisis, tubercles were found;—in the intestines, 26 times- 352 DISEASES OF THE RESPIRATORY ORGANS. in the mesenteric glands, 19 times; bronchial glands, 9 times; cervical glands, 7; spleen, 6; lumbar glands, and the subperitoneal cellular tissue, 4; axillary glands, and anterior mediastinum, 3; subarachnoid cellular tissue, spinal marrow, false membranes of the pleura and peritoneum,, intercostal muscles and ovaries, 2 each; gall-bladder, liver, posterior mediastinum, pleura, vertebras, omentum, uterus, prostate, bladder, cerebrum and cerebellum, medulla oblongata, kidneys and vesiculae seminales, 1 each. (Lombard.) On the other hand, in 100 cases of phthisis in infants, recorded by the same observer, (Lombard.) tubercles were found;—in the bronchial glands, 87 times; in the lungs 73, (30 times in one lung only, 13 in the left, 17 in the right); in the mesenteric glands, 31; spleen, 25; kidneys, 11; intestines, 9; brain, 9; cervical glands, 7; meninges of the encephalon, 6; pancreas, gastro-hepatic glands, [?] cellular tissue lining the peritoneum, 5; inguinal glands, 3; cellular tissue lining the pleurae, 2; lumbar glands, bladder, omentum, gall-bladder and false membranes covering the pleura, 1 each. From these observations, which are wanting, however, in pre- cision, it is evident, that the distribution of tubercles differs greatly in children and in adults; that they exist in children in a greater number of organs at once, and are not so invariably present in the lungs. (Coivan.) In infants, it will be observed, they occur more frequently in the bronchial glands than in the lungs, a fact which has been observed, although rarely, in the adult. They prepon- derate, also, strikingly in the brain and meninges. The common opinion is, that the left lung is more frequently and extensively affected with tubercles than the right, but such has not been the result of the author's observation, nor does it accord with that of many other individuals. (Laennec, Lombard, Mackintosh.) High authority (Louis) has been brought forward in favour of the left lung being most frequently and extensively affected, and it is supported by some observers on this side the Atlantic, (Pro- fessor Morton, of Philadelphia, and Professor Gross, of Louisville); but a recent writer (British and Foreign Medical Review, April, 1840, p. 334), has shown, that, curiously enough, the cases of M. Louis do not, on analysis, warrant his inference, the following being the result in his 50 tuberculous subjects. Cavities in both lungs? Most e*:tensive in ,rifht lunS in ™ in 33 cases. ° L " ... left f " - »J j Doubtful in this respect, - 8 Cavity in left lung only, - ... 7 right - - - - . 6 Tubercles (without ulceraO Right side, - . - - 1 ration) predominating C Left, ... 1 on the j Doubtful on which, 2 50 Both of the lungs seem, therefore, to have suffered as closely as possible to the same amount. OF THE BRONCHIA AND LUNGS. 353 Of one hundred and seventy cases, observed by another patholo- gist, (Fournet,) one hundred and nine presented the greatest share of disease on the right side; forty-six on the left; and in fifteen cases, both sides were equally implicated. If any doubt, however, exist as to which of the lungs is more frequently and extensively affected with tubercles, it must be ad- mitted to be unusual to find the disease equally developed on both sides. 2. TUBERCULAR CONSUMPTION. Synon. Phthisis pulmonalis, Ph. pulmonaris, Ph. pulmonalis vera seu tuber- culoso-ulcerata seu tuberculosa seu scrophulosa, Ph. pulmonalis purulenta ex- ulcerata, Marasmus Phthisis, Haemoptysis Phthisis, Tuberculosis Pulmonum, Pneumopathia tuberculosa, Tuberculous Disease of the Lung, Pulmonary con- sumption, Consumption of the lungs, Consumption, Decline; Fr. Phthisie pul- monale, Crachement de Pus; Ger. Lungenschwindsucht. The preceding remarks on tubercles—as occurring in the lungs more especially—will render the symptoms of tubercular pulmo- nary consumption readily intelligible. There is no disease which is more deeply interesting to the pathologist—affecting, as it does, the young and the promising, and being so fatal—so alarmingly fatal —when once it has become fully developed. It is an old estimate, that perhaps one-ninth part of the whole number of deaths is from pulmonary consumption. (Sydenham.) In Great Britain, the proportion has been conceived to be one- fifth, and it has even been rated as high as one-third of the whole number, (Sir James Clark,) but the former estimate is probably too high for England, (Forbes,) and for any part of the United States. An estimate, as already remarked, (p. 307,) has been attempted (Emerson, of Philadelphia,) of the average mortality from consumption and acute diseases of the lungs, in the four largest cities of the Union—New York, Philadelphia, Baltimore and Bos- ton, from which it would appear, that the average annual propor- tion of the general mortality to the population, was, in New York, 39.36; in Boston, 44.93; in Philadelphia, 47.86; and in Baltimore, 39.17; and that the average of the mortality from consumption alone, to the general mortality, was, in New York, 5.23; Boston 5.54; Philadelphia, 6.38; and Baltimore, 6.21. The mean proportion of deaths from phthisis at Carlisle, London, Plymouth, and the Landsend, is one in 5.6. (Forbes.) In New York, during 1839, the ratio was one in 5.2, excluding casualties and the still-born; and one in six including those. (Walters, of New York.) In Philadelphia, during the same year, the ratio was one to 7.2, of the whole number of deaths. (Report of the Board of Health.) These estimates must be regarded as approximations merely, inasmuch as the same method of obtaining the statistics was not adopted in the different cities. Diagnosis.—The symptoms of tubercular consumption admit of 354 DISEASES OF THE RESPIRATORY ORGANS. a division—in accordance with the progress of the tubercles—into three stages;—the first being that of tubercular development; the second, that of softening, and the third, that of the formation of large caverns in the lung. Between the different stages—as has been well remarked, (Stokes)—time is no exact line of demarca- tion, but when completely established, each has its characteristic symptoms, and physical signs. First stage.—It is proper to remark, that although a certain group of symptoms may accompany tuberculous disease of the lungs, the order in which they present themselves, and the degree of their severity, vary remarkably in different individuals,—in some cases, the symptoms being so pronounced as to excite the attention of the most careless observer, whilst in others they are so trivial as scarcely to be noticed by any but the medical attendant, and occa- sionally not even by him. (Sir James Clark.) In this first stage, the symptoms are mainly those of catarrh,— as cough, some dyspnoea, languor, debility, with at times, in addi- tion, hectic fever, followed by unaccountable' emaciation. The cough exhibits great variety, but it is commonly slight, frequent, and irritating, and is referred to a tickling sensation in the trachea. The expectoration, when there is any, consists of a nearly transparent mucus,—at times, containing small dots of blood. Along with these symptoms, pain in some part of the thorax is often experienced, sometimes constant, but at others intermittent, and occasionally so regularly intermittent, that, as it has occurred with the paroxysms of hectic, it has been mistaken for intermittent fever, and treated accordingly. This pain often occupies the scapulo-humeral articu- lation, and is accompanied with tenderness of the subclavicular region, and often with irritation of the muscular fibres, which causes their contraction on percussion. The combination of this pain of the shoulder with quickness of pulse, it has been affirmed, should always excite alarm. (Stokes.) The pathological condition of the lungs, at this period, consists in the presence of a greater or less quantity of tuberculous matter, —the whole, or a large proportion of which, is in a state of crudity, —that is, more or less firm, of a grayish colour, and somewhat transparent; or partly of a pale yellowish colour and opaque. The pulmonary tissue, and bronchial membranes, in the immediate vicinity of the tuberculous deposits, may have undergone no per- ceptible alteration, or may present a degree of redness and vascu- larity. At this period of the disease, the physical signs are not as valu- able as they are afterwards, unless the tubercles are numerous, and seated—as they generally are—near the summit of one of the lungs. Under such circumstances, the sound, rendered on the percussion of the affected side, will be more dull under the clavicle; the respi- ratory murmur, on auscultation, will be less full and free; in- spiration may be bronchial, expiration more audible, and the OF THE BRONCHIA AND LUNGS. 355 resonance of the voice greater; but unless these indications are unequivocally different on the two sides, they cannot, as a general rule, be much relied upon at this early period, as a means of diag- nosis. All these signs are evidences of deposition at the upper portion of the lung. The sound of the voice, transmitted by the indurations in an unusual degree, is sometimes only a diffused resonance. The sub- jacent arteries are also heard unusually clear below the clavicles; and in cases of tuberculous deposition in the upper portion of the right lung, the sounds of the heart are often heard more loudly in this situation than under the left clavicle. When the sub- clavian arteries are heard with unusual distinctness, it is owing to a partial obstruction of the arteries, by the pressure of indura- tions at the apex of the lung. It has been esteemed a sign of incipient phthisis, (Stokes,) but it cannot be diagnostic, as the same sounds are produced in some healthy persons under slight excite- ment, probably owing to the artery pressing on the clavicle or upper rib. (C. J. B. Williams.) Second stage.—In this stage the diagnosis becomes more marked. The hectic glow and the feVer are more evident; the symptoms of irritation continue; the emaciation and loss of strength make decided progress; the hectic chill in the evening, succeeded by fever, is followed by sweats, more or less profuse; the colourless, frothy expectoration, which had previously attended the cough, is observed to contain small specks of opaque matter, of a pale yellowish or white colour, and resembling curds or cheese. The proportion of this matter gradually increases so as to form patches, surrounded by the transparent portion in which they seem to float, or they fall to the bottom of water, if the sputa have been expectorated into water. Specks or streaks of blood are also perceptible in them, and, at times, haemoptysis occurs to a considerable amount. There is occasionally, in this stage, less oppression or pain in the chest than before; but the shortness of breath, on exertion, is undiminished, if not increased, and the pains which existed in the chest, in the first stage, are continued. Anomalous pains are apt to occur both in this and the next stage, ^n different parts of the body, which add greatly to the distress. In a case, which the author attended some time ago, the most severe neuralgic pains were frequently expe- rienced over the chest, abdomen, and extremities, even at the tips of the fingers, which nothing but opiates would allay; and in one unfortunate case, the pain experienced in the occipital portion of the scalp was almost beyond endurance. This is the period of the softening of the tubercles. They have become « broken-down," or are rendered soft by a secretion from the surrounding pulmonary tissue; and the matter, of which they are constituted, passes into the bronchial tubes. About this period, adhesive inflammation generally unites the pleura costalis to the' pleura pulmonalis, and the pains experienced in the corresponding parts of the chest are often evidences of the slight pleuritic affec- 356 DISEASES OF THE RESPIRATORY ORGANS. tion, which precedes, and is the cause of the union. At other times, the pains are of the neuralgic character just referred to. The dulness on percussion persists, and generally extends over a greater surface downwards. Auscultation now becomes a valuable diag- nostic agency; vesicular respiration is no longer audible in certain portions of the lung, whilst the respiration along the larger bronchia may be unusually loud; the mucous, the crepitant or sub- crepitant rhonchi or rdles are heard—the latter, when the patient coughs, more especially. The resonance of the voice is great over the affected parts, and distinct pectoriloquy may be heard, particu- larly in some portion of the clavicular or scapular regions; but this is not generally audible, unless the cavities are large and empty. The cavernous respiration and voice are indistinct, when the ul- cerations are small. These signs will be heard more markedly on one side than on the other, and this difference is an important ele- ment in the diagnosis. It is proper to remark, that tubercular deposition and development may have proceeded to the extent of rendering the greater portion of the upper lobes impervious to air, and of solidifying those lobes considerably; " yet the solidified portions may be so divided from each other by laminas of healthy lung, and may be so covered by a stratum of vesicular tissue, that the general result of percussion is to elicit a clear sound over the whole of the parietes of' the chest corresponding to the affected lobes." (Graves.) The duration of this stage is extremely various; at times, a few weeks; at others, months, and even years. In a very small number of cases, a curative process is established, by which the effects of the disease are, in a greater or less degree, obliterated; and, if the patient's general health be maintained in a good state, there may be no return of tuberculous disease. (Sir James Clark.) Third stage.—This is the stage in which large caverns exist in the lungs, and which has been termed the "colliquative/' incon- sequence of the wasting induced by the profuse perspirations, which are often attended by diarrhoea. The expectoration is usually very copious. It is not always easy, however, to diagnosticate, in all cases, the purulent sputa from the mucous,—nor is it so important, since the mode of exploration, proposed by Laennec, has led us to a more accurate diagnosis without it. It" is proper, also, to bear in mind, that the lining membrane of the bronchia can, and fre- quently does, secrete a purulent or muco-purulent fluid, without there being any tubercular condition of the pulmonary substance. In a case of measles, which fell under the author's care some time ago, and which was accompanied by severe bronchitis, with evident narrowness of the bronchial tubes, a copious expectoration of a fluid possessing all the properties assigned to the matter of vomica, was discharged, which would doubtless have led to the belief, that an abscess had been formed in the lungs, had it not been that the secretion was established too soon after the commencement of the bronchitis, and that there was an absence of all the physical OF THE BRONCHIA AND LUNGS. 357 signs that indicate the existence of a cavity in these organs. The case terminated fatally, and dissection proved that the whole secre- tion was bronchial. Before tubercles are softened, and their contents discharged into the bronchia, the whole of the matter of expectoration must be supplied by the bronchial mucous membrane. At this time, the sputa—as already remarked—are generally transparent, frothy and tenacious—of the character which is considered " mucous," but the appearance of the expectorated matter varies materially, and, as •in cases of chronic bronchitis, it may become thicker, less frothy, and possess a more equivocal character. Still, the mucous portion will generally predominate so much, that if the sputa be thrown into water, they will swim, buoyed up, more or less, by the im- prisoned air. When the tubercles become softened, and the tuberculous matter passes into the bronchial tubes, the sputa may still consist largely of the bronchial secretion. The bronchial mucous membrane would seem, indeed, to produce the greater part of the sputa in tubercular disease of the lungs. (Sir James Clark.) If they be now examined, they will present the white curdy appearances described as belonging to the second stage of tuberculous consumption. Some of these will be observed at the bottom of the vessel, whilst others are con- nected with, and suspended by, the more mucous portion. In the third stage, now under consideration, when the purulent discharge is very great, it may present the appearance of globular masses, often of an ash colour: these masses predominate greatly over the bronchial secretion, and being usually of greater specific gravity, and less penetrated by the air, they sink in water to the bottom of the vessel. In making these examinations of the matter of expectoration, it is important not to permit too long a time to elapse, after it has been discharged, as the water in the vessel is apt to commingle with it, and thus to create confusion; and like- wise to examine more particularly that which is expectorated on first waking, as, in this way, we obtain the secretion, which has accumulated in the cavity during the night. After all, however, when we reflect on the varying characters of the expectoration^ the uncertainty of its changes according to the progress of the dis- ease, and its occasional absence altogether—for such is the case— we ought not to place too much reliance upon it as a diagnostic symptom, especially in the early stages. In conjunction with other symptoms, it may enable us to ascertain the presence of tubercular disease in complicated cases, and the changes that occur in the or- dinary progress of phthisis. (Sir James Clark.) Along with the generally copious expectoration in the third stage, the dyspnoea often becomes urgent, so as occasionally to threaten suffocation, and the feet and ankles are at times (Edema- tous. Inspection of the chest indicates, that great changes have taken place in that cavity. The shoulders are raised, and brought forward; the clavicles are unusually prominent, leaving a deep 358 DISEASES OF THE RESPIRATORY ORGANS. hollow—more or less perceptible in the first and second stages— between them and the upper ribs; and the chest, instead of being round, is flat. The shoulders are raised at each inspiration, and the chest is dragged upwards, as it were, in place of being expand- ed, as in health. Percussion gives a dull sound, wherever there is solidification, but if it be practised over a cavity, the sound may not be as dull as in the second stage. Auscultation indicates, that there is no respiration in different parts of the lung—none that is vesicular; but the bronchial or tubal respiration may be uncom- monly loud, so as even to be "tracheal," or "cavernous." Cough' ing gives rise to a gurgling—gargouillement—and sometimes this gurgling is heard on inspiration; and pectoriloquy may be more or less distinct—especially in the morning early, after the pus, which has collected during the night in the caverns, has been evacuated. In this state—hopeless as it is—the patient may linger for weeks or months, or he may be cut off with very slight warning. In a case, which fell under the author's care not long ago, the symptoms in the morning indicated but little augmentation of mischief, yet, in the evening, the dyspnoea increased, and in a few hours the sufferings of the patient were terminated. Such cases are not un- common. Often, the disease destroys, by gradually wearing out the sufferer by a hidden, yet not distressing, irritation; but, at other times, the sufferings are considerable, and, not uncommonly, death occurs suddenly, owing to the breaking of a vomica in the lungs, the matter of which cannot be evacuated with sufficient rapidity in the enfeebled state of the patient, and death occurs by asphyxia. Although tubercular consumption must be esteemed essentially the same disease, as regards its anatomical characters and consti- tutional origin, it has been thought proper to make different varie- ties of it. Laennec, for example, recognizes five:—1. Regular manifest phthisis. 2. Irregular manifest phthisis. 3. Latent phthisis. 4. Acute phthisis. And 5. Chronic phthisis. Sir James Clark, also, notices five; whilst Dr. Stokes admits six, besides those that are diversified by complications. 1. Acute non-suppurative. 2. Acute suppurative. 3. Chronic progressive. 4. Chronic ulcera- tion following pneumonia. 5. Tubercle consequent on chronic bronchitis. 6. Tubercle consequent on the cure of empyema. It is doubtful, however, whether, as a general rule, more harm than good does not result from such subdivisions. It is not easy, indeed, for any agreement to exist among pathologists in the number of varieties to be admitted. Accordingly, a recent writer, (C. J. B. Williams,) considers it to be sufficient for his purpose to distto- guish two kinds of consumption, the acute and the chronic, with- out, however, professing, that the line between them is always well marked; and admitting, that each may present considerable variety in its predominant symptoms. In addition to these two varieties admitted by Dr. Williams, Sir James Clark has-the phthisis of infancy and childhbod; the febrile phthisis, differing from the others in being usually ushered in, and attended, during OF THE BRONCHIA AND LUNGS. 359 its whole progress, by a considerable degree of fever,—and the latent. The last—the latent variety—may present itself in two different forms. In one, the constitutional symptoms exist,—as fever, night sweats, emaciation, diarrhoea, &c, without any local indications of the pulmonary disease, or if they be present they are of so slight a character as to pass unnoticed. The other form is more insidious, and, therefore, more important; being attended with neither constitutional nor local symptoms until the tuberculosis has made extensive progress. (Sir James Clark.) The greater number of cases may, however, be regarded latent in the commencement. (Laennec.) This opinion Laennec was led to entertain, in consequence of his finding, that nothing was more common than to meet with numerous miliary tubercles in lungs otherwise healthy, and in persons who had never exhibited any signs of pulmonary consumption; and it has been already remarked, that the lungs may be studded with calcareous tubercles without any existing evidences of phthisis. Since Laennec was first led to adopt this opinion, on anatomical grounds, it has frequently appeared to him quite clear, from a care- ful comparison of the history of the case with the appearances on dissection, that the greater number of the first attacks had been mistaken for slight colds; whilst others were altogether latent, being unaccompanied by either cough or expectoration, or indeed by any symptom of sufficient weight to impress the memory of the patient. These facts, which are confirmed by the results of the author's ob- servation, lead to the important therapeutical deduction, that where there is reason to suspect the existence of a tuberculous diathesis, the greatest attention should be paid to those indications, in order to preserve the pulmonary tissue from more serious inroads. After phthisis has undergone some degree of development, the symptoms may almost wholly disappear, or become latent under new conditions of the system. Pregnancy is one of these; but it occasionally happens, that symptoms of phthisis make their appear- ance, for the first time, during utero-gestation, and that difficulty arises in determining, whether the pulmonic symptoms are induced by the development of sympathies irradiating from, or connected with, the uterine condition, or whether they are truly phthisical in their character. The physical evidences of auscultation are evident in such a case. An attack of mania will often also suspend the symptoms of phthisis; the new state of excitation of the nervous system concentring the morbid action on it, and thus diverting from the organic mischief in the lungs. Of the particular symptoms of phthisis—the cough, dyspnoea, expectoration, haemoptysis, pain of the chest, pulse, hectic fever, perspirations, thirst, diarrhoea, emaciation, oedema, aphthae, &c, not much need be said; yet a few remarks may be advisable on some that have not received, thus far, much notice. Haemoptysis is a very common occurrence, having been observed 360 DISEASES OF THE RESPIRATORY ORGANS. fifty-seven times in eighty-seven cases:—that is, in two-thirds: in twelve cases only, it preceded the cough and expectoration, and in four cases only, it took place in the last days of existence. (Louis.) Of haemoptysis, mention has been made already. It was then stated to be an affection of but little consequence, except when ac- companied by the presence of tubercles, or of tuberculous excava- tions in the lungs; but, in such cases, it is a symptom of serious import. , The pulse varies, of course, materially throughout the disease, being rapid during the hectic paroxysms; but often natural in the intervals. Frequently, however, especially in the more acute forms of the disease, it is permanently rapid, and almost always so in the advanced periods. Sometimes, however, even in the third stage, it remains slow. Recently, great attention has been paid to the pulse in phthisis, (Guy,) and it has been maintained:— 1. That the frequency of the pulse varies within wide limits,—the difference between the extremes amounting to 90 beats. 2. In the same individual, the frequency of the pulse undergoes remarkable fluctuations, passing, in a few days, through a range of upwards of 60 beats. 3. In five out of six cases, the frequency of the pulse in phthisis, exceeds the highest frequency observed in health. 4. The difference between standing and sitting in phthisis, is nearly the same for all frequencies of the pulse. 5. The maximum difference between standing and sitting in all cases of phthisis pulmonalis, falls short of the mean difference in health. 6. From the average results of a considerable number of cases, it appears, that the mean difference in health is six times as great as the mean, and three times as great as the maximum difference in phthisis. 7. On the supposition, that the slight effect produced by change of posture is peculiar to phthisis, it forms one of the most constant and certain of its symptoms. These results require farther observation. There may be other diseases, which exhibit the same, so that they may not be esteemed diagnostic of phthisis. Along with phthisis of the lungs, the larynx is often the seat of disease, as already remarked under another head. Hoarseness or loss of voice is frequently, indeed, an early symptom of the disease. The digestive system also suffers sooner or later, and at the latter periods, more or less endoenteritis frequently prevails, which passes on to the state of ulceration, often complicated with tuberculous deposition under the mucous membrane of the intestines. In many instances, however, phthisis runs through all its stages to a fatal termination, without the supervention of any intestinal disorder. Tubercles, likewise, may form in the brain or spinal marrow, or in the meninges, and give rise to encephalic symptoms. In the female, the catamenia are generally defective, or absent, at an early stage of phthisis, (Laennec,) and their suppression has been regarded as an unfavourable sign, (C. J. B. Williams,) but the author has not been impressed with this circumstance. Pulmonary consumption is essentially a chronic disease, to OF THE BRONCHIA AND LUNGS. 361 mean duration, according to the observation of pathologists, (Bayle, Louis,) is, in hospital practice, twenty-three months. This includes the extreme cases; but more than one-half, in 314 recorded cases, terminated in nine months, and the greater proportion of these be- tween the fourth and ninth months. By excluding the cases, that ended within four months—which amounted to 24—as well as those that exceeded four years—amounting to 19—the average duration of the remaining cases is eighteen months. It is manifest, however, that various circumstances must modify the duration of the disease. Amidst the comforts and advantages of private life, we should expect it to be more protracted: and much must depend upon age, sex, constitution, &c, as well as on climate, season, and other influences. Causes.—These may be divided into the extrinsic and the in- trinsic. a. Extrinsic causes. 1. Climate.—Pulmonary consumption has been seen in all or almost all climates, but by no means in an equal degree of frequency; yet our information as to the precise modus agendi of climate, in causing phthisis, is sufficiently imprecise. A cold, damp, and variable climate—like that of Great Britain—is conceived not only to give the predisposition, but to become an exciting cause of the disease; yet it prevails to a like extent in many of the more dry, less cold, but scarcely less variable situations of southern France and Italy; and it is fearfully rife in many parts of the torrid zone, where none of those conditions of climate are met with. As a general rule, it would seem, that the deaths from the disease diminish in a direct ratio with the mildness of the climate, (Andral); but great heat appears also to have a powerful effect in predisposing to tuberculous disease. (Sir James Clark.) The table—cited in an early part of this article from Dr. Emerson—of the average mortality of phthisis in the four largest cities of the Union—is signally elucidative of the difficulties that environ us, in accounting for either the general, or particular, mortality of any place as compared with that of others. Within the limits of the United States, the range of the thermo- meter is considerable—much more so than in Great Britain. This applies even to St. Augustine, Pensacola, and other places in Florida, which have been regarded as eminently favourable winter retreats for the phthisical valetudinarian. The medium heat is, however, higher in those southern situations; and this, along with other atmospheric advantages, may, in part, counterbalance the evil. Yet, although the climate of the United States is proverbially one of extreme vicissitudes, the number of deaths by consumption is probably not as great as in England, or in many of the situations of southern France and Italy, which have been selected as winter retreats for the consumptive. A respectable physician of the navy (Hulse), has asserted, that he has never known, or heard of, a case of consumption that originated in Pensacola. The West Indies (Dr. John Hunter, Professor Morton, of Philadelphia), and Peru 362 DISEASES OF THE RESPIRATORY ORGANS. would seem to be unusually exempt from phthisis, as a disease of the inhabitants, but the mortality from phthisis, among the British troops and others stationed in the West Indies, is by no means small; and hence it has not been regarded by some as a favourable residence for the phthisical of other countries. (Sir James Clark.) It would appear, indeed, from the statistical report on the sick- ness, mortality, and invaliding among the British troops in the West Indies, (Major Tulloch,) that in Jamaica, with a high tem- perature, consumption is there as frequent among the British troops as in Britain. The results, too, obtained statistically in the West Indies, by no means favour an opinion, which has been promul gated, (Wells,) that there is an antagonism between diseases, which are the product of marshy emanations and phthisis. They prevail together, without seeming to exert any influence upon each other. When a tuberculous individual passes from a warm and dry country, to one that is cold and damp, the tubercles undergo de- velopment. It was observed, that the French regiments suffered more from phthisis in Holland, than in Spain and Italy. (Brous- sais.) Almost all the animals, too, which are brought from the torrid regions to our menageries, die of tuberculosis of the lungs. (Andral.) 2. Season.—In the temperate regions of the globe, winter and spring appear to be most favourable to the development of phthisis, because, in those seasons, there is the greatest union of cold and moisture. The remark has been made, that near the sea there are but few consumptive cases, (Laennec); but this must depend greatly upon the exposure. If, for example, as on the seaboard of the United States, the place be exposed to the constant N. E. storms and winds from the ocean, that prevail during the winter, the effect cannot fail to be seen on the tuberculous. Where tubercles already exist, a warm dry air will have the same influence in favouring their development as the heat of the torrid regions of the globe; and the absence of solar light has been thought to produce the same effect as humidity. (Andral.) It is well known, that privation of light occasions, or favours, imperfect deve- lopment of the frame, and hence any situation, from which light is excluded, may lay the foundation for tuberculosis, which must be regarded as a disease dependent upon defective and vitiated action of the tissues in which the tubercles are formed; and this, we shall see, is dependent, again, upon an unhealthy condition of the system, which favours their deposition. According to the annual report of the interments in the city and county of New-York, for the year 1839, (Walters,) the number of deaths in the different months from consumption was as follows: September, 134; April, 126; -March, 125; December, 124; August, 118; February, 114; January, 101; October, 100; May and No- vember, each 99; June, 88; July. 87;—total, 1315. So far as this table goes, no satisfactory inferences can be deduced as to the effect of season. OF THE BRONCHIA AND LUNGS. 363 3. Atmospheric vitiation.—Atmospheric impurity has, unques- tionably, much to do with the causation of tuberculosis; accordingly, it is found, that they who live in restricted habitations, where ven- tilation is imperfect, and especially where numbers are crowded together in a small space, suffer much from tubercular disease. All living bodies, when crowded together, deteriorate the air so much as to render it unfit for the maintenance of the healthy function. If animals be kept crowded in ill ventilated and badly lighted apart- ments, they speedily sicken. The horse is attacked with glanders; fowls with pep; and sheep with a disease peculiar to them, if they be too closely folded. It would appear, that the young, especially of the animal crea- tion, and particularly of the human species, require the respiration of pure air, otherwise they perish. Experiments have shown, (Jenner, Baron,) that if young animals be deprived of their open range, and especially if the character of their nourishment be modified, a foundation is laid for disorganization and death. A family of young rabbits were placed in a confined situation, and fed with coarse green food—such as cabbage and grass. They were perfectly healthy when put up. In about a month, one of them died; the primary step of disorganization was evinced by a number of transparent vesicles, studded over the external surface of the liver. In another, which died nine days after, the disease had advanced to the formation of tubercles in the liver. The liver of a third, which died four days later, had nearly lost its true struc- ture, so universally was it pervaded by tubercles. Two days sub- sequently, a fourth died; a considerable number of hydatids was attached to the lower surface of the liver. At this time, three young rabbits were removed from the place, where their companions had died, to another situation, dry and clean, and to their proper and accustomed food. The lives of these three were obviously saved by the change. Similar results were obtained from experiments of the same nature performed on other animals. (Baron.) It can hence be understood,that where an individual has tubercles already present in the lungs, confinement to a chamber, with a regulated temperature during the winter season, may be obnoxious to weighty objections, owing to the greater or less degree of vitia- tion of the air of the apartment; and, accordingly,—as will be shown hereafter,—it has been recommended to send the consump- tive invalid abroad, in the winter season, when the air is dry, although it may be cold, rather than to adopt this questionable procedure. It can be farther understood, that such occupations as those of the needle pointer, dry grinder, stone mason, miner, collier, feather dresser, cotton manufacturer, &c, may act as exciting agencies, at least; and probably lay the foundation of phthisis; for, although it has been questioned whether the consolidation of the lung, which is found in such cases, is really tuberculous, the difference is so slight, that they can scarcely be separated. (C. J. B. Williams.) 364 DISEASES OF THE RESPIRATORY ORGANS. It is affirmed, that there is hardly an instance of a mason, regularly employed in hewing stones, in Edinburgh, who liv«s free from phthisical symptoms to the age of fifty. (Alison.) Under such circumstances, extraneous particles have often been found in the indurated lung. In the case, too, of the workers in coal mines, the texture of the'lungs has been found completely blackened by coal- dust, so as to constitute anthracosis. In the case of the steel workers at Sheffield, the fork grinders, who grind dry, so that the particles are readily received into the air, do not reach the age of thirty-two, whilst the knife grinders, who work on wet stones, generally live to forty or fifty. (Knight.) The results of the inquiries of different observers, as to the in- fluence of trades and professions on the production of phthisis, have not been very accordant, and the difference has arisen partly, perhaps, from the circumstance of exposure to vicissitudes, to im- perfect light and ventilation, and insufficient nutriment not having been always taken into sufficient consideration. For example, in the department of Berri, in France, there is a village, in which almost all the inhabitants follow but one profession—that of makers of gunflints, whence they have been called Caillouteux. Almost all these persons die of phthisis, or at least few pass the age of 40 without affording evidences of tuberculosis. (Benoiston de Chateauneuf.) This has been attributed to particles of siliceous dust in the air passing into the lungs; but Andral, who visited the place, affirms, that the dust of the flints can never reach the mouth, and cannot, therefore, be respired. He attributes the phthisis to the workmen being compelled to have their feet in constant contact with very cold stones. It has been presumed, that the inhalation of the fine particles, in the occupations above mentioned, can only act as an exciting cause, by developing predispositions that may have previously existed; it is certain, however, that the mortality from phthisis, in some of those employments, is much greater than in others in which the collateral circumstances would appear to have been quite as unfavourable to the general health. 4. Faulty alimentation is doubtless, also, one of the important extrinsic causes of phthisis, and of the tuberculous condition. Exclusive vegetable diet, or a defective supply of animal food, has been regarded specially obnoxious, but much depends upon habit. If a person has been accustomed to a mixed diet of animal and vegetable food, and is subsequently restricted to either one or the other, his nutrition is apt to become impaired, and cachexia to be induced; but habitual diet has probably not much influence; and, that a free allowance of animal food does not alone prevent phthisis is shown by the circumstance, that in England, where the diet is perhaps more largely animal than in other countries of Europe, phthisis is probably more frequent. (Andral.) 5. Influence of articles of dress.—Where a female is predis- posed to phthisis, irregularities of exposure to cold and moisture, of the body generally, but especially of parts that are habitually OF THE BRONCHIA AND LUNGS. 365 covered, may act as exciting causes of phthisis. It has been gene- rally, too, believed, that tight corsets may prove injurious, by pre- venting the due expansion of the chest, and in this manner favour the disease. When worn at an early age, and before the chest has undergone its full development, they may prevent this, and thus act injuriously. Yet is has been affirmed on high authority, (Louis,) that " the influence of clothing, and especially of corsets, on phthisis, is perhaps a mere assertion without proofs." b. Intrinsic causes. 1. Constitution.—It has been presumed, that the formation of tubercles in the lungs, as elsewhere, originates in a " tuberculous constitution or diathesis," Phthisiosis;—and in " tuberculous cachexia;" Tuberculosis, Morbus tuberculosus, Dys- crasia tuberculosa; Fr. Cachexie ou Dyscrasie tuberculeuse; Ger. Tuberkelkrankheit, Knotensucht. The characteristics of this tuberculous constitution are chiefly those of the strumous or scrofu- lous;—fair skin, light hair, blue eyes, and thick upper lip. Along with these signs, there are often, also, long neck, narrow chest and projecting shoulders. So far, however, as the observation of the author goes, the large mass of phthisical individuals do not present these characters. In the published experience of one observer, (Professor Morton, of Philadelphia,) almost two-thirds of the phthisical patients, which have fallen under his notice, have had dark hair, dark or sallow complexions, and dark eyes; and such has been the result of the author's observation. In the negro, both the scrofulous and the tubercular constitution are often met with, and some of the most decided, and most rapid, cases of phthisis occur in them. In the United States, scrophula—at least in its ordinary glandular forms—cannot be considered as by any means common among the white inhabitants,—that is, if Great Britain be taken as the standard of comparison; but it is one of the diseases to which the black population are especially subject. The tuberculous and the scrophulous constitution appear to be distinct, although congenerous;—at least, an individual may have tubercles existing, to a considerable extent, in the lungs and other organs, without the usual indications of scrophula in the lymphatic glands or ganglions; whilst disease may be prominently developed in the latter, without any evidence of the presence of tubercles in any of the internal organs. Of seventeen cases of scrophulosis, where life had been destroyed by the exhaustion consequent upon profuse discharges from ulcera- ted surfaces and scrophulous caries, only one presented consider- able tubercular deposition in the lungs, and only nine any traces of it. Of eighty-six cases of tubercular phthisis, only one presented any cicatrix or other evidence in the neck, the axilla or the groin, of having suffered from disease of the lymphatic ganglia of those regions. (Phillips.) Of three hundred and fifty-eight cases of tuberculosis of the lung, that fell under the care of a distinguished observer, (Louis,) 31* 366 DISEASES OF THE RESPIRATORY ORGANS. thirty were found to present more or less trace of the deposition of similar matter in the lymphatic ganglia. Narrowness of the chest has been generally considered to afford a predisposition; but according to a recent observer (Woillez,) such is not the case, unless it is coupled with an incomplete develop- ment of the transverse diameter; and therefore, it is incorrect to say, that subjects of small thoracic capacity are more liable than others to pulmonary tubercles. According to some pathologists, a tuberculous constitution- natural or acquired—must always be present before any exciting cause can induce phthisis; according to others, the disease is a chronic inflammation of the pulmonary tissue, and may be de- veloped in the absence of any such constitution. The former of these opinions appears to be most in accordance with observation and reflection. 2. Age.—It was at one time believed, that tubercles in the lungs and elsewhere prevailed only in the adult age, and chiefly between 18 and 35; but it is now sufficiently established, that they may occur at all ages, and even in the foetus in utero. (Husson, Chaus- sier, Cruveilhier, Lobstein, Billard.) From observations made in this country, as well as in Europe, it would appear, that the greatest number of deaths occurs between the ages of 20 and 30; the next in proportion between 30 and 40; the next between 40 and 50; the succeeding grade of mortality is sometimes placed between 15 and 20; at others, between 50 and 60, or even above 60. (Sir James Clark, Professor Morton, of Philadelphia, Bayle, Louis, Lombard.) This remarkable agreement of observers in different parts of the globe warrants the deduction, that after the fifteenth year, fully one-half of the deaths from phthisis occur between the twentieth or fourtieth years of age, and that the mor- tality from the disease is about its maximum at 30, and from that time gradually diminishes. A distinguished observer (Andral,) thinks, from his researches, that males, after puberty, are particularly liable to tubercles be- tween the ages of 21 and 28, whilst females seem to be more ex- posed to them before 20; and M. Lombard is of opinion, that after the age of puberty, females are most liable to tubercles between 18 and 20 years of age; and males between 20 and 25. From the New York report of interments for the year 1839, it appears, that, of 1315 registered cases of consumption, 31 occurred under the age of one year; 39, between 1 and 2 years; 58 between 2 and 5; 44 between 5 and 10; 67 between 10 and 20; 335 between 20 and 30; 318 between 30 and 40; 197 between 40 and 50; 127 between 50 and 60; 68 between 60 and 70; 25 between 70 and SO; and 6 between 80 and 90. (Walters.) The report of the Board of Health of Philadelphia for the same year gives 708 deaths from pulmonary consumption; of which 24 occurred under one year; 15 from 1 to 2; 29 from 2 to 5; 13 from 5 to 10; 5 from 10 to 15; 36 from 15 to 20; 206 from 20 to 30; 164 OF THE BRONCHIA AND LUNGS. 