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W JO ADVaail IVNOIIVN IN I 3 Id 3W JO UVIII'l IVNOIIVN iNOIQiW JO A » V * « M IVNOIIVN V JO UU1I1 IVNOIIVN INIDIOIW JO HVIII1 IVNOIIVN 3NI3I03W JO A H V II 9 U IVNOIIVN for s S^> J" ll LIBRARY OF MEDICINE NATIONAL LIBRARY OF MEDICINE NATIONAL LIBRARY OF MEDICINE K\#/ * -Alt' - w jo ia«iin ivnoiivn jnidiojw jo uviiii ivnoiivn jnoioiw jo ahviibii ivnoiivn f ^^^ly^i i^w!<^^ i kl LIBRARY OF MEDICINE NATIONAL LIBRARY OF MEDICINE NATIONAL LIBRARY OF MEDICINE U LIBRARY OF MEDICINE NATIONAL LIBRARY OF MEDICINE NATIONAL LIBRARY OF MEDICINE LL LIBRARY OF MEDICINE NATIONAL LIBRARY OF MEDICINE NATIONAL LIBRARY OF MEDICINE \ ,RY OF MEDICINE NATIONAL LIBRARY OF MEDICINE NATIONAL LIBRARY OF MEDICINE NATII H V«9U IVNOIIVN 3NI3IQ3W JO A«VH9I'1 IVNOIIVN 3NI3I03W JO ABVH9I1 IVNOIIVN 3NI3I VD9I1 IVNOIIVN 3NI3IQ3W JO A « V a 9 II IVNOIIVN 3NI3I03W JO A IIV II 9 I 1 IVNOIIVN 3NI3II :- V&r5? yRY OF MEDICINE NATIONAL IIBHAIV OF MEDICINE N A T I O N A I L I B R A R Y O F M E D I C I N E NATIC nirmi m a t I o n a L LIBRARY OF MEDICINE NATII PROSPECTUS or THE LIBRARY OF MEDICINE: CONDUCTED BY ALEXANDER TWEEDIE, M.D., F.R.S., PHYSICIAN TO THE LONDON FEVER HOSPITAL, AND TO THE FOUNDLING HOSPITAL ; EDITOR OF THE CYCLOPEDIA OF PRACTICAL MEDICINE, ETC. WITH THE ASSISTANCE OF NUMEROUS CONTRIBUTORS. The design of this work is to supply the want, generally admitted to exist in the medical literature of Great Britain, of a comprehensive System of Medicine, embodying a condensed, yet ample, view of the present state of the science. This desideratum is more espe- cially felt by the Medical Student, and by many Members of the Profession, who, from their avocations and other circumstances, have not the opportunity of keeping pace with the more recent im- provements in the most interesting and useful branch of human knowledge. To supply thisdeficiency, is the object of The Library of Medicine ; and the Editor expresses the hope, that with the as- sistance with which he has been favoured by Contributors, (many of great eminence, and all favourably known to the Public,) he will be enabled to produce a work, which, when completed, will form a Library of general Reference on Theoretical and Practical Medicine, as well as a Series of Text Book? for the Medical Student. It is intended to treat of each Department, or Division of Medicine, each Series forming a complete Work on the subject treated of, which may be purchased separately at a very moderate price, or it will constitute a Part of The Library of Medicine. This ar- rangement is made with the view of giving those persons who may wish to possess one or more of the Series, the opportunity of pur- chasing such Volumes only, an ' thus avoid ■ inconvenience of making a larger addition to the tock of p than their wants or circumstances may require. Each Treatise will be authei :ated by l. ime of the Author; and from the care bestowed in ihe arranges s, it is confidently noped that the want of uniformity noticed in w ts of a similar kind, will be obviated, at least, as far as iscompatit with the execution of the work by a numerous body of united At ors. The First Series will comprehend Practical Medicine. The Second Practical Surgery. The Third will include Midwifery, the Diseases of Women, and the Diseases of Children, &c. The other Departments of Medical Science will be treated of in successive Volumes. A work of this description is a greater desideratum in this coun- try than even in Great Britain, from the great number of country 11 ADVERTISEMENT. practitioners here who have not access to libraries, and whose cir- cuit of practice is so extensive as to afford little leisure for consult- ing elaborate treatises. To supply it the republication of the Library has been undertaken, and the third volume is now pre- sented to the American medical public. The subsequent volumes will appear in quick succession. VOL. IV. will contain, Diseases of the Arteries, - Dr. Joy. Diseases of the Organs of Digestion, Drs. Symonds, George Budd, and Wm. Thomson. Diseases of the Biliary Organs, - - Dr. Wm. Thomson. Diseases of the Urinary Organs, - - Dr. Christison. Diseases of the Uterus and Ovaria, Dr. Ferguson and Dr. Simpson. With Notes, &c, by Dr. Gerhard. VOL. V. will contain, Hasmorrhage,......Dr. G. Burrows. Scurvy,........Dr. Budd. Dropsy, .......Dr. Watson. Scrofula,.......Dr. Shapter. Bronchocele,.......Dr. Rowand. Rheumatism,......- Dr. Wm. Budd. Gout,.......Dr. Wm. Budd. Worms found in the Human Body, - Dr. A. Farre. Formulary, -......- Dr. Joy. Index to the whole, with Notes, &c, by Dr. Gerhard. Volume first contains an Introduction by Dr. Symonds; Inflam- mation by Dr. Alison; General Doctrines of Fever, Continued Fever and Hectic Fever, by Dr. Christian; Plague, Intermittent Fever, Remittent Fever, Yellow Fever, by Dr. Shapter; Infantile Gastric Remittent Fever, by Dr. Locock ; Small Pox, by Dr. Gre- gory; Measles, Scarlatina or Scarlet Fever, by Dr. George Bur- rows ; Puerperal Fevers, by Dr. Locock ; Diseases of the Skin, by Dr. H. E. Schedel. Volume second contains—On the Pathology of the Nervous Sys- tem, Hydrocephalus, Apoplexy, Delirium Tremens, Cephalagia, Epilepsy, Catalepsy and Allied Affections, Spinal Irritation, Spinal Meningitis, Inflammation of the Spinal Cord, Tetanus, Paralysis, Hydrophobia, &c, &c, by Dr. Bennett; Inflammation of theBrain, by Dr. Hope; Insanity, by Dr. Prichard; Hysteria, Neuralgia, &c, by Dr. Thomson; Inflammation of the Eye, &c, by Dr. Taylor, with American notes and additions by Dr. W. W. Gerhard, M.D., of Philadelphia. The American Publishers invite particular attention to the fact, that each volume is complete in itself, and will be sold separately ■ the acquisition of any one will not, therefore, necessitate the pur- chase of the others. The whoJe will, however, form a complete Medical Library. DISSERTATIONS DISEASES ORGANS OF RESPIRATION. BY C. J. B. WILLIAMS, M.D., &c, Professor of the Practice of Medicine, University College, London. THEOPHILUS THOMSON, M.D., Physician to the Northern Dispensary, &c. W. B. CARPENTER, M.D., Lecturer on Forensic Medicine in the Bristol Me- dical School, &c. W. BRUCE JOY, M.D., Fellow of the Kings and Queens College of Physi- cians in Ireland ; Physician to the Dublin General Dispensary, &c. EDITED BY ALEXANDER TWEEDIE, M.D., F.R.S., Fellow of the College of Physicians, Physician to the London Fever Hospital, and to the Foundling Hospital, &c. WITH AMERICAN NOTES AND ADDITIONS, Br W. W. GERHARD, M. D.3 Lecturer on Medicine, Physician to the Philadelphia Hospital, Blocklejr, &c. <$?*" ^^ V,o ^LILTATTf « PHILADELPHIA: LEA AND BLANCHARD. 1841. )\ . V Entebbe, according to act of Congress, in the year 1841, by Lea & Blanchabij, in the clerk's office of the district court for the eastern district of Pennsylvania. SYSTEM PRACTICAL MEDICINE, COMPRISED IN A SERIES OF ORIGINAL DISSERTATIONS. ARRANGED AND EDITED BY ALEXANDER TWEEDIE, M.D.,F.R.S., FELLOW OP THE ROYAL COLLEGE OF PHYSICIANS, PHYSICIAN TO THE LONDON FEVER HOSPITAL AND TO THE FOUNDLING HOSPITAL, ETC. DISEASES OF THE ORGANS OF RESPIRATION. ~n Gcn/'o - Joy.j Nature and Causes. —Forms. —Anatomical characters. —Physical signs- General symptoms.—Complications and secondary affections. — Supposed causes of each form of Hypertrophy.—Duration and prognosis.—Treatment 515 DILATATION OF THE HEART. (Dr. Joy.) Nature and mode of production.—Anatomical characters.—Physical signs.— General symptoms.—Diagnosis.—Treatment ----- 533 PARTIAL DILATATION, OR REAL ANEURISM, OF THE HEART. (Dr. Joy.) Aneurism peculiar to the left side of the heart.—Aneurism of the left ventricle, its causes, symptoms, physical diagnosis, prognosis, and treatment.—Aneu- rism of the left auricle.—Aneurism of the valves - 540 ATROPHY OF THE HEART, p. 544. (Dr. Joy.) CHANGES IN THE CONSISTENCE AND COLOUR OF THE HEART, MORBID EFFUSIONS INTO ITS SUBSTANCE, AND NEW FOR- MATIONS. (Dr. Joy.) Induration.—Softening.—OEdema.—Ha?morrhagic effusion.—Purulent deposits. —Ossification of its vessels.—Surcharge of fat.—Tubercle, fungus haematodes, or encephaloid cancer.—Scirrhus.—Tumours.—Serou3 cysts.—Hydatids.— Cartilaginous and bony deposits ------- 545 RUPTURE OF THE HEART. (Dr. Joy.) Causes.—Frequency in respect of the different cavities of the heart.—Seats ot this lesion.—Symptoms and treatment.—Rupture of the valves of the heart.— Wounds of the heart, and their treatment -.---- 552 POLYPOUS CONCRETIONS OF THE HEART. (Dr. Joy.) Origin and mode of formation.—Anatomical characters.—Symptoms.—Prognosis. —Prophylactic treatment ----.._- 556 HYDROPERtCARDIUM. (Dr. Joy.) Causes.—Symptoms.—Treatment ------- 560 SECONDARY EFFUSIONS INTO THE PERICARDIUM, p. 564. (Dr. Joy.) PNEUMOPERICARDIUM and HYDROPNEUMO-PERICARD1UM, p. 565. (Dr. Joy.) DISPLACEMENT OF THE HEART, p. 565. (Dr. Joy.) HERNIA OF THE HEART, p. 567. (Dr. Joy.) MALFORMATIONS OF THE HEART. CONGENITAL MALFORMATIONS. (Dr. Joy.) Transposition of the heart.—Acardia.—Bicardia.....568 PRETERNATURAL COMMUNICATION BETWEEN THE TWO SIDES OF THE HEART. • (jDr. joy>) Forms of preternatural communication between the two sides of the heart — Cyanosis—Symptoms of this lesion.—Progress.—Treatment - - 559 DISEASES OF THE ORGANS OF RESPIRATION. ON THE DIAGNOSIS OF DISEASES OF THE LUNGS. General observations.—I. Examination of the chest through its physical pro- perties—by sight and touch—by mensuration—by its sounds—by percussion. —Sounds of the respiration—Rhonchi.—Sounds of the voice.—Mode of em- ploying auscultation__Comparative advantages of immediate and mediate auscultation.—Principles and construction of the stethoscope.—II. E xamina- tion of the chest through the vital properties or functions of its organs.— Analysis of the general symptoms.—Dyspnoea.—Cough.—Expectoration.— Pain.—Symptoms connected with the circulation.—Analysis of the pulse.— Symptoms from the venous and capillary circulation.—Of the symptomatic fever.—Respective value of the physical signs, and general symptoms. The knowledge which we possess of the pathology and diagnosis of diseases of the respiratory organs, and consequently of a rational method of treating them, is so entirely of modern origin, that it would be useless in a practical work to refer to the writings of past ages for information on these subjects. The essen- tial phenomena and the products of disease were until lately too little understood even to be described accurately; hence the de- scriptions and names of the older writers, however minutely given and dogmatically applied, are vague and equivocal to the modern reader. The great improvement that has taken place of late years in our knowledge of diseases of the chest, and consequently in their treatment, has mainly arisen from the careful cultivation of pa- thological anatomy, and the successful application of physical means of diagnosis in connection with it; in both these depart- ments, especially the latter, we must give the pre-eminence to Laennec, whose Traite de V Auscultation Mediate maybe regarded 3 14 DIAGNOSIS OP DISEASES OF THE LUNGS. as at once the novum organum, and the principia, of our know- ledge of thoracic diseases. The results and the means ot his dis- coveries have been so far extended and improved by subsequent investigators, as to have changed the subject from being one of the most obscure to be among the most intelligible in practical medicine. It was the defect~of Laennec's practice to trust en- tirely to the physical signs, often to the exclusion of the general symptoms, which are always, especially in regard to the treat- ment, of the utmost importance. Both sets of signs have their value, and it will be our especial object to point out the modes of appreciating each in the study and treatment of the special dis- eases ; to show, as far as is possible, their relative value, by ex- amining them more fundamentally than has generally been done; and, whilst we pay due respect to authentic records of experience, of whatever kind, to make them still more profitable and instruc- tive by careful analysis and generalisation. It is necessary, however, to study the structure of the pulmonary apparatus; the form, position, and connection of its several parts; their relation to physical laws, and the combinations of these laws in their statical and dynamical forces, that is, at rest and in motion. But in doing this it is soon discovered that the object of our study is more than a mere machine, and that it possesses properties, and is governed by laws which are not met with in inanimate matter. We have the vital properties, sensibility, irritability, contractility, added to the mechanism; we have a vital chemistry pervading the materials. Besides the chest, which is mechanically enlarged and diminished, and the lungs and their tubes, which are at the same time expanded and compressed, and the heart and its hy- draulic pipes through which liquid is propelled, there are, also, in these several parts, the vital properties, which not only bind them together in special and complex relations, but connect them also with other organs and members of the body. Here, again, we see the sources of the two classes of signs of health or disease: the physical, confined to the organs and their physical or me- chanical properties as exhibited in these organs ; and the vital ox general symptoms, the result of vital properties, which are not confined to the part, but may extend their operation and seat over the whole frame. Now, as in the maintenance of health, and in the production or removal of disease, each set of properties is concerned both as causes and as signs, so the necessity of duly appreciating both classes must be apparent. It being presumed that the reader has studied the anatomy and physiology of the general structure, functions, and relations of the chest and its organs, the next object is to become acquainted with the signs or symptoms, through which, in the living body, we can judge of the condition of the various parts of the struc- ture, and of the performance of their several functions, and thus, through which, we can distinguish health and disease. The con- PHYSICAL EXAMINATION. 15 dition of the chest and its organs may be examined through two classes of properties, the physical and the vital. The physical properties are studied, especially through vision, tact, and hear- ing. The vital phenomena are studied in the condition of the functions, which are complex properties, or actions dependent on vitality operating in physical structure. I. Physical Examination of the Chest. We examine the chest physically through those properties of form, size, proportions, relative position and density of its parts, at rest and in motion, which are appreciable by our external senses. To assist this examination we must previously possess a good general knowledge of the topography of the several organs within the chest; we must know where each severally lies and reaches with regard to the exterior; so that, when we inspect, feel, or listen, at the different regions of the chest, we may define the general outlines of the organs within. This knowledge must be acquired by personal observation, which should be exercised both on the dead and on the living body. In examinations after death, the position of the organs with regard to the exterior should be observed. The moment the sternum is raised, and be- fore the lungs collapse (which may be prevented by closing the nostrils), the extent to which these organs cover the heart and reach downwards, the position of the air and blood-vessels, the height of the diaphragm, and of the abdominal viscera beneath, should be noticed by the student; and he can transfer these vari- ous sites to the marks or lines of the exterior, such as the nipples, the edges of the pectoral muscles, the number of the ribs. This habit of comparing the outside with the inside of the chest in the dead body may not, however, furnish a perfect knoXvledge of what exists in the bodies of the living; for besides that there is much variety in different individuals, there may, on the cessation of the motions and properties of life, be some changes in the size and condition of the organs, and these changes may vary accord- ing to the mode of death. Thus it is probable that the diaphragm, relaxed by death, permits the abdominal viscera to encroach on the cavity of the chest further than during life; and the volume and position of the heart and lungs will be affected, not only by this circumstance, but by the condition of the circulation and respiration at the time of death, by the influence of time and tem- perature on the stiffening of the muscles, and by other changes which immediately succeed death, such as the disengagement or absorption of gases by which the intestines are distended, which vary much in different cases. It is well to be aware of these modifying circumstances, which can be appreciated only by the habit of personal observation: and it is by such individual expe- rience, rather than from rules and descriptions, that a knowledge 16 DIAGNOSIS OF DISEASES OF THE LUNGS. of the topography of the organs can be obtained in the study of the dead body. , Examination of the Chest by sight and by touch. 1 he other mode of studying the topography of organs is more exact, but more difficult. It is the personal habit of physically examining the living body. The patient standing, or even sitting, with his arms, trunk, and legs in symmetrical positions, and his chest, if possi- ble, entirely uncovered, and exposed to a good light, we view it in front, behind, and from above, and carefully mark its form and proportions, and the corresponding prominences and depressions of the two sides. A healthy chest" is nearly symmetrical, the two sides corresponding in shape and size. The right side is, how- ever, almost always slightly larger than the left, especially at its lower portion, where the difference of measured circumference generally amounts to half an inch. This preponderance in favour of the right side is partly to be ascribed to the contents, the un- yielding mass of the liver; but it is probably also connected with a law which pervades the animal creation, giving a superiority of strength and development to the right side. It is supposed by Dr. Stokes and M. Woillez, that the increased development of the right side is rather a consequence than a cause of the greater strength, and consequent use of its muscles; and they say that the proof of this is seen in the exceptional cases of left-handed persons, in which the left side has a superiority in size. We have observed, on the other hand, in most healthy chests, an advantage on the left side in point of height: the apex of the left lung, and corresponding portion of the chest, rise a trifle higher than those of the right. We are not prepared to say whether this be an original conformation, or whether it result from the habitual in- flation of the stomach, and the unyielding mass of the heart on the left side giving the chest a greater tendency to upward ex- pansion. When these slight exceptions are known, they will not mislead, and they scarcely detract from the general sym- metry of the chest. Whenever there is any considerable depar- ture from this degree of symmetry, or correspondence between the two sides, it becomes pretty certain that there either is, or has been, disease. It has been stated that the chest should be viewed from above, as well as from before and behind. This may be done when the patient is seated on a low seat, with the head a little inclined forward, the observer standing behind or on one side, and looking down on the shoulders. A view is thus obtained of the depth of the chest from front to back, and in this way may often be de- tected between the two sides a want of correspondence, that is not perceptible by the ordinary modes of inspection. If the patient's strength do not permit him to stand or sit up, the chest may be inspected when he is lying on his back, and this may be done by the observer taking his position, not only at the PHYSICAL EXAMINATION. 