367 from 30 to 40; 102 from 40 to 50; 55 from 50 to 60; 38 from 60 to 70; 17 from 70 to 80; 3 from 80 to 90; and 1 from 90 to 100. 3. Sex.—The influence of sex is not settled. The common opinion is, that females are more subject to phthisis, and such is the view of some excellent authorities. (Lombard, Bayle, Louis, Papavoine.) Of 9549 recorded cases of phthisis, (Lombard,) 5589 occurred in females, and 3960 in males. In Paris, according to a report of the Conseil de Salubriti and Chabrol's Statistique de la viile de Paris, the proportion of phthisical males to phthisical fe- males was as 10 to 13.8. In certain other cities, however, of this country and Europe, the ratio was 10 males to from 8.7 to 8.9 fe- males. (Sir James Clark-.) In New York, during the year 1839, the number of males was 704, and of females 611; or in the propor- tion of 10 males to 8.7 females nearly. (Walters.) In Philadelphia, on the other hand, during the same year, the number of deaths from phthisis was—of males 335, and of females 373,—or in the propor- tion of 10 males to about 11 females. 4. Hereditary conformation.—This is one of the most important of the causes of tuberculosis, and especially of tubercular phthisis. A patient, affected with tuberculous cachexia, entails on his off- spring, not tubercles, but a predisposition to them, which may be warded off, by avoiding the exciting causes, but may be developed by causes, which would be entirely inoperative in one not so pre- disposed. It is important, therefore, in the history of any case, to discover, whether the parents or any member of the family have died of the same disease. It would not appear to be tuberculous cachexia alone in the parent which lays the foundation for this fatal malady in the offspring. There are several diseases, which have been supposed to produce the result, and the most frequent and important of these are disordered states of the digestive organs and their consequences;—indeed, any state of deteriorated health in the parent from any cause may give rise to this cachexia in the pro- geny. 5. Inflammation of the respiratory organs and other diseases. —Mention has already been made of the supposed inflammatory origin of tubercles; and those remarks may be transferred to pul- monary consumption. The opinion, that " the term phthisis pul- monalis, as it expresses only the disorganization, which is the product of inflammation of the pulmonary parenchyma, ought not to be applied to this phlegmasia," and that " it would be better to call it chronic pneumonia, thus specifying the tissue of the organ in which the diseases commenced," expired almost with its promul- gator, (Broussais;) yet, there are still many, who consider that irritation or hypeiaemia is, in most cases, connected with tubercular formation and development. (Stokes.) It is questionable, however, whether any greater irritation or hyperemia exists in such cases, than in any other case of heterologous secretion. It seems clear, that in order for inflammation of the air passages to be followed by the production of pulmonary tubercles^ there 368 DISEASES OF THE RESPIRATORY ORGANS. must be a predisposition; and, if this be admitted, it can be readily conceived, that in one individual very slight bronchitis may be sufficient to produce tubercles, whilst others may not become phthisical from the most severe and long continued catarrh. (An- dral.) At the same time, we can understand, that inflammatory affections of the air passages may, by persistence, induce the tuber- culous constitution or cachexy, and, in this way, be not only the predisponent, but exciting, cause of phthisis. A recent writer on diseases of the chest, (Stokes,) separates phthisis into two classes—^the constitutional and the accidental. In the first, tubercle supervenes either with or without precursory irritation, in persons strongly predisposed to it by hereditary dispo- sition, or original conformation. In these, the disease is generally rapid, invades both lungs, and is complicated with lesions else- where. The disease is constitutional, and the affection of the lung, although the first perceived, seems only a link in the chain of mor- bid actions. In the second, the disease is met with in persons not— he considers—of the strumous diathesis, and who have no heredi- tary predisposition to tubercle. In this case, it results from a distinct local pulmonary irritation, advances slowly, and the digestive and other systems show a great immunity from disease. In the acci- dental phthisis, the lesser tendency to abdominal and other compli- cation allows time for the vital powers to act; whilst, in the consti- tutional variety, tubercle is commonly deposited throughout the body, and the patient dies rapidly in consequence of the extent of disease. (Stokes.) Amongst the predisposing causes of tubercular phthisis have been reckoned syphilis, scurvy, rickets, &c, and hence the various epithets, syphilitic, scorbutic, &c. applied to phthisis by some writers. It is questionable, however, whether these affections predispose to the disease in any other manner than by modifying the nutrition of the frame, and evidence is wanting to show, that they can have any agency in the causation of phthisis, unless the tubercular diathesis is present. In many cases, there is unques- tionably a mere correlation of existence. (Andral.) Lastly, in regard to the causation of phthisis, a brief allusion is necessary to the notion, that it is capable of being communicated from one person to another. The author has had no adequate evidence, that it can be extended in this manner; yet, singular in- stances of the kind have been related by different writers, and if they prove nothing more, they exhibit strange coincidences. In Italy, the contagious nature of phthisis appears to be admitted by almost all. When an individual dies at Naples of the disease, in a private house, not only are his effects and the furniture which he has used destroyed, but the walls are scraped and whitewashed, and the ceilings, floors, and partitions removed. Similar views appear to be entertained at Rome, where phthisis is even more frequent than at Naples. (Valentin.) Where such a sentiment prevails so extensively amongst the profession, it would appear OF THE BRONCHIA AND LUNGS. 369 arrogant to presume, that observation has been altogether erro- neous. Certain it is, that the cases are rare, in this country, in which the communication of the disease from one person to an- other by contagion could even be suspected. It can be understood, however, that if a person is constantly breathing the generally de- teriorated atmosphere of the rooms, which the consumptive occupy, by sleeping perhaps in the same bed, the health may ultimately suffer, tuberculous cachexy be induced, and ultimately confirmed phthisis. Pathological characters.—The anatomical characters of pulmo- nary tubercle have been so fully described in an early part of this section, that it is but necessary to refer to it. But, along with the morbid appearances presented in the lungs themselves, by those who have died of phthisis, there are others frequently met with in other parts of the body, which require mention. In the larynx and trachea, ulcerations, of different dimensions, may exist, with more or less redness of the mucous membrane. At times—as in a case recently under the author's care—the vocal cords are entirely destroyed, as well as the superior ligaments of the larynx. Ulcerations of the epiglottis are by no means uncom- mon, even when none exist in the larynx and trachea. They are generally on its laryngeal surface. Adhesion between the lungs and the pleura is almost always observed to a greater or less extent. Where they are old, the bond of union is firm, and not readily lacerable; but where the inflam- mation has occurred a short time prior to dissolution, the false membrane may be soft, readily torn, and present the characters described under Pleurisy. Phthisis has been ranked as one of the causes of aneurism of the heart, but it is not common to find any increase in the size of that organ. Atrophy of the heart is, indeed, more frequently met with than hypertrophy. The author has, in one or two instances, observed fibrinous concretions in the heart, dependent upon the difficult transmission of blood through the lungs, the presence of which was suspected, by auscultation,,during life. The spleen was found—in 90 cases observed—augmented in size, 16 times; diminished, 15 times; healthy, 59 times. Often, tubercles have been observed in it, especially in children. (Andral.) In four-fifths of those who die of phthisis, the digestive organs are found to exhibit more or less evidence of disease. (Louis.) Tubercles, in every degree of development, may be met with in nearly the whole extent of the small intestine below the duode- num; but they are more numerous near the caecum than elsewhere. ulcerations of the small intestine are still more common, and they, also, are more numerous, and more extensive and deep, the nearer we approach the caecum. In 95 cases, tubercles were met with 36 times; ulcerations, 78 times. In some cases, the intestine has been found perforated. The same morbid appearances are met with in the large intestine. The opinion has long been entertained, that 370 DISEASES OF THE RESPIRATORY ORGANS. fistula in ano is, in some measure, connected with the tuberculous cachexy or diathesis. The notion is, however, discarded by excel- lent observers, (Louis, Andral;) nor has the author had any reason to believe in the connection. A modern writer (Professor Morton, of Philadelphia,) states, that he has met with four cases, in three of which fistula supervened so directly on the pulmonary symp- toms, and so kept pace with them, that he " could scarcely consider its presence as an accidental coincidence." The different lesions of the alimentary tube may occur simulta- neously with those of the lung; but more commonly, the symptoms of intestinal inflammation and ulceration take place after the pul- monary mischief has made considerable progress. The mesenteric glands were found tuberculous 23 times, in 102 observed cases, (Louis,) and the glands most affected were those nearest the caacum. The coexistence of tuberculosis of the lung and mesenteric glands is more frequent, however, in the child than in the adult. The cervical glands were found tubercular, and in- creased in size 8 times in 80 cases. The bronchial glands—as before remarked—may also be the seat of tubercles; under such circumstances, they are, usually, of greater size, and of a gray or blackish colour. The peritoneum is, in many cases, found to be affected with tubercular inflammation; or gray semitransparent granulations are met with in the membrane, or in layers of false membrane on its surface, both of which have been considered to be confined to phthisis, (Louis;) but the author has met with one case, in which the lungs were very slightly affected, although tubercles were numerous under the peritoneum. The most common morbid appearance, presented by the liver in* phthisis, is the fatty transformation. In 120 cases, it was ob- served 40 times. The liver, in this condition, is pale, almost always of a light brownish yellow colour, and spotted with red externally and internally. Its volume is nearly always augmented, and, at times, to double its usual dimensions. The increase is almost always at the expense of the right lobe. The liver has been ob- served to overlap a large portion of the anterior surface of the stomach, to occupy the epigastrium, extend the breadth of two or three fingers below the false ribs, and reach the iliac crest and the spleen, which is occasionally covered. (Louis.) Its consistence is usually, in these cases, greatly diminished; and, in very advanced cases, the scalpel and the hands are greased, as by ordinary fatty substances. The fatty transformation of the liver is almost confined to phthisis pulmonalis. Of 49 observed cases, (Louis,) 47 were cases of phthisis. The change is much more common in the female than in the male; as, of the 49 cases above mentioned, ten only occurred in the latter. Tubercles and hydatid cysts have likewise been found in the livers of the phthisical. Generally, in those who are affected with OF THE BRONCHIA AND LUNGS. 371 the fatty transformation, the bile in the gall-bladder has a blackish colour and pitchy consistence, intermediate between that of a solid and a liquid body. (Louis.) In one case, tubercles were observed in the parietes of the gall- bladder, and in the biliary ducts. (Andral.) Very rarely, too, a small quantity of tuberculous matter, unsoftened, has been met with in the suprarenal capsules,and likewise in the kidneys. (Louis.) Of 40 subjects, in whom the genital organs were examined, 3 exhibited tuberculous matter in the prostate; and it was found, at the same time, in the vesiculse seminales and the vasa deferentia. In the female, tuberculous matter has, at times, been met with in the substance of the uterus, and in the ovaries. * Lastly. The arachnoid coat of the brain is often partially thick- ened, presenting more or less numerous granulations in its upper portion, especially near the falx. In three-fourths of the cases observed by Louis, the tissue, uniting the arachnoid to the pia mater, was infiltrated, and the ventricles distended by a very ap- preciable quantity of serum. Hydatids and tubercles are, likewise, found in the encephalon,—rarely in the adult, but more frequently in the child. Treatment.—Although cases of confirmed phthisis may be re- garded as almost universally beyond the resources of art, much may be done in the way of palliation; and it is important to bear in mind, that solitary and circumscribed excavations have unques- tionably cicatrized, or ceased to exert any influence. The chief indications, in the treatment of tuberculosis, are, 1, to diminish any local irritations or hyperaemise that accompany and develop, if they do not lead to, the formation of tubercles; 2, to correct the condition of the system of nutrition, that constitutes the tubercu- lous cachexy; 3, to promote the removal of tubercles already de- posited; and, lastly, to treat troublesome symptoms and accidental complications. (C. J. B. Williams.) Bearing these indications in mind in the subsequent remarks, the treatment may, for convenience, be divided into the hygienic and the therapeutical. a. Hygienic treatment.—It has been stated, that the tuberculous constitution is often communicated by the parent to the progeny. In the way of hygiene, it is, therefore, important, that precautions should be taken by parents themselves, and every step be avoided, that can deteriorate their own general health. If more consideration were bestowed on matrimonial alliances, and a more healthy and natural mode of living were adopted, by persons in that station of life, which gives them the power of regu- lating their mode of living according to their own choice, the pre- disposition, which is so often entailed upon their offspring might be checked, and even extinguished in their family, in the course of a few generations. (Sir James Clark.) " The children of dyspep- tic persons," observes the writer just cited, " generally become the subjects of dyspepsia in a greater degree, and at an earlier period 372 DISEASES OF THE RESPIRATORY ORGANS. than their parents; and if they marry into families of a delicate constitution, their offspring become highly tuberculous, and die of phthisis in early youth and even in childhood." These remarks are unquestionably just; but how impossible is it to regulate the feelings of individuals, so that any prudential restraints shall be regarded! Every practitioner, indeed, who has been consulted respecting the propriety of marriage, where one or both of the par- ties have laboured under a disease, or a predisposition unquestion- ably hereditary in its nature, and who has given advice befitting the occasion, must, at times, have had the mortification to find his advice wholly disregarded, and that he has, at the same time, for ever lost the good opinion of both the parties. On the part of the mother, care is, doubtless, demanded, for the plenary health of the offspring, during .the period of gestation. The prevention of hereditary transmission regards rather the condition of both parents at the time of a fecundating union; for the predis- position is as often given by the male as by the female parent. If the tuberculous diathesis be induced during intra-uterine exist- ence, it belongs to the class of acquired predispositions. As respects children, born with a predisposition to tubercle, or who may have acquired the predisposition, although we are unac- quainted with any direct remedies for it, we can frequently correct it indirectly,—by placing the child under circumstances most favour- able to health; by giving it proper nourishment, with free exposure to air, under precautions that will always suggest themselves, and by proper exercise, warm clothing, and due attention to the re- moval of every source of irritation as it arises. After the period of puberty, when the danger of tuberculous development is shown to be greatest, the same system must be pursued; with frequent friction of the surface; warm bathing; ex- ercise in the open air, especially on horseback, or on the water, and appropriate exercise of the respiratory organs, so as to expand the chest, and ensure the full play of the lungs;—as by taking in deep and frequent inspirations; gymnastic exercises, which employ the muscles of the arms and chest; reading aloud, and public recita- tion under prudential restraints. Some, who have been predisposed to phthisis in early life,—amongst whom may be named Cicero and Cuvier,—have ascribed their exemption from pulmonary disease, to the increased strength, which their lungs acquired in public speaking. (Sir James Clark; also, the author's Elements of Hy- giene, p. 436.) It need hardly be added, that great caution is needed in the adaptation of both general and local exercise to the particular case; and in all cases, the use of instruments, which interfere with the healthy play of the respiratory function, must be sedulously avoided. As regards therapeutical agents, to be employed for the preven- tion of phthisis, so much must depend upon the particular condi- tion of the individual, that it is impossible to lay down any rule of universal, or even of general, application. The practitioner must OF THE BRONCHIA AND LUNGS. 373 be guided by general principles of prevention, and there are nume- rous articles of the materia medica, possessed of the most different properties, which may occasionally be demanded. Those prophylactics are the most to be prized, which improve the general health; and of these, change of air and of climate, ap- propriately applied, is, perhaps, the most effective; but as change of climate is to be recommended as a therapeutical measure also, it will be considered under the next subdivision. b. Therapeutical treatment.—This is,unfortunately,difficult and unsatisfactory, When the disease is once fully formed, it is gene- rally beyond the efforts of art; still, it must be borne in mind, that cicatrization of cavities is sometimes effected. In the earlier periods of the disease, the practice, with many, has been to employ small and repeated bleedings; and the same course has even been pursued in the confirmed stage. Dovar was in the habit of bleeding to the amount of six or eight ounces every day, for the first fortnight, and of increasing the interval between each repetition of the operation, by employing it at the respective inter- vals of every second, third and fifth day, for the three successive fortnights; and the practice of small bleedings, although by no means to the same extent, has been advocated by others. (Mead, Pringle, Donald Monro, Fothergill, Stoll, Hosack, Cheyne, and others.) That symptoms and complications may arise, which may demand general blood-lettings cannot be doubted; but to expect to remove tuberculosis by it is a great error. We feel satisfied, indeed, that much mischief is done by its indiscriminate employment, and that nothing is more likely, in many cases, to confirm the tubercular cachexia. At the same time, when the symptoms indicate the employment of the tancet—when there is inflammatory action or hyperaemia of the pulmonary tissues, associated with the disease, it cannot be pretermitted. Throughout the whole course of phthisis, local blood-letting by cupping or by leeches, practised with the view of removing acci- dental inflammatory or hyperaemic complications, may be had recourse to with marked benefit. Moderate local blood-letting by leeches, below the clavicles, has been recommended, whenever increase of pain or cough, with a bloody tinge of the sputa, &c. indicates an hyperaemic or congested state of the lung, around the suspected indurations. (C. J. B. Williams.) In such cases, it is probable that the local blood-letting acts rather as a revellent than as a depletive. It is, indeed, on revellents, that the hopes of the practitioner—slight as they may be—must mainly repose for the cure of phthisis. Revulsion on the chest may be used in all stages of the dis- ease—more care being demanded during the earlier periods, that too much irritation be not induced. Intermittent revulsion is preferable to the constant, in which latter class may be ranked the perpetual blisters, issues, setons, &c, which do not act by the dis- charge they induce, but by the*counter-irritation. The author is vol. i.—32 374 DISEASES OF THE RESPIRATORY ORGANS. in the habit of employing the tartarized antimony, in the form of ointment, or of saturated solution, which may be rubbed in below the clavicles, twice a day, until the peculiar eruption is induced. The friction is then to be discontinued, but it must be renewed as the crop of pustules disappears; or a fresh place may be selected, so that a new crop may be presenting itself as the former is fading. In rare cases—one of which is at present under the author's care— the tartarized antimony induces much gastric uneasiness. The croton oil may then be substituted, either rubbed on pure, or mixed with olive oil. R.—01. tiglii, p. i. 01. oliv. p. ij.—M. The iodide of potassium has been added to the saturated solution of the tartarized antimony, with the effect of rendering it more irritating, and, perhaps, of acting favourably on the constitution, by being partially absorbed. (C. J. B. Williams.) Issues and setons are considered to cause too much irritation of the system to be useful in the early stage of the disease; but, in our view, their place may be supplied beneficially, in all stages, by the more effi- cacious and more cleanly applications. Some practitioners prefer one revellent and some another;—blis- ters, applied from time to time; ammoniated liniments, of various degrees of strength; moxas; sponging the whole chest, once or twice a day, with salt and brandy, or strong vinegar, or with the lini- mentum cantharides of the U. S. Pharmacopoeia—which consistsof oil of turpentine and cantharides—or with a liniment of oil of tur- pentine and acetic acid, as recommended in bronchitis. (Dr. Stokes.) R.—01. tereb. |iij. Acid, acetic, ^ss. Vitell. ovi, Aq. rosar. ^iiss. 01. limon. 3j—M. One objection to the use of many of these agents is, that they interfere with the physical diagnosis; but they may be so managed, in all cases, by the selection of proper parts of the chest, as to ob- viate this, in a great measure. Purgatives and emetics have been highly extolled by many writers. Their beneficial agency, also,is probably altogether revellent. An objection—urged against the former—is, that as the intestines are disposed to inflammation, purgatives may hasten or exasperate it; but a more important objection is, that their imprudent use—by deteriorating the general health—may add to the tubercular mischief. They are now rarely employed, except under circumstances in which they would be had recourse to in most diseases—viz. as simple evacuants. Emetics were, at one time, regarded as specifics in phthisis; and a great majority of the reputed cures of consumption, related by different authors, have either been performed by emetics, or by decidedly nauseating remedies. (Thos. Young.) The practice has been sanctioned by many therapeutists. (Mor- OF THE BRONCHIA AND LUNGS. 375 ton, of England, Si?nmons, Parr, Bryan Robinson, Thomas Read, Marryat, Dumas, Giovanni de Vittis, Sir James Clark, Cowan, &c.) Sir James Clark, who is a great advocate for the use of emetics, supposes their action to be, in a great measure, me- chanical, by destroying the tuberculous matter, which, according to Dr. Carswell, is first deposited on the free surface of mucous membranes. Emetics—Sir James conceives—may remove this deposit, by the succussion they give to the lungs; and thus may " prevent the localization of the disease, and give time for the correction of the constitutional disorder." The examinations of the author, however,—as elsewhere stated, —have by no means led him to agree with Dr. Carswell as to the primary seat of tubercle; and, besides, this explanation of the modus o'perandi of emetics must be regarded as entirely too mechanical. The main salutary agency has appeared to the author to be ascri- bable to the revulsion, which they operate; and hence the advan- tages of sea sickness, united—as it usually is—with the revulsion, which a thorough change of the physical and moral influences around the individual is capable of effecting. Different emetics have been recommended. Some give half a grain of the tartrate of antimony and potassa, (De Vittis,) and re- peat it in fifteen minutes, if necessary. Others use ipecacuanha, or the more direct emetics,—sulphate of zinc or sulphate of copper. (Sir James Clark.) The repetition of the emetic,—according to the author last cited,—must be regulated by the nature of the case. When it is given with the view of preventing the deposition of tuberculous matter, it may, perhaps, be sufficient to repeat it once or twice in the week. When the case is more urgent, and the pa- tient threatened immediately with the deposition of tuberculous matter in the lungs, or when the presence of such matter is already suspected, emetics, he remarks, may be much more frequently re- peated; but, in all cases, it will be necessary to watch their effects on the gastric system, and to suspend their use, should they appear to excite irritation there. (Sir James Clark.) It will be readily understood, that their indiscriminate employment may tend rather to develop, the very mischief they are intended to prevent. Owing to this cause, and to their unmanageable character, they are not much employed, notwithstanding the high authority adduced in their favour. The tubercular depositions themselves, as well as the morbid consolidations, could not fail to suggest the use of some agent, which might be regarded as possessed of properties to modify the system of nutrition. The efficacy of iodine in the removal of bronchocele, and in certain strumous affections, naturally gave rise to the belief, that it might be serviceable in tuberculosis. In me- senteric tubercles, it is affirmed to have been given with much success. (Brera, Calloway, Krimer.) It has also been much used in pulmonary tubercles by many practitioners, and, according to 376 DISEASES OF THE RESPIRATORY ORGANS. some, with the effect of removing the tubercular depositions. (Ba- ron. Haden, Jahn, Waldack, Professor Morton, of Philadelphia.) The experience of most practitioners has, however, shown, that it is of no marked advantage, even in the incipient stage of the disease,—the stage in which, alone, much good is to be expected from any remedy. The author has used it to a considerable extent, especially in public practice,—in the form of the ioduretted iodide of potassium,—which, by the way, is as valuable a form as any,1— in that of the iodide of potassium,—by some regarded as inert, but not so in the author's experience; in that of the tincture of iodine; of the iodo-hydrargyrate of potassium, the iodides of mercury, &c.; but the most careful and unprejudiced examination has not enabled him to say, that any beneficial effect was induced, which could be unhesitatingly referred to these preparations. 1 R.—Iodin. 9j. Potassii iodid. Qij. Aq. destillat. £vij.—M. Dose, 10 drops, three times a day, in sugared water. In the Baltimore Infirmary, and the Philadelphia Hospital, it was a question of interest with both physician and student to determine this point; and such, unfortunately, was the negative opinion formed. The codliver oil—Oleum jecinoris ase/ft—which contains, it is affirmed, (Kopp,) a minute quantity of iodine, and which has been highly extolled in scrofula, has been given in tuberculosis, and, it is asserted, with advantage. (Hankel, Riecke, Pagenstecker, Rich- ter, Alexander, Haser.) The dose to an adult is from half a spoon- ful to three spoonfuls, two or three times a day, in coffee or with lemon juice, or in the form of emulsion. Of its effects, the author has had no experience. It is, however, an extremely nauseous article. Contrary to the sentiments of most members of the profession, mercury, pushed to salivation, has of late been advised, on respect- able authority, for the cure of incipient phthisis, (Graves, Marsh, Stokes;) and several cases, it is affirmed, were thus treated success- fully, which would, in all probability, have ended in confirmed phthisis. (Stokes.) Dr. Stokes properly remarks, however, that he is anything but sanguine regarding the general employment of mercury in incipient phthisis; and that " the remedy is a two-edged sword, and its exhi- bition must not be lightly attempted." It is, indeed, " anceps remedium." In confirmed phthisis, no- thing can be expected from it: generally, in this stage, the powers of the system require support under the extensive suppuration and irritation. This can be best done by appropriate diet, but it may be aided by any of the vegetable tonics, of which the prunus vir- giniana, (Infus.pruni Virginian. liss. ter die.) is one of the best. It is presumed to possess sedative as well as tonic properties, and it OF THE BRONCHIA AND LUNGS. 377 certainly enjoys the latter. The iodide of iron,—either alone, or taken at periods distinct from the primus virginiana,—is also a use- ful preparation, (liq. ferri iodidi, gtt. xx. ter die.) It is obvious, however, that these agents can only act as palliatives. As substances can be readily made to come in contact with the whole of the air tubes along with the air of inspiration, inhalations naturally suggested themselves in the treatment of phthisis. Of dry fumigations, with resinous and balsamic substances, and with tar, the author can say little from experience. It is not easy to conceive, however, that they can be of much use. The vapour of tar was at one time highly recommended. (Sir A. Crichton, Professor Morton, of Philadelphia, Hufeland, Neumann.) It is diffused through the patient's chamber, by heating the tar to gentle ebullition, with a little carbonate of potassa to retain the irritating pyroligneous acid. In chronic bronchitis, on the other hand, the application of a gentle excitant to the vessels themselves, which are concerned in the secretion, may be, and often is, beneficial; but in that disease, there is no adventitious product to be softened and broken down as in incipient phthisis. (Forbes.) Under chronic bronchitis, allusion has already been made to the effect produced by the internal use of both tar water and creasote, and to their effects in phthisis also. The results of trials with both these agents in phthisis have been discordant. (Reichenbach, Reich, Levrat, He- chenberger, Elliotson, Rehfeld, Otto, Kohler, Spilth, Petrequin.) The inhalation of aqueous and medicated vapours is not more advantageous, and they by no means compensate for the labour necessary to the process. It has been properly suggested, however, that when the air of the chamber is too dry, advantage may be derived from placing a basin of warm water near the patient. (Sir James Clark.) Chlorine has been much used in the way of inhalation, and, ac- cording to the testimony of some, with advantage. (Gannal, Sir James Murray, Cottereau.) The experiments with it, instituted at La Charite and the Hotel Dieu, of Paris, (Rullier,) as well as the testimony of different observers, (Bayle, Albers, C. J. B. Wil- liams, Stokes,) are not encouraging. It produced increase of bron- chial irritation, and arrested the pulmonary secretion. Chlorine, like iodine, may be inhaled from a common dish or inhaling appa- ratus, by dropping any of the acids on a mixture of chloride of lime, so that the chlorine may be disengaged slowly; but the best method is by the apparatus devised by Dr. Corrigan. (See the au- thor's New Remedies, 3d edit. p. 135, Philada. 1831.) The inhala- tion may be repeated twice a day or oftener. Iodine has been also recommended in the form of vapour. (Sir James Murray, Sir C. Scudamore.) The addition of a little tinc- ture of conium was found by Sir Charles Scudamore to be beneficial in subduing the irritating qualities of the gas. His formula is the following:— 32* 378 DISEASES OF THE RESPIRATORY ORGANS. R.—Iodin. gr. viij. Potass, iodid. gr. iij. Alcohol. §ss. Aq. destillat. ^vss.—M. Of this solution, from one drachm to six, and from 20 to 35 minims of a satu- rated tincture of conium are used in each inhalation, which is continued from 30 to 40 minutes. Sir Charles considers it better to add the conium at the time of employing the inhalation. At the temperature of 90°, the volatile properties of iodine are given off very sensibly, but the conium requires more heat, and the temperature of 120° is not \fio much for the iodine. The author's experience is not favourable to the iodine in this for.m, and such has been the case with that of others. (Stokes, Pereira.) Recently, it has been suggested (A. Leigh) to apply a sufficient quantity of iodine ointment on the ribs, and under both axillae, and to cover the head with the bedclothes, in order that the iodine, volatilized by the heat of the axillae, may be breathed. This method is stated to have arrested the progress of the disease. None of these agents can be expected to afford much benefit. If they modify the local symptoms, it can only be to a slight extent, whilst they leave the tuberculous constitution unchanged. Too often, indeed, all that can be done is to palliate the distressing symptoms. One of the most judicious therapeutists of the day, (Trousseau,) has lately advised the employment of the arsenious acid in phthisis, in the way of inhalation. The remedy is not new—the sulphuret of arsenic having been administered, in fumigation, centuries ago. (Pliny, Dioscorides.) M. Trousseau recommends, that the arsenious acid should be used in the form of Cigarettes arsini- cales, which are made in the following manner:—a sheet of white paper is dipped in a solution of one part of arseniate of soda, and thirty parts of water. The paper is then made into small cigars of the length of a finger, and the patient is directed to smoke one or even two daily, so that the fumes may pass into the lungs. The cigars burn readily, the arseniate facilitating the combustion; and, in this manner, " the empyreumatic oil of the paper is inhaled, united with the metallic arsenic, reduced by the contact of the charcoal formed by the burning of the cigar." M. Trousseau does not pretend to cure pulmonary tubercles by this agent, but he thinks the general symptoms may be so far modified by it, as to produce decided improvement in the condition of the patient; which, however, is questionable. The cough, when very troublesome, must be met by the reme- dies laid down under Bronchitis. When there is much accompany- ing irritation, in the early stages, the simple mucilaginous or oily mixtures are to be preferred; in after periods, narcotic mixtures become indispensable. R.—Mucilag. acaciae, Syrup, simpl. aa ^ss. Morphiae sulphat. seu acetat. gr. j. Aquae, giv.—M. Dose, a tablespoonful, when the cough is troublesome. OF THE BRONCHIA AND LUNGS. 379 Where opiates disagree, hyoscyamus, conium or belladonna may be substituted. By many, the hydrocyanic acid has been highly recommended, (Magendie, A. T. Thomson,) alone, or united with opiates. R.—Acid, hydrocyan. medicin. TT[ xij. Morphiae sulphat. seu acetat. gr. j. Syrup. §ss. Aquae, %v.—M. Dose, a tablespoonful, three or four times a day. When these agents fail, two or three leeches, applied over the larynx or trachea, will, at times, prove successful; (Broussais, Osborne, Stokes;) and in some chronic cases, Dr. Stokes asserts, that he has found the common antispasmodic mixture of camphor, valerian, opium, ammonia, and ether give the greatest relief,— doubtless, by the new impressions they occasion in the manner of all reputed antispasmodics and expectorants, which are possessed of excitant properties. He cautions the practitioner, however, to be careful in the employment of remedies, that may check expec- toration, "as it is the natural relief of the lung;"—a pathological view, which may be questioned; although all may be disposed to admit, that the new irritation, induced by improper excitant agencies, may be prejudicial. As to the modus operandi of reputed expectorants, the author's views have been expressed elsewhere. They are all relative agents, and must be adapted to the precise pathological condition, which, in one case, diminishes, and, in another, augments, beyond the due bounds, the secretion of the materials that constitute the sputa. The pain, frequently experienced in some part of the thorax, may be met by a small bleeding from the arm, or by leeching, or cupping—with or without the scarificator, according to the case: or simple revellents, as sinapisms, or a burgundy pitch plaster, or one to which cantharides or tartarized antimony has been added may be applied over the seat of pain. The dyspnoea, which appears in exacerbations, is, in part, a nervous phenomenon, and must be treated either by narcotics, which overpower the nervous erethism, or by excitants, which induce a new impression, and thus act as antispasmodics;—for example, by sinapisms to the chest; and the preparations of ether and camphor internally. R.—Sp. aether, sulphuric, comp. Jjiij. Morphiae sulphat. seu acetat. gr. j. Mist, camphor, £v.—M. Dose, a tablespoonful, when the dyspnaaa is urgent. In cases of acute phthisis, where the skin is constantly warm, and the pulse exhibits permanent excitement,—in addition to general antiphlogistic treatment, and ablution of the arms with tepid water, digitalis has been proposed; and, at one time, its efficacy was thought to be undoubted in phthisis, in general. (Darwin, Ferriar, Fowler, Beddoes, Withering.) It is difficult, however, 380 DISEASES OF THE RESPIRATORY ORGANS. to pronounce a decided opinion upon its agency in phthisis, (Sir James Clark;) but the very difficulty shows, that it has been pro. bably greatly overrated—in many instances at least. The author has employed it extensively in public and private practice; but although the pulmonic symptoms have appeared to be suspended, whilst the system was markedly under its peculiar influence, he« not aware of a single case in which it seemed to produce perma- nent benefit, and the same may be said of the tinctures of lobelia and colchicum. They seem to be indicated, where there is unusual excitement, which they are well adapted, with other agents, to reduce. Where the hectic fever has returned, with distinct chills every evening, an inducement is given to attempt to arrest them by the preparations of cinchona. The author has seen this practice follow- ed; but his experience has been the same as that of a distinguished observer, (Andral); the chill has been removed, and perhaps the violence of the exacerbation diminished, but the heat and sweats have nevertheless persisted. When haemoptysis is present, the treatment will of course vary according to circumstances. The general mode of management has been given elsewhere, (p. 295,) and need not be repeated. For the colliquative sweats, many remedies have been proposed; chiefly belonging to the class of astringents,—mineral and vegeta- ble. As the extent of the sweating is dependent upon that ofjhe previous febrile exacerbation, attention must be paid to moderate the latter—by the cooling regimen; sleeping in a cool, airy apart- ment; changing the body and bed linen; avoiding diet of too stimu- lating character; and, wherever it is practicable, permitting the patient to have the advantage of the open air during the day. Dr. Stokes strongly "denounces the attempt to moderate the hectic sweating by medicines merely, without attention to other circum- stances." The colliquative sweating, like the other stages of hectic, is but a symptom—an effect—which cannot be combated directly; and hence none of the remedies proposed, could be expected to afford much benefit. The author has employed the acetate of lead—the dilute sul- phuric acid, alone, or combined with laudanum, and the various astringents, recommended in such cases, but the results have not been more satisfactory than those obtained by others. [An- dral.) In recent .times, the boletus laricis has "been adminis- tered in these cases, and has received the favourable testimony of many therapeutists. (Barbut, Toel, Trautzsch, Kopp.) It may be given in the form of pill,—three grains, three times a day. Andral was at one time disposed to speak favourably of it; but more recently he has affirmed, that no great advantage has ap- peared to him to have resulted from it. The colliquative diarrhoea generally supervenes at so late a period of the disease, as to render all active treatment unadvisable. OF THE BRONCHIA AND LUNGS. 381 It is truly an inflammation of the lining membrane of the intestines, which soon terminates in ulceration. It may be controlled by attention to diet, allowing only the mucilaginous and the farinaceous aliments; and, in the early stage, by the ordinary cretaceous and opiate medicines advised in diarrhoea. Should these fail, the mineral astringents—acetate of lead, or nitrate of silver—with or without opium,1 may be administered, and injections of starch and laudanum, or of infusion of catechu and laudanum, may be given twice a day, or, if necessary, after every liquid evacuation. The infusions of catechu and kino may, likewise, be administered internally, in the same cases. 1 R.