17 side, but also at the foot and at the head of the bed, from which the corresponding parts of the two sides can be better seen. The inspection of the chest is to be applied not only to its statical condition, but also to its motions; and here it is proper to combine manual examination. Whilst, therefore, we are inspect- ing the chest, we desire the patient to breathe in various degrees; and with the hands and eyes directed to corresponding points of the two sides, we watch and feel the amount and equality of the motions. If the chest is a healthy one, we see the motions as uniform as the chest is symmetrical: the clavicles, scapulas, and upper ribs rise ; the lower ribs rise and spread ; and the abdomen swells, as the diaphragm descends at each inspiration. Atten- tively watching and feeling the chest will often also enable us to trace the limits of some of these movements, so as to indicate the boundaries of the chest. Thus the lower ribs are pressed out- wards by the displacement of the abdominal viscera at each descent of the diaphragm, and constitute a fulness below the limits to which the lungs descend, with a slight flatness or hollow above. These appearances have been pointed out by Dr. Edwin Harrison, as visible indications of the height of the diaphragm and liver. The intercostal spaces and the hollow above the clavicles are also fit marks for this mode of comparison between the two sides. They are strongly marked during full inspiration ; and are liable to be more so than usual where the entry of air into the lungs is difficult from obstruction of the tubes, and less so than usual when the obstruction is more in the tissue of the lung from internal effusion or external pressure. There are many other useful details which are soon learned by practice, when the principles of the examination are properly understood. Applying the hand on the region of the heart, we feel the relation of the respiratory motions to that organ. After a full expiration the heart is felt beating about the cartilages of the third and fourth ribs, as well as under the sternum ; but as the ribs rise, and the lungs expand by inspiration, we gradually lose the beating ; and if it be felt at all, it will now be low as the sixth rib. There are some general varieties of disordered respiration, which are determined by watching and feeling the motions of the chest. Healthy or perfect respiration is both diaphragmatic and costal; but under the influence of disease the motions may be imperfect, and confined either to the ribs or to the diaphragm. Thus, when the diaphragm is prevented from descending by acute pain in it or below it, or by pressure from below, the respiration is wholly performed by the raising of the ribs ; and is called heaving, thoracic, or costal breathing. When, on the other hand, the ribs are immovable in consequence of pain, ossification of the cartilages and ligaments, or paralysis of the intercostal muscles, the breathing is wholly diaphragmatic or abdominal. The movements of respiration may be partial, while one side 18 DIAGNOSIS OF DISEASES OF THE LUNGS. t of the chest is seen to move much less than the other, or when part of one side moves imperfectly; and this partiality ot move- ment may have its cause in the walls, or, as more usually, it may proceed from impermeability of the corresponding portions of lung, in consequence of various diseases. Thus, when lymph or tuberculous matter in the tissue of the lung, an obstruction of the bronchi, an effusion into or a contracted adhesion of the pleura, prevent the inflation and collapse of a part of the lung, the cor- responding walls of the chest will be resisted in their motions, and will be fixed in proportion. Thus in phthisical patients we often see the ribs below the clavicles scarcely moving in respira- tion, and often sunk on one side : in pneumonia and pleurisy, the lower ribs are more commonly fixed. It is proper to mark fur- ther how they are fixed ; whether in a state of dilatation, or in one of collapse; whether the affected part remains full after ex- piration, or is still sunk after inspiration, or whether it is fixed in an intermediate state: we may thus, in certain instances, go some way to distinguish between the different causes of pulmonary obstruction. Mensuration of the chest is a more exact method of detecting inequalities between the two sides. It is generally practised by fixing with the finger a piece of tape by one end at the mesial line of the sternum, and passing it horizontally around the chest to the same point; then, by taking it off at the point where it crosses the spinous process of the dorsal vertebra, the length of two sides may be at once compared. Great care must be taken to pass the tape horizontally around corresponding parts; and attention should also be paid to the degrees of the respiratory act. The most accurate mode is to compare the measurements of the two sides, on a full inspiration and expiration as well as in the intermediate state. Dr. Stokes recommends the use of gra- duated callipers to measure the depth and height of the chest, as well as its circumference, which alone is given by the tape. Such an instrument would doubtless afford more exact results ; but it is not likely to be introduced into general use. We may mention that we have been in the habit of using the tape for the height also, by measuring from the bottom of the sternum to the hollow under the humeral end of the clavicles, and from the latter spot to the spinous process of one of the lower dorsal vertebras. The measurement may also be practised from the top of the sternum downwards and outwards, to the margin of the ribs at either side. These expedients, together with the practice of inspec- tion downwards on the shoulders for the antero-posterior diameter of the two sides, are generally sufficient to furnish the compara- tive dimensions of the sides of the chest. Besides external measurement, which is essentially compara- tive between the two sides, there have been various attempts to measure the internal capacity of the chest by noting the quantity PHYSICAL EXAMINATION. 19 of air that can be exhaled or inhaled. The late Mr. Abernethy proposed to judge of the capacity, and thereby of the soundness of the lungs of a patient, by measuring how much air he could throw at a breath after a full inspiration into a jar inverted over water. Other contrivances have been made to measure how much air can be inspired at a breath from a jar of air inverted over water. The chief objection to these means of measurement is, that their indications are affected not only by the capacity of the lungs, but also by the strength of the respiratory efforts. They are dynamometers for the muscles of respiration as well as pul- mometers; and a weak, delicate, or nervous person, with sound lungs tested by them, would be placed below a pleuritic or phthi- sical patient whose muscular energies are still considerable. So much for examination of the form, shape, and size of the chest by sight, touch, and measurement. It may often give us important indications; but it will seldom inform us of the nature of the obstructions or changes which it discovers; and it cannot detect many obstructions and changes in their smaller degrees. The chest may be immobile, distended, or contracted in parts, but whether from impervious air-tubes, diseased lung, liquid or air in the pleura, or any other of the various causes, sight and touch will rarely inform us. Examination of the chest by hearing. We are led, then, to try another sense which may reach beyond the surface, the sense of hearing. The acoustic phenomena of the chest should be studied, not only by mere experience, like that by which the infant studies objects by sight and touch, and in time becomes acquainted with them; but also, more rationally, by a general- isation of such experience in the laws according to which the phenomena occur. We must accustom our ears to the sounds in all their varieties, that we may be able by experience to know and distinguish them ; but to understand their import, and to read the interpretation which they give to the condition of the parts that produce them, we should study them through the laws under which they occur. We must consider what sound is, how it may be produced, transmitted, and modified ; how the contents of the chest may produce it, and, when produced, can change it: and by comparing its general properties with the mechanism of the chest and its organs, we shall be prepared to understand and arrange the phenomena that experience has discovered, or may hereafter reveal to us. By thus learning the acoustic relations of the chest, not merely as isolated facts, but as parts of an applied science, we may be enabled to escape, in great measure, the errors into which unintelligible matters of memory might con- tinually lead us, and we shall be acquiring a rational pathology, instead of resting on an empirical diagnosis. The character of the present work precluding the introduction of more than a few of the leading principles with regard to sound 20 DIAGNOSIS OF DISEASES OF TnE LUN in general, we must refer for further details to the various treatises on natural philosophy, and to the lectures and treatises of the writer on the physiology and diseases of the chest. Sound is a certain velocity of motion of a body, or ot the particles of a bodv, resisted with a certain force. The moving and the resisting forces acting alternately in opposite directions, constitute the vibrations of sound, which may be seen in a vibrating cord, and illustrated by the slower motions of a vibrating pendulum. The transmission or conduction of sound is the com- munication of the sonorous motion from one body to another, as one ball striking another ball moves it. The reflection of sound is the refusal or rejection backwards of this motion by bodies which cannot receive it, as a wall throws back the motion of a ball. Sound is most readily produced and sustained in bodies of uniform density and elasticity, the particles of which transmit and continue, and do not reject or choke each other's motions. Hence tense and rigid bodies produce and conduct sound better than those which are flaccid and soft. Bodies of very different den- sity and elasticity do not readily receive sound from each other; because their powers of motion differ in force and extent, and must cause them to reflect or choke the motions which they receive from each other. Thus a sound produced by air is intercepted by a solid; and that produced by a solid is far better transmitted by a solid of the same density and elasticity, than by air. The sound of a body much more dense than air, such as metal, may be commu- nicated with greater freedom to air by the medium of a third body of intermediate density, such as wood, and this effect may be increased by extending the surface, and lightening the mass of the third body, as it is done in the sounding boards of musical instruments. The note or pitch of a sound depends on the fre- quency of the vibrations, those of the highest or shrillest notes being the quickest. The duration of a sound depends on the con- tinuance of the vibrations. The sources of sound are such im- pulses as those which affect bodies suddenly, or with some force. Thus the percussion, collision, friction, tightening and breaking of solids cause sound. Sounds are not often produced in air or in liquids but by the aid of solids, which either communicate the motion or offer the resistance: thus we hear the wind only when it whistles in a key-hole, in the rigging of a ship, the leaves of a tree, or the like; and the sound of wind instruments depends on the motion or on the resistance of a solid. But liquids and air together readily generate sound without the aid of solids, by their impulses on each other; and thus are caused all the bub- bling and rushing noises of liquids, from the frothing of beer to the roar of a cataract. Examination of the chest by percussion. As the nature of metal, wood, and other bodies is tested by the sound which they yield on being struck, so we strike or percuss the chest to judge PERCUSSION. 21 of the nature and condition of its materials. The practice of percussion as a mode of diagnosis, we owe to Avenbrugger ; it has been applied and improved by Corvisart, Laennec, Piorry, and others, and now constitutes an important mean of diagnosis in diseases of the chest and abdomen. When the principles on which its indications depend are well understood, the practice becomes easier as well as more instructive; and as we believe that no preceding writers have exposed these principles correctly, it will be well, after stating the general phenomena of percussion, to explain them by a few familiar illustrations. The chest when struck abruptly with the ends of the fingers, yields a rather deep and not very short sound ; which implies that the vibrations are not quick, and that they do not instantly cease. If we strike in the same manner on the thigh, a very different sound results, a short dull tap, implying that the vibrations have no continuance. The same dead tap is obtained on striking the lower part of the chest on the right side, where the liver lies; but all those parts under which the lungs are, yield more or less of the deep hollow sound. Is the seat of this sound in the air, or in the solids of the chest 1 If it be in the air, like that of hollow bodies, it ought to be changed by the same circumstances which modify the sounds in them. Thus, if we take an India-rubber bottle, and strike it, we find that its note is quite different when its mouth is open, from that which it yields when it is closed. But closing the glottis, or aperture into the chest, does not ma- terially change the sound of pectoral percussion. Again, the sound of hollow bodies is deep in proportion to their size. Thus a large India-rubber bottle gives a much deeper tone than a small one ; and its note is raised on diminishing its cavity by compres- sion. It is not so with the chest; for enlarging or diminishing its hollow does not in this way change its sound on percussion: the extremes of inspiration and expiration only slightly raise it. As the sound of percussion of the chest does not follow the law which regulates sounds produced in the air of hollow bodies, we must conclude that it is seated in the solid : and if we study the construction of the chest, we shall see how well-adapted its solids are to vibrate. Composed of layers of membrane, thin muscles, and integument stretched on an elastic frame of bone and cartilage, the walls of the chest are free to vibrate so long as the organs within do not check their motions; were there nothing but air within, these motions would be perfectly unem- barrassed, and the sound would be more prolonged and hollow in consequence, deriving also an additional tone from the note of the cavity within, as in pneumothorax, or over an inflated sto- mach. The light, soft, spongy tissue of the lung scarcely inter- feres with the free vibrations of the walls, whilst the slight sound of its own which it yields, is equally deep with that of the walls with which it becomes combined. Hence, where healthy lungs 4 22 DIAGNOSIS OF DISEASES OF THE LUNGS. lie in contact with them, the walls of the chest give a deep clear sound. But below the sixth or seventh rib on the right side, which is over the liver, and to the left of the lower part of the sternum, which is over the heart, the sound is dull and short, the vibrations being checked by these solid organs beneath ; so it is obvious that morbid changes of the organs, such as a condensation of the lung, or the pouring out of serum into the pleural sac, would in a simi- lar way arrest the vibrations, and render the sound of the chest dull in those parts where these changes occur. On the other hand, changes of an opposite kind, such as dilatation of the air- cells of the lungs, or an effusion of air into the pleural sac, may make the vibration of the walls more free than usual, and thus increase the sound obtained on percussion. These illustrations are enough to show the genera] principles of the acoustic examination of the chest by percussion. It is a test of the density and elasticity of the materials within the chest: as diseases alter these qualities, so will they alter the sound on per- cussion which may thus announce their presence. A few more considerations will suggest some practical application of these principles. As we have seen that the walls of the chest give the sound which we hear on striking the chest, so it is plain that they must be sufficiently tense and elastic to vibrate on being struck. The chests of some persons are so loosely put together, and so flaccid, that they give but little sound, although the organs within are quite healthy. In others, again, there is such a mass of fat and loose integument on the chest, that the walls are completely muffled by it, and they sound but little on percussion. The same difficulty occurs, in other cases, in certain regions where muscles of considerable thickness, or the mammas in females, lie on the walls. In other instances again, the walls of the chest are so drawn in by contracted adhesions of the pleura, that they are too tight to vibrate, and give a hard or dull sound, although the lungs within them may be comparatively healthy. In all these cases we must give to the part struck the equal tension which is wanting, by pressing on it a small piece of some firmly elastic body, such as wood, ivory, stiff India-rubber, or some such sub- stance. This, when struck, gives sound enough; and if it be firmly applied to the chest, the density of the contents within will modify this sound, just as it modifies that of percussion on the naked walls of the chest. The sound obtained by striking a little plate of ivory or wood thus pressed on the chest, is the same in character "as that of striking the chest itself; but it is louder, and as percussion on it gives no pain, the stroke can be applied with such force as to make the vibrations reach the in- terior through any thickness of fat or muscle. By these means we can test the sonorous qualities of the thoracic viscera through the scapulas and muscles of the back, and through fat or cede- matous integuments of any thickness. In this way, too, we can try the resonance or sonorous quality of any part of the abdomen. PERCUSSION. 23 We owe this method of mediate percussion to M. Piorry, who calls this percussion-plate a pleximeter. Mediate percussion is so much better than the immediate kind, that it is now generally preferred. There is, however, an improvement on it which was, we believe, first proposed by Dr. Skerret; it is to substitute for a pleximeter the fingers of the left hand. This mode of percussion has the advantage of convenience as well as of yielding distinct results. Its adaptations are soon found out by a little experience —in fitting the fingers to the inequalities of the chest, sometimes singly, sometimes together, sometimes with their palmar surface outwards, but generally with this applied to the chest and the back to strike on, with other varieties of manipulation to be here- after noticed. To understand the varieties of sound of percussion, and their situations in the chest, it is necessary to bear in mind how the contents of the chest lie in relation to the surface. This varies considerably in different healthy individuals, but the following may be given as an average statement of the position of the thoracic organs after an ordinary expiration. The lungs are in contact with all the upper and middle portions of the walls of the chest. On the right side they reach down to about the sixth rib in front, and the eighth rib at the side, below which the liver comes in contact with the walls, and still lower in the back. On the left side they reach to about the seventh rib in front, except within two or three inches of the sternum, where they seldom reach lower than the fifth rib, there being a space of from one to two superficial inches under and to the left of the sternum, where the heart lies in contact with the walls ; at the side they reach to the eighth rib, whereabout they are bounded by the stomach and spleen, which, with the colon, also bounds them behind, where they reach a little lower. Inspiration greatly alters these limits, both by raising the ribs and expanding downwards the lungs, which then reach a rib lower, and a full inspiration may bring them in contact with nearly the whole of the thoracic walls, while expiration has the converse effect. The sound on percussion corresponds with this description, and by it we may therefore know the position of the organs in a living subject. Thus in all the upper parts of the chest, before, behind, and at the sides, the sound is clear, and equal on both sides. There is also some clear pulmonary sound in the inferior parts of the chest down to the limits to which the lungs reach. But below the fourth rib in front on either side, although the lungs are in contact with the walls of the chest, their lobes are not thick, and beneath them lie the liver on the right side and in front, and the heart and stomach in front and to the left. The vicinity of these organs modifies the sound on percussion, and the more so, the nearer they approach to the surface, where the lungs become thin towards their margins, until they quite give 24 DIAGNOSIS OF DISEASES OF THE LUNGS. place to the peculiar sounds of these respective viscera about the limits before named. There is, therefore, a very slight dead- ening of the pulmonary sound below the fourth rib on the right side, below the middle of the sternum, and below the third rib near the sternum on the left; and this deadening increases down to the margin of the lungs, where the sound has the perfect dul- ness of the solids of the liver and heart. Further to the left the sound takes more or less of the hollow tympanitic character of the air-filled stomach. It appears, then, that the stroke of per- cussion reaches to a considerable depth, to organs an inch or more from the walls; and whatever it reaches, may modify the sound. This suggests to us, that, by varying the force of the stroke, we may make the impulse of percussion reach to different depths, and derive the character of its sound from the superficial, or from the deep-seated organs, as we will. Thus, where the lung overlaps the liver, strong percussion will give a shorter deader sound than gentle percussion, Strong percussion re- ceives the character of its stroke^from the liver, as well as from the lung; whilst gentle percussion, such as by filliping with the finger and thumb, does not pass through the thin layer of lung, and gives still the pulmonary sound. The same mode of percus- sion may distinguish the utmost limits of the lungs over the heart. It is more difficult to determine by percussion the precise limits of the lung on the left side; for, in consequence of the loudness of the hollow stomach sound, and the facility with which it may be elicited, it is apt to disguise the pulmonary sound, even with the most gentle percussion. In this case more may be done by observing the amount of expansion of these parts by a full in- spiration. The extent of this stomach sound varies according to the state of gaseous distension of the stomach; it not unfre- quently reaches, in a slight degree, above the mammilla. There is sometimes a slight dulness on the left side behind, correspond- ing with the position of the spleen; and in case of enlargement of this organ, the dulness may become extensive. It must not be forgotten, that the motions of respiration may produce changes in the character and position of some of these sounds. Inspiration, as it enlarges the lung, renders the pulmo- nary sound clearer, and extends it over every part of the heart, and over a considerable portion of the liver. As the complete and equal enlargement and contraction of the chest, as seen and felt, are signs of the free conditions of the respiratory organs, so the sound on percussion becomes an additional sign of the healthy action, in proportion as the clear pulmonary sound is ex- tended at each expansion of the chest. Percussion is a test, there- fore, not only of the statical condition of the lungs, but of their dynamical state also. This point is not enough attended to by auscultators; yet the neglect of it not only would deprive us of additional signs, but would tend to render deceptive the results PERCUSSION. 