—Plumbi acetat. gr. ij. seu Argenti. nitrat. gr. j. Opii, gr. i. Ext. gentian, gr. ij. fiat pilula. Dose, one, three or four times a day. When these agents have failed, the most marked advantage has been derived from the application of a sinapism or a blister to the abdomen. The blistered surface may be sprinkled with the sul- phate or the acetate of morphia. It remains to speak of a mode of revulsion, which is one of the most important that can be advised in phthisis—we mean the new impressions that are made on the system by change of air and of climate. If the circumstances of the patient do not permit him, in the early period of the disease, or even before it manifests itself— except by the known tuberculous constitution of the individual— to leave the situation which he inhabits for another, he should endeavour to take, daily, such exercise as he is able, short of in- ducing fatigue. If he be the resident of a town, let him seek the air of the country during the day, and return, if compelled, to the city at night; but if he is capable of changing the whole of the circumstances surrounding him, he ought not to hesitate to migrate —especially during the winter—from the temperate regions of the globe to a more genial clime. Even in the confirmed stage of phthisis, where the excavations are small, and the disease probably limited, and not progressive, benefit may accrue from this course; but in the generality of cases of confirmed consumption, it is the height of cruelty to expatriate the sufferer, and to s"end him away to die far from his friends, his comforts and his home. Even in the slighter cases, little or no benefit is to be derived from a brief expa- triation; and it is of importance to impress upon the mind of the patient and his friends, that if the measure is to be attended with favourable effects, it ought to be continued for several successive years, in order to produce a full and permanent influence upon the constitution. (Sir James Clark.) " In a case," says a recent writer, (Stokes,) " with a cavity, yet in which the symptoms and signs are not progressive, the patient's best chance, I believe to be, the use of the seton and travelling. If he does not recover, his life will probably be prolonged. He should take as little medicine as pos- 382 DISEASES OF THE RESPIRATORY ORGANS. sible; he should adopt all strengthening means, and use such a regimen as experience points out as the best. Heated rooms, cough mixtures, acid draughts, inhalations, narcotics,l repeated counter- irritation,' and all the varied and- harassing treatment, which ignorance supposes to be curative—these are not the means of recovery. So long as a drain from the chest does not weaken, it is clearly useful, and all the other means should be calculated to give enjoyment to the mind, and to strengthen the body. The patient's winter residence should be, if possible, in a temperate climate; but his occupation, in summer and autumn months,should be travelling. The temperate, and even colder countries, may be visited with advantage." There is no doubt of the general truth of these observations, but the intelligent author will find, if he employs the " repeated counter- irritation," to which he objects, that it is infinitely less harassing, and more effectual, than the seton, which is at all times a most uncleanly and inconvenient accompaniment. So satisfied is the author, that the good effects of change of cli- mate are altogether dependent upon the revulsion produced on the physique as well as the moral, that instead of selecting a situation for the brumal retreat of the invalid, which has equability of tem- perature as its sole recommendation, he would rather choose one, the temperature of which may be less equable, provided it is not too elevated, as in the torrid regions, or provided the air is not damp. The great object is to select a climate, in which the phthisical valetudinarian can take exercise with safety in the open air, every day during the winter; and the nearer the climate ap- proaches this desideratum, the better is it for the consumptive. In such an atmosphere, the patient ought to be as much in the open air as possible, and take exercise, both by walking and riding, short of inducing much fatigue. Of the places abroad, which are esteemed eminently adapted as sanitaria for the consumptive, Madeira has the favourable testi- mony of most persons. In Italy, Rome, Pisa and Nice are preferred; but no part of Italy is considered to be appropriate during summer. (Sir James Clark, Andral.) The islands of Hyeres, being sheltered from the north wind, are much frequented. " The south of France," says a competent observer, (Andral,) " ought only to be recom- mended as winter residences; for the summer, there, is fatal to the consumptive. Avoid Marseilles, the whole shore of the Mediter- ranean; avoid Montpellier, Pau and Bayonne." In England, Penzance, Torquay, Undercliff (in the Isle of Wight), Clifton, Hastings, St. Leonards, and Brighton, have been recommended, (Sir James Clark, Forbes;) and, within the last few years, Cove, in Ireland, has attained great celebrity. (Stokes.) In equability of temperature, the Cove of Cork would, indeed, seem to be sur- passed by but few places. Observations have shown, that the mean difference of days and nights rarely exceeds four or five degrees, and often, in the winter months, does not exceed one OF THE BRONCHIA AND LUNGS. 383 degree. The town is completely sheltered from the north wind, and owing to its southern exposure receives the full influence of the sun and the southern breeze. (Stokes.) In point of climate, the Bermudas and the Canary Islands would seem to approach nearest to that of Madeira. (Sir James Clark.) To the climate of the West Indies, the author, last cited, has strong objections. That of Santa Cruz especially has, however, been re- commended by many. (Professor Morton, of Philadelphia, Tucker- man, of Boston, &c.) Perhaps, in the territory of Florida, situations may be met with, which possess every advantage, so far as regards atmospheric influences, which the valetudinarian could desire; and if it be granted, that there are objections to St. Augustine on the score of the north-east storms to which it is liable, these objections do not equally apply to Pensacola and to places in the interior. The remarks, thus far made, have relation to the course to be pursued by the valetudinarian during the winter. It is often, how- ever, an important subject of inquiry to decide as to the course to be pursued by him during the summer season. Where the mischief is incipient, there is nothing perhaps comparable to the revulsion, which the change of physical and moral influences, during a sea voyage, is capable of effecting; and even in the more advanced stages, life has appeared to be prolonged by it. The facilities are so great for crossing the Atlantic, that a sea voyage to Europe is easily undertaken, with every comfort provided that is practicable; and from the commencement of May, no countries perhaps could afford greater advantages for a summer journey, and a temporary residence, than Great Britain or France. The invalid can remain some weeks in either, and return to his own country before the autumnal vicissitudes are experienced to any extent, so that he may be ready to make any arrangements that may be advisable for the winter. Next to a sea voyage during the summer, travelling by land, through different parts of this country, may be recommended, and now that the distance between different places has been so much reduced by railroads and steam navigation, a thorough change of atmospheric influences—barometric, hygrometric, thermometric, &c.—can speedily be obtained, with all the other advantages of change of society and scenery, attendant upon travelling exercise. The physician must, however, use his best judgment in adapting his advice to the particular case, employing special caution where the excavations exist to any great extent. Pamphlets have appeared strongly recommending the Red Sulphur Springs of Virginia to the invalid during the summer season; and in many pulmonary affec- tions, in which change of air, scenery, and appropriate mineral waters are indicated, few situations appear to offer more advantage. Possessing a delightful climate, and with accommodations well adapted for the comfort of the valetudinarian,-it is an excellent retreat for all those for whom travelling, air and exercise are deemed advisable, no matter whether or not its waters may possess the 384 DISEASES OF THE RESPIRATORY ORGANS. power of diminishing the frequency of the pulse, and acting mark- edly as a sedative, as is affirmed by some, but denied by other observers. Were they, indeed, possessed of these virtues, they would not be applicable to all cases of phthisis, but where the waters failed, the admirable climate, with all the attendant advan- tages, would not the less exert its beneficial agency. In judging of the sanitarium best adapted for the phthisical in- valid, it need scarcely be said, that the capability of affording the requisite accommodations must always be considered. It matters not what may be the advantages of climate, unless they can be properly enjoyed. As a succedaneum for change of climate during the winter sea- son, a regulated temperature has been advised in the apartments of the sick. The best rule, perhaps,—where this plan is adopted,— is to accommodate the temperature to the feelings of the patient. As a general rule, a temperature of 70° to 76° will answer every purpose. The air of the chamber becomes, however, so vitiated, and proper ventilation so difficult in the depth of winter, and there is, withal, so much monotony in everything surrounding the in- valid, that more of detriment would appear to arise from these circumstances than of good from the equability of temperature. This has, in part, led to the recommendation of vigorous exer- cise, and exposure to the air, as the most efficient remedies in tubercular consumption,—the exercise to be pushed so as to amount even to labour, and the patient not to allow the dread of taking cold to confine him on every occasion, when the temperature may be low or the skies overcast. (Parrish, of Philadelphia.) The general rule would be, to take exercise in the open air, whenever it is dry, and the temperature—even if cool—tolerably equable. The late Dr'. Parrish always ascribed his recovery from phthisis at an early period of his life to the adoption of this course; and his impressions were probably just, as, on dissection, evidences of cicatrization of the lung were perceptible. On several occasions the author has advised this plan, and has never witnessed any disadvantage to accrue from it. On the contrary, the invalid has always appeared to be benefited by the revulsion. On the subjects of climate and change of air, the author has en- tered at length in his Elements of Hygiene, and in the article "Atmosphere," of the American Cyclopedia of Medicine and Sur- gery, to which the reader is referred for further information. It yet remains to mention the diet adapted for the consumptive. In the first stage, it ought to be mild and unirritating, consisting chiefly of milk and the various farinaceous aliments; and, if the patient has been accustomed to indulge freely in animal food, it may be allowed in moderation. Always let it be borne in mind, that the pathological state of tuberculosis, when uncomplicated by inflammation or hyperaemia, is simply perhaps one of defective and depraved nutrition. As the disease advances, the same kind of diet may be persevered in, subject to modifications to suit the par- OF THE BRONCHIA AND LUNGS. 385 ticular case. It has been advised by some, that from the very in- cursion of the disease, the diet should consist of beef-steaks and porter, freely allowed. The author's experience would warrant him in saying, that, as a general rule, a liberal and nutritive diet answers best; but great care must be taken in passing to extremes, and in converting a general into a universal rule. The jellies of the Iceland moss—Cetraria Islandica, as directed to be prepared in the Pharmacopoeia of the United States, and of the Carrageen or Irish moss—Chondrus crispus—are bland and nutritious. R.—Chondr. crispi, ^ss. Lactis recent. §ix. Coque ad ^v. et adde Sacchar. alb. §ss.—§j. To be taken in the course of the day. To these jellies, any dietetic or remedial agent may be added, which is considered to be indicated. Preferences have been given to asses' and to goats' milk over that of the cow, and in Europe much expense is often incurred to procure them. There is, however, no sufficient reason for the belief, that they are possessed of any advantages, which cannot be ob- tained from cow's milk. A notion existed, that the goat should be first of all fed on aromatic plants, but it is now exploded, (Andral,) and properly so. It was also believed at one time, that the white snail, swallowed raw and in quantities, was not only a hygienic but a therapeutical agent in phthisis, and it was brought forward with high pretensions in the 17th century. (Sir Kenelm Digby.) Except by the unpro- fessional, it had, however, been almost universally abandoned, when its use was revived recently by a respectable French practi- tioner, (Sue.) It need scarcely be said, that the only effects snails can induce are those of any gelatinous and mucous aliment; and on this side of the Atlantic, they are considered to possess no ad- vantages that could suggest their employment over less revolting articles of diet. The free use of the chloride of sodium or common salt has been recently recommended very highly in both phthisis pulmonalis and scrophulous affections. (A. Lutour.) Half a drachm to a drachm of the chloride is directed to be administered daily, either in a glass of beef-tea, or in some pectoral infusion. There can be no question, that the use of salt as a condiment will exert a favourable tonic influence, but nothing farther can be expected from it. X. DISEASES OF THE BRONCHIAL GLANDS. The bronchial glands or ganglions are seated around the bron- chia, near to where they dip into the tissue of the lung. Their colour is almost always black, and with them, the few lymphatics, that arise from the superficial and deep-seated parts of the lungs, communicate: the efferent vessels of the glands have been traced into the thoracic duct. vol. i.—33 386 DISEASES OF THE RESPIRATORY ORGANS. It is not uncommon to find the bronchial glands larger than usual, without there being any evidence of their morbid condition during life; and hence it has been concluded, that when hypertro- phied, or otherwise diseased, they seldom produce any striking symptoms. (Stokes.) It need scarcely be said, that if they are so large as to compress the bronchial tubes, they must interfere with breathing; still, the compression may be made so gradually, as to account for the very slight effect they induced in the breathing, in certain recorded cases. (Andral, Berton.) In children, they are frequently greatly enlarged by the deposition of tuberculous matter, and may give occasion to dyspnoea, and evidences of ob- structed circulation. (Carswell.) A writer on this subject, (Stokes,) affirms, that he has never met with any instance of stridulous breathing, or even bronchial compression, produced by this dis- eased condition. Tumours of the bronchial glands—it is affirmed—generally grow forwards; and a recent writer, (C. J.,B. Williams,) states,that he has often seen them pushing out the sternum or the ribs on one side, and causing dulness at those parts, and symptoms of displace- ment of the lung farther down; and that he has known them com- press the great bronchia to a fatal extent. This must, however, be an extremely rare occurrence. The author has often known the glands to be largely hypertrophied in children of scrophu- lous habits, but there were no signs, that could lead to more than a suspicion, that this morbid state existed. The scrophulous dia- thesis may be accompanied with tuberculosis of the lungs, and no signs can enable us to pronounce positively, if signs of compression of the bronchia exist, that such compression is owing to the enlarge- ment of the bronchial glands. These scrophulous enlargements sometimes soften, and are evacuated by ulceration into the bronchia. The bronchial glands are sometimes, also, affected with encephalosis, and it has been suspected, that encephaloid disease of the lungs generally originates in this way, and spreads afterwards along the vessels into the pul- monary tissues. (C.J. B. Williams.) If scrophulous disease of the bronchial glands be suspected, it may be treated as recommended under Scrophulous Cachexia. OF THE PLEURA. 387 CHAPTER III. DISEASES OF THE PLEURA. I. INFLAMMATION OF THE PLEURA. Synon. Pleuritis, Pleuresis, Pleuresia, Inflammatio pleurae, Empresma pleu- ritis, Pleuris, Pleuritica febris, Passio pleuritica, Pleurisy; Fr. Pleuresie, In- flammation de la Plevre,- Fievre pleuretique; Ger. Brustiellentzundung, Ent- ziindung des Brustfells. As the pleura is a serous membrane, the general phenomena, and anatomical characters of its inflammation, are similar to those of the peritoneum, and of serous membranes in general. The membrane, it will be borne in mind, lines the thorax— Pleura costalis—and is reflected over the lungs—Pleura pulmo- nalis. Some difference, consequently, exists, in the phenomena presented by inflammation of the two portions; and when the dis- ease is seated in the pleura pulmonalis;—as in the case of the peri- toneum, the phenomena are modified by the viscus over which the membrane is reflected. a. Acute Form.—Diagnosis.—The main, characters of this dis- ease are,—acute pain in the side, or in some part of the thorax; cough; difficulty of breathing; fever; more or less dulness on per- cussion, with egophony, followed by enlargement of the affected side, and abolition of all sound of respiration and voice. Great variety, however, exists in the phenomena, which renders a farther inquiry into the character of the symptoms and signs necessary. (C. J. B. Williams.) Pain is one of the most constant symptoms of the disease, and, at one time, it would have been considered idle to suppose, that inflammation of the pleura could exist without it; yet there are cases of what is termed " latent pleurisy," occurring chiefly in the weak and in those debilitated by disease, in which neither the pain nor general symptoms may excite more than suspicion; and, not- withstanding, the pleura may have been inflamed for a long time; and the inflammation may be accompanied by copious effusion into the cavity of the pleura;—cases which can only be elucidated by auscultation and percussion. Most commonly, the pain is felt in the region of the nipple, on one side or the other, and it is generally of an extremely lancina- ting character, aggravated by the slightest attempt at inspiration. The pain may, however, be referred to the axilla, under the ster- num or clavicles, or to the region of the scapula, the margins of the false ribs, &c. &c. When the inflammation is seated wholly, or in part, in the pleura costalis, it is increased by pressure on the intercostal spaces: and wherever seated, it is commonly aggravated 388 DISEASES OF THE RESPIRATORY ORGANS. by percussion, inspiration, coughing, lying on the affected side, and by the motions of the trunk; so that the patient makes short and repeated inspirations, and dreads the slightest mechanical change induced by the movements referred to. Usually, in acute pleurisy, the pain exists from the outset; but it is not always fixed at the firsl, which may give occasion to its being confounded with pleurodyne, or rheumatism of the parietes of the thorax. At the end of a few days, however,—sooner or later,—it becomes fixfcd, and constant, and after being for some time excessively severe, it diminishes in violence, becomes obtuse, or may cease entirely before the termination of the disease. (An- dral.) The dyspnoea, which is an accompaniment of the pain, appears to be wholly owing to it; the slightest movement of the ribs, as already remarked, exciting the greatest torture. After the pain on inspiration has abated, or wholly ceased, and the difficulty of breathing continues, it is owing to effusion into the cavity of the pleura, and its degree is, of course, dependent upon the amount of effused fluid. Its character differs, too, somewhat, according to the part of the pleura implicated. If it be the pleura costalis, or both that and the pleura pulmonalis, the breathing is chiefly "dia- phragmatic or abdominal;" if, on the other hand, it be the pleura investing the diaphragm, the diaphragm is kept as free as possible from motion, and the respiration is performed almost wholly by the ribs, or is " costal." The pain, too, is usually referred to the margin of the ribs, and causes unusual distress and dyspnoea. The cough is a very uncertain symptom, being, at times, ex- tremely distressing; at others, entirely wanting. It is commonly short and dry, and never takes place in fits or paroxysms. The decubitus or position of the patient in bed, on the affected side, was mentioned as occasioning an augmentation of the pain; hence, the decubitus has been looked to as affording information in regard to the disease. Not much reliance can, however, be placed upon it, either where the pleurisy is dry, or accompanied by effusion. (Andral, Stokes.) In the great majority of cases, indeed, the position is on the back. (Andral, Piorry.) The rule generally is, that, in the first stage, the position is on the healthy side; but in after periods, when effusion has taken place, it will—for obvious reasons—be on the diseased side. But the exceptions are numerous. After the pain, for example, has ceased, and copious effusion has occurred, the decubitus is often on the healthy side. (Stokes.) Such are the local symptoms, that usually accompany and indi- cate inflammation of the pleura. The general symptoms consist of fever, which is usually present, and, at times, to a great degree; the pulse being hard and .frequent; the skin'hot and dry; and the blood, when drawn, exhibiting so markedly the inflammatory crust or buff, that it has been termed, from this circumstance, crusta pleuritica. OF THE PLEURA. 389 These symptoms, taken collectively, would seem to indicate with unerring certainty the existence of acute pleuritis. They are not all, however, well developed in every case, and, as already re- marked, they may be so nearly wanting, as scarcely to excite a suspicion as to the existence of the disease. In such cases, we have a valuable resource in the physical signs. These, in the majority of cases, leave but little doubt as to the existence of pleurisy, and they are highly satisfactory in determining the effusion of fluid, which is its accompaniment. When the pleura is merely in a state of active hyperaemia, per- cussion may afford no positive evidence; but when this state has continued for a time, more or less thickening or density is produced in the parts affected, which is indicated by dulness on percussion, more or less considerable, according to their density. (Corvisart, Raciborski.) The presence of effusion, however slight, is indicated by dulness on percussing the side in which it is. The fluid naturally assembles at the lowest part of the chest, so that if the patient be erect, it descends behind the pillars of the diaphragm, near the spine; and it must be borne in mind, that on account of the restricted dimen- sions of the cavity of the pleura, in this region, a very small quantity of fluid may rise to a considerable height. At the com- mencement, therefore, the dulness, on percussion, will be at the lower part of the chest, whence it is observed higher and higher, as the effusion proceeds, until, ultimately, it may be evidenced over the whole of the affected side, below the fossa supra-spinosa, and the clavicles. The fact of the dulness supervening much more rapidly than in ordinary pneumonia, and of its being unaccompanied or unpre- ceded by the crepitant rhonchus, generally points out pleuritic effusion. (Stokes.) Prior to the occurrence of adhesions between the pleura pulmo- nalis and the pleura costalis, the lung floats, as it were, on the fluid; and the sound, on percussion, is varied according to the position of the patient. When erect, the dulness is at the infe- rior part of the chest—the clearness above: if the patient turns on his face, the postero-inferior portion of the chest may give a clear sound; and when he changes his position from side to side, similar phenomena are at times observable. These signs are, however, frequently absent, and, probably—as has been sup- posed—in many cases, owing to agglutination of the pleurae, which prevents the fluid from changing place. (Stokes.) In cases of effusion into both sides of the chest, or of " double pleurisy," the dulness is, of course, perceptible on both sides. The signs afforded by auscultation are more varied and more precise than those from percussion. When the inflammation is attended with very severe pain, as is generally the case, the patient restrains, as much as possible, the motions of the affected side; the air, consequently, enters the corresponding lung in less quan- 33* 390 DISEASES OF THE RESPIRATORY ORGANS. tity, and the respiratory murmur becomes less audible than on the unaffected side. (Raciborski.) This has been noticed as an early sign of pleurisy, (Andral,) but it must be equivocal—being depend- ent upon the presence of pain, which does not always exist, and which, indeed, may exist independently of inflammation of the pleura. (C. J. B. Williams.) Early in the disease, a rubbing, creaking or friction sound is heard, which may indicate that the secretion from the pleura has been arrested by the inflammation; or, what is more general, it indicates that plastic lymph has been thrown out, the consequence of which is, the friction—frottement—which, however, may be so slight as scarcely to merit the name oifrblement or " slight grazing touch," but, at other times, is so loud as to resemble the "leather creak," or bruit de cuir neuf, of the French. These signs, when combined with the general symptoms, are valuable in the diagnosis, but they are not of long duration, and, therefore, may not be heard. Friction sounds—as already remarked—occur likewise in inter- lobular emphysema, and as this pathological condition does not speedily change, they persist longer. Recent researches would seem to show, that, as in the case of peritonitis, the sounds are not often produced in pleurisy, unless the lung be at the same time pressed against the chest by a tumour or by effusion, or partially distended by emphysema or by tuberculous or other deposits. (C J. B. Williams.) When the pleura costalis is raised in this manner, it is readily comprehensible how the friction sounds may be in- duced, as well as in cases of what are termed " dry pleurisy," or such as are accompanied only by the effusion of lymph. They are generally most audible in the central parts of the chest, owing to the motion of the pleurae upon each other being most marked in that situation; and in order to be heard, the patient should be on the abdomen. When effusion of any kind takes place to a great amount into the cavity of the pleura, the extent of the respiratory movements must be diminished in a direct ratio with the quantity of fluid effused. The sound of respiration will, likewise, be diminished in the affected side, whilst, in the other, it is more extensive than in the natural state. If the effusion is very considerable, the respiratory murmur can no longer be heard; at times, at the lower and posterior part; and, at others, over the whole of the chest. The lung, compressed by the fluid, is forced, in the majority of cases, on the vertebral | column; and the respiratory murmur—if heard at all in any part of the thorax—is so very indistinctly. Occasionally, in such cases, the respiration or vesicular murmur is replaced by bronchial or tubal respiration, which is heard along the vertebral column on which the lungs are crowded. When effusion exists, and the patient is made to talk, the physi- cian's hand being at the same time applied to the parietes corre- sponding to the seat of the effusion, very slight, or no vibration! may be felt; whereas these vibrations are very manifest in health. OF THE PLEURA. 391 (Reynaud, Hudson, Stokes.) In this way, by placing a hand under each scapula, a pleuritic effusion may be detected by the absence of vibration over the dull portion. Dr. Stokes regards it as of far greater value than the egophony to be described presently. It is a physical sign, however, which does not exist in many cases of females, and boys previous to the change of voice;—the vocal vibrations in them, although audible, being not sufficiently power- ful to be felt by the hand. (Stokes.) The layer of liquid between the lung and the chest modifies or destroys the vibrations, a very different effect from that produced by solidification of the lung, by which the resonance of the voice is powerfully augmented. (Reynaud.) When a moderate effusion has taken place into the pleura, so that there is dulness on percussion, and diminution of the respira- tory murmur in the lower part of the chest, there is a singular resonance of the voice observed, posteriorly, which, appears to be superficial, and separate from the true voice. It is a peculiar tre- mulous, broken voice, somewhat resembling the voice of the goat, and hence termed egophony or "goat's voice." This peculiarity appears to be a kind of bronchial voice modified by its transmission through a stratum of liquid. (Laennec, Reynaud.) This has been considered one of the characteristic signs of pleu- ritic effusion; but the observation of most persons has shown, that it is not so certain as was at one time supposed; usually, when the effusion becomes considerable, the egophony is no longer heard, but there are cases on record in which the whole of one side of the chest was filled with fluid, and egophony still present, whilst in others, where the effusion was slight, it was absent. (Julius Wolff.) Dr. Stokes places but slight value on egophonic sounds in pleurisy. " In many instances," he remarks, " we never find them, and even when present they are extremely inconstant, and, taken alone, have but little value in diagnosis." Between them and those from hepatization of the lung, there is often the closest resemblance. Some, indeed, affirm that they are heard in the second stage of pneumonia, accompanied by the bronchial or tubal respiration, (J. Wolff,) that almost perfect egophony has been heard in the stage of resolution of a few cases of pneu- monia, (Stokes,) and that egophony is only audible in cases in which the inflammation of the pleura is accompanied by inflamma- tion of the lungs. (Reynaud.) The pectoriloquism of phthisis, and the egophony of pleurisy, are regarded as the least valuable of the physical signs of these diseases, (Stokes;) still, the presence of egophony, with dulness on percussion, enfeebled respiratory murmur on the affected side, with absence of the crepitant rhonchus, would be a strong combination of evidences in favour of the existence of pleurisy. The true character of egophony has been described as a certain tremulousness of the voice when it is superficial, and an echo-like slenderness when it is deep seated. (C.J.B. Williams.) 392 DISEASES OF THE RESPIRATORY ORGANS. When the accumulation of fluid is to a great extent in one of the pleurae, it gives rise to an increase of the size of the side, which is evident to the eye, and, if not, is discoverable by mensuration with a graduated tape, or with callipers, similar to those used by many of the French obstetricians for appreciating the distance be- tween the posterior surface of the sacrum and the anterior surface of the pubis, by means of a graduated arc, which is attached to one leg of the callipers, and passes through an eye in the other. The increased size is affirmed, on excellent authority, (Laennec, And- ral,) to be observable early; Laennec says after two days dura- tion of the disease; Andral, on the fourth or fifth day. The author's observation would lead him to fix the appearance of this phenomenon at a later period. It has been usually considered, that protrusion of the intercostal spaces is always coexistent. (An- dral,) but this may be wanting. (Stokes.) Moreover, dilatation of the side may not be present, where even copious effusion exists owing to the displacement of the diaphragm. The observer, in making these comparisons, must bear in mind, that the right side, in health, is often larger than the left. The average result of the most accurate measurements of 20 chests of persons not labouring under disease of the lungs, gave, for the right side, 17.86 inches, and for the left, 17.23, or more than half an inch in favour of the right lung. Of these, the most capacious chest measured 22 inches for the right, and 21.50 for the left. In one case only, the left side was larger than the right, and in three, the sides were symmetrical. In the case in which the left side was more developed, the man was left-handed, and the left biceps measured half an inch in circum- ference more than the right. (Stokes.) The following admeasurements of ten males and ten females were taken partly by the author, but chiefly by Dr. Moore Robinson, one of the resident physicians to the Philadelphia Hospital. None of the individuals were labouring under disease of the lungs. MALES. Ages. Occupations. Left side. Right side. 67 Carrier, 18i inches. 181 inches. 25 Shoemaker and Pedlar, 16 16i 56 House Carpenter, 16i 18 49 Do. 18' 18^ 41 Carriage Painter, 16a in 32 Apothecary, 18 17i 32 House Painter, 14J 15>- 30 Labourer, 17 ni 30 Do. 17 17 42 Do. 17 111 The average of these observations gives 16.92 inches for the left side, and 17.47 inches for the right; or a difference of about half an inch. OP THE PLEURA. 393 FEMALES. As;es. Occupations. Left. Right. Hand l 20 Servant maid, 13 13 Uses b 24 House maid, 16* 16* Dc 25 Do. 15 15 D< 23 Do. 15£ 16 Right. 20 Do. 14 15| Do. 19 Seamstress, 15$ 16 Do. 22 House maid, 16 16J Do. 21 Do. 16£ 16 Left. 21 Shoebinder, 134< 13 Do. 26 House maid, 15i 164 Rightc The average gives 15.1 inches for the left side, and 15.2 for the right, or a difference in the female of not more than one-tenth of an inch. In instituting the comparative admeasurement, the tape may be passed horizontally around the chest, under the nipple, and be made to meet at the centre of the lower end of the sternum. Sooner or later, too, careful examination may exhibit, that the intercostal spaces do not present the usual depressions on the affected side, and ultimately they appear entirely smooth, so that, in thin persons, the contrast is perceptible on careless inspection. It is important, however, to bear in mind, that an effusion, sufficient to dilate the side and displace the heart, may exist for weeks with- out inducing it. (Stokes.) Smoothness of the side is not met with in the earlier periods of the disease, and appears to be peculiar to pleurisy in its advanced stages, as it is not observed in emphysema of the lungs, pneumonia, simple hydrothorax, or enlargement of the liver. Hence, it is esteemed one of the most important of the physical signs of advanced pleurisy. (Stokes, C. J. B. Williams.) In looking for this sign, the patient may be placed obliquely with regard to the light, and it may be more readily seen by regarding the chest from a little distance. (C. J. B. Williams.) The diaphragm, too, may be displaced by the effused fluid, and the displacement may be recognised by examining the upper part of the abdomen, which is found full and resisting. If the fluid be on the right side, the liver is pushed downwards, forwards, and across the abdomen; if on the left, the spleen may be displaced; but the latter displacement is more rare. (Stokes.) When the liver is displaced, a distinct sulcus or furrow may be often felt immediately below the ribs and above the upper boundary of the tumour, resulting from the space left by the touching of two convex bodies—the upper portion of the liver and the protruded diaphragm. On the absorption of the fluid the liver ascends and the sulcus disappears. This physical sign was first observed by Dr. Stokes, in 1832: farther observation has, however, shown, that the disappearance of the sulcus does not necessarily imply the ascent of the liver to its natural position; for the liver may yield to the pressure of the diaphragm, and become deeply indented, or concave 394 DISEASES OF THE RESPIRATORY ORGANS. on its upper surface; so that the disappearance of the sulcus is only favourable when accompanied by the ascent of the hepatic tumour. (Stokes.) More than one case of latent pleurisy has been noticed, in which the tumour, formed by the liver, was long supposed to be the chief disease—the patient not complaining at all of the chest. (C. J. B. Williams.) The displacement of the liver and heart, from pleuritic effusion, was scarcely noticed by Laennec. It is chiefly to Drs. Stokes and Townsend, of Dublin, that we are indebted for our information regarding it. The displacement of the heart is an important sign, which exists from the earliest periods, long before any protrusion of the intercostals or diaphragm. (Stokes.) When effusion has occurred into the left pleura, the pulsations of the heart may be observed, most distinctly, immediately under, or to the right of the sternum, instead of in its usual position; and, again, if the effusion has taken place into the right pleura, the heart is pushed towards the left axilla. (Townsend.) In a case of pleuro-pneumothorax of the right side, Dr. Townsend saw and felt the heart pulsating between the fourth and fifth ribs, near the left axilla, whence it gradually returned to its proper position as the compression was removed by drawing off the fluid from the opposite side. When the fluid accumulates in either pleura, to the extent of producing displacement of organs contained in the other, the me- diastinum, which lies immediately behind the sternum, must be pressed from its situation, so that fluid is immediately behind it; hence it renders a dull instead of a clear sound, when the sternum is percussed. Sometimes this dulness extends half an inch or an inch beyond it. It need scarcely be added, that all these displacements may be produced by pneumothorax, or by an accumulation of air in the cavity of the pleura; but the tympanitic sound on percussion, in the latter case, will distinguish it. (C. J. B. Williams.) Such are the main general symptoms and physical signs of acute pleurisy. If the disease be unaccompanied by effusion, the morbid phenomena generally disappear in a few days, and health is re- stored; but if effusion has occurred, the restoration to health, if it take place at all, may be at an uncertain period. The acute con- dition may pass away, or it may terminate in the chronic. When effusion has been to such an extent as to give rise to the evidences already described, the absorption of the fluid is indicated by change in the respiration, which—if it have been absent—may be heard feebly, and gradually augmenting in the upper portions of the affected side, both anteriorly and posteriorly; the signs, too, of the different displacements gradually disappear, but the thorax may remain more or less contracted, owing to causes described under Chronic Pleurisy. As in other cases of serious inflammation of internal organs, death may take place in a few days; yet this does not happen frequently. OF THE PLEURA. 395 In the bills of mortality of Philadelphia, for 1839, there is ruot one death ascribed to pleurisy. This is an error; as of 26 cases in the Philadelphia Hospital, during the period embraced by the Re- port, one died. The fact, however, shows, that it is not a fatal affection, under appropriate management. Not unfrequently, tu- bercles form in the inflamed pleura. Where this is the case, the patient dies of marasmus and hectic fever, and the case is probably reported as one of consumption. Causes.—The general causes of pleurisy are like those of pneu- monia, and other internal inflammations. In addition, however, it may be produced by external violence, as by wounds and con- tusions of the chest, fracture of the ribs, &c. Organic diseases of the lung, likewise, occasion it. Thus, it has been already remarked, that pneumonia is usually accompanied by some degree of inflam- mation of the pleura,—hence the term pleuro-pneumonia, applied to pneumonia by many, from the supposed constant association of the inflammations; and, also, that the pleura is almost always in- volved, sooner or later, in tubercular phthisis. The latent character of pleurisy, in many cases, has likewise been referred to. Per- sons, indeed, often pass through life without being aware of the existence of adhesions between the pleura costalis and the pleura pulmonalis, which dissection alone reveals. Pleurisy occurs at all ages, and is a disease of intra-uterine exist- ence. Many cases are on record, in which manifest signs of pleuritis and of its concomitant—sero-purulent or purulent effusion—have been observed on the dissection of the still-born, or of those who have died almost immediately after birth. (Viron, Billard, Cru- veilhier, Mende, Kolpin, Zierhold, Wrisberg.) It is probable, too, that pleurisy is more common among young infants, than is gene- rally believed. (Billard.) In the annual report of interments of the city of New York, for 1839, 21 deaths from pleurisy are recorded, whereof 6 were under the age of 5 years, and 3 of these under the age of I. Pathological characters.—The appearances, observed on the dissection of those who have died of acute pleurisy, will be partly understood by the history of the symptoms and signs already given. Simple inflammation of the pleura does not differ, in its morbid appearances, from inflammation of the peritoneum. If death has occurred early, we meet with more or less redness and injection of the sub-serous cellular tissue; the serous coat, in slight cases, being dry, perhaps, but not seeming to be much, if at all, affected otherwise, and preserving its transparency; but, in more severe cases, it exhibits great vascularity, either in points, streaks or patches, or a uniform redness is observed over a greater or less extent of surface, but this last appearance is rare. (Andral.) The membrane is not often thickened, softened, or ulcerated. Very early, however, if the disease has persisted, various altera- tions take place in the secretions from the membrane, which are modified both in quantity and quality. The quantity of fluid may 396 DISEASES OF THE RESPIRATORY ORGANS. vary from an ounce to several quarts, so as, indeed, to fill the whole of one side of the pleura, compressing the lung, pushing the dia- phragm downwards, and with it the liver and the spleen; enlarging the intercostal spaces, and causing them to project outwards; displacing the mediastinum, heart, &c, in the manner already described. The character of the effused fluid varies greatly. Sometimes it is colourless; at others, yellow, limpid and transparent; sometimes containing albuminous flakes swimming in it, but, at others, dis- solved in the fluid and disturbing its transparency. Frequently, the fluid is more or less coloured and turbid, and occasionally very thick, and of a dirty or muddy appearance. In other cases, pus is found in the pleura, or a peculiar fluid resembling half melted meat jelly, or even blood: in the last case, it constitutes the "hemorrha- gic pleurisy" of Laennec, Hemothorax or Hsematothorax; Ger. Blutbrust. The plastic lymph, which is the product of pleuritis, and is some- times thrown out without the effusion of fluid, forms the bond of union in the cases of adhesion, which are so frequently met with on dissection, that they have been properly regarded as the most com- mon of all morbid appearances, and are found to a greater or less extent in nearly all the bodies, which are subjected to inspection. (Hodgkin.) Strange to say, these adhesions were at one time considered to be produced by laughing. (Morgagni.) The plastic lymph appears to be capable of self-organization, like the fluid which is thrown out in ulcers, and the materials of which the new being is formed after a fecundating copulation; and sooner or later the membranes become firmly united. The albuminous exudation assumes different forms. At times, miliary granulations are alone perceptible, separated from each other; at others, large concretions cover the pleura and increase its thickness, leaving it at times smooth and polished; at others, rugous; and at others, with nipple-like projections. These "concretions" frequently extend like bands, (brides) from one pleura to the other, forming bonds of union, which, by intercrossing through the fluid, form cells, of greater or less number and regularity of form. When these adhesions are recent, they are soft, readily lacerable, and have an albuminous appearauce; but sooner or later they be- come transformed into a cellular tissue, which unites the pleura, in the mode so often seen in those who exhibit, on dissection, the signs of a former pleurisy. The adhesions are generally colourless, but, at times, they acquire a yellow, gray, or reddish hue from the fluid with winch they are in contact. At times, they pass to the fibrous, cartilaginous, and even osseous state. Often, too, tuber- cles are found in them, which, at times, become developed with great rapidity. (Andral, Rostan.) These appearances may be found in one or both pleurae, accord- ing as the pleurisy is '• single or double," or they may be confined to a portion of one pleura. The condition of the lung is more or less modified, according to OF THE PLEURA. 397 the extent and nature of the effusion. If the quantity of fluid be very great, the lung may be so much compressed as to form a mere thin strip, occupying a very short space along the spine. In an interesting case, which fell under the author's care, and which he has described in its other relations elsewhere (General Thera- peutics, p. 305, note), the right lung was found reduced to scarcely more than a bulb. The inflammation had passed to the chronic state, and the right pleura was completely filled with fluid. In another case of double chronic pleurisy, both lungs were reduced to mere knobs by the pressure of the fluid, and the consequent con- densation and atrophy. In cases like these, for some days before dissolution, hi^matosis must be executed most imperfectly, and—it must be presumed—by the bronchial tubes themselves. The lung, that is thus compressed, does not crepitate, but is dense, and sinks to the bottom of water. These appearances are, however, more marked in chronic pleurisy than in the acute. Treatment.—The management of pleuritis is much the same as that of pneumonitis. Blood-letting is generally demanded, which must be repeated according to the severity of the disease, and the habit of the patient. When the system has been lowered by two . or three bleedings, it is better to trust to local bleeding, especially by cups, which exert both a depletive and revellent agency; after which a large emollient poultice may be applied over the pained part. (Broussais.) The more powerful revellents, as blisters, are more efficacious after blood-letting. One of the most valuable, however, is mercury pushed so as to affect the mouth. It is esteemed, by some, to occupy the important place as a remedy for inflammation of a serous membrane, which the tartrate of antimony and potassa does for that of the lung itself. The ptyalism—it has been advised— should be kept up until the effusion is absorbed. (M. Hall.) The cough should be alleviated by all the means that are recom- mended under Bronchitis; and, if necessary, full doses of opiates should be given with this view. After the violent symptoms have passed away, and the effusion alone remains—which it does, at times, for a long period—blisters may be applied so as to induce an intermittent counter-irritation, or the seton may be used, (Andral,) but the former are to be pre- ferred; or, the ointment of tartarized antimony may be applied. Diuretics may likewise be administered, as in other cases of accu- mulation of the fluid of serous membranes. Cathartics may like- wise be given, but care must be taken not to reduce the powers of the system too low. In the early period, the diet should be as dry as possible, and the thirst be allayed by small pieces of ice taken into the mouth; and afterwards the diet may be farinaceous, with or without milk. b. Chronic form.—Chronic pleurisy occurs generally in feeble individuals, and may possess its chronic form from the beginning, or, it may be the termination of acute pleurisy. Some, indeed, vol. i.—34 398 DISEASES OF THE RESPIRATORY ORGANS. admit three kinds of chronic pleurisy; 1st, That which is chronic from the beginning. 2dly, That which was acute and has become chronic; and 3dly, That which is complicated with certain organic productions on the surface of the pleura. (Laennec.) Others have described first, the chronic pleurisy, which terminates in empyema; and afterwards, that which ends in permanent contraction of the chest. (Mackintosh.) Diagnosis.—The symptoms and signs of chronic pleurisy are chiefly those that denote copious effusion into the pleura of the affected side, and they are the same if the pleurisy be any of the kinds described by Laennec;—generally, difficulty of breathing, at times amounting to orthopnoea; dry, tickling cough; hectic fever; enlargement of the affected side of the chest, and of the inter- costal spaces; impracticability of lying on the sound side; and, at times, fluctuation; percussion dull; respiration inaudible, except in the region of the vertebral column, and puerile on the opposite side, unless the case is one of "double pleurisy," which is not common. These—it will be observed—are essentially the symp- toms and signs of acute pleurisy, terminating in effusion; and it has been properly remarked, (C. J. B. Williams,) that there is ' less reason for distinguishing formally between acute and chronic inflammations of the pleura, because the transition of one into the other is, in reality, undefined, and the symptoms of the recent dis- ease have sometimes so little of an acute character, whilst one of a long duration occasionally manifests such an intensity of irritation, that the terms "acute" and "chronic" are less applicable to pleuritic affections than to inflammation of most other organs. To the effusion of fluid, whether supervening on an acute or chronic attack, the name empyema has been given, which literally means an effusion of pus, (from tv, " in," and ttvov, " pus;") yet the term has been extended, conventionally, to the effusion of other fluids—bloody, or serous—into the cavity of the chest. Empyema t —in the sense of effusion of pus into the cavity of the pleura—has also received various synonymes—as Empyemaverum,Pyothorax, Pleurorrhcea purulenta, Diapyema, Ecpyema, Ecpyesis, Empye- sis pectoris, Pyosis pectoris, Hydrothorax purulentus, Dyspnaa pyothoracica; Fr. Empyhne, Pyopleurile, (Piorry;) Ger. Em- pyem, Eiterbrust, Brustgeschwiir. The effused fluid may be absorbed in process of time, and the chest may return to its natural position, without any resulting con- traction; and this is, at times, effected so rapidly, that a dilated side of the thorax has been known to lose as much as an inchanda half in eight days. (Stokes.) Commonly, however,—and this is usually the most favourable termination—the fluid is more gradu- ally absorbed, and the affected side, from being preternaturally distended, becomes greatly contracted. This change has been regarded as not simply the result of the parietes passively following the absorbed fluid, but to be attributable to the new structures, formed, undergoing contraction. (Hodgkin.) It is easy, however, OF THE PLEURA. 399 to comprehend, that if the lung has become so far compressed and condensed, by the lymph and effused fluid, as to be incapable of expansion when the fluid is absorbed; flatness and contraction of the chest would be a natural result of atmospheric pressure, if from no other cause. The difference between the two sides is found to be great; the intercostal spaces of the affected side are contracted; the shoul- der is lower; the scapula approaches the vertebral column, and the muscles of inspiration, especially the pectoralis major, lose their volume. In some cases, the lung of the affected side gradually resumes a part of its functions; the respiratory murmur becomes audible, but imperfectly so; and although the deformity of the chest has been manifest, the state of the individual has permitted active exercise of the lung, and public exertion of the voice. (Laennec.) Such—it is presumable—was the fact with one of the individuals, whose chest was examined by the author, and the admeasure- ments of which are given elsewhere, (p. 392.) The difference between the two sides was an inch and a half, and the deformity, of course, obvious on the slightest inspection; the respiratory sounds were distinct on the right side, but by no means so on the left: yet, the individual was an active labourer, and had no recollection whatever of having suffered from pleuritis. Such cases as these strikingly show the inadequacy of physical signs, taken alone, to establish the diagnosis in all cases. Instances have occurred, in which, after the absorption of an effu- sion 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, (Stokes, C. J. B. Williams;) at times, too, after the removal of pleuritic effusion on the left side, the heart is drawn upwards to the left. (Williams.) It need scarcely be said, that although in some cases after the cure by contraction of the chest, the persons preserve excellent health, and exhibit no signs of pulmonary disorder, this is not to be expected. Usually, indeed, there is more or less liability to affections of the respiratory organs, and a cachectic condition, which ends, at times, in tuberculosis. In other cases of chronic pleurisy, the termination by contraction of the chest does not ensue; the fluid continues accumulated, and it becomes necessary to have recourse to some direct means for its removal. Treatment.—Where the symptoms and physical signs, described above, indicate that the state of chronic inflammation of the pleura exists, and there is reason to believe that it has been of some stand- ing, the patient should be confined to the horizontal posture—in bed, for example; and there remain, perhaps, for weeks. The diet should consist of milk and the farinacea; and leeches, or cups, with the scarificator, be applied every two or three days, for the first week or ten days—for a longer or shorter period, as the nature of the case may suggest. 400 DISEASES OF THE RESPIRATORY ORGANS. About the expiration of this time, revellents may be applied to the chest, to as to induce an intermittent irritation—as by small blisters, or by the tartarized antimony ointment; and mercurials may be administered so as to affect the mouth slightly. These may be given from the first, and should their effects not be perceptible when the blisters are begun with, the blistered surfaces may be dressed with mercurial ointment. (J. Hope.) Under the employment of these means, the physical signs may, in the course of two or three weeks, be found to indicate a diminu- tion in the extent of dulness; and, if the heart has been displaced, its return to, or towards, its proper situation. If the febrile symptoms have passed away, after this treatment has been pursued for a time, the diet may be made somewhat more nutritious, by adding light boiled eggs, and perhaps a small quantity of any of the lighter meats,—care being taken not to induce undue excitation. When the inflammatory action has been removed, the absorption of the fluid may be promoted by any of the diuretics, that are employed in cases of hydrothorax, or of other hydropic accumula- tions;—it is well, however, to notice whether albuminuria be co- existent, as in such case, stimulating diuretics must be used with caution. Cathartics may be substituted, which may be repeated twice a week. Iodine has in this stage been highly extolled— employed both internally and externally. (Stokes.) Dr. Stokes advises, that a pint of Lugol's solution, or mineral water should be taken during the day,1 and from a quarter, to half of an ounce of the compound iodine ointment2 be rubbed daily over the side. 1 R.—Iodin. gr. 4. 2 R.—Iodin. gss. Soda? muriat. gr. xii. Potassi iodid. Jj. Aquae destillat. Oj. Sp. rectif. f. £ij. Lugol makes the solution of three Adipis, ^ij.—M. strengths, gr. 4i gr. f, and gr. j. of iodine to the pint of water. By others, the internal use of the iodide of potassium is preferred, (gr. ij. vel iij, ter quaterve indies,) and in more asthenic cases, the iodide of iron. (C. J. B. Williams.) These remedies may be associated with blisters, and their effect in promoting absorption has been, sometimes, singularly rapid. The iodine generally acts as a diuretic, and must be continued until all liquid is presumed to be removed from the pleura. (Stokes.) When the patient is free from fever, and a fortiori when con- valescent, change of air, with gentle travelling exercise, is advisable; a voyage to the West Indies has, indeed, been esteemed Me remedy par excellence, as in so many other diseases of the chest. (M. Hall) Should deformity supervene, it may improve somewhat by time, but as the morbid change in the lung is generally permanent, not much improvement can be expected. Carefully regtilated gymnas- tic exercises, and, "perhaps, electricity," have been suggested to restore the tone of the intercostal muscles, (Stokes;) but, for the reasons already given, it is not easy to see what advantage could OF THE PLEURA. 401 accrue from them. Were they, in any degree, to expand the chest, the morbid condition of the lung would still remain. By many, all remedies in empyema have been esteemed inopera- tive, (Willis, Broussais, Laennec,) but many cases unquestionably recover with the contraction of the kind mentioned. Twenty cases of complete and permanent recovery from empyema, by absorp- tion, have been recorded by one author, (Stokes,) so that—as he properly remarks—the probability of a cure, and the efiicacy of remedies, is much greater than has been supposed. When all remedies have failed, and the patient is threatened with suffocation, or suffers much distress from the mechanical pressure of the fluid on important organs, the operation of para- centesis or puncture of the thorax is the last resource; but the result of many cases, (Dr. Stokes, and others,) which shows, that absorption may ultimately be effected even in unpromising cases, would exhibit, that it may not have been always necessary where it has been performed. The operation is not demanded solely in chronic pleuritis. If, in the acute form, the effusion take place so quickly, and copiously, as to endanger the very existence of the patient, owing to compres- sion of the lungs, and other important organs within the chest, it may be necessary. When the operation is performed in the latter case, the fluid is usually serous, with more or less lymph, and it commonly deposits a further clot of gelatinous fibrine after it has been drawn from the chest; whilst in chronic pleurisies, it presents the appearances described under the head of " pathological charac- ters" of acute pleurisy, and, occasionally, of purulent matter, which is not readily absorbed. These are cases of true empyema, in the sense in which it is usually employed, and in which paracentesis is considered the more necessary; yet it does not appear, that the operation has been equally successful where the fluid has been purulent as where it. has not. (C. J. B. Williams.) Although the operation may be indicated in cases of chronic pleuritis, there are many obstacles to its success. If the lung be bound down, or so condensed that it is incapable of expansion, the removal of pus, or other fluid, merely gives occasion to the entrance of air, or, in other words, the pyothorax is converted into a pneumo- thorax. (Stokes, Toionsend.) Not unfrequently, too, tuberculosis has occurred, and the operation has been performed, when the patient was labouring under phthisis also. In other cases, when fluctuation has been evident,—a circumstance which proves, that air is in the chest; and this, in the large mass of cases, owing to a fistulous communication between a bronchium and the cavity of the pleura; and, as the existence of fistula implies disease, and, almost always, tubercular disease of the lung; success cannot be expected from* the operation. (Stokes.) It has, however, succeeded, notwithstanding these impediments. (Stokes, Toionsend, Hastings, Thomas Davies.) Should any doubt exist asto the presence of fluid, a grooved or exploring needle 34* 402 DISEASES OF THE RESPIRATORY ORGANS. as advised by Dr. Da vies, may be passed into the chest, by which not only the presence, but the character, of the effused fluid may be detected. Where there is no pointing of the fluid, the middle portions of the chest are considered the most eligible places for the operation— between the third and the seventh rib: (C. J. B. Williams): the fifth intercostal space is recommended by some. (Townsend, Stokes.) Lower down, there is danger, at times, of wounding the diaphragm; and this has actually happened. (Laennec, La Motte, Solingen, Stokes.) It has been a question, whether the whole, or only a part, of the fluid should be withdrawn at once; but opinions have appeared to settle upon the ancient method of evacuating the fluid gradually, at successive times, closing the orifice in the intervals. (Morand, Stokes, C. J. B. Williams.) In this manner, less irritation is induced in the morbid surfaces, and time is afforded for the gradual restoration of the lung from the effects of compression, and of the parietes of the thorax from their state of atony. In all such cases — and especially, perhaps, where an extensive surface has been secreting purulent matter—a recuperative action is set up, under which the system sympathizes, and the patient frequently sinks. It has been of late years a question, whether the admission of air into the cavities of serous membranes be productive of as much mischief as was at one time presumed. When the membrane is healthy, the negative of this question is undoubtedly accurate: it has been remarked, however, (C. J. B. Williams,) that there is a vast difference between the result in a healthy and in a diseased serous cavity. In the former case, the air may be absorbed; (Nysten, Speiss:) but, in the latter, the membrane is covered by products highly disposed to decomposition, which—it has been conceived—must augment the irritative fever, and greatly interfere with the absorbing power of the membrane. A recent observer, (Heyfelder,) has, however, maintained, that but little apprehension need be entertained, in morbid cases, from the admission of air into the pleural cavity; and he is favourable to discharging the fluid at once. (Valleix.) When the fluid is purulent, it may be advisable to inject warm water into the chest, with the view of displacing it; and if, after repeated evacuations, there be no apparent disposition to the ex- pansion of the lung, or the contraction of the chest, and matter continues to be secreted, it has been suggested to inject a very weak solution of nitrate of silver or chloride of soda; and if the discharge be fetid, to correct it by injections of chlorinated solu- tions, mixtures of creasote, &c, (C. J. B. Williams;) but it need scarcely be said, that all such applications must be used with the greatest caution, for fear, that inflammatory excitement may be lit up, which may not be easily subdued. In the last stages of the disease, where the operation has not been performed for any reason, the accompanying dyspnoea is, at OF THE PLEURA. 403 times, excessive. This may often be relieved by a slight stimu- lant, (Sp. aetheris sulphuric, comp. 3j. in a little water,) which gives occasion to the expulsion of flatus from the stomach; and both in this case, and in hydrothorax, great relief is at times afforded by a stimulating glyster—as of turpentine, or assafcetida— which prevents the accumulation of flatus, and thus obviates any pressure that might otherwise have been made on the diaphragm. c. Typhoid Inflammation of the Pleura. Sfnon. Bilious Pleuritis, Typhoid Pleuritis, Pleuritis Typhoides seuTyphodes, Pleuritis Biliosa, Typhoid Pleurisy, Bilious Pleurisy. The remarks, that were made on Typhoid inflammation of the lungs, are strikingly applicable to typhoid pleurisy, both as regards the diagnosis and method of treatment. It is apt to occur in the enfeebled and broken-down constitution, and may be secondary to some other morbid condition. The affection, too, is insidious, and the signs often latent,—being indicated rather by sinking of the powers of life than by any new suffering. Like typhoid pneu- monia, again, although it forms suddenly, it is slow of removal; is frequently combined with gastro-enteric disease;—hence, the epithet " bilious," given to it at times;—and does not admit of antiphlogistic treatment. (Stokes.) It is observed as a secondary disease in the course of typhus or spotted fever, and of the exanthe- mata, in puerperal fever, in typhoid arthritis, and diffuse inflam- mation; in bad forms of erysipelas; in phlebitis, and, it has been conceived to be a consequence of purulent absorption. (Stokes.) It would not appear, however, to occur frequently as a compli- cation of typhus; as, of fifty-seven observed cases it was noticed but once. (Louis.) Two such cases have beeu detailed by Dr. Stokes. In one, on the fourteenth day of a severe maculated fever, a sud- den sinking was observed, with the friction sound or frottement over the left side. On the next day, the patient, a young female, had the appearance of an individual in cholera. She had perspired copiously, and was covered with a miliary eruption; there was severe orthopnoea, and she speedily sank. A double effusion had existed. The left pleura contained a large quantity of whey- coloured fluid; whilst, in the right, the effusion was more san- guinolent and serous. In both, lymph occurred in a reticulated form over the whole serous membrane, and also in the pericardium. In many of these cases, the cavity of the pleura may be found to contain sero-purulent or purulent collections, although during life symptoms of pleurisy were either absent or very slightly marked. At other times, however, the invasion of the disease is accompanied by severe pain. In all these cases, the physical signs, that denote effusion, will sufficiently indicate the nature of the affection. Treatment.—The same cares and cautions are necessary in the treatment of typhoid pleuritis as in that of typhoid pneumonia, to which the reader is, therefore, referred. 404 DISEASES OF THE RESPIRATORY ORGANS. II. PLEURODYNE. Synon. Pleurodynia, Pleuralgia, Pleuritis Spuria, Pneumonia Externa, Pseu- dopleuritis, Dolor Pectoris Exterrius, Thoracodyne, Pain in the Side, Stitch in the Side, Bastard or False Pleurisy; Fr. Point de Cote, Douleur de Cote; Ger. Seitenstechen, Seitenschmerz, Falsche Seitenstich. Pain, at! times, attacks the side suddenly, so as to give rise to a "stitch," which continues for a time and then passes off; but, at other times, is of longer duration. It is of a neuralgic character, and appears to be seated rather in the muscles, or their aponeu- roses, than in the pleura. The various forms of pleurodyne may be distinguished from pleuritis by the absence, in the former, of the febrile symptoms, of dulness on percussion, of the friction sound, and the other signs and symptoms, that indicate pleurisy. There is generally, also, more or less soreness on pressing the muscles of the chest. Pleurodyne is not unfrequently met with in nervous, hysterical persons, and, at times, occasions great suffering,—occasionally, in- deed, as much as pleuritis itself. (M. Hall.) It is, also, an accom-. paniment of chlorosis; and, Dr. Hall remarks, is in such cases so like chronic pleuritis, that he has known patients to be bled and blistered for the twentieth time, under this erroneous impression. Yet the slightest attention to, and acquaintance with, the physical signs, would have shown the difference. Treatment.—The treatment of this neuralgia must consist chiefly in revellents applied to the part affected—as cups, with or without the scarificator; sinapisms, hot applications—as salt heated, or a hot flannel; blisters, ammoniated lotions, &c; and, if the pain recurs frequently, the emplastrum belladonnae, or emplastrum opii, or a " warm plaster," containing a small quantity of cantharides or of the tartarized antimony, may be kept upon the part. Narcotics may, also, be required internally, when the pain is violent. They should be given in full doses;—for example, two grains and a half of soft opium in the form of pill, or a correspond- ing quantity of any of its preparations. Should the disease be connected with hysteria, or with the anaemic condition that constitutes chlorosis, the remedies which are adapted for such morbid conditions, and are mentioned under those diseases, must be prescribed. A recent-writer, (Max. Sirnon,) has recommended the use of emetics in pleurodyne. Their good effects are, doubtless, owing to revulsion. III. DROPSY OF THE PLEURA. Synon. Hydrops pectoris, Hydrops thoracis, Hydrothorax, Dyspnoea et Or- thopnoea hydrothoracica, Dropsy of the chest; Fr. Hydropisie de poitrine, H. des plevres, Hydropleurie, (Piorry); Ger. Brustwassersucht, Wasserbrust. Prior to the time of Laennec, idiopathic hydrothorax was esteem- ed an extremely common disease. It is now, however, as generally admitted to be rare. A recent writer, indeed, (Stokes,) remarks, OF THE PLEURA. 405 that he has never seen a case of it; the accumulation being, in all cases, owing to disease of the heart, or lungs, or of some of the solid viscera of the abdomen. As in the case of the effusion of pleurisy, the fluid is contained in the cavity of the pleura, and is essentially an accumulation of the secretion, which takes place from the pleura, and which, in health, is intended for its lubrica- tion; and, like other hydropic accumulations, it may occur under three circumstances mainly,—in the first, the exhalent vessels may secrete more copiously than in health, or the hydrothorax may be "active;" in the second, the exhalents may pour out their proper quantity, but the vessels, whose office it is to absorb, may take up too sparingly; and in the third, there may be some obstacle in the heart, or elsewhere, to the proper return of blood to the centre of the circulation. In the two last cases, the resulting hydrothorax may be considered " passive." Diagnosis.—The symptoms and physical signs, which denote the existence of hydrothorax, are extremely like those of the effu- sion that takes place in pleurisy; so that it is not an easy matter to distinguish between a slight attack of acute pleuritis, and one of active hydrothorax. (Andral.) Generally, however, along with dyspnoea, which is proportionate to the amount of the fluid effused,— with difficulty of lying on the affected side; and in cases of double hydrothorax, panting respiration, and difficulty of breathing, except when in the sitting posture, energetic action of all the respiratory muscles and extreme anxiety of countenance,—there is absence of the inflammatory and local symptoms of pleurisy, with more or less effusion into the cellular membrane, as evinced by oedema of the lower extremities, and the ordinary evidences of dropsy. The physical signs are—dulness of the affected side, egophony, if the fluid be small in quantity,—(although egophony often exists when there is no fluid in the thorax,)—and absence of respiratory murmur in the part corresponding to the effusion, with the substi- tution of tubal respiration. The affected side is also larger than the other, and, according to general testimony, there is an enlarge- ment of the intercostal spaces; and, at times, fluctuation has been distinguished; but one eminent observer (Stokes) affirms, that he has never observed dilatation of the intercostal spaces or protrusion of the diaphragm in hydrothorax, and this fact he ad- duces, amongst others, as an argument in favour of his view of the cause of muscular displacement in empyema,—that in the latter the innervation of the muscles is implicated so that they become paralyzed. Causes.—These are the same as those of dropsies in general. The disease occurs at all ages, but is more common after the age of 40. It has been observed in the foetus. (Carus, Cruveilhier.) As already remarked, however, it is commonly symptomatic of disease of some thoracic or abdominal viscus. Pathological characters.—The fluid of hydrothorax is like that of ascites. It is thin and limpid, and generally occupies but one 406 DISEASES OF THE RESPIRATORY ORGANS. pleura. Its quantity is very variable; sometimes, it amounts to many pints. Twelve pounds have been seen in one side of the thorax. (Laennec.) The pleura is found to be healthy, but blanched by the fluid that bathes it; and the lung of the affected side is, of course, found compressed towards the vertebral column or the apex of the thorax, as in cases of pleuritic effusion. Treatment.—As hydrothorax is commonly a symptomatic affec- tion, it can only be met by remedies that are adapted for the removal of the primary mischief. To promote the absorption of the fluid, the general antihydropic treatment is desirable. As a part of this, revellents, especially such as act on the kidneys, are found highly serviceable, and great faith has been reposed in the digitalis, espe- cially when combined with opium. R—Tinct. digital, gtt. xl. Tinct. opii, gtt. v. Mucilag. acac. giij. Aquae, %v.—M. Dose, a fourth part, every 5 or 6 hours. It has been considered especially advisable in the asthenic diathesis, with debility, pallor and feeble pulse. All the diuretics elsewhere recommended, (see Hydropic Cachexia,) may be administered in this form of dropsy; and advantage is derived from occasional cupping and blistering'to the chest. Where all remedies have failed, and the patient suffers great inconvenience from mechanical pressure by the fluid, the operation of paracentesis has been recommended and performed; but it can only be had recourse to with the view of affording temporary relief, inasmuch as it does not modify the pathological condition on which the dropsical accumulation is dependent. IV. AIR IN THE PLEURA. Synon. Pneumothorax, Pneumathorax, Pneumatothorax, Physothorax, Asth- ma aereum a physothorace, Emphysema pectoris; Ger. Luftbrust, Brustwind- sucht. The phenomena presented by air effused into the cavity of the pleura are, in many respects, analogous to those produced by liquid effusions; and where they differ, the causes of the difference are readily understood. The disease may be either simple, or the air maybe mixed with liquid (hydropneumothorax,hydroaeropleurie. —Piorry.) Diagnosis.—The patient complains of great dyspnoea, which is in a ratio with the quantity of air effused, and the rapidity with which the effusion occurs. The affected side is rendered prominent, but this is not always the case, and there is unusual clearness on percussion over the whole of the affected side; or, if the patient be sitting up, the resonance may be marked at the upper portion of the chest, whilst it may be dull beneath, denoting the presence ofa liquid. This unusual sonorousness is accompanied with absence of the sound of respiration, except near the root of the lung, where it is tubal. OF THE PLEURA. 407 When, along with pneumothorax, the pleura contains fluid, and there is a fistulous communication with the bronchia, the respira- tion may be markedly cavernous, and there may be more or less gurgling, with a peculiar sound, called tintement mitallique, (Laennec,) "metallic tinkling" or "ringing noise of metal." This sound is peculiar, but not constant, and although it is regarded as unexplained, (Andral,) has nevertheless received many attempts. at explanation. (Laennec, Dance, Spittal, Beau, C. J. B. Wil- liams, Houghton, Thomas Davies, Guthrie, Magendie, Professor Bigelow, of Boston, &c.) The view of Spittal and Beau,—that it is caused by a bubble of air from the open bronchium, which passes through the liquid, and bursts upon its surface, seems to be the most correct. It has been suggested, however, that there must be a cavity, whose walls are preternaturally susceptible of vibration, as is the case when the pleura is preternaturally distended, so as to overcome the obtuse or muffling effect of the contiguous soft organs,—as the lung, diaphragm and intercostal muscles; (Professor Bigelow, of Boston;) and such may be the case. Dr. Bigelow considers the immediate or exciting cause of the metallic tinkling to be a forcible or sudden disturbance of the liquid in a vibrating cavity like that described,— the explosion of bubbles of air from beneath the surface of the liquid appearing to be the most common cause of such disturbance; and this explanation seems to be as satisfactory as any that has been offered. It not uncommonly happens, that when the patient changes his posture—as from the horizontal to the upright—drops of liquid adhere to the pleura, or are retained by false membranes, and sub- sequently fall upon the surface of the liquid, causing a noise similar to that which is produced by the falling of a drop of water into a decanter containing a portion of liquid. This is regarded as a variety of the tintement metallique, which may accompany the inspiration, the voice or the cough. Whenever, too; hydropneumo- thorax exists, if the thorax be shaken, the fluctuation of the liquid will be heard. This method of detecting the existence of fluid is as old as Hippocrates, and has been called " Hippocratic succus- sion." When the effusion of air, or of air and fluid, is considerable, there may be the same signs of displacement, or what has been termed " eccentric displacement," (Stokes,) as in the effusion of pleurisy. The disease may terminate favourably by absorption, but this is a rare occurrence. As it is generally connected, however, with tuberculosis of the lung, the prognosis must be unfavourable; yet it does not necessarily terminate speedily. Andral remarks that it may continue for some days, and even for more than a month. It has been known to exist for six years, (Laennec,) and in some cases, under the new morbid condition of the pleura, the tubercu- losis of the lung appears to be arrested. In a case of phthisis with 408 DISEASES OF THE RESPIRATORY ORGANS. perforation, the patient, a bricklayer, made several extraordinary rallies, during each of which he returned to his occupation. (Houghton.) He lived upwards of a year. In another case,a gentleman, after recovering from the first violence of the affection, gradually regained flesh, strength and appearance; the hectic totally subsided, the pulse became quiet, and he took exercise every day. He could trot or canter his horse, were it not for the "splashing in his chest," which annoyed him. (Stokes, Barlow.) Similar cases are noticed by others. (C. J. B. Williams, Gerhard, of Philadelphia.) Causes.—Pneumothorax may arise spontaneously, by the ex- halation of air from the pleura, in the same manner as from the peritoneum; but this is probably a rare occurrence. It may, like- wise, arise from a wound of the chest; but, most commonly, it is occasioned by some communication being formed from without— as from the lung—with the cavity of the pleura. This may consist in a tuberculous excavation, with a fistulous opening into the pleura; or it may result from pneumonia terminating in an abscess, which has broken into the pleura; from gangrene of the lung impli- cating that membrane; from laceration of the lung or pleura by pul- monary apoplexy; or from cancer of the lung; or, it is affirmed, (Andral,) from the simultaneous rupture of some of the pulmonary vesicles and pleura: any cause, in short—which opens a commu- nication between the bronchia and the cavity of the pleura, may occasion it. Pathological characters.—Air is, at times, found alone in the chest; but more commonly—as before remarked—it is mixed with fluid, usually of a sero-purulent character. The gas may be in- odorous, or fetid, and may consist of oxygen, or azote, or pure hydrogen, or sulphuretted, or phosphuretted hydrogen. In 70 cases, the affection was double, or on both sides, twice; 41 times on the left side, and 27 times on the right. (Andral.) Treatment.—It would not seem, that the mere communication of a bronchial tube with the cavity of the pleura ought to be necessarily fatal; but this simple case rarely presents itself. Usually, it is pneumothorax, with tuberculosis of the lungs, that we have to treat; and inasmuch as the latter is almost incurable, U cannot be rendered less so by combination with the former. It has been affirmed, indeed, that where pneumothorax has proceeded from the opening of a gangrenous or tuberculous abscess into the pleura, the chances of recovery are infinitely small; and that there is no instance recorded of such an event. (Stokes.) Irritation may be allayed by opium and its preparations, and counter-irritants may be applied to the chest, from time to time. The efforts of the practitioner will, indeed, be mainly restricted to palliation. When air accumulates in the chest, owing to the smallness of the opening of communication between the bronchial tube and the cavity of the pleura, so that oppressive dyspnoea is experienced,- a question arises as to whether it may not be advisable to puncture the chest, and let out the air. This has, indeed, been done in OF THE PLEURA. 409 several instances, and, it is said, with great temporary relief. (C. J. B. Williams.) There is much difference of opinion, however, on this point; whilst one writer, (Williams,) affirms, that the risk of the operation is not great; another, (Stokes,) asserts, that in cases of great accumulation and distress, the relief is much less than might have been expected, and there is great liability to gan- grene of the pleura—a fact which he asserts he has repeatedly verified; and noticed that the " rapidity of the destruction of the serous membrane, is truly singular." Where the disease has been produced by any of the forms of pulmonary mischief, referred to under the head of causes, and especially from tuberculosis, but little advantage can be expected from the operation. The disease will still proceed on its course. As a means of permanent cure— like paracentesis for the removal of effused fluid simply—no benefit can be expected from it; and from what has been said, the physi- cian will have recourse to it only after careful deliberation. It will be always well to choose a place for the operation, beneath the sur- face of the liquid, if any be present, so that both the air and the liquid may be evacuated. It might seem, that little or no precau- tion is necessary to prevent air from being admitted, as the disease itself consists in the admission of air to the cavity of the' pleura. It is air, however, that has undergone a change in its temperature before it has reached the cavity, and, therefore, is less likely to produce irritation. It is, consequently, advisable to prevent, as far as practicable, the entrance of air through the opening made by paracentesis. V. PERFORATING ABSCESS OF THE LUNG. A few remarks may be made here upon those cases, in which purulent collections form exterior to the lung, and afterwards per- forate its tissue, so that they are evacuated through the bronchial tubes. They are cases of what has been called " Perforating abscess of the lung." (Stokes.) These abscesses may be formed by purulent collections in the parietes of the thorax or abdomen, which may reach the lung owing to adhesion between the pleura costalis, and the pleura pul- monalis, so as to form a fistulous communication with the lung; or, purulent collections in the pleura may open in this manner; or abscess of the liver may make its way through the diaphragm, and be discharged in the same manner. (Berton, Stokes.) Of this last form, the author has met with two marked cases, both of which were fatal. Recovery, however, not unfrequently takes place. VI. MORBID PRODUCTIONS IN THE PLEURA. The pleura, like other serous membranes, is liable to various other lesions of nutrition. a. Cartilaginous and osseous depositions.—These are occa- sionally, but not frequently, met with. Commonly, the bony matter is deposited in thin plates, and cartilaginous deposits are usually vol. l—35 ' 410 DISEASES OF THE RESPIRATORY ORGANS. met with, also. At times, calcareous concretions are observed in the fluid effused during chronic pleuritis. They are probably formed at the surface of the pleura, and become detached. b. Serous cysts.—These are very unusual, but they have been observed; and, when very numerous or large, they may give rise to all the signs of liquid effusion into the pleura. (Cruveilhier, Andral.) Not uncommonly, indeed, after—or in the course of— chronic pleurisy, the fluid is collected in cysts, owing to pseudo- membranous brides or prolongations, which divide the cavity of the pleura into several compartments. c. Ulceration.—This is an unusual occurrence in serous mem- branes, and when it does exist, it is probably dependent upon the breaking down of tubercles. In one case, in which there were five large ulcers in the left costal pleura, the lung contained hundreds of tubercles, in every stage of development; and in the upper lobe, there was a large excavation, the margins of which firmly adhered around the principal ulcer of the pleura. (Professor Gross, of Louisville.) d. Tubercles.—These occasionally form in the pleura, and are generally associated with tubercles of the lungs. At times, they are so large as to compress the lung, but commonly they are of small size, varying from that of millet to that of hemp-seed. (Laen- nec.) The author has frequently met with them, under both the above mentioned circumstances. In cases of pleuritis, they occa- sionally form with great rapidity in the false membrane thrown out. Examples are on record, in which the false membranes have been found studded with tubercles, in persons who died of pleurisy of not more than a fortnight's duration. (Andral.) e. Cancer.—Scirrhous and encephaloid masses are met with, at times, in the pleura; occasionally, in numerous small formations, but, at others, so large as to fill one side of the chest, compressing the lungs, and giving occasion to dulness on percussion, absence of respiratory sound, except along the great bronchial tubes, and great dyspnoea. These morbid productions form, also, in the me- diastinum, so as to constitute "cancer of the mediastinum," which is denoted by pain, sometimes excessively lancinating and shooting, under the sternum, with progressive emaciation, and the general symptoms of the cancerous diathesis. In other cases, pulsations have been felt, owing to the pressure of the tumour on the aorta, so as to lead to the belief in aneurism of the aorta; and, along with these, the sternum lias become absorbed by the pressure, and an outward projection has been visible. (Andral.) The cases are, however, to be distinguished by the symptoms above mentioned, and the absence of those physical signs, which are shown, else- where, to indicate the existence of aneurism of the aorta. In three out of five observed cases, cancer existed in other parts of the body. (Andral.) ASPHYXIA. 411 CHAPTER IV. ASPHYXIA. Synon. Apnoesphyxia, Apnoea, Apneustia, Anhaematosia, Mors Apparens, M. Putativa, Asphyxy, Suspended Animation; Fr. Asphyxie, Anhematosie; Ger. Scheintod. The term Asphyxia, in its original acceptation, means " want of pulse," (a, privative, and 09v§($, " pulse.") In this sense, it was used by the older writers, (Galen,) and is still employed, occa- sionally, by the moderns. It is not many years since suddenly fatal cases of heart affection were described under the name Asphyxia idiopathica, (Chevalier;) and we find the term, even at the present day, extended so as to include every variety of suspended animation; but, in its usual acceptation with the best writers, like apnoesphyxia, it is restricted to cases of apparent death, which result primarily, and principally from the suspension of respiration; whilst syncope is commonly applied to death commencing in the heart, and apoplexy to the variety which is primarily dependent upon a suspension of the action of the brain. Of late, too, the epithet " Asphyxia" has been applied to the condition of malignant cholera, marked by pulselessness and other symptoms of collapse,— an extension of application, which the term would scarcely seem to admit, although many of the phenomena are present, which characterize asphyxia from suspension of the respiratory function. In describing the phenomena and treatment of asphyxia, it will be convenient to refer, first of all, to them as they regard asphyxia in general, and afterwards to describe the different varieties. I. ASPHYXIA IN GENERAL. Causes.—Asphyxia, in the sense in which we employ the term, may be produced by any agency, that interferes with the due aeration of the blood. Of the necessity of a due supply of arterial blood, or of blood that has undergone such aeration, no one doubts; but its absence has not always been regarded as the main cause of asphyxia; on the contrary, the common belief has been, that the presence of unconverted, or, in other words, of black or venous blood in the tissues is positively deleterious, and that asphyxia is caused rather by its presence in the vessels, than by the absence of blood possessing arterial qualities. Assuming, for the present, that the former of the opinions is the more correct, it will be obvious, that mechanical or other impedi- ments, which interfere with the necessary contact between the blood in the pulmonary vessels and atmospheric air, or air necessary for producing the conversion of venous into arterial blood in these organs, will be the cause of asphyxia. 412 DISEASES OF THE RESPIRATORY ORGANS. Accordingly, any agency, which prevents the due expansion of the chest, by pressing upon its parietes,—as in the punishment occasionally inflicted by the Turks on their prisoners, which con- sists in burying them up to the neck in earth or sand, and pressing the earth, firmly around them,—or, as in that which has been directed by the tribunals of more civilized countries, by placing weights on the chests of the wilfully mute,—will prevent the due quantity of air from entering the lungs, and induce a most painful form of asphyxia. In the latter case, breathing might, for a time, be accomplished by the diaphragm; but, in the former, even this imperfect respiration is prevented by the firm pressure of the earth on the abdominal parietes, which necessarily prevents any descent of the diaphragm. It is obvious, too, that any disease, which mechanically inter- feres with the due elevation of the ribs, must produce more or less of this effect; as where water, or air, or other fluid, is effused into the cavity of the thorax, constituting the affections respectively known by the names hydrothorax, pneumothorax, and pyolho- rax; or where the lining membrane of the chest—the pleura—is inflamed, so that elevation of the ribs, or any attempt at elevation, excites intense pain. In the last case, however, the obstructed aeration is not as strongly manifested, owing to respiration being still carried on, although imperfectly, by the diaphragm. Another cause of asphyxia is the insufficient supply, or total absence, of oxygen in the inspired air. Hence, extremely rarefied air, and various gases, which are not of themselves positively dele- terious, may become negatively so. Unless the air contains a due quantity of oxygen, and that properly diluted by nitrogen,.the change of the venous blood into arterial cannot be effected. In atmospheric air alone we find the admixture of these gases in the requisite proportion. Unless this air be supplied in proper quan- tity, the beneficial conversion cannot be sufficiently effected, and asphyxia may equally ensue. The negatively injurious gases are,—hydrogen and azote, to which carbonic acid has been added by some, (Roget,) but its lethiferous influence is exerted in a somewhat different manner. The hydrogen and azote are capable of being respired for a short time, and they destroy, simply because they do not contain oxygen; but carbonic acid, as well as various other gases, in a concentrated state, cannot be breathed at all, producing, the very instant any attempt is. made to inhale them, a spasmodic closure of the glottis. They belong, therefore, to a third set of causes, comprising those that produce asphyxia in consequence of their forming media that are incapable of being inhaled. The irrespirable gases are,—carbonic acid, ammoniacal gas, muriatic acid gas, deutoxide of azote, nitrous acid gas, and chlorine. Different writers have classed under the same head, oxygen, car- bonic oxide, protoxide of azote, carburetted hydrogen, sulphuretted hydrogen, and arsenuretted hydrogen; but these cases give rise to ASPHYXIA. 