25 of statical percussion. For example, in judging of the goodness of sound on percussion, we generally compare the sounds on the two sides of the chest, where in health the structures and sounds are the same; but if we do not attend to the movements of res- piration, we may strike one part when the chest is contracted, and the other when it is full, and obtain results which differ from this cause only, and not from any internal change. In practising comparative percussion, therefore, in cases requiring delicacy, it is proper to desire the patient to hold his breath for an instant while the comparison is made; and it is often useful to try the sound when the chest is expanded to the utmost, when it is contracted, and in the intermediate states. The varieties in the sound of percussion from special diseases will be considered when those diseases are described, but a few examples will be useful here to illustrate the subject. The indu- rations of the upper lobes of the lung are often small, and so scat- tered through its substance, that they scarcely affect the sound on percussion; but by a full expiration, they are brought closer together, and if more on one side than on the other, they may then sensibly deaden the sound on that side, especially if gentle percussion be used below the clavicles, and not on a very small surface. Again, the indurations, especially if of some standing, tend to restrain the lung from its full expansion ; and if there be a difference on the two sides, it thus may be detected only on a full inspiration. In the disease called emphysema of the lungs, the air-cells are permanently dilated: they contain an unusual quan- tity of air, which expiration cannot expel: this may be detected by percussion used as a dynamical test; the regions of the heart and middle part of the liver being covered by the permanently distended lung, give, even after expiration, a clear sound. There is one more point to be noticed respecting percussion at the ex- tremes of the respiratory act. Full inspiration makes the sound clearer: full expiration has the contrary effect; but they both raise the note a little; they make its pitch higher. This is in conse- quence of forcible inspiration or expiration, which are muscular actions, straining the walls of the chest, and thus rendering their vibrations quicker, and therefore the sound higher, as in tightening a drum. It is unnecessary to add more on the principles of percussion ; but it will be useful to give some directions with regard to the practice. In this as in every other art requiring some manual dexterity and the exercise of the senses, practice is necessary to familiarise the beginner with the phenomena and the mode of ob- taining them. In obtaining the sounds of percussion, he soon finds that some dexterity is necessary even in mediate percussion, which is the easiest mode. The fingers or pleximeter should be closely pressed on the walls of the chest: and if the object be comparison be- 26 DIAGNOSIS OF DISEASES OF THE LUN tween the two sides, they should be placed on corresponding parts, whether between the ribs, along them, or across them. Care should also be taken that the mode of striking be the same, whether it be with one or several fingers, with their tops (in which case the nails should be kept short) or the flat of the last phalanx, or with the knuckles, each of which modes is sometimes preferable. Filliping with the middle finger and thumb often gives more uniform and delicate results, especially when the patient is in an inconvenient position, or suffers from tenderness of the walls of the chest. This is also the best mode for abdominal percussion. When striking the clavicle, attention should be paid to what part is struck ; for the sternal portion of this bone always sounds much clearer than the humeral end : so also in percussing this or any other part, the direction of the stroke should be perpendicular towards the lungs, and not sideways, or the sound will be modi- fied, not by the lungs, but by the adjacent muscles or other parts towards which the impulse is directed. It is from neglecting this precaution, that beginners sometimes get nothing but dull sounds all over the chest. It is not generally necessary to use much force in percussion : in fact, many of the most valuable results are obtained by gentle mediate percussion ; but the mode must be varied in different cases. When it is desired to test the den- sity of a small spot, percussion with a single finger is best; whilst for trying a surface of greater extent, flat percussion with several fingers answer better. In doubtful cases it is proper to try both. In percussing the regions of the back and shoulders, the bony pro- minences of the scapulas and ribs should be sought, for these trans- mit the impulse to the interior far better than the'thick layers of muscle. But as the scapulas are movable bones, it is necessary to see that they are in corresponding places on both sides; and to insure this, and to increase the tension of the muscles, it is well in examining these regions to desire the patient to cross his arms in front, and to bend his head forwards. At that part of the chest near the humeral end of the clavicle, a most important region for examination, there is often a falling away of the chest; and the more tense the pectoral muscles are made, the further they are removed from the walls : here then, instead of making the mus- cles tense, they must be relaxed, by letting the elbow hang close to the side, whilst mediate percussion is practised in this region. The best posture of the patient for percussion is erect or sitting; and in comparing the two sides, both before and behind, the ob- server should be directly opposite the front or the back. When the patient is lying down, the sound is modified by the matter on which he is lying: if it be a soft feather-bed, the sound is more dull; if a mattress, or anything hard, the sound will often be in- creased, because the elasticity of the contents of the chest is in- creased by the unyielding matter behind it. So also the vicinity of a wall or other hard surface causes a reverberation which AUSCULTATION OF RESPIRATION. 27 gives to the side nearest to it too loud a sound. On the other hand, the vicinity of curtains or other drapery deadens the sound. As most of the effects of percussion are judged by comparison, the chief object of the cautions given is to take care any of the external causes of modification may not act unequally on the dif- ferent parts of the chest. The patient may sometimes be removed from the influence of these to the middle of the room ; and when this cannot be done, these modifying causes must be equalised as much as possible. Little needs to be said about pleximeters, for they are not gene- rally necessary : M. Piorry much exaggerates the advantages derived from them. A thin circular plate of wood or ivory, with two projections or a raised rim by which it may be held firmly to the chest, is one of the best forms: the surface to be struck should be covered with soft leather, to prevent the clack of the fingers on it. We give the preference to a little oval piece of boxwood, about an inch long, three-quarters of an inch wide, and one-eighth of an inch thick, with a strong handle two inches long rising from its outer margin, at an angle of about forty-five de- grees. The handle is convenient for holding it firm to the chest without interfering with the percussing fingers.* The chief pre- caution necessary in using it, is to take care that it be applied flat and not tilted. Auscultation of the respiration. Let us now inquire into other modes of producing sounds in the chest, which may prove signs of the condition of the organs within. The contractions and re- laxations of the muscles of respiration are in general too gentle to cause sound; but when forcible or sudden, they sometimes produce a sound of tightening, a kind of muscular sound. This is often evident when there is an abrupt catch in the breathing, and during the act of coughing, though it does not furnish any sign of importance. But the internal motions and passage of air to and from the lungs produce sounds ; and inasmuch as this passage of air is the great object of respiration, we may expect to find in these sounds signs of the manner in which this object is accomplished. These and most of the other acoustic motions of the chest were first discovered and described by Laennec, who may well be regarded as the father of the art of auscultation. We shall endeavour so to illustrate and extend this art by the aid of physical and physiological science, that we may be enabled to deduce respectively from the phenomena the condition of the organs, and from any known condition of the organs the pheno- mena which it would produce. The air enters the lungs by atmospheric pressure, to fill the increased space made in the chest by the action of the muscles * A sketch of this form of pleximeter is given in the writer's lectures, pub- lished in the Medical Gazette.—(Author.) 28 DIAGNOSIS OF DISEASES OF THE LUNGS. of inspiration. On its way to the most expansible parts of the lungs, the fine tubes and cells, it strikes against the sides and an^es of the larynx, trachea, and its ramifications, with force sufficient to produce a particular hollow blowing sound. We may hear this on applying the ear to the fore part of the neck, or at the top of the sternum. As the current of air becomes subdivided and spread in the small bronchi, it loses a part of its velocity, and the sound becomes of a more diffused and less hol- low character: it is more like the sighing of a gentle breeze among the leaves of trees; and in passing into the cellular ter- minations, all of the hollow tubular sound is lost, as may be per- ceived on applying the ear to most parts of the chest where the lungs lie. This sound seems to depend here chiefly on the im- pulse of the air against the angles and sides of the minute tubes and cells, but partly also on the opening and stretching of these cells, and perhaps partly on a propagation of the louder sound of the passage of air in the larger tubes. Where inspiration ceases, expiration begins; and a portion of air is pressed out of the cells and small tubes by the collapse of the walls of the chest, and by the contracting properties of the pulmonary tissues. There is a remarkable difference between inspiration and expiration; in inspiration air is the moving body, and rushing through the tubes distends the passive lung : in expiration the lung is the moving body, and by its contraction (backed by external pres- sure) drives before it the passive air. In either case there is a pressure exerted between the air and the interior of the cells, and doubtless this proves the means of assisting the chemical changes that take place. But it is plain that there must be a difference between the sounds of inspiration and expiration. In inspiration air moving with some velocity meets with the resist- ance of the angles and sides of the tubes and cells which it has to dilate. Here must be sound in the whole passage of the air, from the nostrils down to the pulmonary cells. In expiration the motion begins with the lungs; and the air passively yielding to it, there is not motion or resistance enough to produce sound, until by the converging together of the small tubes the impelled air is gathered into a current in the larger tubes, where, impinging against their sides with its now acquired velocity, it at length produces sound. These remarks explain why in natural inspira- tion there are three kinds of sound produced by the motion of the air through different parts, and hence called tracheal, bron- chial, and vesicular. In expiration there are at most only two, bronchial and tracheal. These differences, which were over- looked by Laennec, have been noticed by Andral, Louis, and Dr. Cowan, who ascribe their discovery to the late Dr. Jackson, a young American, who studied at Paris. They deserve attention, and are obviously dependent on the causes which have been mentioned. It is needless, however, to distinguish them in ge- AUSCULTATION OF RESPIRATION. 29 neral descriptions, and we shall class them together as the sounds of respiration. * The bronchial respiration varies in intensity on the two sides, and is de- cidedly more distinct in the right lung than the left, especially at the summit. This arises from 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. Hence in healthy individuals, especially if they should be thin and their respiration loud, there is a slight difference in the two sides, the left affording a respiration which is almost purely vesicular, and the right one that is slightly blowing or bronchial. This fact was overlooked by Dr. Jackson in his investigations upon the subject: it be- came known to the editor by examining the respiration of children at the hos- pital at Paris, who afterwards died of acute diseases unconnected with the lungs, and offered this difference during life. Subsequent investigations proved that the same difference existed in adults. In cases of disease a given obstruction to the passage of the air produces a much more decided bronchial respiration in the right lung than in the left, and allowance must always be made for the natural inequality. If the left lung present a slightly blowing respiration, the evidence of disease is therefore more decided than if it should exist on the right side. But in case of disease of either lung there is little probability of error if the observer retain a clear recollection of the natural sounds of the respiration. The sounds of respiration can be heard on applying the ear to different parts of the chest, being transmitted through the parietes to the parts beneath with sufficient distinctness ; and as the healthy sounds vary in these different parts, we may judge of the natural distribution of the tubes, by listening to these sounds. Thus we find in any part of the neck, and at the upper part of the sternum, there is the hollow blowing sound which results from the passage of air to and fro in the trachea, which is therefore called tracheal respiration. A little lower down than this, over the space of two or three inches on each side of the top of the sternum, between the scapulas, and sometimes in the axillae, there is the sound called bronchial respiration, its whiffing or tubular character denoting that it is produced by the passage of air in the bronchial tubes. In most other parts of the chest is heard the vesicular respiration, which is a diffused murmur caused by the air penetrating through the minutest tubes, and into their numerous vesicles or cells. The question naturally occurs, why is the bronchial respiration heard in comparatively few parts of the chest, when bronchial tubes of considerable size are distributed in so many parts of the lungs, within an inch or less of the surface? Why is not the sound a mixture of the tubular and vesicular sounds? The an- swer and explanation is, that in consequence of its softness and 5 30 DIAGNOSIS OF DISEASES OF THE LUNGS. inequality of density, the healthy tissue of the lung is a bad con- ductor of sound, and does not transmit the sound ot broncnuu respiration to the surface, except in points where the tubes are large, and approach quite close to the walls of the chest. I he flaccid tissue, composed of the different materials, membrane and air, effectually arrests all the slighter sounds produced in the tubes within it. An important corollary from this is, that, as this arrest of the sounds of the interior depends on the light spongy structure of the lung, so any disease increasing the density of that structure, augments its conducting power, and enables it to transmit the sounds. Hence we find that a great increment of solid or liquid in the lung, as in pneumonia or tuberculous disease, or the compression of its superficial parts by a moderate quantity of liquid in the pleura, as in a recent pleurisy, often not only diminishes the vesicular murmur in consequence of the obstructed state of the cells, but also adds a bronchial or tubular sound of breathing in those parts where naturally the respiration is purely vesicular. As the several sounds of respiration depend on ihe resisted motion of the air, so they vary according to the velocity of that motion, and the degree and nature of the resistance to it; they are loud when the air passes in and out forcibly and quickly, and low when it passes gently and slowly. So, on listening to a per- son's breathing, it may be scarcely audible at its ordinary rate ; but if he breathe quick and short, it will be distinct enough. Taking a long breath may not answer the same purpose ; for although much air is thus taken in, it may not enter with suf- ficient rapidity to cause the increased sound. Coughing answers better, for the full inspiration which succeeds coughing is gene- rally quick also; and it is often useful, where the sounds are ob- scure, to magnify them by this more forcible act. But there is a limit to this power of increasing the sound of respiration by increased effort. If an individual tries to breathe very hard and quick, as after violent exertion, the movements of the lungs can- not keep pace with those of the external muscles of respiration, and the air does not freely enter, the sound will be diminished or altered rather than increased. As we can vary the sound of respiration by varying the act in the same individual, so we find that a difference exists naturally in different individuals ; in some, as in many robust adults, the ordinary respiratory sound is-very low and faint; in others as in children, in nervous females, and in slight irritable persons, it is loud and distinct. In the last-mentioned cases, the respiratory movements are more brisk ; and although air may not be taken in more frequently or in such great quantity as in other cases, yet it enters more suddenly, and meets with greater resistance in its passage, so that it must cause more sound. As this loud respiration is commonly met with in children, Laennec called it AUSCULTATION OF RESPIRATION. 