413 no symptoms resembling asphyxia. They are positively delete- rious, and the only difference between their action and that of other poisons is, the part of the economy through which they make their impression. They are properly, therefore, poisons. They are capable of being breathed: they produce a train of morbid phe- nomena, which, in the case of some of the gases, rapidly succeeds, even if the gas be only allowed to come in contact with the skin, and they are no more the cause of asphyxia, than would be the vapours of arsenic, or of hydrocyanic acid, if inhaled. A last set of causes are those, which mechanically prevent the entrance of air into the pulmonary organs, whether such obstacle be seated externally or internally. To this set belong—hanging; strangulation, and every variety of smothering; obstruction of the air passages by the entrance of extraneous bodies, by the pressure of tumours, or by any morbid thickening of the lining membrane of the tubes. Any disease, too, which gives occasion to the effu- sion of blood or other fluids into the minute bronchial ramifica- tions, and thus prevents the air from exerting its necessary action on the blood, produces death in this manner. Direct or indirect irritation, or paralysis of the pneumogastric nerves, causes asphyxia, and death, partly in this way, and partly by impairing the powers of the respiratory muscles. From the phenomena that follow the section of these nerves on both sides, it would seem, that the first effect is exerted on the tissues of the lungs, which, being deprived of the nervous influence they receive from the brain, are no longer capable of exerting their ordinary elasticity—or muscularity—whichsoever it may be. Re- spiration consequently becomes difficult; the blood, owing to defec- tive oxygenation, no longer circulates freely through the capillaries of the lungs; the consequence of this is, that transudation of its more watery portions takes place, and occasionally effusion of blood, owing to rupture of the small vessels, or to transudation through their parietes; so that ultimately all communication is pre- vented between the inspired air and the blood in the pulmonary vessels. The conversion of venous into arterial blood is completely prevented; the animal becomes asphyxied, and death is the inevi- table consequence, because the mischief done to the nerves by the section, cannot be repaired. Diagnosis.—The general phenomena of asphyxia necessarily vary according as the supply of oxygen is diminished, or totally withheld; and according to the degree in which the supply is di- minished. There are some slight differences, also, according to the precise mode in which the supply is cut off; but still, ceVtain symp- toms and appearances are met with in all. When the access of oxygen is in any manner prevented, a few seconds elapse before any uneasiness is experienced; but after this, a marked feeling of distress indicates the necessity for. satisfying one of the most imperious wants—that of respiring—the besoin de respirer. This feeling soon becomes insupportable; the animal 414 DISEASES OF THE RESPIRATORY ORGANS. gasps, and yawns repeatedly, and makes use of every effort to obtain a supply of the indispensable fluid. The whole body is agitated. The limbs quiver, and are convulsed, or thrown into tetanic spasms. "Almost instantaneously, especially if respiration has been slightly practicable, and the supervention of asphyxia therefore gradual, the feeling of distress is attended by vertigo and stupor: the face becomes livid, especially the lips, and the orifices of the mucous membranes; and, at times, the whole surface assumes the same hue. The sensorial functions are suspended in a few moments; and, almost simultaneously, the muscles lose the power of contraction, so that the individual falls. In this state of apparent death, an obscure circulation alone exists in the great vessels, whilst the functions of the capillary system continue. The praecordial region presents, at times, a dulness on percussion, which extends as far as two inches to the right of the sternum, and three inches above the space usually occupied by the right heart. This dulness is owing to the engorgement of the right cavities. (Piorry.) Soon the circulation ceases, first of all in the larger vessels, and after- wards in the capillaries; and, with this cessation, the functions of secretion, nutrition, and calorification are arrested. The asphyxia has now become positive death. Pathological characters.—Examination of the body after death exhibits general lividity of the surface, and of the face more espe- cially. The parenchyma of the different organs is filled with fluid, especially that of the liver—which is sometimes quite purple—of the spleen, kidneys, and lungs. The whole capillary system, indeed, is surcharged with blood of a dark colour, which is described by some writers as always fluid, (Adelon;) but to this there are many exceptions. (Birard.) The blood appears to be wholly collected in the pulmonary artery, the right side of the heart, and the venous system generally, whilst the pulmonary veins, the left cavities of the heart and the arteries are empty, or contain but a small quantity of fluid. The appearances, however, differ somewhat, according as the respiration is at once obstructed, or has taken place, although imperfectly, for a time. In the former case, death ensues more promptly, and there is less suffering; and, on examination, the cu- taneous capillaries and the various organs are less charged with blood, and the fluid is less exclusively collected in the venous system. The appearance of the countenance has been looked upon as a means of discrimination in death from asphyxia, where there has been much previous struggling; but it is extremely fallacious. The mechanical* obstacles to the return of blood from the head, in some forms of asphyxia, and the convulsive efforts in all, give rise to protrusion of the eyeballs, and to more or less distortion of the features, whilst life exists; but these signs usually disappear, so that when death has unequivocally taken possession of the frame, no indications of suffering may be perceptible in the countenance. It has been remarked, (Copland,) that where no obstacle exists to ASPHYXIA. 415 the action of the inspiratory muscles,—the obstruction to respiration being in the air passages,—the efforts to renew the air in the lungs are much more convulsive and laborious; the anxiety is extreme, but of short duration, and is rapidly followed by abolition of con- sciousness, voluntary motion, and of the function of circulation. In this case, the writer quoted considers Shakspeare's description of the frightful physiognomy of Duke Humphrey, after death from suffocation, physiologically accurate:— " But see! his face is black and full of blood; His eyeballs farther out than when he lived, Staring full ghastly like a strangled man; His hair uprear'd; his nostrils stretch'd with struggling: His hands abroad display'd, as one that grasp'd And tugg'd for life, and was by strength subdued." Many of these signs may, or may not exist, and this will be greatly dependent upon the length of time the mechanical violence may have been applied. If the rope, for example, were removed prior to the coagulation of blood in the vessels, they might be entirely absent; but if kept on until all circulation—general and capillary—had ceased, the congestion of blood in the vessels, and the protrusion of eyeballs, might be present as in Duke Humphrey's case. Usually, however, whatever distortion or mark of suffering may have existed prior to dissolution, there is little or no evidence of it after the spirit has passed, when the features usually exhibit a placidity of expression—a "rapture of repose"—singularly con- trasting with their previously excited condition. (See the author's Human Physiology, 4th edit. ii. 640, Philad. 1841.) The author has had different opportunities for examining the countenances of those who have been judicially hanged,—where the rope has conse- quently been removed prior to the total abolition of the vital properties,—and in none of the cases were there the evidences of suffering, in the features, that have been so often described—by poets more especially. There is another symptom of asphyxia from mechanical obstruc- tion to respiration, to which the author's attention was first directed by Dr. H. H. Hayden, of Baltimore,—viz. redness of the teeth, which cannot be removed by maceration, so as to have the white- ness restored. This is probably owing to the same venous con- gestion that is observable in the mucous membrane of the larynx and pharynx, and to the venous engorgement observed in the brain. The flow of blood in the veins of the tooth is arrested by the causes inducing the asphyxia, so that engorgement of the dental veins supervenes, with consequent transudation. (See the article Asphyxia, by the author, in the American Cyclopedia of Prac- tical Medicine and Surgery, ii. 465. Philad. 1836.) With regard to the duration of life in cases of asphyxia, or rather to the capability of resuscitation, it is impossible to say anything definite. Where once the heart has ceased to beat, it is extremely difficult to restore it. We know nothing whatever of the cause of 416 DISEASES OF THE RESPIRATORY ORGANS. its action; but distension by an appropriate fluid appears to be indispensable; unless, therefore, we can succeed in propelling the blood from the lungs to the left side of the heart, so as to excite there the requisite stimulation, our efforts at resuscitation will be vain. But, although we may lay it down as a general rule, that where the action of the heart has ceased, in asphyxia, for a few minutes, we shall too often fail in saving the individual, much may depend upon a difference of resistance referable to age, con- stitution, corporeal condition, &c. It is probable, too, that the more slowly the state of suspended animation has been induced, the greater will be the chance of restoration, the organs retaining longer the power of being reanimated. In some of the varieties, too, of asphyxia, lesions are apt to be produced, which inevitably destroy. It is important to bear in mind the cases on record, in which resuscitation has been effected, as in drowning, after an immersion much longer than that, which we have laid down as usually sufficient to render asphyxia irretrievable; but, at the same time, we must unhesitatingly reject many of the marvellous stories that have been handed down to us on this subject, and which, strange to say, find believers even at the present day. Notwithstanding these traditionary histories, and the philan- thropic recommendation, that our attempts at resuscitation should be continued for several hours in cases of asphyxia, (Curry, Wag- ner, W. B. Carpenter,) it is but too true, that our efforts will generally be fruitless, after a perfect asphyxia of a few minutes duration. On the occasion of a melancholy catastrophe at Albany, in the state of New York, (August, 1840,) when a considerable number of perrons were submerged, although some of the sufferers were removed from the water in less than five minutes, and in two or three cases respiration was imperfectly performed, in no single in- stance did the medical gentlemen succeed in their efforts at resus- citation. The public journals of Great Britain, in giving the par- ticulars of a casualty on the river Lea, (September, 1840,) also men- tion, that although seven persons were taken from the water within three minutes, not one was resuscitated. On this occasion, a witness deposed, that he had been acquainted with the Lea for the last thirty years, and had seen many persons drowned in it, but that he had never known any one that had been submerged in its* waters even for a minute recover from the effects of such submersion. At Navarino, ample opportunity occurred for putting the powers of the best divers to the test. (Lefevre.) Dr. Lefevre witnessed the performances of those who were employed to fish up the relics of the Turkish fleet sunk in Navarino harbour. The depth to which they had to plunge was 100 feet; but though the Greek divers are, and have always been, famous for their powers, none of them could sustain submersion for two whole minutes together. Seventy- ASPHYXIA. 417 six seconds was the average period in fourteen instances accurately noted; and frequently, after reaching the surface, blood issued from the mouth, eyes, and ears of the swimmer. But, in general, these people can repeat their task three or four times an hour. The pathology or theory of asphyxia has excited great attention from the physiological pathologist. (Halter, Goodwyn, Bichat, D. Williams, Kay, Edwards, J. Reid, &c.) Before attention was directed to the chemical phenomena of re- spiration, or to the changes produced on the blood in the lungs, it was generally supposed, that when respiration is suspended, the circulation ceases, owing to some mechanical obstacle existing in the lungs, or to their collapse; and this view was even maintained at a late period. (Coleman.) It was soon, however, established, that no such mechanical impediment exists to the passage of the blood through the lungs, even after the most forced expiration, and that it continues to circulate freely through them. Accordingly, Goodwyn rejected this hypothesis, and having properly appreciated the importance of the conversion of venous into arterial blood, and the necessity of a due supply of the latter for the maintenance of the circulation and of life, he supposed, that in cases of asphyxia, the blood, being no longer exposed to the influence of the air, and therefore retaining its venous character, .is unable to stimulate the left auricle and ventricle to contraction; the heart, consequently, in his view, becomes, as it were, paralyzed, and dies first. In Goodwyn's theory, no obstacle is conceived to exist to the circulation of the blood through the lungs; the cause of the asphyxia is the non-conversion of venous into arterial blood, and, as a conse- quence thereof, the arrival, at the left side of the heart, of blood not possessing those qualities that are requisite for exciting its cavities to contraction. This view of the phenomena of asphyxia met with considerable favour from physiologists, and was generally adopted, until the appearance of the Researches of Bichat on Life and Death. That distinguished individual, equally with Goodwyn, ascribed the first link in the chain of morbid phenomena to the non-conversion of venous into arterial blood; but he rejected the idea of Goodwyn, that any paralyzing influence is exerted upon the left side of the heart, and attributed the whole of'the phenomena to the poisonous effects of the venous blood on the different tissues of the body. The theory of Bichat commanded universal assent for a long period, and a recent writer, (Devergie,) considers, that it " alone merited the suffrage's of all physicians." Of late years, however, it has been subjected to a fresh examination, (D. Williams, Kay, Edwards,) the results of which have shown, that many of the views of Bichat have been too implicitly received, and that some of them must be unhesitatingly rejected. It is evident, indeed, that Bichat attached too much importance to the presence of black blood in the different tissues, and that the mischief is rather to be ascribed to the absence of blood in the ar- 418 DISEASES OF THE RESPIRATORY ORGANS. teries. Were the experiments and observations of Edwards, Kay, and others, considered insufficient to establish this, the singular phenomena, exhibited by malignant cholera, would complete the demonstration. They are calculated, indeed, to give the dernier coup to the theory of Bichat, and to shake all our ideas regarding the connection of the sensitive and locomotive functions with the circulation and haematosis. (Berard.) Every one who has witnessed that strange malady, must have observed the nervous and muscular actions preserved until within a few moments of dissolution, when the whole of the vascular system has been so filled with black blood, as to render the surface blue, and when arterial pulsations, even in the larger vessels, have been imperceptible. These striking phenomena have, indeed, led M. Magendie to affirm, that the contact of arterial blood is neither indispensable to cerebral action nor to muscular contraction; and a recent writer, (Madden,) has gone so far as to assert, that the brightening up of the mind prior to dissolution, which is occasionally witnessed, but far less fre- quently than is imagined, is probably produced by the "stimulus" of the dark venous blood circulating through the arterial vessels of the brain; but this idea is opposed to all received notions on the subject. In opposition to the views of Bichat, it has been maintained, that the earliest effect of the interruption of respiration is to impede and arrest the circulation of the blood in the capillary system of the lungs. (D. Williams, Kay.) All the organs of the body, in Dr. Kay's view, consist of a con- geries of small blood-vessels, denominated, from their minuteness, " capillaries." These vessels are possessed of peculiar powers, by which, in a healthy state, they admit only fluids of a certain quality, excluding those that are incompatible with the functions of the part. They even resist the forcible introduction of other fluids, when injected with a syringe. In the lungs, minute blood-vessels exist in an exquisitely delicate net-work. In these vessels, the venous blood is exposed to the influence of the atmospheric air; its qualities are changed; it loses its dark hue, and acquires a bright red colour; and hence, it is probable, Dr. Kay thinks, that the vessels in which the arterial blood circulates, must differ in their peculiar sensibilities, from those which propel the venous blood. The laws generally observed to regulate the action of the small vessels in other structures, would, he conceives, be violated, if the vessels which usually convey arterial blood, were able to convey, with equal facility, venous blood in every state of "its changes, until it acquires its darkest colour. When air is no longer inspired, a con- siderable quantity of this fluid remains in the ultimate bronchial subdivisions, and so long as this air contains a certain portion of oxygen, the blood undergoes its proper change in the pulmonary vessels, and the circulation proceeds with its ordinary activity; but as the proportion of oxygen diminishes, the conversion is more and more imperfectly accomplished; the circulation becomes progres- ASPHYXIA. 419 sively feebler, and slower, "until, when venous blood enters those vessels which formerly conveyed arterial blood only, this degene- rated fluid is no longer able to excite their action, and the circula- tion stagnates in the structure of the lungs. The pulmonary veins then discharge their last meagre supply through the left auricle into the left ventricle, which propels its last and feeblest tide into the arteries, in which the circulation has, every moment, become more scanty, until the pulsation has gradually been extinguished." (Kay.) In this way, Dr. Kay accounts for the congestion of the venous system, and especially of the right side of the heart, and of the pulmonary artery, whilst his theory equally explains the emptiness of the pulmonary veins, and the left side of the heart. The general conclusions which Dr. Kay deduces from all his investigations, are: First. That the circulation is arrested after respiration ceases, because, owing to the exclusion of oxygen, and the consequent non-arterialization of the blood, the minute pulmo- nary vessels, which usually convey arterial blood, are incapable of transmitting venous blood, which therefore stagnates in the lungs. Secondly. That the arrestation of the circulation is sudden when the lungs are entirely deprived of air, and that blood ceases to flow from them into the left cavities of the heart, even in the smallest quantity, in about three minutes and a half. Thirdly. That even supposing a great quantity of venous blood were transmitted through the lungs, it would not impair their contractility; but, on the contrary, it is even capable of supporting this power for a cer- tain period. That venous blood does not possess any noxious quality, by'which the organic functions of these tissues can be de- stroyed, but is simply a less nutritious and less stimulating fluid than arterial blood: and, lastly,—that the functions of the muscular fibres cease in asphyxia, because the circulation, and, consequently, the supply of the fluid which is necessary to life, is arrested in the lungs. Recently, fresh experiments have been instituted by an excellent observer, (J. Reid,) which do not accord, in all respects, with those of Dr. Kay. Dr. Reid concludes, that the suspension of the func- tions of the encephalon are chiefly, if not entirely, dependent upon the circulation of venous blood in the arteries. He does not, how- ever, maintain, that venous blood exerts any noxious influence upon the functions of the nervous texture; but believes, that the effects are solely attributable to the want of the proper excitation of the organ; for when the circulation of arterial blood is renewed, its functions rapidly manifest themselves, provided this be done within a given time. Dr. Reid believes, that the order of succession in which the vital processes are arrested in asphyxia is as follows:—The venous blood is at first transmitted freely through the lungs, and reaches the left side of the heart, by which it is driven through all the textures of the body. As the blood becomes more venous, its circulation through the vessels of the brain deranges the sensorial functions, and rapidly 420 DISEASES OF THE RESPIRATORY ORGANS. suspends them, so that the individual becomes unconscious of all external impressions. The functions of the medulla oblongata are enfeebled about the same period that the sensorial functions are arrested, but are not fairly suspended for some time longer. Imme- diately after the sensorial functions are suspended, and the blood has become still more venous, it is transmitted with difficulty through the capillaries of the lungs, and, consequently, begins to collect in the right side of the heart. A smaller quantity of blood must now necessarily reach the left side of the heart; and this diminution of the quantity of blood sent along the arteries, conjoined with its venous character and the ultimate arrest of the circulation, being circumstances incompatible with the manifestation of vitality in the other tissues of the body, general death is sooner or later induced. This view, consequently, ascribes the phenomena of asphyxia chiefly to the circulation of blood that has not been oxygenated in the lungs, or, in other words, of blood devoid of the proper excitant agency, and subsequently, to arrest of the blood in the capillaries of the lungs, which occasions the flow of arterial blood towards the left heart to be arrested. As a consequence of the want of the stimulus of distension, the left cavities lose their contractility; the right auricle, which continues for a time to receive blood by the venae cavae, being the ultimum moriens. The nervous, muscular, parenchymatous, and other tissues, no longer receiving a supply of-arterial blood, cease also to act: but those organic functions, which are effected in the capilla. ries of the general system—as nutrition, secretion, and calorifica- tion—yield last; circulation continuing in the capillaries for some time after it has ceased in the larger vessels. These are probably the chief agencies concerned in the pheno- mena of asphyxia. Were the view of Bichat adopted, we might vainly attempt resuscitation by inflation of the lungs, seeing that every tissue, even that of the heart, has been poisoned to the total destruction of its irritability; and this has generally been regarded as a powerful objection to the view of that distinguished physiolo- gist. Treatment.—An attentive consideration of the different pheno- mena of asphyxia, presented during life as well as after death,and a comparison of these phenomena with the theory they seem so naturally to suggest, will leave but little doubt in the mind of the practitioner, as to the general resuscitative measures he ought to adopt. Still there are many particulars on which doubt might be indulged, and on which, indeed, a diversity of opinion yet exists amongst therapeutists. The general indications will consist, first, in removing the indi- vidual from the causes that have produced the asphyxia; and, secondly, in endeavouring to restore respiration, circulation, and innervation—the great vital functions, which mutually react on each other, and therefore require the simultaneous application of remedies adapted to each. ASPHYXIA. 431 The consideration of the mode of fulfilling the first indication will necessarily fall under the examination of the particular varie- ties of asphyxia, as it must differ in each variety. The chief means for fulfilling the second are,—to expose the body to that degree of heat which experience has shown to be best adapted for the support of the vital powers, and simultaneously to attempt to restore the suppressed respiration. From certain experiments, instituted on different classes of animals, (W. F. Edwards,) it would seem to result, that an eleva- ted temperature of the body exhausts the nervous action, unless the animal is able, at the same time, to have a due supply of air, and that there is a temperature, remote from the extremes of too great heat, and too great cold, which is best adapted for the re- covery of those in whom respiration has been from any cause arrested. When the management of the different varieties of asphyxia falls under consideration, this subject will have to be again referred to, in its relation to each; and its bearings on the asphyxia of the new-born infant, or of one thrown into a state of suspended animation in the first few days of its existence, will be strikingly apparent. In all varieties of asphyxia, a temperature at all approaching that of the body,—and a higher than this has been recommended by the Royal Humane Society of London, whose directions are the rule of conduct over every part of Great Britain at least,—must, for the reasons assigned, be positively injurious, and a fortiori, if such elevated temperature be applied through a medium, that shuts off from the skin the vivifying influence, which the contact of air is capable of exerting. In but few cases can it be safe to have the air of the apartment higher thaw 75° or 80°. Radiant caloric, where caloric is demanded, is manifestly to be preferred to the conducted,—unless its application, in the latter way, be partial, so as not to interfere greatly with the free exposure of the surface to the contact of air. The body may be placed before the fire, or in the sunshine; and warm flannels, or bags of warm grains, or of salt or sand; or bottles of warm water, or warm bricks, may be placed on small extents of the cutaneous surface. A proper temperature might be applied to the back by the tin mattresses, filled with warm, water, used during the prevalence of cholera in several of the cholera hospitals. In this partial mode of apply- ing warmth, sufficient surface is allowed for the action of the air, as well as for the employment of friction, which, with some other agencies, and especially that of artificial respiration, are the grand means for restoring suspended animation. (Kay.) It was remarked, that the application of warmth must be made simultaneously with another operation,—insufflation—the most essential, indeed, of the appliances and means that have been re- commended for the removal of asphyxia. It must be recollected, that in this condition, respiration and cir- culation are suspended, and that innervation, which is under the vol. i.—36 422 DISEASES OF THE RESPIRATORY ORGANS. dependence of these two functions, is almost annihilated. Irrita- bility, however, still exists, whilst the blood-vessels, and the cavities of the heart, contain venous, and usually liquid, blood. Unless, indeed, this were the case, and if fibrinous concretions had formed in the cavities and in the great vessels, all attempts at resuscitation would manifestly be fruitless. In all these cases, death super- venes on the arrestation of a single vital function intimately cate- nated with the rest; but views have differed regarding the first seat of death; fortunately, under every view that has been entertained in moderrutimes. the same plan of management has been inculcated. At one period, it was universally supposed, that death, in drown- ing, is owing to the oppression of the water swallowed; but as soon as the labours of observers, (Detharding, Plater, and others,) showed that this was an error, and that death results from the privation of air, pulmonary insufflation was recommended. The theory of Goodwyn, as before shown, maintained, that the con- tractile power of the left heart is destroyed, owing to venous blood being sent into it. Accordingly, insufflation was proposed, to change the quality of the blood—in the pulmonary veins, sinus venosus and auricle—to blood capable of arousing the left heart to contraction. Goodwyn's erroneous views of the nature of the affection led him, however, to the injurious recommendation, to introduce a large quantity of air at each inflation—upwards of 100 cubic inches, for example in the case of the adult;—a recommenda- tion which, if universally embraced, could not fail to be followed by the unhappy consequences that are found to result from an injudicious employment of artificial respiration. Bichat, Kay,and indeed every author on the subject, whatever may be the theory he adopts,—equally recommend its employment. Under die view embraced by Kay, it is clearly the most philosophical plan of treat- ment that could be devised. Asphyxia, according to him, essen- tially results from the privation of air preventing the due conver- sion of venous into arterial blood; and, as a result of this, stagna- tion taking place in the pulmonary capillaries. To remove such stagnation, and re-establish the flow, this conversion must be effected; after which, arterial blood makes its way through the vessels adapted for it, but which did not allow the passage of venous blood; and in this way, the circulation, when it has not been too long suspended, may be restored. The most simple mode of employing artificial respiration is that proposed by Leroy, and which has since been described, at length, in the reports of the Royal Humane Society of London. It has a signal advantage of being available in cases where no professional individual is at hand, and can always be employed without the slightest apprehension of evil. A piece of strong flannel, an old blanket, sheet, or other cloth, most easily attainable at the moment, is to be cut of the following size, and in the following manner. It should be six feet in length, ASPHYXIA. 423 and in breadth eighteen inches. Six strips are then to be cut or torn lengthwise on each side. Each strip is to be three inches broad, and two feet long. The untorn portion (two feet in length, and eighteen inches broad) is to be placed under the back of the patient, from the armpits to the upper part of the thigh bones. The strips are then to be brought together over the chest and abdomen, interlacing each other from the opposite sides, as the fingers are interlaced in clasping the hands. The strips, thus arranged, are to be gathered into a bundle on each side; and if they are then drawn in opposite directions by two assistants, the edges of the bandage will be made to approach, and firm and equal pressure will be produced on the chest and abdomen. The assistants—having thus compressed the body of the patient by drawing the bandage in opposite directions—should then relax it, permitting the chest to re-expand, and perform this process at the rate of about twenty times in the minute. If the head and shoulders be elevated, the contents of the abdomen, on the relaxa- tion of the pressure, will cause the diaphragm to descend by their gravity, and will thus enlarge the chest. By applying the flame of a candle, or the fine down of a feather, to the mouth and nostrils, it will be seen, that on each firm pressure by the bandage, air is expelled from the lungs; and on the relaxation of this pressure, the chest regains its original size, and air rushes in. Such is the plan, which may be had recourse to almost from the first moment that the body is discovered, and whilst any other means are in preparation from which more beneficial effects are anticipated; but, as soon as it can be accomplished, a more effective method of re-exciting the respiratory movements should be adopted. The pipe of a pair of bellows may be inserted into one nostril, whilst the mouth and opposite nostril are closed by an assistant, and the windpipe, in the superior prominent part, commonly called Pomum Adami, is gently pressed back. Then, by forcing air into the lungs, and alternately expelling it by pressing the chest, respiration may be imitated. In this way, air may be sent into the lungs about twenty times in the minute, so as to imitate natural respiration as nearly as possible. Another, and a more satisfactory method of insufflation, is, to pass into the larynx a bent silver canula, the larger extremity of which can be attached to the end of a flexible tube, so as'to admit of a ready execution of the process. The finger must be passed towards the root of the tongue, on which it must press; in this way, the epiglottis is raised, and, by carrying the canula along the fin- ger, it readily slides into the larynx. Where none of the apparatus described is at hand,—but this can rarely happen, for in almost all situations, a bandage, of the kind re- commended for establishing artificial respiration, can be met with,— it has been advised, that air should be forcibly blown into the lungs, by applying the mouth of the operator to that of the patient, closing 424 DISEASES OF THE RESPIRATORY ORGANS. his nostrils with one hand, and gently expelling the air again, by pressing the chest with the other, or by the aid of an assistant; and if any difficulty be experienced in this method, air may be blown in at one nostril, keeping the other closed, and pressing the larynx back upon the oesophagus, in the mode already described, so as to prevent the introduced air from passing down into the stomach; or one of the curved canulas may be introduced, and air sent through it. But this method has not met with the approbation of every observer, and for obvious reasons. When the air issues from the lungs of an individual, it has experienced such a change in its com- position as to be no longer adapted for continued respiration. It has ceased to be the appropriate fluid—atmospheric air—for the maintenance of the respiratory function, as experiments on animals sufficiently demonstrate. On the other hand, the introduced air has its temperature elevated, so that the advantage of the higher temperature, it has been conceived, may nearly counterbalance the disadvantage of less purity, (Copland); but this may be advanta- geous or disadvantageous according to the case. It is more than doubtful, indeed, whether in any case of asphyxia, in the adult, the application of a temperature of upwards of 90° to the body can be useful. It has been considered, (BSrard,) that the danger or dread is slightly exaggerated, as the air is so little changed; and moreover, in spite of every precaution, where a tube is not used, the air must pass, more or less, into the pharynx and even into the oesophagus, so that it cannot enter in quantity into the lungs. The advantages, however, attending the insufflation of the pure air of the atmosphere, are so overwhelming, that it ought always to be adopted, when practicable. There is, indeed, one variety of asphyxia where such deteriorated air can hardly be looked upon as so objectionable—the asphyxia of the new-born child, or of one that has respired but for a short period. The presence of a full portion of oxygen is not here so indispensable as it is afterwards; but this variety will have to be considered hereafter. At one period, pulmonary insufflation was universally practised, and without the slightest cautions. It was even recommended, as has been observed, that the air should be forced into the lungs so as to penetrate the minute air-cells. Experiments have, however, shown, (Southwood Smith,) that although a moderate inspiration favours the passage of the blood through the lungs, great distension by air checks almost entirely the circulation through them, by the mechanical compression of the vessels. In recent times, too, it has been shown, that the apparently simple operation of inflating the lungs is not as devoid of danger as was for a long time imagined; and it has been attempted to prove, that many cases may have resulted fatally from the violence of the insufflation, and consequent lesion of the pulmonary structure. (Kay, Magendie.) Some of the statistical evidences on which this opinion is founded will be given under the head of Asphyxia from submersio?i. ASPHYXIA. 425 Bichat had remarked, that where air is forced violently into the lungs of an animal, infiltration of air may be produced owing to rupture of some of the pulmonary vesicles, and, within the last few years,a series of experiments has been instituted, (Leroyd'Etiolles.) which have confirmed the observations of Bichat. He found, that if air was blown into the lungs, and with no greater strength than that of an expiration from the human lungs, it proved fatal to rab- bits, foxes, goats, sheep, and other animals. The experiment was performed by briskly inflating the lungs from the mouth of the operator. All animals were not, however, equally affected by the operation. The tissue of the lungs of the dog, for example, is denser than in the animals mentioned, and, therefore, resists the insufflation better; and the same remark applies to the lungs of infants, which were not lacerated, even when the inflation was practised with considerable force,—a fact which was confirmed by the experiments of others. (Magendie, Dume"ril.) Similar experiments, made on the dead bodies of adults, exhibited that a like rupture of the air-cells could be effected by simple oral insuffla- tion. Where the pulmonary vesicles are ruptured in this manner, the air passes into the cavity of the pleura, and presses upon the lungs, so that they cannot be inflated, unless the effused air be removed by a puncture made into the chest, and re-inflating the lungs by the trachea. A post mortem examination of many of the cases, that proved fatal after insufflation, sufficiently exhibited their true pathology; the diaphragm being found pressed into the abdomen, so as to form a prominent elastic tumour in that cavity, and the lung contracted into a small space in the chest. In experiments on animals, relief was afforded by making a puncture through the parietes of the chest, immediately after brisk insufflation had been practised, and thus permitting the effused air to issue from the cavity of the pleura. The animals, treated in this manner, recovered, although they exhibited much embarrassment in breathing for some hours. To remedy these inconveniences, Leroy recommends a modi- fication of the resuscitative apparatus. He employs the double- valved bellows of Hunter, to the handles of which he has adapted the graduated arc of a circle. One end of this arc is attached to one handle of the bellows, whilst the other passes through a mor- tise-hole in the other handle. The extent to which the handles are separated is measured by the graduated arc, and thus the quantity of air sent into the lungs may be determined. With his bellows, he measured the quantity of air expired, without effort, into a bladder, by persons of different ages, and marked upon the arc of the circle the point to which the handle of the bellows was raised in each, lie moreover had the curved tubes, to be intro- duced into the glottis, made of a different calibre, according to the age, so as to render it impossible to introduce the proper quantity 426 DISEASES OF THE RESPIRATORY ORGANS. of air, as indicated on the arc of the bellows, more rapidly than it would be inspired at that age. The apparatus is simple, and its adoption has been properly and strongly advised, on the ground, that verbal directions often fail to impress the mind with a due sense of the dangers attending insufflation, especially when it must be performed in such excite- ment, and confusion, as cannot fail occasionally to diminish the caution even of experienced persons. (Kay.) In most of the cases of asphyxia, however, that occur, no such apparatus can be at hand, and the operator is consequently constrained to make use of the agents which present themselves. These should of course be employed with the greatest precaution, to prevent the evils that have been depicted by Leroy. In adopting any form of insufflation, it is important to imitate, as far as possible, the natural movements of inspiration and expira- tion; not to go on incessantly forcing air into the lungs, but, by means of the pressure before mentioned, to force the air from the chest before a fresh quantity is sent in. This is one of the strong objections that may be urged against the plan, which has been recommended, where difficulty is experienced in introducing a curved tube into the glottis,—o'f making an incision into the windpipe, and inserting the nozle of the bellows into it, so as to maintain artificial respiration. In order that expiration shall be accomplished, the nozle must necessarily be alternately withdrawn and inserted, so that great violence must be done to the parts. A fatal case of this kind has been given. (Franks.) Lastly, it has been recommended to substitute oxygen gas for atmospheric air, and that the-resuscitative apparatus should con- tain a quantity in a well-stopped bottle. (Wagner.) But, althongh it might seem probable, that the substitution of oxygen would be advantageous, so few cases of its employment are on record, that a respectable surgeon, (Armiger,) when about to prepare a work on suspended animation—which has not yet seen the light—so- licited from the profession accounts of cases successfully or unsuc- cessfully treated, but his call was not responded to. Goodwyn employed this gas in several instances in asphyxia of the smaller animals, and he thought, that recovery was commonly more expe- ditious than where atmospheric air was used; but at the same time he admits, that he had never been able to resuscitate an animal by oxygen gas, after atmospheric air had been vainly employed. We can readily appreciate the principle on which inflation with oxygen gas should be recommended; but it is not so easy to com- prehend that on which a mixture of 80 parts of atmospheric air and 20 of chlorine should have been advised, (Ackermann,) unless it were upon the same principle that Hunter advised the inhalation of stimulating vapours. The recommendation appears, however, to have fallen still-born from its originator. Agents of this kind were sure to have early suggested them- ASPHYXIA. 427 selves. The vital powers being suspended, or, as it was conceived, in a state of torpor, excitants would naturally seem to be demanded in every case of asphyxia. Friction has been advised by all, although its importance, even as an auxiliary means of restoring life, may have been much overrated. (Roget.) It can, of course, be of no use where the circulation has entirely ceased in the capil- lary vessels; but, in such a case, all applications would probably be equally unsuccessful: when, however, even an obscure circula- tion goes on in them,—and we have seen that this may be the case for some time after the action of the heart has ceased,—the remedy is certainly philosophical, if used with the more important means already considered. The effect of frictions, like that of local excitants in general, is to produce rubefaction, or, in other words, to solicit the blood into the extreme vessels, so that an impulse is thus communicated to the. greater and more important parts of the vascular system; whilst the excitation of the subcutaneous nerves is communicated to the brain, and thence to every part of the organism. In such cases, therefore, as admit of any hope of relief, the employment of friction may be strongly inculcated. It may be applied with the naked warm hand, previously dipped in flour, to prevent abrasion; or by the flesh-brush. The part of the body that may be selected with this object is not material, but generally the extremities are recommended. Various other excitants have been advised, such as tickling the nostrils or the fauces with a feather; applying spirits of hartshorn or aromatic vinegar to the Schneiderian membrane by the same instrument; burning sulphur under the nose of the patient, as well as other volatile irritants; but they can be of little or no use until the sensibility is restored by other means,—and then they are probably unnecessary. With similar views, brandy and water, or hartshorn and water, or negiis, have been thrown into the stomach by means of the stomach tube; and irritating turpentine or spirituous enemata, or salt, or vinegar, or chlorate of potassa in solution, have been ad- ministered in the same form. Their use can only be productive of benefit under like circumstances, and they had better be cau- tiously employed in all. The effect of electricity, in the different forms in which it is adopted in medicine, on the functions of sensibility, and muscular contraction, could not fail to suggest it early to observers as a means for restoring suspended animation. It is doubtless a most valuable agent, but is rarely available, for reasons that are obvious. (J. P. Frank, Thillaye.) It has been strongly recommended by the latter gentleman on the strength of numerous experiments on ani- mals. As the object, in these cases, is to arouse the respiratory muscles to action, the electric shock may be passed through the shoulders, or through the chest in any direction. Neither common 428 DISEASES OF THE RESPIRATORY ORGANS. nor galvanic electricity is possessed of any power in restoring the action of the involuntary muscles. The author has frequently attempted to re-excite the action of the heart, intestines, fibres of the uterus, &c, soon after the cessation of respiration and circula- tion, by means of the galvanic stimulus, but without the slightest success, although the voluntary muscles responded to it most ener- getically. Besides, were the action of the heart to be re-excited by it, this could be but momentary. An appropriate stimulating agency is distension, and unless the respiratory movements were restored, and conversion of venous into arterial blood effected, so that the latter could reach the left heart, the action of that organ could not be maintained. Every attempt, therefore, is properly made to restore the action of the respiratory muscles, so that hae- matosis may be accomplished. It has been advised, that the great nerves should be exposed in the neck; and that whilst the wire, connected with one pole of the galvanic battery, is applied to the pneumogastric nerve, for ex- ample, the other wire should be placed on the epigastrium. It is unnecessary, however, to expose the nerves, for experiments have sufficiently shown, that the galvanic influence is more strongly exhibited when the integuments are left entire. As the intestinal tube retains its excitability for a long time, it has been advised to pass the galvanic current through the tube,by placing one of the poles in the pharynx and the other in the rectum. (Marc, Sestier.) A new method of application has been suggested, (Leroy d'EHolies,) which, at the first aspect, appears to be most formi- dable, but is really less so than it seems, in consequence of the im- punity with which fine needles can be made to penetrate even the most important organs. He introduced an acupuncture needle on each side, between the eighth and ninth rib, until the needles reached the fibres of the diaphragm. He then established a gal- vanic current between these, by means of a pile of twenty-five or thirty pairs of plates, an inch in diameter. The diaphragm imme- diately contracted, and an inspiration was made. He now inter- rupted the circle, when the diaphragm, urged by the weight of the abdominal viscera, and aided by gentle pressure made on the abdomen by the hand, returned to its former position, and an ex- piration was accomplished. In this way, the two respiratory acts were made to succeed each other, and regular respiration was re- induced. A continuous current was, likewise, applied in some cases, but the respiratory movements were irregular, and nothing like natural respiration resulted. Leroy tried his method on animals asphyxied by submersion,and when they had not been under water more than five minutes, they were often resuscitated. The experiments were witnessed by Magendie. On different occasions, Leroy asphyxied animals of the same species, and apparently of like strength, and whilst those ASPHYXIA. 429 that were left to themselves perished, those that were treated by galvanism recovered. Recently, a case has been published, in which the galvanic in- fluence, from a battery of fifty plates, was applied immediately to the diaphragm, through an incision made below the seventh rib. The muscles of the chest and abdomen were instantly thrown into spasmodic action, which subsided, in a few minutes, into the regu- lar movements of respiration. The man had been six or seven minutes under water. (J. Ferguson.) . As an aid, therefore, to pulmonary insufflation, and an important one, galvanism might be advantageously employed in asphyxia; but, as has been already remarked, it can rarely be available. Cer- tainly no time should be lost in adopting the other energetic and indispensable measures that have been already advised. It has been recommended, that as only a very small apparatus is neces- sary, batteries, consisting of a few plates, might be kept wherever there are station-houses for the reception of persons in a state of asphyxia. (Kay.) The suggestion is good; and they might with propriety also form a part of the cabinet of apparatus of the private practitioner; but whilst an assistant is preparing it for action, the practitioner should be energetically engaged in using his other means of resuscitation. The employment of galvanism has like- wise another advantage, in cases of asphyxia,—in being a test of the presence of excitability or irritability. Where none is evidenced, death is absolute. The operation of blood-letting requires much caution, when practised to anything like the ordinary extent; but there are, per- haps, few cases of asphyxia, in which blood can be abstracted, where the loss of a few ounces would not be beneficial, along with other resuscitative measures. The venous system is. always sur- charged with blood, and the removal of this quantity could scarcely fail to aid in the re-establishment of the circulation, without the danger of its extinguishing vitality, that has been apprehended. It is a measure, however, regarding the propriety of which, much difference of opinion has existed. Mr. Hunter strongly reprobated it, and the Royal Humane Society, of London, recommend the " utmost caution" in its employment. On the other hand, a modern writer (Wagner) regards the removal of the oppression of the en- cephalon, owing to the accumulation of blood in its vessels, as the second indication to be fulfilled in many kinds of asphyxia, the first being the restoration of the circulatory and respiratory movements. It has already been remarked, that the abstraction of some ounces of blood must usually be beneficial in aiding the restoration of the circulation; but the grand evil, after all, is the deficiency of fluid sent by the arteries, which bleeding can only rectify indirectly, by aiding in the re-establishment of the circulation. A recent writer affirms, that when the individual has only just lost all conscious- ness, a " large bleeding" may produce the most satisfactory results, aud that if it cannot always be employed at the first, it often facili- 430 DISEASES OF THE RESPIRATORY ORGANS. tates the restoration of the circulation, when attempts at respiration are made. (Devergie.) The general reprobation of blood-letting, in asphyxia, seems scarcely warranted; and, indeed, as we have already said, there are, perhaps, few cases in which a moderate abstraction of blood would not be beneficial. By some, (Larrey, Marc,) it has been advised, that blood should be drawn by cup- ping from the dorsal, epigastric and hypochondriac regions. Such are the chief remedial agents employed in asphyxia. No- thing has been said of stomach brushes, and stomach mops, for stimulating that organ; of the internal use of phosphorus, (Good;) of the instillation of hot water on the head, scrobiculus cordis, genitals, spine, &c ; the dropping of hot sealing-wax on the head; sticking needles under the nails; the application of the actual cautery, &c.—because these are forms of excitants, from which but little good could, in any case, be expected, whilst there are others that are more appropriate in all. With regard to the length of time that the resuscitative measures should be continued, it is difficult to lay down any precise rule. We shall find, when the particular forms of asphyxia are con- sidered, that, in some, restoration appears to have been effected after a greater lapse of time than in others, so as to have given rise to the idea, that the impression made on the nervous system by the cause producing the asphyxia, may have occasioned syncope rather than true asphyxia. Under the possibility, that restoration may still be accomplished in very unpromising cases, it has been ad- vised, that the means should be persevered in for several hours, and, indeed, until cadaveric rigidity begins to appear. A good deal must necessarily depend upon the length of time the individual has been exposed to the agency that has occasioned the asphyxia; and the practitioner, in every case, will have to be guided by his own judgment as to the probability of success from the application of any restorative measures; bearing in mind the cases on record of recovery after a long suspension of the vital manifestations, but, at the same time, recollecting that such fortu- nate examples are extremely rare. Occasion, however, will present itself for a recurrence to this subject. When the resuscitative measures are beginning to be successful, slight convulsive snatchings of the respiratory muscles take place at longer or shorter intervals; with gaspings, sighing, slight flutter- ing at the heart, palpitations; and afterwards regular respiration and circulation. The patient should not be abandoned by the practitioner immediately after resuscitation has occurred, as, in consequence of the'condition in which the encephalon has been placed, during the existence of asphyxia, and the irregular move- ments occurring during the recovery, delirium or convulsions may supervene. A case is given in a respectable French periodical, in which the most furious delirium came on immediately after resus- citation from drowning, and where blood-letting appeared to be clearly indicated. The propriety of bleeding will have to be judged ASPHYXIA. 431 of by the presence of the usual signs, that denote increased action of the encephalic vessels. The case of a corporal of the guards is given, (Paris,) who was seized with cramp as he was bathing, and remained for several minutes under water. By judicious assistance he recovered, and appeared to those about him to be free from danger, when he was attacked with convulsions and .expired. It has been suggested, (Roget,) that if the respiration had been artificially supported at this period, so as to have maintained the action of the heart, until the black blood had returned from the brain, the life of the soldier might, probably, have been preserved; but it is more likely, that some lesion had taken place in the encephalon, consequent on the modified circulation in that viscus, rather than on the presence of black blood in the vessels, which must have been sent back towards the heart from the first re-establishment of the circulation,—and this view is confirmed by the fact, that convulsions sometimes occur a considerable time after recovery has, to all appearance, been effected. Various inflammatory symptoms are apt to supervene, owing to the same irregularity,—which must be met as they arise, until the functions are restored to the healthy condition. II. VARIETIES OF ASPHYXIA. The remarks made, in the history of asphyxia in general, will render it unnecessary to dwell, at any great length, upon the dif- ferent varieties. Respecting the number of these, the greatest discrepancy has existed, in consequence of the difference of latitude given to the acceptation of the term. The causes, previously re- ferred to, will guide us in establishing a few varieties:—first, those that arise from any mechanical obstacle to the due expansion of the chest;—secondly, such as are dependent upon an insufficient supply, or upon total absence, of oxygen in the inspired air;— thirdly, those that are produced by irrespirable gases;—and fourth- ly, such as are owing to any mechanical cause, which prevents the entrance of air into the lungs. a. Asphyxia from mechanical obstacle to the expansion of the chest. The brief allusion, that has been made to the first of these, will be sufficient. It can rarely happen, that asphyxia is induced by any extrinsic cause, that can prevent the due expansion of the chest in inspiration, and therefore, as a question of therapeutios or of legal medicine, it is possessed of but little interest, whilst its pa- thology does not differ from that of asphyxia in general. As, how- ever, death takes place in consequence of imperfect haematosis, and supervenes gradually instead of suddenly, as in many of the other forms of asphyxia, the evidences on dissection may be more equi- vocal: there may not be the same extent of fulness in the right heart, or of vacuity in the left; nor ought we to expect those ex- 432 DISEASES OF THE RESPIRATORY ORGANS. travasations into the lungs or encephalon, which are so common whenever the circulation from the right side of the heart to the left has been suddenly arrested. Allusion has been already made to the cases in which this variety of asphyxia has presented itself,—namely, as a punishment in Turkey, and as a means of judicial compulsion, where a witness has persisted in remaining wilfully mute. Occasionally, too, it has happened, that this mode of taking away life has been adopted criminally with the infirm, as in some of those infamous examples of turpitude, which excited so much horror and alarm, in the Bri- tish metropolis, a few years ago. In these cases of refinement of cruelty, after the victim had been " hocussed,"—as it was termed in the slang vocabulary,—by stupefying him with opium in some form, the hand was pressed upon the mouth so as to prevent the entrance of air, whilst the expansion of the chest was prevented by sitting upon the body. In this way, death was as speedy as if a ligature had been passed around the neck, or the individual had been thrown into an irrespirable medium. A case is described, (Roget.) in which asphyxia was nearly in- duced in a pugilist, a cast of whose body was being taken in one piece. As soon as the plaster began to set, he felt deprived of the power of respiration; and to add to his misfortune, was cut off from the means of expressing his distress. His situation was, however, perceived in time to save his life. A similar accident happened to an illustrious individual in this country, (President Jefferson,) when the artist Browere was taking a cast of him. Mr. Jefferson informed the author, that he was in imminent danger of suffoca- tion, and the family were so seriously alarmed that the plaster had to be broken off. b. Asphyxia from insufficient supply or total absence of oxygen. Of this variety there are many examples. It has been before remarked, that extremely rarefied air, and various gases, which are not of themselves positively deleterious, may become negatively so;—or, in other words, they may destroy, not in consequence of their being possessed of any noxious property, but because they do not furnish the oxygen, which is indispensable to haematosis. Hy- drogen and azote are in this category. If an animal be placed in either of these gases, it breathes for a minute perhaps; but the con- version from venous to arterial blood in the lungs being prevented, arrest of the circulation, in the radicles of the pulmonary veins, occifrs, in the same manner as in other cases of complete asphyxia. We can hardly, however, imagine the case, in which asphyxia from exposure to these gases could happen to man. The same may be said of an extremely rarefied atmosphere. For the purpose of experiment we occasionally place one of the lower animals under the receiver of the air-pump; and rapidly exhaust the air: the effect is here speedy, if the vacuum be suddenly formed, and the patho- logy of asphyxia, thus induced, is like the forms which we have ASPHYXIA. 433 just considered; but if the rarefaction be made more gradually, asphyxia is longer in being produced, and the phenomena are much more equivocal. In the respiration of animals, the oxygenous portion of the air is more or less consumed, and carbonic acid, of a nearly equal volume, takes its place. In other words, the vital portion of the air is ab- stracted, and an equal volume of air, which is altogether irrespirable, is added to the azote—which, as we have seen, is itself negatively injurious. Now, if an animal be confined in a restricted quantity of atmospheric air, it can exist so long as there is oxygen enough for due haematosis, and so long as the deadly agencies of the car- bonic acid and the azote are not powerful enough to destroy. The bad effects of confined air might, therefore, be mainly, if not wholly, ascribed to the presence of an undue quantity of carbonic acid, and to the uncombined azote, left after the disappearance of the oxygen. This, at least, is one view of the matter; but those physiologists, who believe that the air is taken into the pulmonary vessels with- out decomposition; that its oxygen disappears in the course of the circulation, and that carbonic acid is formed in the system, and merely given off at the lungs,—a view which appears to be the most in accordance with observed facts,—would ascribe the phe- nomena to the deleterious agency of the carbonic acid. Instances have occasionally occurred, where death has been caused in this way,—as in a diving-bell, where the air could not be renewed; but the most melancholy example on record was in the— since celebrated—"Black Hole" at Calcutta—a place of confine- ment 18 feet by 18, or containing 324 square feet, in which one hundred and forty-six persons were shut up, when Fort William was taken, in 1756, by Surajah Dowla, Nabob of Bengal. The room allowed to each person a space of 26§ inches by 12 inches, which was just sufficient to hold them without pressing violently on each other. To this dungeon there was but one small grated window, and the weather being very sultry, the air within could neither circulate nor be changed. In less than an hour, many of the prisoners were attacked with extreme difficulty of breathing; several were delirious, and the place was filled with incoherent ravings, in which the cry for water was predominant. This was handed to them by the sentinels, but without the effect of allaying their thirst. In less than four hours, many were suffocated, or died in violent delirium. In an hour more, the survivors, except those at the grate, were frantic and outrageous. At length, most of them became insensible; and, eleven hours from the time they were im- prisoned, of the one hundred and forty-six that entered, twenty- three only came out alive, and these were in a highly putrid fever,— from which, however, by fresh air, and proper attention, they gradually recovered. A similar instance happened in London, in ^1742. Twenty persons were forced into a part of Saint Martin's round-house, called "the Hole," during the night, and several died. In these, and in all similar cases, the lethiferous influence is doubt- vol. i.—37 434 DISEASES OF THE RESPIRATORY ORGANS. less of a compound character; beingdependent both upon diminution of oxygen, and the presence of uncombined azote, and of an unusual quantity of carbonic acid. This acid, given off in respiration, is heavier than atmospheric air, and consequently accumulates near the ground, where ventilation is impracticable or neglected, and it can "thus be readily understood, that where the only aperture into the chamber is by the roof, or by a window high above the ground, the lower strata of air may become irrespirable for some time be- fore the upper. c. Asphyxia by irrespirable gases. The gases which produce death by occasioning a spasmodic closure of the glottis, or which are irrespirable, are not many. They are chiefly the carbonic acid, ammoniacal gas, muriatic acid gas, deutoxide of azote, nitrous acid gas, and chlorine. It has been before observed, that different writers have classed under this head, oxygen, the protoxide of azote, carburetted hydrogen, carbonic oxide, sulphuretted hydrogen, and arsenuretted hydrogen; but these gases give rise to no symptoms resembling asphyxia. They are positively deleterious, and act upon the frame as poisons, under which head they are considered. A similar remark might, indeed, be extended to the gases enu- merated as producing asphyxia by spasmodic closure of the glottis, when their strength is reduced below a certain point. Above this, contraction of the muscles that close the glottis is produced, as soon as the gases come in contact with them; but if sufficiently diluted, they may pass into the lungs, and exert upon those organs, and through them on the organism, the peculiar effects which they are capable of inducing. Thus, carbonic acid may cause symptoms of narcotism, whilst the ammoniacal gas, the muriatic acid, the deut- oxide of azote, the nitrous acid gas, and chlorine, may produce violent irritation, and inflammation of the air passages. It is, how- ever, in their relations to asphyxia, that they have to be considered at present. Carbonic acid gas is by no means an uncommon cause of as- phyxia, and it has not unfrequently proved fatal more slowly by the poisonous narcosis which it induces. It has been found, that air was still irrespirable, when it contained three-fifths of its volume of this gas. (Sir Humphry Davy.) Carbonic acid accumulates wherever combustion is going on; but it is the accumulation from brasiers of charcoal, where ventilation is impeded, that has been most lethiferous. The public journals con- tain accounts of many persons who have perished during the night, from this cause; and it was the method adopted by the younger Berthollet to rid himself of a disagreeable existence, in which he succeeded. In crowded apartments, artificially heated and well lighted, inconvenience,—such as hurried respiration and circulation, giddiness, &c.—are not unfrequently experienced from the presence of this gas, and allusion has already been made to its being con- ASPHYXIA. 435 cerned in the fatal affair of the Black Hole. It is the fixed air given off during the vinous fermentation; and, in the large vats of exten- sive ale and porter breweries, sufficient of the gas is often contained at the bottom to destroy those who may venture down. It is usual to pass a lighted candle to the bottom, and if it continues to burn, the descent may be made with safety,—carbonic acid not support- ing combustion. In like manner, it is met with in deep wells, and the same plan is adopted to discover whether the air will allow of combustion and respiration; but many a labourer has fallen a vic- tim to his want of attention to this precautionary measure. This air likewise constitutes the choke-damp of the coal mines, in con- tradistinction to the fire-damp, which consists of carburetted hydro- gen. It issues in some volcanic regions in great quantities, from fissures in the rocks, and is found in caverns, as at Pyrmont in Westphalia, and at the celebrated Grotto del Cane at Naples, so called in consequence of the number of dogs that are asphyxied in this collection of irrespirable gas. Carbonic acid is also extricated in considerable quantity in limekilns, by the agency of heat, which drives it off from the limestone or carbonate of lime,—and the public prints have detailed many cases in which life has been lost, owing to the wayworn traveller having laid himself down to rest in the warm but destructive atmosphere around one of these fur- naces. Lastly.—Plants evolve carbonic acid in the night, which renders the air of confined apartments unwholesome, and, in some cases, induces asphyxia. An instance of this kind is cited from the public prints. (Paris and Fonblanque.) A gentleman, having frequently had his pinery robbed, the gardener determined to sit up and watch. He accordingly posted himself with a loaded fowling-piece in the green-house, where, it is presumed, he fell asleep, and in the morn- ing was found dead upon the ground, with every appearance of suffocation, supposed to have been occasioned by the disengage- ment of "mephitic gas" from the plants during the night. Carbonic acid cannot be breathed in a pure state, or even, as we have seen, when diluted with two-fifths of its bulk of atmospheric air. It occasions an immediate spasmodic closure of the glottis, which cannot be overcome by the strongest efforts,—preceded by painful irritation of the glottis and the upper parts of the throat. When, therefore, a person descends into a brewer's vat, a foul well, &c, in which the gas is in a concentrated state, he dies as speedily from suffocation, as when a ligature is tied round the neck so as to completely shut off the entrance of air into the lungs. Air, however, which contains a much smaller quantity of this gas, is unfit for prolonged existence. Experiments have shown, that animals perished in about three minutes, when plunged into an atmosphere containing about one-fifth of its volume of carbonic acid. But in order that asphyxia may ensue, it is not necessary that the air of a room, in which charcoal is burning, should be as strongly impregnated as this. There is an obvious difference be- 436 DISEASES OF THE RESPIRATORY ORGANS. tween a mixture of free carbonic acid and air, and a mixture con- taining carbonic acid actually produced at the expense of the oxygen of the air. If only one-fourth of the oxygen be removed by combustion, it will contaminate the air with one-twentieth of carbonic acid and render it asphyxiating. (Varin, Devergie.) With regard to the discrimination of asphyxia produced by the inhalation of carbonic acid, nothing can guide us except the history of the event, which may be deduced from the circumstances sur. rounding the individual,—not from any intrinsic evidences. Patho- logical anatomy, independently of circumstantial evidence, does not indicate any phenomena, which distinctly show, that death has resulted from this variety of asphyxia rather than from any other. Treatment.—In the treatment of asphyxia from the respiration of carbonic acid, the first important procedure is to withdraw the patient from the deleterious atmosphere, and strip him of his clothes, in order that the air may come freely in contact with his skin. He must then be exposed to cool air, and cold water be thrown upon his face, until the respiratory movements re-appear. The reasons for this plan of management have been given previously. Friction over the chest must also be employed, and ammonia may be held to the nostrils, so as to stimulate the oppressed energies. These are the most important steps, but, in addition, insufflation has been advised to remove the noxious gas from the lungs, and to re-excite respiration; and Galvano-puncture, in the mode recommended by J^eroy d'Etiolles, for stimulating the diaphragm to contraction. It has been conceived too, that the insufflation of oxygen might be serviceable; and, by some, blood-letting has been employed; but it is not easy to discover the rationale of the action of these agents. The judgment of the practitioner must suggest to him, whether these or other means, adapted to particular emergencies, may be indicated. The ammoniacal gas, as well as the muriatic acid gas, the deutoxide of azote, nitrous acid gas, and chlorine—when in a state of concentration—are so acrid, that, when inhaled, the most violent irritation of the air passages is induced. It has generally been conceived, that they prove fatal by occasioning spasmodic closure of the glottis; but, from some experiments, (Broughton,)ti would seem, that certain of them pass the rima glottidis in suffi- cient quantity to produce phenomena, which are apparent on dis- section. In some experiments, which Mr. Broughton made on the effects of chlorine on mice, he found, that they fell dead in less than thirty seconds, and, on opening them, the lungs were tinged with the yellow colour of the gas, and the peculiar odour of chlorine was perceptible throughout their structure. Still it is probable, that death arises from asphyxia,—not from the poisonous influence of the gas, the effects of which could scarcely be exhibited in so short a space as thirty seconds. The smell of these agents will enable us to judge—in the absence of any history of the case—as to the cause of the asphyxia. ASPHYXIA. 437 The treatment is similar to that for asphyxia by carbonic acid gas; and, in addition, insufflation with sulphuretted hydrogen gas—largely diluted with common air—may be had recourse to advantageously. As these gases are extremely irritating, there may be a greater necessity for the employment of blood-letting, in asphyxia induced by them. d. Asphyxia from mechanical obstacles to the entrance of air into the lungs. The most interesting varieties of asphyxia are those that are owing to some mechanical cause preventing the entrance of air into the lungs, Some of these we shall consider in detail. 1. Asphyxia by submersion or drowning.—This is perhaps the most common, and one of the most interesting in the phenomena which it presents. It differs according as the submersion is complete from the first, or the person has risen again and again to the surface. In the former case, we should expect the post mortem appearances to be unequivocal. When a person falls into water, and remains beneath the surface, an effort is made to inspire; but this is impracti-^ cable, in consequence of the medium being irrespirable. Water is, however, drawn in, but as soon as the fluid reaches the glottis, the muscles which close it contract spasmodically; little or no water can enter, and death takes place with the same phenomena as present themselves in strangulation. These, as we have before shown, are,—accumulation of blood in the pulmonary artery and right side of the heart, owing to the non-conversion of venous into arterial blood, and more or less vacuity in the pulmonary veins, and left side of the heart. It is an important question of forensic medicine,—whether there are any intrinsic appearances about the found drowned, which can enable us—in the absence of all history of the case—to pronounce definitively, that death has taken place by drowning. It has often been affirmed, that the presence of water, or, at all events, of frothy mucus, in the bronchial tubes, is characteristic of this variety of asphyxia. But dissidence has existed on this point amongst observers. At one time, the entrance of water into the bronchia was considered to be the essential cause of death, but it is now sufficiently established, both by experiments on animals, and by observation of the bodies of the drowned, that but little water is to be looked for;_generally, indeed, there is none; but there may be a small quantity of frothy mucus, totally insufficient, however, to account for death. By many (Wepfer, Conrad, Becker, Wald- schmidt, Littre, Petit, and others,) water has never been met with in the air tubes; and many observers (Morgagni, Halter, Evers, Desgranges, and others,) assert, that, in their examination of several drowned persons, they have neither found water nor froth, although in other cases, some of these observers have met with both one and the other. Louis instituted several experiments with the view 37* 438 DISEASES OF THE RESPIRATORY ORGANS. of testing this matter. On immersing animals in coloured liquids, he discovered the liquids in the trachea, and sometimes even in the last bronchial ramifications. His experiments were repeated by Goodwyn, both for the purpose of proving that water positively enters the trachea, and of dispelling an idea, which had been enter- tained, that the frothy mucus is nothing-more than a secretion from the bronchial tubes, owing to extreme engorgement of the pulmo- nary artery, during the last struggles of the individual. Three animals were immersed in mercury, and after death an apprecia- ble quantity of the metal was found in the air passages. Experi- ments by others, (Berger, Orfila, Piorry,) have led to similar results. Admitting, then, that a small quantity of water may enter the bronchial tubes, we can readily understand, that if the individual were to rise to the surface and attempt to breathe, the inspired air, becoming mixed with the water and mucus of the bronchial tubes, might communicate the characters assigned to this frothy mucus; but it is not quite so easy to understand that any frothy mucus or liquid should be met with in the drowned unless under these con- ditions. If the individual, after immersion, took in any fluid and remained beneath the surface, or, in other words, did not inspire afterwards, it could scarcely be frothy. This would appear to be the view embraced by many. (Orfila, Piorry, Taylor.) Orfila is of opinion, that a greater or less quantity of water is generally drawn in during the agony of drowning, and that the existence of froth in the bronchi depends, in a great measure, on the circum- stance of the animal's having risen to the surface, and respired air once or twice previous to its final submersion. It need scarcely be added, that whenever froth is met with in the air passages, it is a proof, that the individual was immersed alive,—respiration being indispensable to mix the air with the liquid. The fact, however, of water being met with in the tubes is not a sufficient proof that the person came to his death by drowning. It has been affirmed, (E. J. Coxe, Evers,) that if cats be first strangled, and then thrown into water, and suffered to remain there for 12 or 14 minutes, no water will be found in the lungs, except when the abdomen is compressed. In the latter case, the air and mucus being driven from the lungs, the liquid will be able to enter. Others, however, (Orfila, Piorry,) have deduced, from their experiments, that in the case of dogs, killed by strangulation, and immersed in water a short time after death, water constantly enters the trachea, and may pass even to the last bronchial ramification, if the animal be kept in a vertical position, with the head upwards,—in other words, as if it had died from drowning. Hence it may be inferred, that the entrance of water into the air passages is not necessarily a vital act. to presence in the trachea, bronchia, and even in the ultimate subdivi- sions of the bronchial tubes, is not a certain sign that the person was living at the time of immersion, even if it should be shown that the liquid is of the same nature as that in which he is found ASPHYXIA. 439 drowned. Still, as has been remarked, (Devergie,) this conclusion is not entirely rigorous, unless we infer that the same results occur on man as on dogs. Again.—It has been affirmed, that the presence of the frothy mucus is not of itself positive evidence of death from submersion, and that it has been observed in other kinds of death. Orfila says, it is not necessary that water should enter the trachea, in order that this frothy fluid should be found; and that the tracheae of those who have been hanged always contain some of it. The first of these assertions has been confirmed by daily observation; but Devergie—although he does not deny the latter—asserts, that he has opened the bodies of thirteen individuals who had been hanged, and that in none did he meet with frothy mucus in the trachea. He suggests, moreover, that it is important to have cor- rect ideas respecting the nature of this froth, in order that it may not be confounded with frothy sputa. The froth of the drowned, he says, is commonly white, with very minute and numerous bubbles of air, constituting a foam (mousse) rather than a froth (icume). It never adheres to the trachea by the mucus, but is applied immediately to the tube. The same slightly viscid water, of which it is formed, attaches it to the trachea: all the bubbles that constitute it have a very fine aqueous envelope; they are readily divisible, and often, when the trachea is opened, the greater part subside like soap-bubbles. Whence, he concludes, the frothy water of the drowned has but little similitude to the sputa either of pneumonia or of catarrh, and that attentive observation will prevent them from being confounded. From all, then, that has been said, it is manifest, that although our knowledge on this matter needs some of that certainty, which is so desirable, the presence of frothy water, or of frothy mucus, does not perhaps afford us any unquestionable evidence that death has taken place from drowning rather than from any other form of asphyxia. Devergie is of opinion, that the strongest of the pre- sumptive signs of drowning is the existence of the non-mucous froth or foam on the internal membrane of the trachea—itself in a sound state. Again.—It was at one time thought, that the stomach would be found largely distended with fluid in cases of death from drown- ing; but this also is erroneous. Perhaps, in all cases, some fluid will be swallowed, whilst the power of deglutition remains; but the convulsive action, induced in the muscles of the throat, will gene- rally prevent much from passing. After death, it does not make its way into the stomach. The presence, therefore, of the fluid of immersion in that organ would be evidence, that the person had been thrown in alive; but the evidence loses much of its value, from the difficulty there must always be in establishing the identity between the fluid in the stomach, and that into which the body had been cast. All these are interesting topics of medico-legal inquiry. 440 DISEASES OF THE RESPIRATORY ORGANS. A fluid state of the blood has been considered, by almost all writers on this subject, as an evidence of death from drowning. It would be a singular circumstance were this the fact;—unac- countable, indeed, unless we were to consider, that the fluid of immersion were to penetrate the tissues to mix with one of its solutions; and we know the avidity with which water will pene- trate animal membranes to accomplish this. In canvassing this point, Devergie states properly, that the existence of coagula in the vessels of the drowned is very uncommon, and that the fluidity of the blood is such, that it flows like water,—but he judiciously adds,—this fluidity ought to be common in cases of sudden death; and he says, that he has found it so in a number of persons, who had destroyed themselves otherwise than by submersion. Such, also, has been the result of the observations of the author on this subject. Of the general impracticability of resuscitation in cases of as- phyxia by drowning—where the causes have been fully and effectively applied—even a few minutes after the cessation of respiration, mention has already been made, when treating of asphyxia in general. Allusion was also made to fabulous narra- tions of restoration after a long immersion. It is but too true, however, that an immersion of a few minutes only will often seal the fate of the sufferer. It has been asserted, that if the submer- sion has not exceeded five minutes, and no blow against a stone, or other violence, has occurred to complicate the effects, the efforts at resuscitation, if properly conducted, will generally be successful. After a quarter of an hour, recovery is not very common; after twenty minutes, or half an hour, it may be considered hopeless. The longest period recorded in the Reports of the Royal Humane Society is three quarters of an hour; and from the first report of the establishment for the recovery of drowned persons in Paris, it would appear, that, out of twenty-three cases restored to life, one had been three quarters of an hour under water; four, half an hour; and three, a quarter of an hour; the rest for a much shorter time. (Roget.) It must be borne in mind, too, that an individual, who falls into water in a state of syncope may be submersed for a much longer period, and be capable of restoration, than if he fell into the water in full vital activity. To this variety of asphyxia, the epithet " syncopal" has been applied. The same may be said of one, who receives a powerful cerebral concussion, prior to, or at the time of, immersion. He is, probably, in the same condition—so far as his vital functions are concerned—as if he were in a state of syn- cope. (W. B. Carpenter.) It may be remarked, by the way, that the cases which we see related of good swimmers being drowned are often, probably, of this last class. They are struck by the wave, stunned, and ren- dered incapable of exertion. Perhaps, the safest rule is to attempt resuscitation, unless the ASPHYXIA. 441 signs which characterize the existence of death are present,— according to some, unless putrefaction, or cadaveric rigidity, has supervened; but the humane practitioner requires no guide of this sort. He must judge according to his best powers of discrimination, whether the case be one of asphyxia, or of permanent privation of vitality, and, if any doubt remains on his mind, his efforts must be continued until the doubt is removed. Treatment.—As regards the treatment of this form of asphyxia, much need not be said, in consequence of the immediate applica- tion which the remarks made on the general treatment of asphyxia have to this variety. The rules to be adopted may be summarily expressed as follows:— When the body is taken from the water, the mouth and nostrils should be cleansed, and if frothy mucus exists in the fauces it may be removed by the finger enveloped in a handkerchief. The wet clothes should be removed; the body be wiped dry, and be wrapped in a dry blanket: in this way it can be taken to the nearest habita- tion, oii a board, or in a cart. When the body has been conveyed to a room, admitting of a good fire, if the water has been colder than.the medium temperature of the climate, it may be stripped, placed upon a sofa, table, or on a board supported on chairs, before the fire, at such a distance, that the radiant heat does not act too powerfully upon it, and care being taken that the air of the apart- ment is not above 75° or 80°. (Kay.) A greater degree of heat than this is noxious, for reasons before mentioned; and it has been properly observed, that great caution should be used in the appli- cation of an elevated temperature to even a part of the body, excepting to the extremities—and they ought not, perhaps, to be excepted—lest the vital power of some important organ should be thereby enfeebled. Such is the course, as regards the application of warmth to the body, most commonly pursued; yet, as previously shown, it has been a matter of question with some, whether the temperature of the body should not be kept depressed even when that of the atmos- phere is low, until respiration has. been restored by insufflation. Whatever doubts may exist on this point, there can be none, that any undue elevation of temperature is positively injurious, and that temperature, as Dr. Kay has observed, must be regarded as exerting chiefly a conservative influence. As soon as the body has been placed in the favourable circum- stances mentioned, attempts must be made to re-excite respiration, during which the head and chest should be kept raised, and the nostrils and mouth clea'nsed and open. From what has been before said, the rationale of the following recommendations will be obvious. Let the individual be so ex- posed, that the atmosphere can act on the body; employ friction; and artificial respiration, according to the plans previously advised, by means of the bandage, and the instrument of Leroy or any 442 DISEASES OF THE RESPIRATORY ORGANS. other at hand, with the precautions that have been pointed out, lest serious mischief be done to the delicate fabric of the lungs. Whilst artificial respiration is carried on, and especially if there be signs of returning animation, the warmth of the patient may be somewhat increased, and bottles of warm water, or warm bricks,or warm flannels, may be applied to the feet, knees, armpits, pit of the stomach, and along the spine. The warmth of a healthy per- son lying by the body is said, in the Report of the Royal Humane Society, of London, to have been found, in some cases of adults, but particularly of children, very efficacious. In the same report it is affirmed, that the warm bath, where it can be procured, is preferable to all other means of communicating heat; but the ob- vious objection to it is, that free exposure to the air is prevented, whilst the experiments of Edwards have established, that water exerts an injurious influence on the nervous and muscular systems. As respects the use of stimulants, blood-letting, and other agents —often had recourse to in this and in other forms of asphyxia— what has been already observed, when touching on the treatment of asphyxia in general, is sufficient, and the same may be said of the means that are necessary after recovery. It need scarcely be remarked, that the absurd practice of hanging up the drowned by the heels when first taken out of the water,and of rolling them on casks, ought to be universally reprobated. They were introduced at a period when death from drowning was sup- posed to be owing to the entrance of water into the chest and abdomen. If, in the language of the motto adopted by the Royal Humane Society, of London, " lateat scintillula forsan"—the feeble spark could scarcely fail to be extinguished by such treat- ment. 2. Asphyxia from hanging and strangling.