31 puerile respiration. So, also, by rendering the respiration quicker and more energetic, it may be made to sound loud in those cases in which it is naturally faint, as by the quick short breathing just mentioned, or, better still, by desiring the person to hold his breath for a while; the quick strong inspiration which follows, is noisy enough. Disease sometimes brings about this same change; thus, if a considerable portion of the lungs be obstructed, the force of the act of breathing will be concentrated on the remain- ing portions, and the air will be carried in and out of them with unusual energy and noise. Hence Andral terms this partially increased respiration supplementary. So also, under some cir- cumstances, without any obstruction, the want of breath may be increased, as it happens during moderate exercise, in some degree during digestion, and on exposure to cold ; here the whole respiration is more energetic and its sound louder. Further, as the act of breathing depends on a particular impression of the nervous system, so it may be supposed, when this system is pre- ternaturally sensitive, the ordinary impression produces an in- creased effect; here, again, the respiration becomes more ener- getic and noisy. This appears to be the chief cause of the in- creased sound of respiration in fevers and other diseases where the nervous sensibility is exalted. Lastly, it is possible, by an ex- ternal restraint of some parts of the chest, to render the sound of respiration louder in other parts. Thus, by inclosing the abdo- men and lower part of the chest in a tight belt (and the experi- ment is already prepared in the persons of tight-laced females), the sound of respiration is made unusually loud in the upper parts ; and it may be seen by the heaving of these parts how their mo- tions are augmented. Acute pain or tenderness of some of the parts moved in respiration would have somewhat of the same effect as a ligature, for it would cause an instinctive restraint of these parts, which would throw on others supplementary labour. It appears, then, that there may be much variety in the sound of respiration without disease of the lungs; and except in the case last mentioned, it is where there is a comparative discrepancy in the several parts of the lungs rather than any absolute difference, that disease of these organs is indicated. Thus, if we find the respiration loud on one side and obscure on the other, or clear in the lower part of the chest, indistinct in the upper, we may well suspect some obstruction to exist in those parts where the sound is obscure; and the nature of that obstruction is then to be tested by percussion and other means. There is another kind of variation in the respiratory sound that has not been attended to—that which affects its duration. In this, as in other varieties, there are absolute differences in dif- ferent individuals, and in the same individual under different cir- cumstances ; but we shall only notice the comparative discrepant 32 DIAGNOSIS OF DISEASES OF THE LUNGS. cies in the same subject and at the same time, which alone con- stitute signs of disease. We may hear the sound of inspiration on one side distinct and prolonged during the whole inspiratory act, whilst on the other side it is loud enough at first, but is ab- ruptly arrested before the act is complete, and it is stopped with a sort of hitch. Hepatisation or compression of the lower portions of the lungs will do this; so will a movable plug of tough mucus in the bronchial tubes. In other cases, again, we find the cir- cumstances reversed: there is in a part of the lung no sound during the first part of inspiration ; but towards its end, when the chest is most expanded, there is a short wheeze. This happens where the bronchial tubes are so far obstructed that air will not pass through them, until they are distended by a full inspiration, as in bronchitis. It appears also in extensive pleuritic effusions which distend the parietes of the chest beyond the medium state of respiration; it is only the acme of inspiration that can then in- troduce air into the compressed lung, and it is at this period alone that the respiratory sound is heard. There are other morbid varieties of respiration, such as cavern- ous respiration, caused by the passage of air in and out of an unnatural hollow or cavity in the lung ; and where this cavity is very large, the sound becomes amphoric, like that of blowing into a phial. These and other varieties will be noticed when we treat of the diseases which produce them ; and are included in the tabular view of the sounds given further on. Rhonchi. We have hitherto considered the sounds produced by the passage of the air to and fro in the lungs, and we found that the varieties of these sounds depend on the size of the tubes, and on the force with which the air strikes against their sides and angles, and that they may be shortened or stopped by vari- ous kinds of obstruction. We have now to describe a class of novel sounds which arise from partial obstructions to the passage of the air; obstructions which permit the air to pass, but not without such a resistance as causes an increased and modified sound. Thus, if a bronchial tube be narrowed by the swelling of its membrane, or by mucus secreted by it, the air will pass through the narrowed portion with increased velocity and increased re- sistance; and hence the sound is changed from a simple breathing or Blowing to a louder wheezing, bubbling, whistling or snoring, according to the nature of the obstruction. These new sounds Laennec called rales or rattles. We prefer the Latin term rhon- chus (which is from the Greek />o>^oc), as more expressive; and it has been adopted by most English writers. If there were one, it would be desirable to use an English word, for nothing in- jures the purity of a language more than the introduction of foreign words. The rhonchi may be divided into the dry and the humid, accord- ing as the impediments that produce them are solid or liquid. RHONCHI. 33 Of the dry rhonchi there is the sibilant or whistling rhonchus, which is sufficiently described by its name, and may generally be imitated by whistling between the teeth. It is produced by the passage of air through a small and somewhat circular aper- ture; and this aperture may be formed by a slight obstruction of a small tube, or by a greater obstruction in tubes of larger size. It generally occurs in tubes narrowed by swelling of their mucous and submucous coats, such as occurs in the early stage of acute bronchitis; but it is heard also in asthma, where the tubes are congested and constricted by the spasmodic contraction of their circular fibres; and it may happen, also, when viscid mucus clings to and diminishes the caliber of the tubes. The sonorous rhonchus is a snoring, humming or droning sound, and may vary in loudness or key, from an acute note, like that of a gnat, down to the grave tone of a violoncello or bassoon. It must be produced by an obstruction leaving a flattened aperture, the lips of which, or the moisture on them, yield to the passing air with a vibrating resistance. Partial swelling of the sides of a tube, particularly at its bifurcation, a pellet of tough mucus in it, or external pressure on it, may cause such a flattened opening within the tube; and the sound in question, therefore, occurs in various forms of bronchitis, and often accompanies tumours which press on the bronchial tubes. When caused by tough phlegm, coughing generally changes or removes it; when from the other causes, it is generally more permanent. When quite permanent, it usually depends on the pressure of a tumour, or some deposit outside the tube. The key or note depends chiefly on the size of the aperture left: when this is small, the note is high ; when large, it is more of a bass: from this may be inferred, that the latter can have its seat only in the large tubes; but as a more considerable obstruction may flatten their caliber to the smallest size, these may also be the seat of the acute notes. Almost every variety of this rhonchus may be imitated by blowing between the lips moistened with saliva, and almost closed. There is another rhonchus, which may be called the dry mucous, because it is produced by a pellet of tough mucus obstructing a tube, and yielding to the air only in successive jerks, which cause a ticking sound like that of a click-wheel. When the air is driven very fast, these click-sounds pass into a continuous note, and con- stitute the sonorous rhonchus. Sometimes, again, particularly in inspiration, the click-sound suddenly stops, the tough mucus being forced into a smaller tube, which it completely closes, and may not be dislodged again, but by dint of forcible coughing. Now, as any of these rhonchi may be produced in only one tube and yet be very loud, it is not to be supposed that they are important in proportion to the noise they make. It is rather when they are permanent, or when several of them are heard at once in different parts of the lungs, that- they bespeak disorder 31 DIAGNOSIS OF DISEASES OF THE LUNGS. that may be serious, either from its continuance or from its "The humid rhonchi depend on the passage of air in bubbles through a liquid in the lungs, and their varieties are produced by differences in the size of the tubes, and in the nature and quantity of the liquid, which cause varieties in the bubbling sound. A bubble is a portion of air contained and slightly compressed, by a thin film of liquid, which preserves its integrity by its molecular or aggregative attraction; when this attraction is overcome by the gravitation of the liquid, the motion of the air, or any other disturbing cause, the bubble bursts; as it bursts, the air from it, slightly expanding, gives to the adjacent air an impulse which, if forcible enough, produces sound. In the bub- bling passage of air through a liquid, the air is the moving body, the liquid gives the resistance; and in proportion as these are strongly and suddenly opposed to each other, the louder will be the sound produced. * If the air pass with force, it makes most noise in a liquid of some tenacity, which offers it most resistance; but if it move slowly, such tenacity may retard the breaking of the bubbles, and therefore diminishes the sound. Again, air passing through a liquid in large tubes, gives most sound when the liquid is thin, because the bubbles form and burst quickly; but in passing through very small tubes, air causes more sound with a rather viscid liquid, which, adhering to the tubes, is not carried before the air so readily as one of a thinner nature. This rule is applicable to bubbling sounds or rhonchi heard in the chest. The mucous rhonchus may be heard in large and smaller bronchi down to the size of a crow's quill; and in these tubes its gurgling or crackling presents different degrees of coarseness. It is an irregular and varying sound, composed of unequal bub- bles, and often interspersed with some whistling, chirping, or hissing notes. Its most common cause is acute bronchitis, which, after its onset, is attended with a secretion of liquid mucus into the bronchial tubes; and the passing of the sibilant and sonorous rhonchi of the first or dry stage into the bubbling of the second or secreting stage, is often marked by a curious combination of chirping and cooing notes, like those of birds in a bush. When the bronchial tubes become enlarged by disease, or when morbid cavities are formed by the destructions of portions of the lung, the bubbling of air through liquid in these is of the coarsest kind; it is quite gurgling, and, if the liquid be scanty, has a hollow character, and is called cavernous rhonchus. When there is a little liquid in the smaller bronchi, the bub- bling or crackling is more regular, although the sound is weak, and is sometimes only a roughness added to the ordinary respi- ratory murmur. This is the submucous rhonchus. It may result from slight degrees of bronchitis, and owes its importance only RHONCHI. 35 to its being permanently present when such slight inflammation is constantly kept up by the irritation of adjacent tubercles in an incipient state. When there is more liquid, not viscid, in the smallest tubes and terminal cells, the rhonchus has a still more crepitating character, and resembles that heard on applying the ear near the surface of a liquid slightly effervescing, such as champagne or bottled cider. This is the subcrepitant rhonchus, which is heard in oedema of the lungs, humid bronchitis, and other affections in which liquid and air occupy the extreme tubes, and are forced through each other in the motions of breathing. But the most perfect and equal crackling is that of peripneu- mony, and is therefore called the crepitant rhonchus; it exactly resembles the sound produced by rubbing slowly and firmly be- tween the finger and thumb a lock of one's hair near the ear. We believe that this sound depends on the forcible passage of air through a little viscid mucus in the finest tubes, narrowed by congestion and deposit around them, but we shall have occasion to investigate this subject under the head of Pneumonia. Of all these different rhonchi, we may repeat what we said of the morbid sounds of respiration, that they may occupy the whole of the respiratory movements, or be confined to part of them. Thus, an obstruction which is sufficient, at the commence- ment of inspiration, to cause a rhonchus, may be insufficient when the tubes are dilated by the distension of a full breath, or there may be the converse; an obstruction which is total in low degrees of respiration and stops all sound, in forced or extensive efforts, as in coughing, occasions a rhonchus. This suggests to us the propriety of using these different degrees of respiration to test the nature and extent of bronchial obstructions. It may also be inferred from what has been said, that the different stages and degrees of force in respiration may change the note of the differ- ent rhonchi, and thus produce such a variety as that which we hear in the chests of some catarrhal and asthmatic patients. Laennec used to call this combination of piping sounds rhonchus canorus. It may be readily conceived, too, that these several rhonchi may be variously combined, or exist at the same time in different parts of the lung, and give rise to numerous combina- tions which it is needless to dwell on. It has been stated that the loudness of a sonorous or sibilant rhonchus is no proof of the severity of the disease ; nor is the fact of its being audible over the whole chest, unless the respiratory murmur be at the same time absent or very feeble in parts. But the presence of the bubbling or crepitant rhonchi does imply mischief proportioned to its extent; and if they are heard over a large space, and accompanying the whole act of respiration, diminishing or destroying the natural murmur, they denote disease of a very serious character, because, as our hearing informs us, there is an 36 DIAGNOSIS OF DISEASES OF THE LU obstructing liquid in the tubes where there ought to.bej only air, and the function of respiration must be injured in pioportion. Auscultation of the voice. We now proceed to examine an- other class of sounds—those of the voice as transmitted through the chest. We have found that the sounds of respiration, which are chiefly produced by air passing in the lungs, are transmitted to the air on the surface of the chest. In like manner the sounds of the voice, which are strongly communicated to the same air, are transmitted modified by the size of the tubes, and the nature of the substance through which they pass; and thus these sounds also become signs of the condition of the organs that transmit them. On applying the ear to the throat or upper part of the sternum of an individual whilst he is speaking, the voice is heard so loud that it seems as if he were speaking into the ear, only the articu- lation is not so distinct. The reason of this is obvious : the sound of the voice, although originating in the vibration of the glottis, is propagated to the air above and below it; that below, being pent up, is not heard without bringing the ear into contact with the parts where the tubes run, and it there resounds with all its force. This is called tracheophony, or the natural tracheal voice. But when the trachea divides and subdivides, there is not only a division of the sound into smaller tubes, and a consequent diffu- sion of it and reduction of its strength, but at this division the tubes plunge into the spongy tissue of the lung, which, as we have before found, is a bad conductor, and tends to stop the sound. Hence over the chief bronchial ramifications, on each side of the upper part of the sternum, at and between the scapulas and in the axillas, the voice is still heard, but more diffused and distant than at the throat and sternum, and the articulation is still less distinct. This is natural bronchophony, or bronchial resonance. In other parts of the chest, as the voice gets into the finer tubes with their more flaccid coats and minute cells, its vibra- tions are either choked and destroyed, or in some parts they may be transmitted across the tissue to the parietes in merely an ob- scure diffused fremitus. This may be called the pectoral fremitus, or vibration. It may also be felt by the hand applied to the chest. Before describing the modifications of these sounds by disease, we must notice some natural varieties and their physical causes. Natural bronchophony, or the vocal resonance in the bronchial tubes, is most distinct in thin persons with a high or treble voice, as in females and children : shrill or treble notes penetrate fur- ther into the small tubes, because their vibrations are less exten- sive, and need less room than those of deeper tone. This may be understood on observing the different vibrations of the cords of a musical instrument: the motions of the treble cords are short AUSCULTATION OF THE VOICE. 