—The pheno- mena of death from hanging and strangling are identical, so far as regards the intrinsic evidences. The extrinsic differ some- what, in consequence of the situation of the cord, which in the latter case is horizontal; in the former more vertical. It can be understood, too, that in the former there may be dislocation of the cervical vertebiae, whilst in the latter this is not to be expected; but more mischief may be observable in the rings of the trachea, owing to the violence with which the rope has been tightened with the view of rendering death certain; for strangulation is primdfacie evidence of homicide; hanging, of suicide,—it not being a very easy matter to hang a person against his will. Occasionally, too, strangulation has been effected by putting a stone or a coal in a handkerchief, and tightening it so that the coal may press upon and obstruct the windpipe; and cases have occurred of manual strangu- lation, the evidences of which have been apparent in the ecchy- mosis produced wherever the points of the fingers have pressed. It is obvious, that the intrinsic phenomena must differ in these cases, according as the ligature is effectually or imperfectly applied; and, again, a difference may exist as regards the ratio moriendi, ASPHYXIA. 443 —whether, for example, death has begun in the lungs, or whether, owing to the dislocation of the vertebrae and consequent injury to the spinal marrow, the organs of innervation have been the first to be deprived of vitality. Now, as injury to the spinal marrow could not be easily induced in death by strangulation, this must be esteemed as the more simple form of the two. Of old, the idea generally entertained was, that death in strangu- lation was,caused by the cord pressing on the jugular veins, and thus interrupting the return of blood from the encephalon, whilst its transmission to the brain by the vertebral arteries was uninter- rupted. Engorgement of the cerebral vessels consequently super- vened, and apoplexy. The striking objections to this view were, —that these very vessels may be tied without producing fatal apoplexy, or apoplexy at all. Even the vertebral arteries have been tied, along with the jugulars and carotids, on animals,—and yet they have survived the operation. In some experiments, in which Dr. Kay included both the carotid and vertebral arteries in ligatures, one or two of the animals recovered, although they were exceedingly weak for some time after the operation. More recent experiments (Sir A. Cooper) seem to establish, that the functions of the brain are more under the influence of the vertebrals than of the carotids; and that in certain animals—as the rabbit—these functions are instantaneously suspended, when the circulation is simultaneously arrested in both one and the other. Again,—Dr. Kellie tied the common jugular and the recurrent veins low down in the neck on two dogs, one of which appeared to suffer no inconvenience; the other, although rather dull and heavy for two days, speedily recovered. Another strong objection to the view, that death is owing to hyperaemia of the encephalic vessels, is presented by the well- known experiment of Dr. Monro, Sen., who suspended a dog after having made an opening into its trachea below the place where the cord encircled the animal's neck. Through this aperture the dog breathed freely during the period of suspension, which was three quarters of an hour. He was then cut down, and did not appear to have sustained any serious injury. When, however, the cord was placed below the orifice, and the suspension was renewed, he soon died. (Curry.) The works on medical jurisprudence refer to cases, in which attempts have been made to save the lives of criminals, by making an opening into the trachea, (Mahon, Fodire, &c. &c.) A well- known case of this kind is that of Gordon, who, at the commence- ment of the last century, was sentenced to be hanged for highway robbery. He had become very rich by his avocation, and offered a large bribe to induce a young surgeon to attempt to defraud the law of its victim. An incision was made in his neck, and a tube was introduced through it into the trachea, in such a manner, that 444 DISEASES OF THE RESPIRATORY ORGANS. respiration might go on, if the upper part of the neck were con- stricted by the cord. The man was, however, very heavy, and it was considered that other accidents, besides the mere interruption of respiration, were produced by the fall, for when the body had been suspended the accustomed time, and was cut down, and handed over to the friends, the surgeon drew blood from the jugular vein, and used the utmost exertion to resuscitate him, but in vain, Some slight evidence of vitality was manifested. Once he opened his eyes and sighed; but this was all. A surgeon of the Austrian army informed M. Richerand, that he had saved a soldier by practising laryngotomy, some hours before the man was suspended. It certainly cannot be considered as by any means established, that congestion in the encephalon occurs in death from strangula- tion or hanging. The affirmative view has doubtless been em- braced, chiefly in cousequence of the marked turgescence of the vessels of the integuments of the head and face. After death from hanging and strangulation, the vessels of the scalp, and of the integuments of the head and neck, are gorged with blood, as well as those of the mucous membranes of the eyes, nostrils, and lips, and not unfrequently blood exudes from the nose and mouth. ' From these outward signs of turgescence, it was inferred, that similar engorgement of the encephalon existed; but, although Mor- gagni, De Haen, and others, directed their attention for a long time to the subject, they did not discover any signs of engorgement in the brains of such as had died by suspension; and the observations of Coleman on animals, and of others, (Monro, Kellie, Wutson,) on the bodies of criminals and others who had been hanged, con- firm their assertions. Neither is there any appearance of congestion in animals that are killed after a ligature has been put on both the internal jugular veins, or when these vessels have been obliterated by the pressure of tumours. It is proper, however, to remark, that some recent observers (Remer, Casper, Fleischmann) affirm, that in a great majority of those who had died from strangulation, they observed signs of apoplexy. Taking all the facts into consideration, we are, perhaps, justified in inferring, that the ligature of the vessels of the neck does not occasion immediate death, and that the constriction by the cord, in suspension and strangulation, does not produce death by engorge- ment of the vessels of the brain. We have, therefore, to look for another chief cause of death. This is, doubtless, as had been occa- sionally suggested, (Belloq,) and has recently been much insisted upon, (Kay,) the interruption of respiration. The duration of life, in these cases, may be modified, as has been already suggested, by various circumstances,—such as the mode in which the rope is "fixed; the height from which the body has to fall, &c. A humane executioner can expedite death by adding his weight to that of the criminal, so as to luxate the ver- ASPHYXIA. 445 tebra of the neck; and Louis found, that the Parisian executioner could generally occasion death without a struggle, by rupturing the ligaments which unite the first and second vertebrae, or the liga- ment which confines the processus dentatus of the latter, so as to occasion pressure on the spinal cord. It may be laid down as a general rule, that death will supervene in a longer or shorter period, according as the obliteration of the air passages is more or less complete. Sometimes, as already remarked, the rope may be placed between the lower jaw and the larynx, or in such a position, that a small supply of air may enter the lungs; or unusual rigidity of the.cartilages of the larynx may exist, so as to permit air to enter—if not in sufficient quantity to maintain life, at all events to prolong the sufferings. This is often the case with those who attempt to destroy themselves. In a recent case of penal hanging, in which a series of hetero- geneous experiments were performed, the pulse was perceptible at the wrist for seven minutes; and the pulsations of the heart for twelve. (Amer. Journ. Med. Sciences, May, 1840, p. 16.) The interruption to respiration must, then, be regarded as the chief cause of death from suspension; yet, as Dr. Kay has observed, the condition of the sanguiferous system is considerably modified in this form of asphyxia, and the circulation in the brain is some- what affected, though congestion may not be induced. The sphinc- ters are frequently relaxed; the urine and faeces consequently escape, and there is often erection of the penis with emission of semen. The cause of these different symptoms has been a topic of inquiry. Orfila attributes the last symptom to traction of the spinal cord, consequent on the extension of the ligaments of the vertebral arti- culations; and in support of the opinion, he affirms, that erection is a frequent consequence of traumatic affections of the cord: he cites, also, a case in which it occurred in consequence of luxation of the fifth cervical vertebra. Dr. Kay—and we suppose every phreno- logist will join with him—is inclined to attribute it to some vascular disturbance of the cerebellum. Emission is, however, by no means as frequent an occurrence as has been supposed. In 77 cases, it was noticed 19 times. It is liable, too, to occur from other causes, such as injuries of the spinal cord by direct violence, as by puncture. The membrane of the urethra has also been found greatly injected. It has been affirmed, (Devergie,) that some effusion of semen into the urethra almost always takes place, although it may not be apparent externally, and that it is detected by the presence of the peculiar animalcules; but fresh observations are necessary. In some animals, the ligaments of the spine can be readily stretched so as to cause death. Every cook knows that this is the case with the rabbit,_and we may readily conceive, that death might be produced in this way in man also. (Orfila.) We have before referred to some of the accidents that occasionally complicate asphyxia by suspension;—the injury to the larynx, &c. vol. i.—38 446 DISEASES OF THE RESPIRATORY ORGANS. There have also been cases in which true apoplexy has occurred,— effusion of blood having taken place in the brain; but these appear- ances present themselves in a few instances only. They are by no means to be looked for in simple cases of asphyxia from ban?. ing or strangulation. In a manuscript note, furnished by Sir Benjamin Brodie to Dr. Paris, (Paris and Fonblanque,) it is stated as the opinion of that distinguished surgeon, that if an animal should recover from the direct consequence of strangulation, it may probably suffer from the effects of the ligature on the nerves afterwards. Sir Benjamin passed a ligature around the trachea of a Guinea-pig, and tied it firmly on the back of the neck with a knot: the animal was uneasy, but nevertheless breathed and moved about: at the end of fifteen minutes, the ligature was removed; but on the following morning the animal died. On dissection, no preternatural appearances were discovered in the brain, but the lungs were dark and turgid with blood, and presented an appearance similar to that which is ob- served after the division of the pneumogastric nerves. " I do not." says Sir Benjamin, "positively conclude from this experiment,that the animal died from an injury inflicted on the nerves of the eighth pair, but I think that such a conclusion is highly probable, and it becomes an object of inquiry, whether a patient, having recovered from hanging, may not, in some instances, die afterwards from the injury of the par vagum." Treatment.—With regard to the treatment of asphyxia from suspension—or strangulation—it does not differ much from that which is applicable to asphyxia in general. The chief modification demanded is by the state of engorgement of the venous system of the outward head, produced by the constriction of the cord. The ligature must be removed immediately from the neck, and the head and shoulders be elevated; and the body should be stripped,and exposed freely to the air, even when the temperature is somewhat low. The application of heat is the more unnecessary in this case, as the body has not been immersed in a cold medium, as in cases of drowning. Artificial respiration must be adopted as soon as possible, with the other agencies and cautions that have been already advised. Bleeding may be useful, to relieve the tur- gescence of the external vessels,—but only for this purpose. Especial care must be taken not to extinguish the flickering spark of vitality, and it need scarcely be observed, that during recovery the abstraction of blood may be practised with great advantage, should symptoms of irregular vascular action about the head seem to indicate its employment. 3. Asphyxia from smothering.—Asphyxia from smothering does not differ, in its essential phenomena, from the other varieties. Except in the case of children, it is scarcely known, and even in them, it may be regarded as a rare occurrence. Occasionally it occurs to them as an accident, or perpetrated as a crime. It is pos- sible, too, for an adult, in a state of intoxication or great debility, to ASPHYXIA. 447 get into such a position as to prevent the entrance of air into the air passages. Death, too, is not unfrequently produced by what is called " overlaying children," which does not always mean that they have been smothered by the mother lying'upon them. Fatal accidents have happened from the young infant being pressed too closely against the side of the mother during her sleep, so that respiration has been arrested; and it has happened, that fatal as- phyxia has been caused by the anxious care of the mother to wrap her infant so as to shield it against the inclemency of the weather. Children, again, have been smothered by being folded up in a sort of turn-up bedstead, once much employed—by the poorer classes especially—in a double capacity,— " A bed by night; a chest of drawers by day." The same differences may occur in this variety of asphyxia as in those that have been considered,—according as the condition has been induced at once, or as respiration may have gone on, though imperfectly, for a time. Treatment.—As to the treatment, it is precisely that which has been laid down under the former heads, with the exception of the means demanded for their peculiarities. Asphyxia from smother- ing, may, indeed, be looked upon as the most simple form: to it, therefore, the directions for the management of asphyxia in general are strikingly appropriate. 4. Asphyxia from tumours and other morbid conditions.— Among the causes that give rise to asphyxia, by preventing the entrance of air into the lungs, are enumerated;—obstruction of the air passages by the entrance of extraneous bodies, by the presence of tumours, or by any morbid thickening of the lining membrane of the tubes. For an account of the pathological phenomena, which are consequences of morbid actions going on in the parts, we must refer to the chapters that consider such lesions. It need scarcely be said, that if such extraneous bodies or morbid condi- tions shut off the air at once, simple asphyxia is produced; if more slowly, the phenomena—as in other varieties of asphyxia—must be modified by the circumstance; and that the cases will have to be treated—medically or surgically—according to rules laid down elsewhere. The same may be said of asphyxia produced by wounds in the parietes of the chest, which admit the air freely into the cavities of the pleura, and occasion contraction of the lungs. By those who have employed the term " Asphyxia" in its wide acceptation, many other varieties have been admitted. Thus, one writer (Most) enumerates Asphyxia from drinking; A. from poisons; A. from cold; A. from lightning; A. from hemorrhage; A. from vio- lent passions or emotions; A. from concussion or contusion; A. from luxation of the cervical vertebrae, &c; but, according to the definition of asphyxia, given in this article, their consideration would mani- festly be out of place here;—the-first link in the chain of morbid phenomena being seated in the functions of innervation or circu- 448 DISEASES OF THE RESPIRATORY ORGANS. lation, rather than in that of respiration; yet Dr. Kay, who, as we have seen, has so well explained the theory of asphyxia, has indulged in an episode on Death from cold, which is as much out of place as would have been Death from apoplexy, or many of those other varieties that have been admitted by Most, Wagner, and such as allow a more extended acceptation to the term. There is a form of asphyxia, however, which may, with much propriety, be considered in this place,—according to the views which we em- brace of its theory and phenomena. This is the Asphyxia of the new-born infant. e. Asphyxia of the new-born infant—Asphyxia neonatorum. It is well known, that during intra-uterine life, no more blood passes through the lungs than is necessary for their nutrition, and that the blood of the foetus is sent to the placenta, whence it passes back by the umbilical vein; doubtless after having experienced some changes in the placenta, which better adapt it for the nutrition of the new being. The precise mode, in which the nutrition of the foetus is accom- plished, has been a topic of discussion amongst physiologists for ages. The facts and arguments appear to us decidedly in favour of the view which considers, that the human placenta has no direct agency in embryotrophy, and it seems to us, that all that is neces- sary—in order that a foetus shall be developed in utero—is, that there shall be an absorbing surface surrounded by a nutritive substance, which will admit of being absorbed. The cutaneous envelope of the foetus—monstrous or natural—is such a surface,and the liquor amnii such a fluid; whilst the matter of the umbilical vesicle, and the jelly of the cord, when these parts exist, and pos- sibly some material derived through the placenta—after it exists— may lend their aid; but the participation of the last organ is cer- tainly questionable. Its function is probably to admit of the foetal blood being shown to that circulating in the maternal vessels, in order that some change may be effected in the former, which may better adapt it for serving as the pabulum, whence the secretions from which the foetal orga«s have to be elaborated, must be form- ed. (See the author's Human Physiology, 4th edit, ii, 4S8, Philada. 1841.) The placenta, in other words, may be esteemed a respiratory organ for the foetus; and yet its presence does not appear to be in- dispensable, as there are many well authenticated cases of children having undergone intra-uterine development, in the absence of umbilical cord, umbilicus, and placenta. Still, when these parts have once existed, they are necessary for complete foetal develop- ment, and anything that interferes with the due passage of the blood along the cord will produce asphyxia,—not only by prevent- ing the requisite changes of the blood in the placenta, but by the interference with the circulation, which has to be effected by the umbilical cord and placenta, until the independent circulation is established by pulmonary respiration. (Velpeau.) We can thus ASPHYXIA. 449 understand, that if the cord comes down in such a manner as to be strongly compressed for some time before delivery, asphyxia may be produced;—should the cord, for example, descend before, or with, the head. In like manner, when the breech, feet, or knees, present, there is danger to the child, unless the delivery be rapid. Occasionally, too, the child is still-born, apparently in consequence of some morbid condition of the organs of innervation. Thus, owing to pressure of the head, in its passage through the pelvis, or to some modification in the encephalo-spinal centres, or in the nerves distributed to the respiratory organs, the function of respira- tion is not established, notwithstanding that the circulation appears to go on well along the cord: the child seems to be in an apoplectic condition. Asphyxia may persist longer in the new-born child than in the adult, in consequence of the powers of calorification being but im- perfectly developed, and there being, in consequence, less need for a highly oxygenized blood for its support. Treatment.—It has been a question, whether the umbilical cord should be divided in these cases as soon as the child is extruded. In reply to this it may be remarked, that if all circulation has ceased in the cord, there can be no advantage whatever in keeping the connection between the child and the placenta entire, especially as the union cannot fail to interfere with the due application of such means as may be esteemed necessary. Indeed, where the circula- tion continues, but is becoming weaker, whilst the breathing has not commenced, it has been properly doubted, whether if the con- nection with the mother interfere with the application of other efficacious means, it should be permitted to continue, when, owing to the placental circulation having become weaker, it seems evident that the application of such means cannot be longer delayed with impunity. (Kay.) Sometimes, when the child is extruded and the placental circu- lation continues, the stimulus of a smart stroke on the breech will arouse the dormant energies, and the child will immediately begin to cry; but if this be insufficient, the infant had better be exposed to a moderately warm temperature, that is, to the moderate warmth of the fire, but so that the air can come in contact with a large sur- face of the body. Edwards found that the young of some species of warm-blooded animals, when deprived of air, live longest in a temperature of about 68° Fahrenheit, and this may be taken as a guide to the proper temperature for the still-born infant. Generally, immersion in a warm bath is had recourse to, but the rationale of its action is by no means unequivocal, whilst, as Dr. Kay has ob- served, it is not necessary to the application of a proper degree of warmth to the body of the child; it prevents the beneficial effects of the atmosphere on the skin; and, moreover, it is found, as we have seen, to exert a depressing influence on the nervous and mus- cular systems. 38* 450 DISEASES OF THE RESPIRATORY ORGANS. In addition to these means, friction with the dry hand, or with stimulating liniments, especially over the regions of the chest and stomach, as well as the application of spirits to the nostrils, to rouse the respiratory nerves to action, have been recommended. Should any mucus obstruct the mouth and pharynx, it ought to be removed by means of the finger enveloped in a piece of fine linen, dry or dipped in a solution of common salt. But, after all, these means will often be found unsuccessful, and it becomes necessary to have recourse to artificial respiration. This is, indeed, the great reliance of the practitioner in severe cases,aud its salutary influence is frequently very marked. Whilst artificial respiration is persisted in, the cord will often be observed to pulsate, and to cease when the operation is suspended. In the still-born foetus, it is not found practicable to execute artificial respiration by mere pressure on the chest, in the mode recommended for the adult. In one case, Dr. Blundell diligently operated in that manner for fifteen or twenty minutes together, without producing resuscitation, and, on examining'the child on the following day, he found that scarcely a particle of air had entered the lungs. Nor can insufflation be readily effected by blowing in at the mouth. The only mode of doing it effectually is by means of a curved canula or some analo- gous instrument. The author has been in the habit of carrying a tracheal pipe, or tube of silver, closed at the end, and with'an aper ture near the extremity, to give passage to the air and mucus. The introduction of this instrument into the larynx is by no meansdiffi- cult, with a little care. All that is necessary is, to pass the forefinger of the left hand upon the root of the tongue as far as the opening of the larynx, and then to insert the tube, held in the right hand, along the finger as a director. It will readily enter, and by pressing on the neck, it can easily be discovered, whether the instrument is in the trachea or the oesophagus. The lungs may then be inflated by blowing air from the lungs of the practitioner through the tube, and forcing it out again by pressing on the thorax and abdomen, and repeating this five-and-twenty or thirty times in a minute,—the respirations of the new-born infant being as numerous as that. It has been objected, that the air, sent into the lungs of the fetus from those of the adult, cannot be as efficacious as pure atmospheric air; but it is to be borne in mind, that the young being does not require such highly oxygenized air as the adult. In inflating, care must be taken, as has been previously inculcated, that it is not driven in too powerfully. The experiments of Leroy d'Etiolles show, that insufflation may be performed with much less risk in the infant than in the adult, because the structure of the lungs is firmer in the former, and consequently there is less danger of rupture or dilatation of the air cells. If the bellows of Leroy are at hand, which they scarcely ever are on such occasions, they may be employed. It has also been proposed, that a small galvanic apparatus, like that recommended by Leroy, and before described, might be used with advantage to ASPHYXIA. 451 rouse the diaphragm to contraction. " The acupuncture needles might be introduced into the diaphragm, one or two lines on each side of the chest, and two wires, each leading to an opposite pole of the galvanic circle, might be connected with.these needles. On completing the galvanic circle, a contraction of the diaphragm would be produced, which might be suspended by removing one wire, for a moment, from its connection with the battery. The relaxation of the muscle might then be effected by gentle pressure on the abdomen, and this process might be alternately repeated until respiration was established." (Kay.) Such appears to be the most approved mode of resuscitation in cases of the Asphyxia neonatorum. Desormeaux, however, com- plains of his want of success from inflating the lungs, even when assiduously used, and he places his main reliance on external means for exciting the respiratory muscles to contract. For this purpose, he recommends a species of douche or ablution with some alcoholic liquor. This the practitioner takes into his mouth, and, having held it there a few seconds, he ejects it forcibly against the anterior paries of the infant's chest. It is rarely necessary, he says, to repeat this more than twice or thrice. Velpeau says he has adopted the plan, and with success. It has been also advised, that a cupping-glass should be applied to the nipples of the child, or that they should be sucked by the mouth, (Van Swieten, Saccombe, Wagner;) but, as Desormeaux has remarked, the only use in this can be to excite the action of the muscles. It is utterly impossible, that any dilatation of the chest could be produced by it, as has been believed by many, who were more credulous than judicious. (Velpeau.) It is unnecessary to dwell upon the many other expedients that have been occasionally adopted. If the means pointed out should fail, we ought not to expect advantage from such agents as the smoke of linen or burnt paper, or onions or garlic introduced into the rectum, or the application of stimulants to the nose. Their cautious use may be advisable when the spark begins to be ignited, but not before. When the means are beginning to succeed, the pulsations of the heart and of the cord—if the child be still attached—gradually return; the muscles resume, by degrees, their natural firmness; the skin becomes less pale, and calorification is re-established. Some slight convulsive gasps are made, which become stronger and stronger, and ultimately the child attains sufficient vigour to cry, after which it maybe looked upon as safe. This, at least, is a general rule; but every practitioner must have had the mortifica- tion to find, that even when he has succeeded so far, unfavourable symptoms have presented themselves, and the child has sunk. Velpeau refers to two cases in which he had succeeded in restor- ing the movements of the heart and the lungs for more than three hours, by means of insufflation and galvanism; yet both infants were subsequently lost. 452 DISEASES OF THE RESPIRATORY ORGANS. The same question has been agitated here, as in other cases of asphyxia:—How long ought we to persevere in our efforts at re- suscitation? It has been advised, that they should not be relin- quished under two or three hours,—but all this must be decided upon by the good sense of the practitioner. Let him bear in mind, that many a child has been thrown aside as dead, which might probably have been saved. A woman, run over by a stage, was carried into St. Thomas's Hospital, London, and died in a kw minutes after admission. Dr. Blundell was requested by Mr. Green to assist in the Caesarean section. In thirteen minutes from the last respiration of the mother, the child was taken out. In fifteen minutes from the last respiration of the mother, Dr. Blundell began the artificial respiration, and, during fifteen minutes longer, he continued it. Ultimately, the child was completely resuscitated, and, according to Blundell, if due care had been taken of it, it would probably have been living still. He affirms, also, that a Mr. Tomkins of Yeovil, a gentleman very accurate in his observa- tions, used resuscitants for an hour and five minutes by the watch, before obvious signs of life appeared. The child recovered, and lived for some time afterwards. Still, much must be left to the judgment of the practitioner. Where, from the appearance of the foetus or other evidences, he has reason to believe, that it has been for some time dead in utero, all his endeavours must necessarily be abortive. It is only incases in which the child has perished in the birth, that means can be available,—and in such case all the energetic measures, which we have recommended, should be put in force, and not abandoned until hope is lost. Mr. Burns says, that when a child does not breathe soon after it is born, it is not always easy to say whether it is alive, as we have, at this time, no criterion of death except putrefaction; and, therefore, that it behooves us always, unless this mark is present, to use means for preserving the child. His remark might be extended to every case of apparent death happen- ing at any age, but there is generally a catenation of phenomena, which enables us to pronounce with tolerable certainty before this criterion of death is observable. There can be no doubt, however, that so long as there is any hesitation in the mind of the practitioner as to whether the child is dead or not, his efforts should be perse- veringly continued. Where there is any reason to believe that the state of suspended animation is dependent on, or connected with, an apoplectic con- dition,—as where the respiration is very slow and laborious, and there is evidence of venous engorgement of the head and neck, with pulsation in the cord—advantage is often derived from per- mitting a teaspoonful or two of blood to flow. Where the attempts at resuscitation have been successful, in the case of asphyxia of the new-born, the same attention is necessary during recovery—that is, for a day or two afterwards—as in the varieties of asphyxia previously mentioned. BOOK III. DISEASES OF THE CIRCULATORY APPARATUS. CHAPTER I. MORBID CONDITIONS OF THE BLOOD. After the follies of the humoral pathology had experienced from pathologists the ridicule which they richly merited, it was for a long time believed, that the fluids are never the seat of dis- ease, and Solidis?n— spleen, in the same manner as in the liver. Pathological characters.—The inflammation may be found to j have been seated in the substance of the spleen itself, or in its en- I velope, and it may present various appearances. The inflammation | may have ended in softening or in induration of the organ; but these conditions, when observed on dissection, are not perhaps suffi- cient evidence of the previous existence of inflammation. (Andral) OF THE SPLEEN. 553 They may be dependent upon a vice of nutrition, like similar conditions of other organs. The affection may also end in suppu- ration, and the pus may either be collected in one cavity or in several, and it may be discharged into the cavity of the peritoneum; or, by the formation of adhesions between the parietes of the abscess and the neighbouring parts, it may pass into the stomach, intestines, left side of the chest, &c. An interesting case of probable suppuration of the spleen has been recorded. (Professor Gross, of Louisville.) The pain, which was of a sharp, lancinating character, similar to that which accom- panies acute pleuritis, continued almost uninterruptedly for nearly two weeks. The spleen gradually augmented in volume, and at the expiration of this time, it projected over towards the umbilicus, forming a large rounded tumour between the linea alba and the margin of the ribs. In a short time, fluctuation was perceived, and, on introducing a trocar, about three pints of fetid, dark coloured matter, issued from the incision. The wound was kept open for several days, by means of a tent; but in a short period it closed, and the patient's health began gradually to improve. This case supervened on repeated attacks of intermittent fever, and was characterized by excessive irritability of the stomach, great pain and tenderness, and an impending sense of suffocation,—caused, no doubt, as Dr. Gross suggests, by the pressure of the enlarged organ upon the diaphragm. The disease was probably suppuration of the spleen; yet doubt must exist, as no opportunity occurred for establishing the point by dissection. It may have been connected with, but not originat- ing in, the spleen. Gangrene of the spleen is a very unusual occurrence. Treatment.—Acute splenitis requires the same management as the like pathological condition of other internal organs;—general and local blood-letting, followed by revellents, the warm bath, cathartics, rest and regulated diet. The chronic form must be treated by local bleeding and revellents, and by the other agents that are advised under Hypertrophy of the organ. II. HYPERTROPHY OF THE SPLEEN. Svnon. Hypertrophia seu Supernutritio splenis seu lienis, Intumescentia lienis, Splenalgia subinflammatoria chronica, Splenoncus, Splenemphraxis; Fr. Hypertrophie de la rate, HypersplSnotrophie, (Piorry;) Ger. Milzgeschwulst. Hypertrophy of the spleen must be distinguished from vascular hvperaemia or engorgement—the latter disappearing gradually with the cause that induced it; whilst the former is an addition to the substance of the viscus, which may remain for life, or disap- pear under agencies to be mentioned hereafter. Vascular engorge- ment of the organ—splinohtmie, (Piorry)— is present in many diseases, and strikingly so in typhoid and intermittent fevers. It is rare in the former disease not to meet with the spleen tumid and more distinctly prominent, (Louis;) and there is probably no vol. i.—47 554 DISEASES OF THE GLANDIFORM GANGLIONS. severe case of intermittent fever, which does not exhibit more or less of splenic enlargement. The fact is one of the strongest evi- dences in support of the function that has been ascribed to the spleen (Rush) of serving as a diverticulum to the blood when thrown into irregular distribution from any great disturbing agency. Such we may consider the paroxysm of an intermittent to be. During the cold stage, the blood leaves the surface of the body, and circulates more largely in the internal organs; hence the spleen becomes engorged; and under the repeated recurrence of the paroxysms, it may be understood that the organ itself may become more permanently engorged, and to such an extent as to require time before it can regain its wonted size; or, its nutrition may become modified so as to constitute hypertrophy. In highly malarious districts, splenic disease, of the nature under consideration, is attended with a series of symptoms which have been termed, in the aggregate, splenic cachexia; and although this vice of the whole system of nutrition is more frequently seen in torrid climes we not uncommonly meet with it here. The patient is sallow, almost anaemic; liable to dropsical effusions, and to hemorrhages, which are checked with difficulty, owing to the irre- gularity in the circulation, which is partly owing to the modified transmission of the blood through the spleen. A writer on tropical diseases (Twining) has described the cha- racter of this cachexia accompanying splenic engorgement and hypertrophy in a manner that would apply to a similar condition in a less degree which we yearly witness in our highly malarious districts. " During the continuance of vascular engorgement of the spleen," he observes, " patients are very prone to foul slough- ing ulcers from slight wounds or bruises. When local inflamma- tions or ulcers exist in patients who are suffering from the severer degrees of spleen disease, those peculiar characters of active inflam- mation, and that healthy constitutional energy on which the depo- sition of coagulable lymph depends, and by which we find injuries repaired, and the extension of ulceration, as well as the progress of sloughing arrested on ordinary occasions, seem to be in a great measure, if not entirely, subverted. " Blood drawn from veins of patients suffering from splenic cachexia varies much in appearance: sometimes it coagulates imperfectly, and no serum is separated; in other cases, the cruor is black and soft, and after being exposed to the air, its sur- face does not generally assume that more florid colour which we observe on the top of a coagulum of blood drawn from the vein of a healthy person; and it seldom exhibits a buffy coat, except when ardent pyrexia is present, or where the disease is attended with acute pain in the side. The serum when heated coagulates as firmly as that of a healthy person, but the coagulum is more friable and less tough, and it frequently has a slightly yel- lowish appearance: sometimes it has a greenish colour. " During the vascular engorgement of the spleen several of the OF THE SPLEEN. 555 characteristics of scorbutus are present: there is a tendency to hemorrhage from slight causes or injuries; leech-bites, blisters, and issues occasionally ulcerate during the rainy season, and, at times, the slightest ulcerations are apt to slough. Foul gangrenous ulcers of the lips and gums are liable to form, in consequence of slisht local irritation, (and often without any obvious cause,) whereby the jaw-bones become carious and exfoliate, and the teeth fall out. Haemoptysis, as well as haematemesis, occasionally occurs when the spleen is very large; and probably the blood, which is vomited, sometimes flows into the stomach from vessels communicating directly with the splenic vein, as the intumescence of the spleen has been observed in some cases to be immediately reduced by these evacuations of blood. Profuse hemorrhages from the lungsor sto- mach sometimes suddenly destroy life; but we see other cases in which the functions of the system not having been much disor- dered previously, the patients recover quickly after these profuse losses of blood; the enlargement of the spleen for the time subsides, and the disease is thus entirely cured. The results of these spon- taneous hemorrhages should not be forgotten in deciding on our plans of treatment in ordinary cases of spleen disease." Diagnosis.—Hypertrophy of the spleen may be detected by careful observation. The increase of size may be partial or total; and the degree to which it exists may be somewhat determined by the dulness of sound on the percussion of parts which ordinarily yield a clear sound. If the enlargement be upwards towards the diaphragm, it may not be detected by pressure; and, on the other hand, it must be borne in mind, that the fact of the viscus being felt distinctly beneath the ribs may not be a positive evidence of enlargement, but may be owing to some effnsion into the left side of the thorax pressing upon the diaphragm and slightly dislocating the spleen. Pressure and percussion will generally, however, indicate the existence of hypertrophy. Causes.—It has been already remarked, that not only vascular engorgement but hypertrophy of the spleen may be owing to malarious influence, or to the diseases induced by it. So common a sequence of intermittent fever is induration with enlargement of the viscus, that it has received the names, Ague-cake, Placenta febrilis, &c. In the course of the intermittent and remittent fevers of Bengal, and of almost all the low and marshy districts in India, enlarge- ment of the spleen is said to take place often so suddenly, that in a few days it can be seen as well as felt, extending far below the cartilages of the false ribs. The degree of enlargement is variable: it is very common, we are informed, (Twining,) to see the spleen extending downwards on a level with the umbilicus, and laterally from its usual situation as far as half-way between the cartilages of the ribs and the umbilicus. In extreme cases, the diseased spleen fills more than half the abdomen, extending to the right of the navel, whilst its lower extremity reaches the left iliac region. 556 DISEASES OF THE GLANDIFORM GANGLIONS. Several cases of this enormous tumefaction are to be seen yearly in Calcutta; and some of them recover. (Twining.) Pathological characters.—Hypertrophy of the spleen may be induced by nutritive irritation of the organ, in which case it appears to be entirely healthy, and merely enlarged. This has been denied; and a recent writer, (Professor Gross, of Louisville,) remarks:— " Some writers, and, amongst others, Dr. Abercrombie, speak of what they call simple enlargement of the spleen, unaccompanied with derangement of structure; if such a state exists, I have never met with it, and am much.disposed to doubt the possibility of its occurrence." " This remark," he adds, " applies, of course, ex- clusively to cases of permanent hypertrophy, and has nothing to do with that tumid and erected condition of the spleen which results from the temporary congestion that occurs during the cold stage of intermittent fever, or from violent emotions of the mind." The author has met with several cases of hypertrophied spleen, in which the most careful examination did not indicate any change from the characters presented by the organ when in health; and he can as readily comprehend the occurrence of hypertrophy of the spleen without inflammation, as he can that of tumours or of any form of polysarcia. If the vessels of the system of nutrition, whose office it is to take up, do not execute their functions in an equal ratio with those whose office it is to put down, hypertrophy must necessarily ensue. There may be, in such case, nutritive irritation, but without there being any reason to invoke the presence of an inflammatory process. In many cases, however,—probably in most,—along with hyper- trophy, the nutrition of the organ is morbidly changed; and it is found to be softer or harder than natural. At times, indeed, it is so soft, that it resembles a clot of blood enveloped in a thin mem- brane, which, in the advanced stages of softening, readily gives way. The enlargement, in such cases, is more or less globular. In other cases, it is of the oblong kind; and the organ is more firm than natural, and the edge thin and notched; and lastly, a uniform opaque-white, or milky colour of the peritoneal coat is observed,— the membrane being unusually tough, like a thin bladder that had been dried and afterwards wetted in hot water,—the substance of the spleen itself being, at the same time, soft and flexible. This is said to have been observed in the necroscopy of persons who had been long subject to agues. » Treatment.