37 and quick, so as to be scarcely visible, whilst those of the bass are long and quite distinct. So in a person with a bass voice, the sound will hardly pass into the subdivisions of the tubes, and there will be little or no bronchophony : but if the voice be strong, it will not be entirely lost, for it will pass across the whole spongy tissue, and throw it all, more or less, into a diffused vibration, which may be heard and felt in many parts of the chest in the character of pectoral fremitus. We find, then, that treble tones give more of bronchophony, and bass ones more of the pectoral fremitus. The same occurs with the morbid sounds; and if we can get our patients sometimes to change their tone of voice, we may thereby more effectually test the condition of their pectoral organs. Now, as with corresponding varieties of respiratory sound, so with these sounds of the voice, they become signs of disease when they are heard out of their proper places. To know what these proper places generally are, it is necessary to study the anatomi- cal disposition of the tubes, and tissue of the lungs in the different regions. But there is another standard more applicable to indi- viduals, viz., comparison between the two sides of the chest. As there is an approach to symmetry in the structure of the two sides, so there is, in health, a general correspondence between their sounds ; and as disease scarcely ever affects both sides at the same time in the same degree, it will make the phenomena of one side to differ from those of the other. For example, if under one clavicle the voice resound loudly, whilst it is scarcely heard under the other, it is certain that there is some physical difference between the two sides that does not exist naturally; or if below the third rib in front there be heard the tubular or bronchial voice, which is generally confined to the immediate neighbourhood of the large bronchi, it may be inferred that there is an altered condition of the parts. Let us inquire what altera- tions will change the natural disposition of the sounds. An increase in the density of the pulmonary tissue by a solid or liquid effusion, or even extensive sanguineous congestion in it, will improve its conducting power, and enable it to transmit from the bronchial tubes the vocal sounds which they receive from the trachea. This is morbid bronchophony, and it is usually accom- panied with bronchial respiration. If, then, the voice be heard resounding in a part of the chest where it is not usually heard, it may be suspected that the lung is in some way increased in den- sity; but this is not certain until it be tested by further means, for there is another change which may also increase the vocal resonance of a part. If, instead of the sound being better con- ducted from within, it is increased in strength and extent by an enlargement of the bronchial tubes, it may then be heard in situa- tions where it does not naturally reach the walls of the chest. In both cases it may more or less resemble the natural broncho- 6 38 DIAGNOSIS OF DISEASES OF THE LUNGS. phony heard near the top of the sternum, and between the scapulas; but it often presents considerable modifications. Thus, when transmitted from the middle-sized bronchi, it comes rather as diminutived bits of voice than as articulate words; and for rea- sons before mentioned, low tones are not transmitted; so that if the patient varies his cadence, some words are heard and others not. When arising from dilated air-tubes, or when transmitted from the larger tubes, the resonance is more noisy and continued, varying less with the tone of the voice. If the air-cells over the resonant tubes be still open, the sound will be diminished when they are dilated by a full inspiration, because they then tend to intercept it more. The loudest bronchophony is caused where the middle and upper lobes of the lung are pressed against some part of the walls of the chest by a liquid effusion in the pleura, which cannot displace the lung from that part, because it is bound to it by old adhesions. But what modifies the transmitted voice in the most remark- able manner, is a thin layer of liquid between the lung and the walls of the chest. The liquid is thrown by the vocal resonance of the lung into a state of irregular vibration, which causes it to transmit the voice in a broken tremulous manner, so that it sounds to the ear outside like the bleating of the goat. Hence Laennec called it cegophony (aiyce liquid in the bronchi. ( air through ) Submucous - a liquid in the finer bronchi. Subcrepitant - liquid in the smallest bronchi. „ ( viscid liquid in compressed Crepitant - - - } smallest bronchi. Cavernous - liquid in a morbid cavity. SOUNDS OF THE VOICE TRANSMITTED THROUGH THE CHEST. Natural Sounds, heard in a healthy chest. Tracheophony, in the neck and at the top of the sternum. Bronchophony, near top of the sternum, between the scapulae, in the axillae, &c. Pectoral fremitus, in many parts of the chest. Morbid Sounds, transmitted or produced by a diseased chest. Bronchophony, transmitted by condensed pulmonary tissue. iEgophony, the same vibrating through a thin layer of liquid, Pectoriloquy, resounding in a cavity in the lung. Tinkling, a changed echo of the voice or cough in a large cavity. SOUNDS PRODUCED BY THE MOTIONS OF THE LUNGS. Sounds of friction, when the pleurae are dry, or rough from deposits. Emphysematous crackling, by the irregular passage of air between the lobules. STETHOSCOPE. 41 We shall now describe shortly the methods of auscultation or the means which we use to obtain a cognisance of those acoustic phenomena which we have found to be signs of the condition of the organs within the chest. We have already described the methods of percussion ; and we have now to study the best mode of listening to the signs of the motions of the chest. All these signs can be heard by the direct application of the ear to the chest, and this immediate method of auscultation is so easy and simple, that it commends itself strongly to us, and in many cases is used with advantage. The sounds proceeding from the walls of the chest are communicated to the ear, and especially to the air contained in the external meatus, and are thus propagated in the most direct and unmodified manner to the organ of hearing. Immediate auscultation is exclusively practised by some, both at home and abroad ; and as it is much more easily learnt than the mediate method, it will probably always have its advocates among those who prefer ease to exactness. But if we can hear the signs so well by the unassisted ear, it may be asked, what is the use of the stethoscope ? We shall first mention some positive objections to immediate auscultation; and on examining the principles of the stethoscope, we shall find that it has, in many cases, considerable positive advantages. To apply one's ear, and therefore the nose, face, and so forth, to the chest of a patient who is dirty, blistered, or wet with perspiration, would be dis- gusting. To apply it to the chest of a patient labouring under an infectious disorder would be unsafe. To apply it to the per- son of a young female would scarcely be delicate. Moreover, it is difficult to apply the ear well to some parts of the chest, such as the arm-pit, and below the clavicles or between the scapulas in thin persons. Besides this, disturbing noises sometimes arise from the contact of one's hair or clothes with the patient's chest; and unless the practitioner's neck be pretty long and flexible, this easy method will be found, after all, more fatiguing than the mediate method; still, in a great many instances, it may be used with advantage, especially in examining the regions of the back, and in children where the stethoscope might cause alarm, and could not be so steadily or quickly applied. In practice the chief advantages of immediate auscultation are the great facility and quickness of its application. The whole chest can be explored with nearly the same accuracy and with much greater quickness than ift he stetho- scope be used : and in no case is there any objection to the direct application of the ear to the posterior parts of the thorax ; the simple expedient of throw- ing a thin towel, or muslin cloth, over the shoulders of the patients, removes the observer from direct contact with the body of an uncleanly patient; which constitutes the only objection to this method of auscultation. For this reason those who are really familiar with auscultation, and use it as an ordinary every- day means of exploration, almost always prefer the immediate application of the ear. 42 DIAGNOSIS OF DISEASES OF THE LUNGS. There are, however, many decided advantages in using the stethoscope for the examination of the anterior parts of the chest. A better .dea may be ob- tained of the sound and impulse of the heart, and the hollows about the clavi- cles may be all examined more accurately, and the exploration of the chest of women is freed from the objections which are obvious enough in direct auscultation. We want an instrument, then, to transfer the sounds from the chest to our ear, which must be a good conductor of sound; and as the power of bodies to conduct sound depends on the strength and uniformity of their elasticity, and their capacity to vibrate like the body that produces the sound, we must have an elastic material, of density resembling that of the sources of sound within the chest, and of the walls of the chest through which they are transmitted. But the sources of the pectoral sounds vary : some, as the voice and respiration, or at least the hollower sounds of respiration, are produced in air; whilst in others, such as the sonorous rhonchus, the rubbing sound, and the sounds of the heart, the solids are chiefly concerned : we shall therefore need a varied capacity in our instrument to receive these sounds. It should be a uniform solid, and the lighter it is the better, provided it be thoroughly rigid. Now nothing answers to this description so well as wood ; and in the light kinds of wood with a stiff longitudinal fibre, such as pine-wood, deal, cedar, and the like, we find these qualities in perfection : through a cylinder of such wood, about eight inches long, and an inch and a half in diameter, adapted to the ear at one end, most of the pectoral sounds may be heard; but those best which originate in solids, such as the sounds of the heart, of friction and sonorous rhonchi. The sounds of respiration and of the voice are also heard through it, but not nearly so distinctly as with the naked ear. We need, therefore, an aerial conductor for these sounds, be- cause they originate in air, and can best be transferred through air. By perforating the cylinder with a bore a quarter of an inch in diameter, it becomes a tube through the column of air in which the respiration and voice may be heard with increased distinct- ness. But as this column of air is in contact with only a small spot of the chest, it can transmit only the sounds produced under or very near that spot, and the instrument thus prepared is well- adapted for the exploration of small parts of the chest. But we want the instrument also to transfer the sounds of larger spaces: the sounds of so limited a space are often too weak to be heard alone; and besides, it would be very tedious to go over the whole chest, dotting in this way a quarter of an inch at a time. Now, if the column of air be enlarged at the base where it is in contact with the chest, by hollowing out the wooden cylinder into a fun- nel shape, it will conduct the sounds produced on this greater STETHOSCOPE. 43 extent of surface, which are reflected by the funnel into this cen- tral bore, and conveyed concentrated to the ear. This also gives the instrument the power of concentrating or magnifying the sounds ; they are thus heard as strong at the distance of several inches or even a foot or two from the chest as they are to the ear in close contact with it; nay, in some cases they are even stronger. The best shape for the excavated end is that of a long funnel or cone, with its apex terminating in the central bore; for this directs the sound at once in the right direction without re- peated reflexions, which may modify it. As we still sometimes want to explore small spots of the chest, by means of a perforated plug the excavated end can be filled and the instrument recon- verted into a simply perforated cylinder. To make the instru- ment more portable, the upper part of the cylinder may be re- duced to a stem half an inch or less in diameter, leaving only at the top a sufficient width for the ear; or this top may be made of a harder wood, or of ivory. Wood is so excellent a conductor of sound, that when once the vibrations are in it, they can be con- veyed by a very small body of fibres. Thus the stethoscope, although a simple instrument, performs several offices in relation to sound, the chief of which may be enumerated as follows: 1. To conduct sound by its solid walls. 2. To conduct and concentrate sound by its closed column of air. 3. To transfer sounds from its column of air to its solid walls, or the converse, when circumstances impede their transmission by one of these ways. 4. To diminish this power of transfer, and contract the field of hearing when small spots are to be ex- plored. We have now only to add a few words on the method of using the stethoscope. It is quite necessary that the instrument should be applied in close contact with the chest and the ear ; the least tilting uncloses the column of air, and occasions great loss of sound outwardly as well as a confusing entrance of extraneous noises. To prevent this tilting, it is best to hold the stethoscope by its pectoral end firm on its base, and then to apply the ear flat on the top. If the inequalities of the ribs leave chinks be- tween the chest and the instrument, a fold or two of linen will fill these, or the stethoscope may be used with the stopper in. For the sounds generally, it is better to use the instrument without the stopper; but when it is an object to determine, whether a sound is produced in a limited space, or over some extent of surface, the circumscribing power of the stopper is wanted. Thus it is often of importance to determine, whether a local resonance is produced in a small cavity, or merely transmitted by conso- lidated lung from several bronchial tubes distributed over some extent of surface. The simply perforated cylinder will often do this by showing the size and shape of the limited spot in which the resonance or pectoriloquy of a cavity can be heard in its full 44 DIAGNOSIS OF DISEASES OF THE LUNGS. strength, while the bronchophonic resonance is transmitted less strongly and may be traced over some extent of surface, gener- ally in the known direction of these tubes. The stopper is also useful in shutting out the sound of respiration, when it is an object to listen to the sounds of the heart or arteries, and in many other circumstances which will be noticed in the history of special diseases. In conducting physical examination, due care should be taken to avoid fatigue or annoyance to the patient. There are cases in which a complete physical examination will do more harm than the information which it may bring can do good; but they are few, and it must be left to the discretion of the practitioner to hold the balance between too much and too little examination. Experience soon points out that the observer must also consult his own ease in the act of auscultation ; for a constrained or painful posture impedes the hearing and disturbs the attention. For this reason, it is sometimes easier to hear with a flexible ear- tubs than with the straight stethoscope, although the latter is by far the best instrument for general purposes. II. Examination of the Chest through the Vital Properties or Functions of its Organs.—Analysis of the General Symptoms of Diseases of the Chest. We have been hitherto occupied in considering the physical properties of the chest and its organs, and the manner in which these properties may become signs of the condition of these parts. We have now to examine them through their vital pro- perties, which, combined with certain physical and chemical powers, constitute function. Physiology teaches us that the elementary vital properties immediately concerned in the function of respiration, are sensibility and contractility, to which may be added, the power of secretion. These properties are closely linked together with the chemistry and mechanism of the organs of respiration, so as to constitute their healthy function. Any excess, defect, or disorder, of any of these properties, will be more or less felt throughout the links of this chain, and hence may arise not only derangement of the function of respiration, or dyspnoea, but also new phenomena proceeding from a loss of due balance of the same properties, such as cough, expectoration, and pain; and linked as the vital properties are with those of other organs, there may be added disorders of these in the form of disturbance of the circulation, and its sign the arterial pulse, general fever, disorder of the secretions of the kidneys, liver, and intestines, and of the digestive, nutritive, and sensorial functions. ■the phenomena arising from these severai disordered properties are what are called the vital or general symptoms of disease DYSPNOSA, 45 which we now have to consider in relation to the organs of respi- ration. It may be inferred, and will be more apparent as we proceed, that these general symptoms, dependent as they are on such a linking together of many properties, the laws of which are but imperfectly understood, must be far less simple and intelligible than the physical signs; and the variable measure of the vital properties also renders general symptoms far more uncertain than these signs, in their degree, and even in their presence. We cannot with any certainty, as with the physical signs, from a knowledge of the phenomena, and the laws which regulate those phenomena, deduce the condition of the parts which produced them, nor, from knowing the condition of parts and physical laws, deduce what phenomena the parts ought to develop. For example, the solids of the body have sensibility, which varies not only in different parts, but in the same parts at different times, and this for reasons which we cannot discover; therefore we cannot calculate on it. The contractility of moving parts also varies in a similar manner; and we can by no means gain, from the cha- racter of their motions, a criterion of their true condition. In- stead, therefore, of pursuing the synthetic as well as the analytic method, which we have done with regard to the physical exami- nation of the chest, we shall shortly analyse the chief general symptoms of diseases of the chest, and by that examination endeavour to determine their nature and varieties, and their value in teaching us to discover, to measure, and to treat these diseases. Dyspnoea, difficult or disordered breathing, is the most important general symptom of disease of the chest, inasmuch as it implies some interruption to the due performance of some part of the great function of the chest—respiration. Dyspnoea may be caused by circumstances affecting any one or more of the several elements concerned in the function of respiration, viz. the blood in the lungs, the air, the machinery of respiration by which these are brought together, and the nervous system through which the impression which prompts the respiratory act is conveyed from the lungs to the medulla oblongata, and thence to the muscles which move the machinery; in fact, all the causes which in excess produce asphyxia, in slighter degrees occasion dyspnoea. Subjoined is a table which exemplifies these causes of dyspnoea; but the character of the symptom itself must first be described. When anything interferes with the sufficient action of the air on the blood, the impression which prompts the acts of breathing not being relieved, causes a quicker and fuller repetition of this act, and if the interference still remain, the breathing will con- tinue to be more or less hurried and forced, until the sensation or impression is reduced to the ordinary standard of almost uncon- sciousness. An individual in whom the breathing is hurried may 7 46 DIAGNOSIS OF DISEASES OF THE LUNGS. not be sensible that it is accelerated ; whilst in another who feels the oppression, there may be little appearance of shortness of breath. Again, the feeling of dyspnoea must greatly depend on the condition of the sensorium ; for whilst some patients are conscious of the slightest infringement on their respiration, others, particularly in congestive fevers, are brought to the verge of asphyxia without complaining of any oppression. So, too, we are sometimes astonished to find, on opening the bodies of the dead, a whole lung diseased, or one side of the chest full of serum, where the patient had not complained at all of dyspnoea; while, in other cases, a much smaller lesion of the organs has been attended with the most distressing orthopncea. It is, how- ever, rather to the sensation of breathlessness than to merely ac- celerated breathing, that the word dyspnoea is generally attached, for, translating it as difficult breathing, this expression can be hardly applied when the difficulty is overcome by accelerated movements of which the patient may not be conscious. But we shall here advert to frequency of breathing, as well as the feeling of dyspnoea. The number of respirations in a healthy adult male at rest, generally ranges about twenty in a minute. It is more in children and in females, and it becomes increased in all cases, not merely from affections of the lungs or connected organs, but also from general weakness or depressing causes, which, diminishing the strength of the muscles of respiration, oblige them to make up by the frequency of their contractions what is wanting in their energy. Probably there are some nervous conditions of the system also, in which the breathing becomes accelerated, from what Cullen called mobility, a greater readiness to move than power to complete the motions. We have seen the breathing hurried in some cases of hysteria, without the patient being conscious of it, and without either real weakness or pectoral disease to ac- count for it. These cases are of no consequence in themselves, but should be known, that they may be separated from those of true dyspnoea. In many other cases, especially those, we be- lieve, where the nervous system is affected, the breathing is not accelerated, but suspirious, a sigh or deep breath being taken from time to time; yet the patient is often not conscious of any oppression or unusual effort. This may be called irregular breath- ing, and there are several other varieties, which we have not time to consider in detail. The rhythm in breathing probably depends entirely on the chain of influences which we before described as concerned in the act, and not on any peculiar perio- dicity, such as that which seems to reside in the heart; and therefore irregular breathing must depend on a change in one or more of the links in that chain. The feeling of dyspnoea is one of a very peculiar and distress- ing character. Even when slight in degree, its permanent op- DYSPNOSA. 47 pressive influence is very wearing; and when severe, it causes the most indescribable suffering, with such a feeling of impending death, that the most courageous are often unmanned by it. The constrained postures of the patient, the anxious or even desperate expression of his countenance, the painful straining of all the muscles that can in any way, however distantly, assist in the respiratory movements, bespeak the intensity of the feeling, which is far worse than the most acute pain. It is worthy of remark, however, that this feeling is experienced in its severest degrees only by those in whom the dyspnoea comes on rather suddenly, especially when the sensibility is entire, and the lungs are not diseased, as in obstructions in the trachea or large bronchi, spasm or swelling of the glottis, and spasmodic asthma. In these cases the sensibility is not gradually blunted by the circulation of im- perfectly oxygenated blood ; nor has the activity of the functions, which require arterial blood, been^owered by previous depressing causes. Opium, belladonna, camphor, and other narcotics, will sometimes relieve the symptoms of dyspnoea not only by dead- ening the sensibility, but also by diminishing the activity of those functions and secretions which require oxygenated blood, and therefore a free supply of air. If we could temporarily produce a state approaching to the torpor of hybernating animals, we might diminish the bad effects, as well as the painful feeling of dyspnoea; and we believe that such a state is actually induced in those who are habitually asthmatic, in whom all the functions are brought to a lower standard, and who thus suffer with impu- nity such an encroachment on the function of respiration as would be fatal to an individual of a common standard. The feeling of want of breath has been used as a means of testing the condition of the respiratory organs. A person whose respiration is free and unembarrassed, can hold his breath longer than one whose lungs are diseased. Dr, Lyons has proposed to measure the condition of the lungs by the time which he can hold the breath, after a full inspiration ; and to insure accuracy, the patient is desired to count numbers during this time. A healthy person with a good chest can continue counting for forty- five seconds without taking breath, whilst those with diseased lungs often cannot keep on for twenty seconds. The same ob- jection may be made to this test that we made to the measur- ing of the exhaled air proposed by Mr. Abernethy, that it is a test as much for the strength of the muscles of respiration as for the condition of the lungs. Besides, both the feeling of want of breath, and the power of augmenting the respiratory movements, vary considerably in different healthy subjects. It is well known that divers acquire the power of remaining under water for two or three minutes (it has been said more) without taking breath. In diving animals there is a structural provision to enable them to continue some time without air. The chief venous trunks are 48 DIAGNOSIS OF DISEASES OF THE LUNGS. very tortuous, and admit of dilatation, so that the venous blood can accumulate in them, instead of distending and embarrassing the right cavities of the heart and the lungs. Perhaps some change of this kind may be somewhat produced in divers by the often repeated practice of holding the breath. Professor Faraday has described another mode by which a person may be enabled to hold his breath for a minute and a half, which is double the time usually practicable. This is by making in suc- cession five or six full and forcible inspirations, which seem to so completely change the air in the lungs, that there is left in them a stock of pure air capable of lasting during that time. The knowledge of this fact may be useful, if ever it is wanted to hold one's breath for a time in going into the suffocating atmosphere of a sewer, a mine, a house on fire, or the like, or in diving. Dyspnoea is often a symptom demanding great attention in diseases of the lungs; but it must be studied in conjunction with the other general symptoms and the physical signs, for in itself it is most vague and inconclusive. This may be perceived on in- specting the subjoined tabular view of the causes of dyspnoea, which is founded on the physiology of respiration. This table deserves attention, not only in showing the varied nature and origin of the symptom, but also in contrast with the tables of the physical signs, the causes of which are much less varied, and far more appreciable. But when, through the means of the physical and other general symptoms it has been made out on what cause the dyspnoea depends, then this symptom often becomes a valua- ble measure of the increase or diminution of the disease, and a useful guide of practice. PROXIMATE CAUSES OF DYSPNOEA, OR DIFFICULT BREATHING. By IMPEDING THE ACCESS OF PURE AIR TO THE LUNGS. a. Mechanical. Rigidity of parts of the ) ( Ossification of cartilages ; induration of respiratory machine \ ( the pleura; rickety distortions. Pressure on ditto. - e.g. Tumours or dropsies of the abdomen. "Effusions in, swellings of, tumours Obstructions of the air- } J pressing on, the air-tubes. tubes ---- £ e-g-"^ gpasm of the glottis ; spasm of the (_ bronchi. rPleurisy, Compression of the lungs e.g. \E?u*\on* °r t,imoursJ gydrothorax, r B b ( in pleural sac - - j Pneumothorax, LAneurism, &c. f Engorgement of the vessels. | CCEdema, Alterations in the tissue ) I Effusions - - j Hepatisation, of the lungs - - \e-Z-< (Tubercle, &c. s ' C Emphysema, | Altered structure - < Dilated bronchi, L C Vomicae, &c. COUGH. 49 b. Chemical. Defi tt c. Vital. the air - - - {e&' MephUic gases; rarefied air. rital. Pain of parts moved in ) ni , , . . . . 0 respiration - - \e,g' PIeuroayne 5 pleuntis; peritonitis, &c. Paralysis of muscles of ) ( InJuries °f the spinal marrow in the ditto. e.g. < neck, &c. ( Paralysis of the bronchi (*?). Weakness of ditto - - e>g. 5 Excessive prostration from ataxic fevers, Spasm of ditto - - - e.g. Tetanus; spasmodic asthma, &c. 2. By THE STATE OF THE BLOOD. a. Mechanical. Obstruction to the pas- ) < Diseases of the heart and great vessels; sage of the blood - ) ( tumours pressing on them. b. Chemical. An excessively venous i v. , .. .,. ... , ,,,. . \ e.g. Violent exertion; idiopathic dyspnoea (i). Deficiency of red particles e.g. Anaemia; chlorosis. 3. By the nervous relations of respiration. Excessive sensibility of) s Hysteric dyspnoea; cerebral fevers; the par vagum - - ) ( neuralgia (]). Defective ditto - - e.g. Coma ; narcotism, &c. (breathing slow). Cough. Another symptom, which is even more common in diseases of the chest than dyspnoea, is cough. The act of cough- ing consists in one or more abrupt and forcible expirations, ac- companied by a contraction of the glottis, trachea, and upper bronchial tubes. The expirations being more complete than usual, especially when there are several of them, are followed by a deep forcible inspiration, the force of which is shown by the loud respiratory murmur, which, by the ear applied to the chest, may be heard to accompany it. The muscles chiefly concerned in the act of coughing are the abdominal muscles and intercostals, the combined contraction of which effects a strong pressure on the contents of the chest. The common cause of cough is phlegm, or some other matter irritating the air-passages, and the object or final cause of the cough is to expel or expectorate this matter. The proximate cause of cough may be said always to be some irritation, either direct or by sympathy, of the sentient parts of the air-tube, or of the nerves which render them sentient. Some parts of the bron- chial membrane are much more sensitive than others ; that lining the glottis and larynx is excessively so, and the least irritation of it is enough to excite coughing. That of the trachea and large bronchi is less, for foreign bodies have been known to lodge in them for some time without causing any coughing, so that some have supposed that they have nothing to do with the production of this symptom ; but when the sensibility of these parts is in- creased by inflammation or nervous excitement, anything irri- tating them will also excite coughing. It is easy to see why the sensibility of the air-tubes should be greatest at their entrance : 50 DIAGNOSIS OF DISEASES OF THE LUNGS. it is the door-keeper, placed there to exclude, or, by calling other forces to its aid, to expel anything improper which may intrude. But the other parts of the tubes have also a preserving sensibility, which may bear a little, but is soon roused into activity by con- tinued irritation. We find the parallel of this in the alimentary canal in the natural state. The sensibility that excites the action of vomiting is peculiar to the fauces at one end of the tube; and that which induces the striving of defascation resides chiefly in the termination of the rectum at the other end : but uncommon degrees of irritation, or an exalted sensibility, will occasion the same actions to be excited by impressions on other parts that are usually insensible: hence arise the vomiting caused by an over- irritated or inflamed stomach or duodenum, and the tenesmus and purging excited by a similar state of the colon. We shall see this more fully on considering the various causes of cough. As other irritations, cough may be excited either by an unusual irritant acting on the tubes in their natural state, or by the ordi- nary circumstances, which, although not usually irritating, yet become so by the exalted irritability of the tubes, or, as is the more common case, by a combination of these causes. We have an example of cough excited simply by an unusual irritant, when a portion of food or of bronchial mucus lodges on the membranes of the glottis; and an irritant may act by sympathy as well as by direct application, as when we excite coughing by introducing a probe pretty far into the ear. The cause by increased irrita- bility is exemplified in the cough of early bronchitis and nervous asthma, which the mere inhalation of air is sufficient to excite. There are both an unusual irritant and increased irritability, in the secreting stages of bronchitis and other affections, where an unusual quantity, and sometimes an irritating kind, of mucus is poured out on an over-sensitive membrane. This more complex cause of cough is frequently induced by the continuance of the other causes ; thus, the continued application of an irritant will develop an increased sensibility; an increased sensibility and irritation will be followed by inflammatory excitement and the secretion of matter, the quantity and quality of which add to the irritation. Thus we see how the physiological causes of cough become identified with the pathology of bronchitis, or inflamma- tion of the membrane of the air-tubes; and, in common parlance, a bronchial inflammation is called a cough, this being the most prominent symptom. But although this inflammatory condition is often developed by the continuance of causes which produce cough, yet it is not necessarily so, and there may be irritation or increased sensibility, or both, enough to cause cough, and which may yet be. short of the degree or the conditions requisite to pro- duce inflammation. It has been stated that the irritation which causes cough may not be applied to the bronchial membrane itself, but may be exerted COUGH. 51 from a part more or less distant. Thus cough may be excited by tubercles in the parenchyma of the lungs, by inflammations or irritations of the pleura, peritoneum, stomach, liver, and so forth ; and although we may conjecture that these irritations are con- veyed through the nervous branches which connect these several organs and the air-tubes with one common sensitive centre, yet we cannot explain why they should be sometimes conveyed, and at others not; for although cough does frequently accompany the pathological conditions to which we have just adverted, yet irritations and inflammations of the stomach, liver, peritoneum, nay, sometimes even of the pleura and pulmonary parenchyma, often arise without any cough whatever. It has been attempted to explain these discrepancies by assuming that there must be bronchitis present to produce cough, and that, when these several distant irritations do not excite bronchitis they are unaccompanied by cough; but this view increases instead of diminishing the difficulty, for it leaves unexplained the reason why this supposed bronchitis should occur in some cases and not in others; and bronchitis, although including cough, is more than cough, and needs something more to produce it. We may conjecture about local weaknesses, constitutional peculiarities, and irregular sen- sibilities, as causes of these differences, and this is all that we can do towards explaining them : but this is not what an explanation ought to be; this is referring phenomena not to known general properties, and the laws which govern them, but to individual peculiarities and undefined influences, the laws of which are not known. These considerations furnish another proof of the un- certainty of general symptoms as means of diagnosis. Still, when cough does occur, and its cause has been made out by the aid of other signs, it deserves attention, not only as a symptom, but as a morbid action of a distressing and hurtful kind, which some- times may require remedies expressly to relieve it. This illus- trates what has been said before, that general symptoms, although much less constant and instructive than physical signs with re- gard to the diagnosis of organic lesions, yet, when positive, often tell us more of those general conditions of the system, which be- come our guides in the employment of remedies. Under this impression we shall examine some of the varieties of cough which present ihemselves in different cases, and trace the connection between their characters and variations in the ele- ments that constitute them. Of course the study of a symptom in any individual case must be conjoined with a proper survey of its functional or organic cause ; but as we have also (some- times only) to treat the symptom, it is highly useful to study its varieties, and thus to render it more practically instructive. The cough may vary according to, 1. The irritant exciting it; 2. The sensibility feeling the irritation; 3. The movements 52 DIAGNOSIS OF DISEASES OF THE LUNGS. thereby excited, which consist of (a) the contraction of the muscles of respiration, and (b) the contraction of the air-tubes; 4 The condition of the bronchial membrane and its secretion. Under these heads, we shall meet with the varieties of cough with which everv practitioner is familiar. 1. The violence of a cough will, ceteris paribus, be in propor- tion to the degree of irritation that excites it. For example, a healthy person whilst eating or drinking incautiously, suffers some food to enter the glottis; the cough thereby excited will be more severe with wine or anything peppered, than with water or any bland food. So in the early stages of catarrh, although the sensibility of the membrane is increased, yet the thin saline- tasted secretion also acts as an unusual irritant upon it, and keeps up a short teasing tickling cough, with continued attempts to clear the throat. When the irritation is more moderate, but irremovable, like that occasioned by incipient tubercles in the pulmonary tissue, the cough will generally be of that slight hacking kind, with little or no expectoration, that is so well- known as one of the first symptoms of pulmonary consumption. The irritant here remaining the same, the circumstances which increase this cough are those that augment the sensibility of the lung and air-tubes, such as a quickened state of the circulation from exertion, heated rooms, or during the assimilation of stimu- lating food. 2. We have already adverted to increased sensibility as being concerned in the cough of recent bronchitis or bronchial irrita- tion. It becomes, however, more developed when the cough has lasted several hours, and instead of being short and tickling only, it comes on in more violent and prolonged fits, which are quite irresistible, and often accompanied by a feeling of soreness. The heightened sensibility of the air-tubes is further manifested by the readiness with which breathing air at all cold, or swallow- ing anything at all irritating, will excite cough. We have be- fore remarked how this increased irritability of the inflamed air-tubes is commonly joined with the augmented irritation of their secretion; but we do sometimes meet with cases in which the increased sensibility is purely nervous, unaccompanied by any secretion; and the cough is brought on by \he slightest cold or irritating matter in the air. Even strong odours will some- times cause it. These nervous coughs are to De treated chiefly by various remedies which diminish the sensibility of the nervous system, such as narcotics, or sometimes by those which excite stronger impressions in other parts, such as epispastics and the application of heat. 3. Besides the sensibility of the bronchial membrane, another property connected with the nerves, muscular mobility, may be the source of some varieties of cough. We cannot here examine COUGHING. 53 me circumstances under which a change of proportionate rela- tion takes place between the action of the motory nerves in general, and the impressions which excite them. It is sufficient for us that the fact is well known, that in certain conditions or states of the system, an ordinary impression will excite inordinate motions; while in others the motions resulting from similar im- pressions will be imperfect, and below the natural amount. It is thus also with the motions of muscles concerned in coughing; they may be excessively mobile, so that the least irritation will set them agoing; and, like a clock without its pendulum, they continue their impetuous motions, until their strength has fairly run out. This is the convulsive cough which we meet with in some hysterical and nervous subjects, and its convulsive character is the more evident from the fact, that it sometimes alternates with chorea, or convulsive affections of other sets of muscles. The same uncontrollable character is, however, often communi- cated, by a nervous temperament or peculiar nervous affections, to coughs arising from common causes, which thus shake and exhaust the patient in an unusual degree, and require appropriate modifications of treatment to subdue them. Hooping-cough in its after stages is of this kind, and from our experience we should say, that the shaking uncontrollable nature of the cough is more characteristic of pertussis, than the hooping, which is not always present, especially in adults. This leads us to consider on what hooping depends; and here again we shall find the use of our physiological divisions, which explain some other varieties of cough that are sometimes met with. In considering the physiology of respiration, we are led to be- lieve that the act of expiration is aided by the contraction of the circular fibres of the air-tubes. In the forcible expirations which constitute ordinary coughing, there is also a simultaneous con- traction of the air-tubes, and especially of the aperture of the glottis, through which the air is driven with the greatest force, in order to expel any irritating matter. Now the contraction of these tubes may be excessive, defective, or irregular, and this will occasion other varieties of cough. When their contraction is excessive, being also generally irregular, they give the wheezing character to the cough, so remarkable in asthmatic subjects. A wheezing cougl- does not always depend on contraction of the circular fibres, fir other constrictions of the bronchi will also cause it; but if we listen to the chest of a nervous asthmatic, we may often hear, in the forcible expirations of a fit of coughing, sibilant and sonorous rhonchi, which are too transient to be pro- duced by the thickening or secretion of the tubes. Where the irri- tability of the bronchi is great, their contraction may not, as usual, cease during the act of inspiration ; and it is this spasmodic con- striction affecting particularly the upper part of the air-tube during the forcible inspiration which succeeds to coughing, that 54 DIAGNOSIS OF DISEASES OF THE LUNGS. causes the hooping sound. This state of things happens chiefly in the irritable frames of children when affected with convulsive couo-h ; and the violence and repetition of the expiratory efforts of this cough occasion the back draught to be the more forcible, sonorous, and prolonged. If we apply our ears to the chest of a child during a fit of hooping-cough, we are surprised to find how little sound we can hear there with all these noisy external efforts : in fact, the continued constriction of the bronchial tubes permits very little motion of air into and out of the tissue of the lungs: in the convulsive cough of adults, again, in which there is seldom hooping, the respiratory murmur of the long inspiration, or back draught, is pretty loud, whilst the succession of coughs here also consists more of external than of internal movement. In all these kinds of cough, antispasmodics will often give more relief than any other class of remedies. But we may have an opposite condition of the circular fibres of the bronchi, a weakness or deficiency of action, a paralysis, so that they do not contract as usual during the expiratory efforts of coughing. This constitutes the hollow or barking cough which we sometimes hear in chronic bronchitis, and now and then in febrile and nervous affections. This cough is, as we shall pre- sently find, accompanied with a difficulty of expectoration; hence it is sometimes very distressing, and particularly so when, as it occasionally happens, it is combined with a mobility of the external muscles of respiration, rendering the cough convulsive and paroxysmal. The tearing and exhausting fits of this kind of cough are sometimes quite agonising ; and we may judge from the bloated, congested appearance of the lips and face, how much these fits impede the respiration and circulation, and how much they may thus tend to increase and perpetuate the diseased con- dition of the bronchial tubes. In some such cases we have seen the terebinthinaceous medicines, with external counter-irritation and occasional emetics, give most relief; but the treatment will depend on various circumstances, which cannot be entered into at present. 