—This must be regulated greatly by the accompany- ing symptoms. If the enlargement of the spleen be observed in the course of febrile affections, it will remain as long as these affections continue; after which it gradually subsides. In the cases of hypertrophy that follow long protracted intermittents, the same plan of management, which is demanded for the cure of the inter- mittent, is appropriate. The sulphate of quinia, in the ordinary doses, has been found highly efficacious; as well as the carbonate of iron, in full doses, (gr. xv—xxx, ter die.) OF THE SPLEEN. 557 Of late, strong testimony has been induced in favour of very large doses of the sulphate of quinia (gr. xij —lxxx, and more, in the 24 hours;) the most obstinate cases having yielded to continuance for a few days of this treatment. (Bally, Piorry, Nonat.) The sulphate of quinia has also been used in such cases, both endermically and iatraleptically,1 but this course appears to have had more effect upon the fever than upon the splenic enlargement. 1 R.—Quiniae sulph. gr. xl.—I. Adipis, 3ij.—M. Some of this ointment to be rubbed on the groins and armpits three times a day. In most cases, the action of the sulphate of quinia is aided by the previous abstraction of blood, by cupping or leeches, from the left hypochondrium. Occasionally, the application of a mercurial plaster, with which six or eight scruples of the sulphate of quinia have been incorpo- rated, has removed the enlargement effectually. (Voisin, Bouyer.) The plaster must be renewed, when the substances of which it is composed are exhausted, which requires from 40 to 50 days. This method, however, must be slow in its action. In some cases, where the enlargement is very great, the viscus weighing eight or ten pounds, the treatment has, of course, to be protracted. No better preparations exist than the combinations of bromine or iodine with iron, (Ferri. iodid., vel bromid. gr. ij, ter die,) gradually increasing the dose. The iodide of iron is preferable to the other preparations of iodine, in the generality of cases, owing to the concomitant cachexia, which is rarely absent. Should such not be the case, however, the ordinary preparations of iodine, (Tinct. iodin. gtt. x, ter die; vel Potassii iodidi. gr. ij, ter die,) in gradually increased doses, may be prescribed. The preparations of mercury have been frequently given in these cases; but care must be taken not to push them to ptyalism for fear of inducing an augmentation of the cachectic condition. A combination of mercury and iodine may be given with much advantage, where it is considered proper to prescribe the former. R.—Hydrarg. deuto-iodid. in syrup, bene distributi, gr. v. Micae panis, Pulv. sachari albi, aa q. s.—ut fiant pilulae lx. Dose, two, morning and evening; to bo gradually increased. Along with th^ internal use of the preparations of iodine, the iodine alone, in the form of ointment,1 may be rubbed on the region of the spleen night and morning; or the ointment may be com- posed of iodine and iodide of potassium;2 or of iodine and mercury.3 1 R.-lodin. gr. iij. l B—Iodin. 3ss. Adipis, 3H.-M. Po?a?s- L°.d,d-#• Adipis, gij.—M. 3 |j.—Hydrargyri proto-iodid., vel Deuto-iodid. §j. Adipis, gvij.—M. 47* 558 DISEASES OF THE GLANDIFORM GANGLIONS. When the hypertrophy of the spleen is very great, advantage may be derived from methodical compression by means of an ap- propriate bandage. The diet should be regulated according to the attendant pheno- mena. If symptoms of febrile or inflammatory action exist, it should be restricted. On the other hand, when the splenic cachexia is established, it may consist of animal food easy of digestion; and wine, or porter, or both may be permitted to an extent warranted by the special case. Flannel may be worn next the skin; and, where circumstances admit of it, change of air may prove advan- tageous. III. ATROPHY OF THE SPLEEN. Svnon. Atrophia splenis seu lienis; Fr. Atrophie de la Rate. This is not a very common occurrence; yet many cases are on record. The viscus has been seen not larger than a walnut, (Andral;) and a case has been recently described in which it was scarcely as big as a billiard ball. (Professor Gross, of Louisville.) In this case, it was of a grayish colour, rounded in figure, indurated, almost bloodless, and weighed only one ounce. Both coats were thickened, and the innermost was partially converted into cartilage. The patient—a man, 72 years of age—had died of tubercular phthisis. It is said to have been observed chiefly in connection with chronic affections of the alimentary tube, liver and kidneys; with ascites, and with profuse discharges of blood from different parts of the body. An interesting case of this kind has recently fallen under the care of the author. IV. TUBERCLES, CALCAREOUS DEPOSITS, SEROUS CYSTS AND HYDA- TIDS, &C. IN THE SPLEEN. Some of these affections are by no means unfrequent. Tubercles are often met with in children, and they are generally coexistent with similar morbid productions in the lungs. Calcareous deposi- tions are not common, and the same may be said of serous cysts and hydatids. These and other morbid productions give rise to no symptoms that are pathognomonic; and, accordingly, they are less interesting to the therapeutist than to the pathologist. V. DISLOCATION OF THE SPLEEN. Synon. Dislocatio splenis seu lienis, Splenectopia. The spleen may be dislocated or removed from its place, but this must of course be an uncommon occurrence; and, when it does take place, must give rise to phenomena, that are often by no means easy of comprehension. But few such cases are on record. (Meckel.) One of a deeply interesting character fell under the author's notice, and has been described by him elsewhere. (General Therapeutics, p. 305, note. Philada. 1836.) It happened in the person of an estimable lady, the wife of a physician, who had resided for some time in a malarious region of Virginia; and, whilst there, had suffered from the endemic fever of the country, which had left be- OF THE SPLEEN. 559 hind it a manifest enlargement of the spleen. During her visit to her family in Baltimore, she was attacked with symptoms of severe thoracic and abdominal mischief, somewhat paroxysmal in their character, which yielded so much to appropriate management that the author, who had been requested by a professional friend,—Pro- fessor Hall, of Baltimore,—to see her, considered it unnecessary for him to continue his attendance. She was, at this time, about six months advanced in pregnancy. From this period, the author heard nothing more of her until about a week prior to her dissolution, when he was again requested to visit her two days after her deli- very, which had been somewhat premature. She was then labour- ing under great pulmonary and cardiac distress,—the heart being evidently hypertrophied. She was so much enfeebled, however, that auscultation was postponed, and could not subsequently be practised, as she died in a short time afterwards. On examining the right side of the abdomen,—in which pain had been experienced, especially on change of posture, a large tumour w^s found extending from the hypochondriac region as far as the pelvis. The umbilical margin of this tumour could be felt distinctly lobated, as if it were shaped like the cactus. The tumour was perceptible in some positions of the patient more than in others, evidently changing its seat in the abdomen. On examining the urine, she had been found to be labouring, at the same time, under albuminuria. Taking these circumstances into consideration, with the fact, that in a fall from a horse, some years previously, she had injured the right lumbar region, and that although she had not experienced any prominent or protracted signs of renal or vesical irritation, she had occasionally suffered from severe pain in the loins, and from some uneasiness in passing the urine, there could be little hesitation in referring the tumour to the right kidney; and, under the whole aspect of the case, in re- garding it almost hopeless, and demanding palliative management only. From the time of her delivery, she gradually sank until the period of her dissolution. On opening the abdomen, the tumour of the right side was found to be an enlarged spleen, which had broken away from its attach- ments, and was resting, with it's convex surface on the brim of the pelvis; the lower extremity of the organ being turned up so as to reach the lumbar region. It was suspended by its peritoneal and vascular attachments, and could be moved freely in any direction. The left kidney was greatly hypertrophied, nearly four times the natural size, mottled on its surface, the cortical substance granular, and the tubular discoloured in parts, and evidently diseased; the pelvis of the organ was enlarged, and the parietes of the ureter were hypertrophied. The left kidney was healthy. In the thorax, the heart was found in a state of hypertiophy, and the right lung com- pletely atrophied, its place being occupied by a purulent or sero- purulent secretion, which completely filled the cavity of the pleura. Treatment.—It is scarcely necessary to say, that if the disloca- 560 DISEASES OF THE GLANDIFORM GANOLIONS. tion of the spleen be detected during life, no skill on the part of the practitioner can restore it to its former situation. That position must of course be selected for the patient, which gives occasion to the least inconvenience; this will probably be on the left side; but it can rarely happen, that the dislocated organ does not speedily give rise to fatal inflammation of the peritoneum. CHAPTER II. DISEASES OF THE THYROID GLAND. The situation of the thyroid gland is at the anterior part of the neck, beneath the skin and some subcutaneous muscles. It re/ts upon the anterior and inferior part of the larynx, and the first rings of the trachea; and passes outwards, so as to overlap, on each side, the great vessels and nerves of the neck. It is formed of lobes and lobules; has a red and sometimes a yel- low colour; and presents, internally, cells or vesicles, filled with a viscid, colourless, or yellowish fluid, which appears like a weak gum. The thyroid gland is larger in the foetus than in the adult; and, therefore, has been supposed to be inservient, in some manner, to foetal existence. It continues, however, through life, receives large arteries, as well as a number of nerves and lymphatics; and, consequently, the inference would seem to be, that it ought to fill some important office throughout the whole of existence. It has been supposed, (T. W. King,) that the absorbent vessels of the thyroid convey its peculiar secretion to the great veins of the body. The idea, indeed, prevails—as previously remarked—that all the glandiform bodies are concerned in the function of absorption; but if we admit this, it is impossible, in the present state of knowledge, to decide in what manner they act. The average weight of the thyroid is about an ounce. It may suffer from acute inflammation and its results, (Hoioship); but this happens, spontaneously, very rarely, and only, it has been affirmed, (Copland,) in scrophulous persons. The physician is, indeed, but seldom consulted, except for one of its diseased condi- tion—hypertrophy. I. HYPERTROPHY OF THE THYROID GLAND. Synon. Bronchocele, Deironcus, Struma, Panus thyreoideus, Tumidum Gut- tur, Hernia Gutturis, Thyreocele, Thyreoncus, Thyreophyma, Thyremphraxis, Thyreophraxia, Derbyshire Neck, Swelled Neck; Fr. Goitre; Ger. Kropf, An- schwellung der Schilddnise. Hypertrophy of the thyroid gland, to a slight extent, often exists OF THE THYROID GLAND. 561 without exciting any attention; but it is, occasionally, to such a degree as to occasion an unsightly deformjty. Diagnosis.—In this, there is usually no difficulty. The patient's attention, or that of the friends, is directed to a swelling in the situation of the thyroid, sometimes commencing in both the lobes; but, at others, in the isthmus between them. This swelling may proceed to a certain extent and no farther, and it may be so small as not to induce the patient to seek for medical advice; at times, however, the hypertrophy goes on increasing, until ultimately it invades the whole of the anterior part of the neck from the chin to the sternum. The tumour is rarely equable, but admits of the distinction being made between the lobes and the isthmus; and it is commonly more developed on one side than on the other. In the early periods of the disease, and often for years, the tu- mour is soft and elastic, but in the progress of time, it becomes harder, and, in some cases, ultimately acquires the consistence and feel of fibro-cartilage. Causes.—Of the causes of goitre, nothing satisfactory has been offered, until of late. It was at one time universally supposed to be owing to the drinking of snow-water from the summits of lofty mountains by the inhabitants of the valleys beneath;—but the fact that the disease exists in countries in which snow is never witnessed—as in Sumatra—was sufficient to dispel this idea. In Captain Franklin's expedition to the polar sea, goitre was found to be very prevalent at Edmonton, where the soil is calcareous. It was discovered that the disease attacked those only who drank of the water of a certain river—the Saskatchanan—and that the natives, who confined themselves to snow-water in the winter, and drank of the small rivulets which flow through the plains in the summer, are exempt from it. (Richardson.) These facts naturally draw attention to the water of the district as a cause of the disease; indeed, in many places, it has been usual so to ascribe it. At Nottingham, in England, where it prevails, the common people refer it to the hardness of the water,—that is, to its impregnation with calcareous salts, (Manson;) and a recent writer on bronchpcele, (Inglis,) affirms that the presence of mag- nesian limestone, always implies the co-existence of the disease. If to this testimony we add that of a recent writer in India, (M'Clel- land,)—who states, that in the course of his professional inquiries, which extended over 1000 square miles, and were prosecuted with- out any regard to theory, no instance occurred, in which goitre prevailed to any extent, where the villages were not situate on or close to limestone rocks,—the evidence is strong, indeetl, that goitre may be owing to the drinking of water containing calcareous salts. Still, it is proper to observe, that there are many places, as the Valois, in which there are no limestone formations; and in other cases where goitre prevails, the water contains no calcareous salts. (Humboldt.) Although it is probable, therefore, that water, con- taining calcareous salts, may afford a predisposition, something, at 562 DISEASES OF THE GLANDIFORM GANGLIONS. present inscrutable, in the locality is necessary for the development of the disease; and, perhaps, after all, we know no more in reality, of the immediate cause of this endemic, than we do of that of en- demic diseases in general. The disease is known to prevail, especially at the base of lofty mountains, in many parts of the globe. It is endemic at the foot of the Alps—where it is frequently associated with cretinism—and of the Appenines; in Derbyshire, where it is called the "Derbyshire neck;" at the base of the South American Andes, where it is called "papas;" and in the valleys of the mountain chains in most parts of this country. The author has seen many cases of it in the vicinity of the Blue Ridge, in Virginia, and it is prevalent in the mountainous regions of Pennsylvania, New-York, New-Hampshire, Vermont,&c. This very day, (Dec. 18, 1S40,) he has exhibited to the class at the Philadelphia Hospital, a case of soft goitre in a female, recently from Baden, in Germany, where the country is mountainous, and the disease by no means uncommon. In this case, there is the peculiarity of a varicose condition of the external jugular vein and its various tributaries,' probably produced by the pressure of the enlarged thyroid gland, preventing the ready return of the venous blood to the heart. But although most frequently seen in deep valleys of mountainous regions, it is sometimes endemic in lofty situations:—for example, at Bogota, 6,000 feet above the level of the sea. (Humboldt, Row- land. ) Goitre is much more common in females than in males. Of 49 cases, admitted into the Hampshire County Hospital, England, in ten years, 48 were in women. (A. Crawford.) Of 70 patients, treated in the Chichester Infirmary, in nine years, two only were males, and they were boys of a very feeble and feminine habit,and backward for their years. (Watson.) Of 25 or 30 cases, treated by the author, all were females. It would appear, however, that in Switzerland, and in some parts of India, where the disease pre- vails extensively, the proportion of males is greater. It is rarely seen before the age of puberty; but cases have been met with in the new-born. (Fode're', Nicod aVArbent, Grdtzer.) Pathological characters.—It has been remarked, that the cha- racters of the tumour are different at different stages of its existence. At first, it is soft; but the texture gradually becomes of greater consistence, until, ultimately, it may acquire a cartilaginous hard- ness. It may be naturally inferred, that the internal character of the tumour will correspond with these external indications. In the soft condition, when cut into, it generally gives issue, on pressure, to a ropy gelatinous fluid. In the more chronic cases, the con- sistence is greater; and, owing to the enlargement of the cells which enter into its composition in the healthy state, it appears to be in- terspersed with numerous cysts of about the size of a pea, which contain a fluid varying in character, but generally glairy. In very old cases, osseous depositions exist, and these are frequently accom* OF THE THYROID GLAND. 563 panied by cartilaginous formations. The latter may also exist alone. Occasionally, the whole organ is transformed into an osseous capsule, filled with various kinds of matter, especially the jelly-like, the suety, and the meliceric. (Professor Gross, of Louisville.) Dr. Gross states, that he has a specimen of the kind in his cabinet; one of the lobes has almost disappeared; the other is converted into a firm solid capsule, as hard as bone, though scarcely a line in thick- ness. On sawing through this osseous tumour, which does not exceed the volume of a hen's egg, he found it filled with a white, curdy, friable substance, not unlike semi-concrete cheese. Hypertrophy of the thyroid gland—like other hypertrophies—has been presumed, by many pathologists, to be the result of chronic inflammation; but the remarks on hypertrophy of the spleen are equally applicable here. Any loss of balance between the vessels of nutrition that deposit, and those that take up, which induces a preponderance of the deposition by the former, may give rise to it. That this, however, is often combined with chronic inflammation, is shown by the concomitant alterations of structure; but these are probably concomitants only, and the inflammation, which gave rise to them, may have had nothing to do with the production of the hypertrophy itself. Treatment.—The discoveries of modern chemistry, have ren- dered the management of this disease much more simple than it was formerly. It had long been known, that under the adminis- tration of burnt sponge, the nutrition of the hypertrophied thyroid was frequently so modified, that the enlargement gradually disap- peared; but as it was a matter of difficulty to discover any agent in it, to which the remedial efficacy could be referred, many thera- peutists were not disposed to place much reliance upon it, and fre- quently subjected it to very imperfect trials. The discovery of iodine in it, led to the employment of the former, and soon the published cases of its wonderful agency, were numerous. Nor, as in the case of many other therapeutical agents brought forward with equally lofty pretensions, has it declined in the estimation of practitioners. The author has succeeded in wholly removing nearly twenty cases of soft goitre by it; and multitudes have been equally successful. (Hufeland, Grafe, Baup, Jdger, Seller, Ficinus, De Carro, J. Reid, Manson, Elliotson, Lugol, &c. &c.) It has been advised, by some, that its exhibition should be preceded by blood-letting; and, as the abstraction of blood fa- cilitates absorption, this may be advisable,—especially where little, if any, effect seems to be induced by it, after it has been administered for some time. By many persons, the internal administration of the iodine has been trusted to alone, either in the form of the tinc- ture (gtt. x. ter die in aq. sacchar.), of the solution of thu iodide of potassium, (same dose as the tincture,) or of Lugol's solution— which is a solution of the ioduretted iodide of potassium. 564 DISEASES OF THE GLANDIFORM GANGLIONS. R.—Iodin. Qj. Potass, iodid. J}ij. Aquae, gvij.—M. Dose, ten drops, three times a day. Whatever be the preparation of iodine employed, it must be persevered in for a length of time, and the dose be gradually increased. The author has never witnessed any marked benefit from it until it had been continued for at least a month. Others prefer the external administration of iodine in the form of the unguentum iodini,1 the unguentum potash iodidi,2 the unguen- tum iodiuii compositum of the London Pharmacopoeia,3 the unguen- tum hydrargyri iodidi, or the unguentum hydrargyri biniodidi of the same Pharmacopoeia,4 &c. &c. 1 R.—Iodin. gr. iij. 2 R.—Potass, iodid. gss. Adipis, gij.—M. Adipis, |jiss. A drachm to be rubbed on the tumour twice a day. 3 R.—Iodin. 3ss. 4 R-—Hydrarg. iodid., vel biniodid. Potass, iodid. Jj. fj. Sp. rectif. f. 3j. Cer«e alba?, gij. Adipis, ^ij.—M. Adipis, ^vj.—M. The various other preparations of iodine may likewise be pre- scribed. (See the author's Neiv Remedies, 3d edit. Philad. 1841.) Some have advised, that the external use of the remedy should be prescribed first; and that, at a later period, it should be directed internally also. The preparations of bromine, as well as bromine itself, appear to be equally efficacious in the treatment of goitre, but they are not as much employed. It is not improbable but that the animal charcoal in the burnt sponge may be possessed of some efficacy in modifying the nutri- tive actions in the hypertrophied thyroid. It is asserted, (Weise,) that goitre, even when scirrhous, has been made to disappear under the use of animal charcoal, especially when associated with burnt sponge. R.—Carbon, animal, gr. vj. Spong. ust. gr. xij. Pulv. rad. glycyrrh. 3ss.—M. et divide in partes vj. equates. Dose.—One, night and morning. Many other therapeutical agents, that modify the function of nutrition, as the liquor potassse, the carbonate of soda, the muriate of lime, mercury, &c, have been prescribed, but they are far infe- rior to those above mentioned. When the tumour is so large as to threaten suffocation, and does not yield to the remedies recommended, the aid of the surgeon becomes necessary,—either to extirpate the hypertrophied gland, or to interfere with its nutrition by tying the thyroideal arteries,or by passing a seton through it. These, however, must be the last resource, and can very rarely be required. 565 CHAPTER III. DISEASES OF THE THYMUS GLAND, AND SUPRA- RENAL CAPSULES. The thymus gland—being an organ chiefly of foetal existence- is not of much interest in its pathological relations. It is situate in the superior mediastinum. Its appearance is glandular, and its colour very various. In the progress of age, it diminishes, so that in the adult it is extremely small, and in old age can scarcely be discovered amongst the cellular tissue. It is surrounded by a thin cellular capsule, which sends prolongations internally, and divides it into lobules of unequal size, in which several vesicles, filled with a milky fluid, are distinguishable. The ordinary weight of the thymus at birth is said to be about half an ounce. The chief pathological condition of interest is the hypertrophy of this organ, which is sometimes met with, and has been regarded as a cause of asthma in children. (See Thymic asthma.) In such cases, the gland has been found to weigh an ounce or two, and to be so voluminous as to compress not only the lungs and the tra- chea, but the pneumogastric nerves in their passage downwards. The disease appears to consist in simple hypertrophy. Often, no change whatever of structure is perceptible. Various degenerations—calculous, scirrhous, &c. of the thymus are recorded to have been met with, but they are so rare as not to merit any more than a mere mention. The supra-renal capsules, situate above the kidney, and which were at one time supposed to be the seat of atrabilis or melan- choly, are not possessed of much pathological—still less, therapeu- tical—interest. CHAPTER IV. DISEASES OF THE MESENTERIC GLANDS. The mesenteric glands or ganglions are a part of the absorbent system, and hold the same ratio to the chyliferous or lymphatic vessels of the intestines, that the lymphatic ganglions of the axilla and groin—for example—hold to the lymphatics of the upper and lower extremities. In them, the lymphatic vessels of the mtes- vol. I.—48 566 DISEASES OF THE GLANDIFORM GANGLIONS. tines terminate; and the chyliferous vessels traverse them in their course from the intestines to the thoracic duct. In health, their substance is of a pale rosy hue, and their consistence moderate. By pressure, a transparent and inodorous fluid pan be forced from them. Difference of opinion exists as to their structure. According to some, they consist, essentially, of a pellet of chyliferous vessels, folded a thousand times upon each other, subdividing, and anasto- mosing almost ad infinitum, united by cellular tissue, and receiv- ing a number of blood-vessels. In the opinion of others, again, cells exist in their interior, into which the afferent chyliferous ves- sels open, and whence the efferent vessels set out; these cells being filled with a milky fluid, carried thither by the lacteals, or exhaled by the blood-vessels. (J. Midler.) In the general opinion of physiologists, these ganglions impress changes on the chyle in its passage through them, and animalize it, or serve to transform it into the nature of the being to be nou- rished. This is supposed by some to be produced by the fluid exhaled into their cells. Others consider, that the veins of the glands remove from the chyle everything that is noxious,—or purify it. Howsoever effected, it would seem, that they impress important changes on the chyle; as its rosy colour is more marked on the thoracic, than on the intestinal, side of the glands, and it is richer in fibrine after having traversed them. (Tiedemann and Gmelin.) Such being the case, it can be understood, that disease of these bodies must interfere with the important process of animalization, and may give occasion to the impaired nutrition, which character- izes their state of inflammation. In two ways, such inflammation may act. In the first place, it may interfere with the animaliza- tion of the chyle; and in the second, it may prevent the course of the chyle through the chyliferous vessels towards the thoracic duct, I. INFLAMMATION OF THE MESENTERIC GLANDS. a. Simple inflammation of the Mesenteric Glands. Synon. Adenitis mesenterica, Mesenteric Ganglionitis; Ger. Entziindung der Chylusdnisen. Simple inflammation of these ganglions appears to be by no means a common affection. If, however, prolonged irritation should exist in the mucous membrane of the intestine, they may become inflamed in the same manner as the lymphatic ganglions in the axilla and groin are inflamed from sources of irritation seated in the upper or lower extremities. The connection, too, of this affection with an inflamed state of the kitestines, or with gastro-enteritis, has been long pointed out; and hence, in the de- scription of the anatomical characters of different fevers, an altered condition of the mesenteric glands will usually be found, where there were, at the same time, diseased appearances in the intes- tinal mucous membrane. (Broussais, Chomel, Louis.) On this OF THE MESENTERIC GLANDS. 567 point, most recent authors are in accordance. It is not equally settled, whether the same condition of the ganglions may not be induced by inflammation of the peritoneum. Broussais lays down the proposition, that "the mesenteric ganglions do not inflame from simple peritonitis;"—this fact, he says, he has observed in a vast number of cases. He states, that in engorgements of the cel- lular tissue of the mesentery and omentum, subsequent to chronic peritonitis, we find tuberculous ganglions in the midst of lardaceous muscles, and fibrous, scirrhous, encephaloid or melanosed tissues; but, he adds, that if the mucous membrane of the small intestines be closely examined, ulceration or some other trace of enteritis will generally be found. In another work, the same writer is bolder, and less justified in his generalizations. "These small parenchymatous bodies,"—he observes—"are endowed with great vitality, and whilst it is impossible to discover any sympathy be- tween the lacteal vessels and the rest of the body, we observe very active sympathies between the mesenteric ganglions, and the gastro-intestinal mucous surface. This discovery belongs likewise to the physiological doctrine, which has shown that all gastro-ente- rites are accompanied by tumefaction of the mesenteric glands. Although chyle may be charged with acrid, irritating, or even poisonous matters, they traverse the ganglions with impunity, provided they do not inflame the gastro-intestinal mucous surface. Our attention has been for a long time directed to this question, and we have not observed any instance of mesenteric ganglionitis, which had not been preceded by well-evidenced gastro-enteritis." Although, however, it may be admitted, that inflammation of the mesenteric glands, is most commonly caused by irritation in the lining membrane of the intestines, it can doubtless arise inde- pendently of such irritation, (Evanson;) in the same manner as inflammation of the lymphatic ganglions may arise spontaneously, independently of any irritation in the lymphatic vessels on the peripheral side of those ganglions. When simple inflammation of the mesenteric ganglions exists, it cannot be diagnosticated by any special morbid phenomena. As it is so generally connected with disease of the intestinal follicles or of the mucous membrane, the symptoms that indicate these pathological conditions will alone attract the attention of the prac- titioner, although they may lead him to suspect the presence of dis- ease of the ganglions. b. Scrophulous inflammation of the Mesenteric Glands. Synon. Atrophia infantum, A. glandularis, A. infantilis, A. mesenterica, Macies infantum, Pauiatrophia, Scrophula mesenterica, Tabes mesenterica, 1. glandularis, Scrophulous or Tubercular degeneration of the mesenteric glands or eancrlions; Fr. Carreau, Scrofules ouEcrouelles m6sentenques, Ltis.e mesen- terique* Rachialgie mesenterique, Physconie mesentenque, Lntero-mesentente. (Baumes); Ger. Darrsucht der Kinder. Scrophulous inflammation of the mesenteric ganglions, and tabes mesenterica stand towards each other in the relation ol, 568 DISEASES OF THE GLANDIFORM GANGLIONS. cause and effect; yet, they are so generally associated, that the terms have been used by most writers synonymously. Originally, the French term Carreau, (" a square tile,") was employed figura- tively by authors, to designate any disease, that was characterized by hardness and swelling of the abdomen,and,of course, it embraced enteritis with tumefaction of the mesenteric ganglions, scrophulosis of those ganglions, tubercular peritonitis, &c; but, at the present day, its acceptation is restricted to the affection now under con- sideration. Diagnosis.—Scrophulous inflammation of the mesenteric gan- glions may appear under two forms, which are very distinct. It may be latent, as it were, or be attended by well marked pheno- mena. Scrophulous matter may be deposited in the ganglions, and yet there may be no symptom that attracts the attention of the practitioner to them. This has been accounted for, by the assertion, that in such cases the tubercles are crude, and that it is the process of softening, which alone gives occasion to functional disorder. It would not seem, however, that this explanation is satisfactory, inasmuch as mesenteric tubercles have been seen in the most advanced starge of mollescence, without having given occasion to the least indisposition. A young girl, who enjoyed excellent health, fell into the fire, and died a few hours afterwards. On dissection, twelve mesenteric ganglions were found tuberculous, and some of them in a state of suppuration, (Bayle;) and many similar cases have been observed by the pathological anatomist. (Guersent, H. Bell.) Perhaps, the satisfactory mode of accounting for the innocuous- ness of this pathological condition is the absence of any inflamma- tory^ complications of the intestine or peritoneum, (Guersent,)— complications, which appear indeed, to give rise to the phenomena that constitute tabes mesenterica. The writer, just cited" divides the disease into two stages, accord- ing as the ganglions can, or cannot, be felt through the parietes of the abdomen. In the first stage, the main symptoms are:—increased size of the abdomen; emaciation; puffiness and paleness of countenance; at times, loss of appetite, but more commonly, great voraciousness and insatiable appetite; vomiting of glairy matter, and uneasiness after having eaten; alternation of constipation and diarrhoea; alvine evacuations of a gray colour resembling clay; and, towards even- ing, a febrile movement with dryness of the skin. It is obvious, however, that none of these symptpms are diag- nostic of the disease, and that they may all belong to simple chronic endoenteritis. In the second stage, the functional phenomena are of more importance. The mesenteric ganglions are now so large, that they can be felt through the parietes of the abdomen; giving the feeling of hard, round, knotted or knobbed bodies, seated deeply in the middle portion of the abdomen, and painful when pressed upon. OF THE MESENTERIC GLANDS. 569 Copious diarrhoea is now a general concomitant; and there is con stant fever, with extreme emaciation. Frequently, too, there is oedema of the lower limbs; and, occasionally, accumulation of serum in the cavity of the peritoneum, and even in the chest; under which the patient gradually dies in the last stage of marasmus. Where the tuberculous masses are very large and hard, fhey may give occasion to serious inconvenience by pressing upon im- portant organs. Thus, they have been known to obstruct the pylorus and the biliary ducts, the ureters, the vena cava inferior, and the vena porta,—in the last case occasioning ascites and ana- sarca of the lower half of the body. (H. Bell.) It is clear, from the above detail of symptoms, that the only pathognomonic symptom of tabes mesenterica is the presence of hard, knobbed, tumours, deeply seated about the middle part of the abdomen; yet these may be confounded with scybala in the intestines. Scybala, however, are generally contained in the left iliac region, and they are not painful when pressed upon; whilst the mesenteric tumours are usually seated in the umbilical and right iliac regions. Moreover, scybala are generally accompanied by constipation, whilst mesenteric ganglionitis is as commonly associated with diarrhoea. (Guersent.) If doubts, however, should still exist, they may be dispelled by the administration of a gentle cathartic, which may remove the scybala. In the first stage of tjpe disease—as already remarked—there is no pathognomonic symptom. Causes.—As the predisposition to this disease would appear to lie in scrophulosis or tuberculosis, it would seem, that all those causes, which have been elsewhere pointed out as favouring the development of those conditions, must equally favour the develop- ment of scrophulous inflammation of the mesenteric ganglions. It is important, too, to bear in mind the unfavourable influence of a complication with inflammation of the lining membrane of the in- testines; and, therefore, to avoid all such unwholesome food, as might derange the gastric and intestinal functions, and thus aug- ment the morbid condition of the ganglions. The disease has been considered as one of infancy exclusively; but this is not accurate. Tubercular enlargement of the mesenteric glands has been found at all ages, even in the foetus, and in adults. In one-fourth of those who had died of phthisis, and whose bodies were examined, (Louis,) tubercles were found in the mesenteric ganglions. In 100 adults, who had died of phthisis pulmonalis, they were found by another observer, (Lombard,) ten times; and in the examination of the bodies of 100 tuberculous children, thirty- one times. At the Hopital des Enfans Malades, of Paris, in tuber- culous subjects, from two to fifteen years of age tubercles were found in the mesentery in one half. From these facts, the disease is evidently more frequent in childhood. The common opinion is, that girls are more liable to it than boys, (Guersent;) but this does not appear to rest upon sufficient 570 DISEASES OF THE GLANDIFORM GANGLIONS. statistical evidence. It is true, however, as regards the predisposi- tion of the two sexes to tuberculosis, (Bayle, Laennec, Andral, Louis;) but although it probably applies also to tabes mesenterica, this is not certain. The author has stated elsewhere, that although the scrophulous and the tuberculous cachexia are congenerous affections, it by no means follows, that, they are identical. They may exist, however, together; and such would frequently appear to be the case with the disease under consideration. In most cases, it appears to resemble the affection of the lymphatic gan- glions of the neck, so common in children, and which we un- hesitatingly refer to scrophulosis. When the disease has once become fairly established, the gan glionic affection must terminate either by the softening of the tuberculous matter, or by its transformation into a calcareous sub- stance; the latter being the more favourable termination; but it is very rare. When the tumours soften, they may give occasion to peritonitis; or the matter may, by adhesions, be discharged into the intestines; or, where the tumour is very large, adhesions may take place between it and the abdominal parietes, and the matter may be discharged through them by an ulcerative process. The danger of the disease has been regarded by some (Guersent, H. Bell,) to be dependent mainly upon the diseases with which it is complicated. M. Guersent, indeed, affirms, that he has not met with a single case in which a child died from it alone: in all the fatal cases, which he has seen, it was combined with other diseases capable in themselves of causing death. Pathological characters.—In the first period of tabes mesente- rica, the mesenteric glands are red, and hypertrophied, and at times very friable, but at others indurated. Occasionally, there is no alteration whatever in their appearance. The scrophulous matter is at first disseminated in the form of white points, which gradually increase in size, and ultimately invade the whole or the greater part of the ganglions; forming rounded masses, of different sizes, which appear superposed, as it were, on the ganglions. The tuber- cles—if they may be so termed—go on augmenting,and may form large tumours, which have been compared to chesnuts deprived of their envelope. They have been seen of the size of a hen's egg, and even larger. As the tubercular matter is deposited, it subjects the ganglions to pressure, so that they frequently become greatly diminished in size, and at times their natural texture cannot be recognized. In all fatal cases, evidences exist of complications of even greater importance than the primary disease itself. Almost always, there are marked evidences of inflammation, simple or tubercular, of the peritoneum, or of the mucous membrane of the intestines, or of both; and in the large mass of cases, the endoenteritis is accom- panied by inflammation and ulceration of the intestinal follicles. It would seem to rarely happen, that tubercles exist in the me- senteric ganglions alone. Commonly, the bronchial ganglions are OF THE MESENTERIC GLANDS. 571 affected, and tubercles are found in greater or less quantity in the lungs. They pass, too, through the same stages as similar forma- tions do elsewhere. They do not, however, proceed, like the pul- monary tubercles, to complete softening; and are scarcely ever transformed into liquid pus; an additional fact, which exhibits the similarity between the inflammation of the mesenteric ganglions, • and that of the ordinary lymphatic ganglions, in which the pus is always mixed wjth a matter of a cheesy appearance. It would appear, from all that has been said, that the danger from scrophulous inflammation of the mesenteric ganglions is mainly dependent upon the accompanying complications. When once, however, the disease has proceeded so far that the enlarged ganglions can be felt through the parietes of the abdomen, and it is not till then—as already remarked—that we are certain of the true nature of the affection, the prognosis must be of the most un- favourable character, inasmuch as complications will be found to be co-existent; and under the cachexia thereby developed, no ex- pectation can be entertained, that the tubercular matter will be taken up. The generality—if not the whole—of the cases of tabes mesen- terica said to have been cured, have probably been cases of disease resembling tabes, in which the symptoms accompanying the first stage were present, but the enlarged glands were not felt through the abdominal parietes. Too much stress has been laid on unusual prominence of the abdomen as a symptom of this disease. Such prominence certainly cannot be caused by enlargement of the mesenteric ganglions, unless when they have attained an enormous size. Moreover, the ganglions have frequently been found diseased in those who presented no particular abdominal protuberance,—and, as already remarked, they have been extensively softened, where the person has appeared to be in good health, and no ganglionic affec- tion was suspected. (Guersent, Evanson.) Treatment.—As scrophulous enlargement of the mesenteric glands, when it exists to such a degree as to be distinctly felt through the abdominal parietes, is usually fatal, in consequence of the mis- chief in other parts with which it is complicated, it is not neces- sary to dwell upon the treatment. It must be such as is adapted for the palliation of those complications. As, however, it has happened occasionally, that when the enlarged glands have been perceptible to the touch, the complications have been to a slight degree, it may be proper to adopt such a course as is advisable in scrophulosis in general, and as is laid down under scrophulous cachexia. With this view, the preparations of iodine promise the best success; but as there is frequently concomitant inflammation of the lining membrane of the intestines, it may be preferable to use them externally, rather than internally. All the preparations of iodine are not, however, equally well adapted for external use, as some of them induce too much irritation of the skin. The iodide 572 DISEASES OF THE. GLANDIFORM GANGLIONS. of lead1 is not liable to these objections, (Evanson,) and it has been employed in cases of enlargement of the glands with gratifying success, in cases in which frictions with other preparations of iodine had been used ineffectually. ( Velpeau, Guersent, Roots.) 1 R.—Plumbi iodid. gi. Adipis, 3j.—M. If it be desired to administer any of the preparations of iodine internally, a solution of the iodide of potassium,;1 or of the iodu- retted iodide of potassium;2 or—what suits the scrophulous consti- tution better, perhaps—of the iodide of iron,3 may be prescribed. A small quantity of laudanum added to each dose may prevent them from disagreeing. 1 R—Potass, iodid. gj. 2 R.—Iodin. 9j. Aquae destillat. ^j.—M. Potass, iodid. ^ij. Dose, to a child, three or four drops, Aqua? destillat. 3vij.—M. three times a day. Dose, to a child, two or three drops, three times a day. s R._Ferri iodid. 9j. Aquae destillat. ^j.—M. Dose, to a child, two or three drops, three times a day. Where there is much tenderness on pressure, and accompanying febrile irritation, it may be necessary to employ antiphlogistics, taking care not to carry them farther than is indispensable, inas- much as they may augment the existing cachexia, which—as elsewhere shown—is one of defective nutrition, and therefore de- manding rather the corroborants that are advised under scrophu- lous cachexia. The whole hygienic and therapeutical treatment, there recommended, is indeed required. It has been properly remarked, too, that in the inflammatory form of tabes mesenterica, the lungs have almost always been diseased for some time; and the liver, spleen and subperitoneal cellular tissue are frequently invaded by the tubercles.. " The patient is tormented by hectic fever; the tabes is then said to be in its third stage, and all the pre- tended resolutive medicines would be incendiary and dangerous; they would accelerate the fatal termination. 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