4. Besides the sensitive and motory apparatus concerned in the act of coughing, we have the secretion of the air-tubes, which may also by its qualities modify the character of the cough. Ac- cording to whether this secretion is present or not, the cou»h may be humid or dry; and according to the relation of the quali- ties of this secretion to the powers of expectoration, the cough may be loose or tight; and these varieties may be combined with the other species of cough, as those may with each other; and thus are produced the endless host of different kinds of cough that we meet with in practice. Without pretending to affirm, that it is always possible to classify these by the division now pointed out, we may state that we have often found this analysis useful in drawing attention to the predominant changes of vital EXPECTORATION. 55 property, as manifested by symptom, and in thus distinguishing cases which require different modes of treatment. Expectoration. The expectoration is another symptom of thoracic disease, which must be considered as the result of vital as well as physical properties, and therefore it is included under the head of general diagnosis, although it sometimes approaches in character to a physical sign. The word expectoration strict- ly means the act of expelling anything from the chest; but by a figure of speech it is also applied to the matter so expelled. We shall find that both the act and the matter of expectoration may present us signs of the condition of the pectoral organs. If we consider the structure of the bronchial tree, we shall perceive that natural breathing tends to prevent the accumula- tion of matters in its tubes, in spite of gravitation. The area ot the smaller divisions of the bronchi is considerably greater than that of their trunks; and it may be represented as the divided base of a hollow cone or funnel, which is concentrated gradually in the trunks, and completely in the windpipe. The air, in the more sudden act of expiration, passes with greater rapidity and force as it converges into these trunks, and therefore tends to carry through them any superfluous matter that may be present on the bronchial surface. This will explain how the finer bron- chial tubes of the most dependent parts of the lung are, in health, kept clear of any accumulation. Possibly the ciliary motions of the mucous membrane may, as MM. Purkinjie and Valentin have surmised, tend to the same effect. But it is the forcible acts of special expectoration, hawking, and coughing, that tend most effectually to clear the air-passages; and they do this by both increasing the force and fulness of the expiratory effort, and at the same time contracting the upper tubes and trachea, so that the air acts with greater force on any superfluous matter in them. The repeated closure of the glottis in coughing increases the expulsive effort by letting out the air in successive sudden jerks, which are more forcible than any continued act of expiration would be. We see this exemplified in cases where the operation of bronchotomy has been performed. The patient often cannot expectorate effectually so long as air can pass out from the artificial opening, and he is in danger of suffocation in consequence; but on closing this during the act of coughing, the force of the air can be directed in the natural way against the accumulated matter. By attention to this particular, suffocation has been averted in more than one instance after this operation. In certain diseased conditions of the larynx, the pa- tient cannot close the glottis; and hence also expectoration may be difficult, while the cough assumes a continuous uncontrolla- ble character, which we might have added as another variety to those before enumerated. This is what M. Trousseau calls a belching cough. 56 DIAGNOSIS OF DISEASES OF THE LUNGS. There is another element essential to the proper performance of the act of expectoration—the capacity to make such a full in- spiration as shall carry the air in beyond the accumulating mat- ter, so that it mav oil its forcible passage out again, carry this matter before it. Hence we see why weakness, which prevents a sufficient inspiratory effort, or obstruction of the terminal and most expansible parts of the air-tubes, which renders this effort ineffectual, may stop the act of expectoration, and by permitting the accumulation of matter in the air-tubes may speedily conduce to a fatal result. Inability to expectorate is the immediate cause of death in many cases of various diseases; in fact, it is a part of the article of death itself; and when we hear the rattle in the throat of the dying, we hear the sign of the accumulating bar- rier which is shutting out the breath of life. Sometimes, even at this stage, there are sensibilities enough in the system to feel the force of a stimulant which may excite the sinking powers to another struggle ; expectoration is once more accomplished, and breath once more renewed; and where there is no irrecoverable alteration of structure, this act of expectoration may in some few instances turn the balance in favour of recovery. It is un- necessary to say, then, how important it is to study the act of expectoration, and to acquaint ourselves with those means that may excite or promote it. Most practitioners have seen instances in which a patient has been snatched from the jaws of death by the timely administration of a diffusible stimulus, such as a warm aromatic draught, with carbonate of ammonia or ether, together with such a change of posture and other circumstances as might most favour the expulsion of the matter that was suffo- cating him. A great deal may often be done in less urgent cases by attention to the posture of the patient. This is particularly the case with children, and with aged patients who have nearly as much difficulty in expectorating as children. They should never be suffered to be for many hours in the same position, and children should not even be permitted to sleep many hours at a time if the secretions from the lungs are retained. In most instances the act of expectoration is easiest in that pos- ture in which the respiration is most free, which is commonly the semi-erect posture: but some patients expectorate more freely when lying on one side; and we remember a phthisical patient who really appeared to be several times saved from suffocation by alternating his posture from lying down to sitting up in a particular manner, suggested by a knowledge of the condition of the lungs in that case. When this expedient was neglected, the patient was so shaken with frightful fits of fruitless cough, and so op- pressed with the accumulating matter, which they could not ex- EXPECTORATION. 57 pel, that speedy suffocation seemed inevitable. In some cases, the act of expectoration may be favoured by another kind of ac- tion, in which the expiratory muscles are concerned, that of vomit- ing ; and we shall find hereafter, that some emetics may exert an influence of an important nature on the bronchial tubes, be- sides this mechanical one. The character of the expectoration frequently furnishes us with very instructive signs. It is the product of diseased action, and in its physical or chemical qualities it may inform us some- what of the nature of that action, of the condition, and some- times of the position, of the parts from which it comes. As, however, we have seen that the effort of expectoration is some- times unsuccessful, there may be no expectoration to judge of; and besides this instance, most children and some adults can- not spit out what they expectorate, but swallow it. The basis of expectoration generally is the secretion of the mu- cous membrane of the air-tubes. This is naturally a transparent, colourless, slightly glutinous liquid, like thin mucilage. The chief animal matter which it contains is that called mucus, which seems to be a sort of imperfectly coagulated albumen, and the varieties of sputa presented by disease commonly depend on an unnatural condition or quantity of this animal matter. There is also saline matter, which may vary in quantity, and so may the proportion of water. From the recent experiments of Dr. Gold- ing Bird, as well as those of Dr. Babington and Mr. Brett, it would seem that the condition of the animal matter in the expec- toration depends in great measure on the proportion of saline matter with which it is combined, this being in abundance in transparent and viscid expectoration, and defective in the opaque kind, with little viscidity, and least of all in that which is abso- lutely purulent. Dr. Babington found, that on mixing pus with a solution of common salt, after a time it became converted into a nearly transparent viscid mass like mucus; and Dr. G. Bird rendered the physical and chemical resemblance perfect by adding a little soda, and then passing a current of carbonic acid gas through it. (Guy's Hospital Reports, No. vi.) Mr. Brett, in a valuable communication to the medical section of the British Association in 1837, states that he found the saline matter of transparent viscid mucous expectoration to amount to from 20 to 33 per cent, of its solid matter, whilst that of the opaque viscid mu- cus of chronic bronchitis was from 16 to 23, and the puriform expectoration of the last stage of phthisis was only from 9 to 10 percent. These researches confirm the opinion we have long held, that the difference between mucus and albumen seems to consist in their physical condition, rather than in their chemical constitution. Mucus is a transparent glutinous matter, not coa- gulable by heat, as liquid albumen is, and not solid and opaque like coagulated albumen; but on ultimate analysis it is not found 58 NOSIS OF DISEASES OF THE LUNGS. to differ from this principle. When, therefore, we see expect* rated ^tropaquPe and solid, or liquid and coagulable by heat, ™ oses the only distinguishing characters of mucus, and is strict- !y albuminous. For this reason, we submit the following general classification of expectorated matter:— 1. Mucous, more or less transparent and viscid. 2. Albuminous, opaque without viscidity. 3. Watery, thin and transparent. 4; Compound, composed of combinations of the preceding kinds. 1. Mucous expectoration is that most like the natural secre ion, being transparent, and more or less viscid. It is the general re- sult of simple acute inflammation of the mucous lining of the air- tubes, in which case it is increased in quantity, and particularly in viscidity; in fact, the glutinous character of the sputa, and the tenacity with which they stick together and to the containing vessel, or fall out in a ropy mass, was described by Andral, and we think correctly, to be a mark and, in some degree, a measure of acute bronchitis. From the researches just alluded to, it would appear that the viscidity of these sputa depends on their quantity of mucus, which is albumen combined with saline matter, to which is sometimes added free uncoagulated albumen. In the most intense forms of inflammation, and where the disease occu- pies the finer tubes, to the glutinous character of the mucus is added a frothiness, arising from the mixture of those air-bubbles in the tubes, which in their breaking cause the mucous and sub- mucous rhonchi. But the most intense bronchitis is that accom- panying inflammation of the parenchyma: here we have the most viscid form of sputum, through which air driven produces the crepitant rhonchus ; and the blood in the distended vessels of the engorged parenchyma communicating a little colouring matter to it, gives it that reddish or rusty tinge which is so characteris- tic of the sputa of peripneumonia. The transparent or semi- transparent condition of these viscid sputa distinguishes them from the albuminous kind, into which, however, they pass in the advanced stages of all the more inflammatory affections of the bronchial membrane. The mucous expeptoration has commonly a saltish taste, and with its saline matter is probably connected its irritating quality, so marked in the early stage of bronchitis. 2. The varieties of albuminous expectoration are pretty nu- merous, for under this head are comprehended the opaque kinds of sputa which have no remarkable viscidity, such as the puru- lent expectoration of chronic bronchitis, the fibrinous or polypous sputa of plastic bronchitis, and the more compound combinations of these with caseous and other matters, which are voided in the advanced stages of pulmonary phthisis. This class of sputa de- notes an error of secretion, farther than the mucous from the na- tural standard, there being a defective proportion of saline matter, as well as an excess of albuminous ; but their production gener- ally announces a decline of inflammation from its most acute EXPECTORATION. 59 form. Probably, the very throwing off of so considerable a mass of animai matter, is the means of relieving to a certain extent the inflamed vessels ; for we frequently find the purulent or polypous expectoration in intense bronchitis attended by a remarkable diminution in the signs of local and general excitement. This remark has been made also by Dr. Stokes. But such an expec- toration ceases to be a favourable sign when it continues, either with undiminished irritation, or with proofs of general weakness ; for then a change is implied, either in the structure, or in the habitual action of the membrane, which, secreting pus instead of mucus, goes beyond the mere removal of a temporary congestion, and proves itself a cause of irritation and exhaustion. Much has been written about the modes of distinguishing pus from mucus in the expectoration. On these formerly the diag- nosis of pulmonary phthisis was supposed to depend. These tests are not now much attended to, not only because it is well known that pus may be produced without any ulceration or consumption of the lung, but also because these distinctions cannot be complete between matters that pass by insensible gradations into each other. The chemical composition of pus resembles that of the colouring globules of the. blood, and differs from mucus in con- taining a notable quantity of iron. 3. Watery expectoration is that kind in which a liquid of only slightly glutinous quality is coughed up in greater or less abund- ance. This appears to contain very little animal matter, and to be rather a diluted mucus than to have in it anything peculiar. It is often covered with a froth, particularly when it is coughed up with much effort. This secretion is to be regarded as the result of irritation, with a relaxed state of the vessels, rather than of inflammation ; but it may occur as a consequence of this lesion, as well as of congestion or obstruction to the circulation of the blood in the lungs. It is the expectoration of what is called hu- mid asthma and pituitous catarrh. Some persons of a relaxed habit have it during a common cold, or any form of bronchial inflammation. It sometimes tastes more salt than usual, and in this case it commonly causes a more incessant teasing cough. 4. Under the head compound expectoration, are classed various combinations of the preceding kinds, which we meet with in almost every form of pectoral disease. They are either products of different parts, in distinct pathological conditions, although coughed up at the same time ; or they may in some cases proceed from the same part in an intermediate pathological stale, and capable of secreting different kinds of matter. An example of the latter is the opaque or muco-purulent expectoration of the lat- ter stages of bronchitis, in which the opacity and colour of albu- minous matter is apparent, whilst it is held together by a mucus of some tenacity. In the concocted sputa of declining acute bron- chitis, the mucus predominates ; whilst the loose albuminous mat- 60 DIAGNOSIS OF DISEASES OP THE LUNGS. ter is more abundant where the inflammation tends to pass into a chronic state. The sputa of chronic bronchitis, and in fact of most chronic diseases of the lungs and air-tubes, are almost always more or less mixed ; for it generally happens that the dif- ferent parts of the membranes and tissues are variously affected ; and when, as in the advancing stages of phthisis, there is struc- tural lesion or destruction of parts, there is the greater reason for a more heterogeneous kind of expectoration. In these cases, however, the albuminous kinds mostly predominate, in the form of muco-purulent, purulent, caseous, or tuberculous matter, and coagulable or fibrinous lymph, occasionally tinged or mixed with the colouring matter of the blood: these constitute the bulk of the expectoration of the consumptive. In catarrhal diseases of a chronic kind, we commonly see very opposite forms of sputa expectorated together. Thus in a spitting-dish full of thin, frothy watery expectoration, we often find portions of tough and almost solid semi-transparent mucus, as if some parts of the tubes were throwing off the water, and others the animal matter, in a sepa- rate form. When the subject of catarrh is treated of, we shall find that these opposite products do not imply an equally opposite pathological condition. After hemoptysis, it is very common to see fibrinous concretions, together with purulent and mucous matter, all more or less tinged with blood. In other affections it is not uncommon to see the sputa streaked with blood; and this sign is of less importance when the cough is violent, because it may then merely proceed from a slight abrasion caused by the force of this mechanical action. When, however, there is often blood present, without much force of cough, and especially if there be pus with it, we may suspect the presence of ulceration in some part of the air-passages. The colouring matter of the blood in an altered state, may also be combined with other forms of sputa. Thus, in scorbutic persons affected with humid catarrh or bronchitis, the expectoration is a thin, reddish-brown liquid, like prune juice or diluted treacle; and in the last stages of pul- monary disease, the colouring matter, from the final pulmonary congestion which precedes death, is seen in the dirty reddish- brown or greenish tinge of the purilaginous sputa. It is evident then, that the matter of expectoration will often inform us of the pathological condition of the lungs and their tubes; and its quantity or quality may sometimes suggest proper reme- dies. In some cases we may learn other things from it. Thus, when in consumption, tubercular matter with portions of pulmo- nary tissue is expectorated, the conclusion is obvious. We also sometimes see the expectoration present physical signs of the state of the interior by its containing albuminous or compound matter, moulded into the shape of the tubes or cavities from which it comes. The large rounded flocculent mucopurulent sputa of advanced phthisis are often such as could only accumu- PAIN. 61 late in a cavity; and the tubular or vermicular albuminous mat- ter which is coughed up in the plastic kind of bronchitis, suf- ficiently explains whence it comes, by its being an exact mould or cast of the bronchial tubes, sometimes in an aborescent form, from several of their divisions. We must not omit to~notice a test, which is erroneously used to determine the nature and source of sputa, whether they float or sink in water. The floating of a sputum merely depends on the number of air-bubbles retained in it, and although pus alone, or tuberculous matter alone, will not retain these bubbles, yet a small addition of tenacious mucus will enable them to do so. Again, although the sputa formed in ulcerous cavities are less likely to contain air and to float than those formed in the tubes, yet we not unfrequently find the concocted expectoration of acute bron- chitis, which is formed exclusively in the large tubes, sink in water; whilst the mixed product of a vomica and the adjoining tubes, which has been churned together with air, floats. This hydrostatic test of expectoration is then a very inconclusive one; but it may be useful in sometimes causing a rough separation of the albuminous matters from those of a more viscid mucous kind. Other details regarding the matter of expectoration might be given ; but enough has been said to illustrate how it may prove useful in diagnosis and practice. From this it will appear how much more valuable its indications may become when conjoined with the physical signs, by which we may often detect the posi- tion, and measure the amount of the local disease, of which the matter expectorated is the product. We shall find many exem- plifications of this position hereafter. Pain. The only other morbid phenomenon, connected speci- ally with the modified vital properties of the organs of respiration, is pain. We know that pain may arise either from an excessive impression on the nerves of sensation, or from an excessive sen- sibility of these nerves, to which common circumstances of posi- tion, motion, &c, then become painful. The latter is the more common cause of pain in internal diseases; but it is not unusual to find them combined, as when a tumour, or effused matter, presses on or stretches parts morbidly sensible. The most com- mon causes of pain are inflammation, and those kinds of vas- cular excitement that are allied to it: this vascular excitement is generally attended, in the first instance at least, with an exal- tation of the nervous function. But the nervous function may be primarily excited ; and although the increased sensibility thus produced seldom lasts long without more or less stirring up the function of the vessels also, yet we may for a time have pains purely nervous, such as pleurodyne and pectoral neuralgia. Further, as inflammation is not the only cause of pain, so the pain present in inflammation is by no means an index of the extent of 9 02 DIAGNOSIS OK DISEASES OF THE LUN the inflammation, nor even of its situation. Most extensive in- flammations have been known to occur, not only in the paren- chyma of the lungs, but in the bronchial membrane and pleura also, without producing anv pain ; and it frequently happens in phthisis, that the pains chiefly complained of are low down in the sides, when the disease is almost entirely in the upper lobes of the lungs. So likewise in bronchitis and pneumonia, the pain is often confined to the sternal, lateral, or scapular regions, whilst the disease occupies other parts. There are, nevertheless, some general characters with regard to pain, which may render it useful as a symptom of disease of the chest. It is commonly remarked, that the pain of parenchyma- tous and bronchial inflammations is dull and diffused, whilst that of inflammation involving the serous and fibrous membranes of the pleura and pericardium is of a sharp lancinating character. This is generally but not constantly true; and we may find it ex- plained by the circumstance, that the par vagum, which supplies the bronchi and lungs, is by no means so sensitive a nerve as the spinal intercostals, which are distributed on the pleura and pericardium. For this reason, too, there is more apt to be acute pain when the costal pleura or the coverings of the great vessels are inflamed, than when the pulmonary pleura is the chief seat of disease. A further distinction in the variations of these divers kinds of pain will confirm the opinion, that they belong to dif- ferent orders of sensibility. The dull, heavy, or aching pain of bronchitis, or pneumonia, is generally pretty constant, although it is increased by full inspiration, exertion, or the breathing of cold air ; yet even then it gives the feeling of soreness under the ster- num, rather than of severe pain. It often resembles the pain of dyspepsia, which is probably seated in a branch of the same nerve, and is also usually referred to the sternum. The degrees of pleu- ritic pain, on the other hand, are sudden, extreme, and intoler- able. If it be not felt in ordinary breathing, a long breath, or a cough, just sufficient to bring the membranes to a requisite degree of tension, causes that sharp stitch of the side—that sudden catch of the breath, that has been considered so characteristic of pleu- risy. When it is constant, the patient is obliged to hold his side to diminish its severity, by restraining the motions of the chest; and thus placed in opposition to the sensation which prompts the act of respiration, this sharp pain may cause such a voluntary restraint of these acts, as to bring the patient to the verge of as- phyxia. It is under these circumstances that the breathing be- comes partial, as formerly described, and patients whom pain constrains to breathe only with the diaphragm or with one side, will perform this supplementary respiration so well, that they are completely free from pain, although the inflammation is as acute and the membranes as tender as ever. Sometimes we may detect the latent tenderness by pressing between the ribs of the affected side ; but we arc more likely to succeed if we restrain the sup- PULSE. 63 plementary respiration by pressing on the abdomen or on the healthy side, and then desire the patient to cough, or to take a sudden long breath. If there be any exalted sensibility or tender- ness, it is pretty sure to be discovered by this means; and we have several times met with patients who denied having any uneasiness or tenderness, yet they winced at the pain developed in this way. As a general rule (not however without some exceptions), we may consider a fixed permanent pain, or a permanent tenderness, which depends on the same pathological cause, an indication of inflammation, or congestion, or some analogous condition of the vessels; and when present it deserves attention, not only as an object of treatment on its own account, but also as an index, which together with the pulse, cough, fever, and other general symptoms, shows the increase and diminution of the complaint, and the effects of remedies, even before these become manifest from the physical signs. Still, if we trust to it alone, it will nega- tively deceive us in those numerous cases of extensive disease in which it is absent, or scarcely complained of; and it will posi- tively deceive us in those cases in which modified nervous sensi- bility—a mere neurosis—is the only or the chief disorder. We come now to examine shortly the nature and value of the symptoms which diseases of the organs of respiration develop in other functions. Physiology indicates the close relations which subsist between the organs of respiration and those of circulation'; and prepares us to expect that disease in the former should disturb the latter, and develop symptoms in the function of circulation. Accord- ingly we find such symptoms in the state of the arterial pulse, and in that of the superficial capillary and venous parts of the circulation. The pulse. The pulse has for ages been relied on as a guide in the diagnosis and treatment of all diseases; but those who have had much experience, know how fallacious it sometimes proves; and those who have had little experience must acknowledge that it is very difficult to distinguish the varieties of the pulse from one another. Some of the fallacies and difficulties connected with the pulse as a sign, appear to arise from our studying it too em- pirically,—from our not rationally considering those elements on which its varieties depend, and a knowledge of which would enable us to understand and to foresee the circumstances which are capable of producing these varieties. To guide the student to this knowledge, we will give a brief analysis of the nature and varieties of the pulse of arteries. The arterial pulse is caused by the jets of blood thrown at cer- tain intervals of time into the arteries by the contractions of the ventricles of the heart. The motion originates exclusively in these contractions, although it may be modified by the blood 64 DIAGNOSIS OF DISEASES OF THE LUNGS. which is moved, and by the tubes which convey it. Now here are three elements:—1. The heart; 2. The blood; and, 3. The arteries ,—and variations in the condition or action ot each ot these cause varieties in the arterial pulse. Let us consider a few of these variations. 1. Without noticing the modifications in the action of the heart resulting from disease of that organ—a subject to be considered hereafter—it is plain enough, that if the other elements be equal, the strength and frequency or rhythm of the contractions of the left ventricle of the heart, will determine the strength and fre- quency of the arterial pulse. But the contractions may have another quality—that of abruptness : being rather brisk and short than strong and complete, they communicate to the pulse that character which is called sharp. Now what property in the heart gives it this abruptness of contraction ? what but an ex- treme irritability? There is sometimes this irritability in inflam- mations and fevers; but we find it also in conditions of mere nervous irritation, of which it is more distinctive. And it is when these coexist with inflammation or fever, that the pulse presents a sharpness, in addition to other qualities more peculiar to inflammation. In sthenic irritation, or those connected with fulness and tone of the vascular system, which may tend either to acute inflammation or to active haemorrhage or other discharge, the heart's contractions are strong as well as sharp ; and so is the pulse. In these cases, although the original irritation were local, it has now reached the centre of the circulation, and thence, distributed through the whole system, becomes general. But let us see how the other elements modify the pulse. 2. There can be no doubt that the blood in the heart and ves- sels determines by its quantity the character of the arterial pulse: very possibly it does so by its quality likewise ; but this is not so easy to prove. The fulness and strength of the pulse in the arte- ries depend materially on the quantity of blood in them ; and when the pulse is frequent as well as full, there is the greater proof of plethora, inasmuch as it shows that there is a considera- ble jet thrown into the arteries at each contraction, notwithstand- ing that the contractions are so frequently repeated. But there may be a full system of bloodvessels without a large or strong pulse,—as when the heart is acting feebly or faintly ; and where its irritability is lowered, such a mode of action may be actually caused by the congestion or distension which for a time oppresses the function until it is roused into reaction. Under these cir- cumstances, bloodletting will often increase the fulness and strength of the pulse. The opposite condition—a defective quan- tity of blood—will modify the pulse differently according to the state of the other elements, the action of the heart, and the arterial tubes. When the irritability of the heart is reduced, together with the quantity of blood, the pulse will become softer, weaker, PULSE. 65 and less frequent. But it frequently happens, especially in nerv- ous temperaments, or where the depletion has been carried to excess, that the diminution of the blood is accompanied with an augmented irritability of the heart, and the pulse becomes not only quicker, but sharper than usual; and the effect of the abrupt jets into a small bulk of blood contained in imperfectly distended tubes, is to give to the pulse that jerking or bounding character, as if a mere ball of liquid were suddenly shot through the empty tube, which is so remarkable in the irritation of inanition and chlorosis. 3. But we cannot fully understand the variations of the pulse without attending to the properties of the tubes in which it is felt. If the arteries were tubes of an unyielding or an unvariable character, then the pulse in them would more uniformly repre- sent that of the heart, which would be transmitted through them unmodified. But we know that they are not so: they possess properties of elasticity and tonicity, which vary according to cir- cumstances, and which modify the pulses from the heart, by changing the size of the tubes, and the yielding or the resisting nature of their walls. It is plain that the impulse of a jet of blood must be differently transmitted by vessels when they are large and yielding, and when they are contracted and tense : in the first case the pulse would be soft and full, in the latter hard and small. We know but imperfectly what are the circum- stances which affect the tonicity and elasticity of the arterial coats, and thereby the pulse: further experiments are wanted to elucidate them, but the following are pretty well-ascertained, and they should not be forgotten in estimating the signs of the pulse. Cold causes the arteries to contract, and therefore ren- ders the pulse smaller. We know how a cold lotion will often diminish the fulness and throbbing of the arteries of an inflamed part; and we have seen the same effect of cold more strikingly produced in the large arteries. In the experiments on the sounds of the heart carried on in February 1835, we repeatedly observed, that when the aorta of an ass, recently killed, was plunged into cold water, it contracted, so as not to permit the introduction even of the little finger, and its coats acquired an increased thick- ness and rigidity: the pulmonary artery did not contract nearly so much. The circumstance of temperature must therefore be taken into account in judging of the pulse ; for cold may render the pulse of an artery small and hard, or, if severe, small and weak, when the action of the heart and the condition of the sys- tem would give it the reverse qualities. Heat, on the other hand, within certain limits, tends to diminish the tonic contrac- tion of the arteries ; so that under its influence they receive more strongly and fully the pulse from the heart. We know how warmth restored to a limb makes it throb with these expanded pulses. 66 DIAGNOSIS OF DISEASES OF THE LUNGS. But there is another circumstance that may modify these ac- tions of heat and cold on the pulse, besides proving by itself a cause of modification—the condition of the capillary circulation. When this is not free, the artery will be more distended, and therefore the pulse harder and stronger than usual; and thus in fevers, where the surface is pale and constricted in the cold stage, and dry and unrelaxed in the hot stage, the pulse often preserves through these changes of temperature a hardness and strength which would be much more varied were the capillary vessels free and exhaling their usual excretion, and which is actually dimin- ished under the influence of a warm bath or temporary moisture of the skin, although the fever still continue. Again, whatever view we take of the nature of inflammation, we cannot, in the present state of pathological knowledge, doubt that the circula- tion through the inflamed vessels is to a certain degree obstructed; whilst, either as a consequence of this, or from some cooperating influence, the vessels leading to the part become dilated, and being thus more open than others to the pulse-wave from the heart, which their distended coats cannot temper as usual, they become the seat of that throbbing hard pulse, that has been mis- taken for increased action of the vessels themselves. And there are many other variations in the pulse explicable on these principles, but this is not the place to consider them further in detail. There is, however, one more cause of variety connected with the arteries, so frequently occurring, that it must not be over- looked, viz., the difference in the arteries of different individuals. Without any adequate difference in the action of the heart, in the quantity of blood, or in the temperature, we find a very re- markable variety in the character of the pulse in different healthy individuals ; and the same difference extends to the modifications of disease. Some have always a soft large pulse; in others it is small and feeble ; in others small and hard : others, again, have habitually a hard strong pulse, which scarcely becomes soft under any circumstances. The first depends on the arteries being large, with thin elastic coats. The small feeble pulse may result from their small size and thin coats : this is common in females, and may coexist with inordinate action of the heart. The hard wiry pulse is connected with small arteries with rigid coats; and the same rigidity or deficiency of elasticity in the coats of arteries of larger size gives that unvarying hardness and strength to the pulse which we so often meet with in old people, and which ren- ders it so uncertain a sign in these cases. We may often, in the radial artery, feel the permanent thickening and hardness of its coats, which thus, like a tube of glass or metal, rigidly transmit the heart's pulses, without tempering them by any yielding or spring. With these peculiarities of pulse there are often con- nected characters of constitution or temperament, and proclivities PULSE. 67 to disease or health, which are of great importance in guiding us in practice. Besides the general causes which modify the pulse, which we have now briefly considered, there are some specially connected with diseases of the pectoral organs. Those arising from diseases of the apparatus of the circulation will be treated of in the article devoted to that subject. But severe affections of the respiratory organs also sometimes signally modify the pulse, and that in a manner which may tend to confuse its indications. We know how closely the heart is linked with the lungs ; by the cir- culation even more closely than by mere position ; for the lungs may be said to lie between the two compartments of the heart, and any considerable obstruction in the lungs will derange the usual relations of these compartments. There is then a disten- sion or over-stimulation of the right side of the heart; while the left, receiving a diminished quantity of blood from the lungs, and that not thoroughly aerated, is less excited than usual, and may give to the arterial pulse a character of weakness and smallness that by no means represents the condition of the whole vascular system, and which often is remarkably contrasted by the action of the right side of the heart, as felt or heard under the sternum. These varieties are produced by any of those affections of the chest which infringe far on the respiratory function. These are more commonly those of the bronchial and parenchymatous kind, which have accordingly been described to be accompanied by a softer and weaker pulse than those affecting the serous mem- branes. But a pleurisy may occur also with a small weak pulse, when the effusion or pain is such as to interfere largely with the function of the lungs. Neither is it to be supposed that the pulse in severe pneumonia or bronchitis is always weak, even when these affections infringe considerably on the function of the lungs. Even under asphyxiating influences the left ventricle may some- times become excited, together with the right, and give a sharp- ness to the pulse, which, combined with the arterial tension of fever, may be readily mistaken for hardness and strength. But this character is seldom permanent; and we generally find in all diseases, when the function of respiration is much impaired, that the pulse soon loses its body and strength. These considerations suggest the expediency of examining the state of the circulation not only by the arterial pulse, but also by the pulsations of the heart itself, and by the condition of the veins and capillaries. Under the circumstances just mentioned, when the indications of the arterial pulse are most variable and deceptive, we may often find useful signs in the condition of the venous and capillary part of the circulation. The distension of the more superficial venous trunks, especially the jugulars, in which a double pulsa- tion often shows also the retropulsive action of an over-distended 68 DIAGNOSIS OF DISEASES OF THE risht ventricle,-the fulness of the capillaries of the lips, tongue, hroat cheeks eyelids, nails, and other parts, at first having a florid and flushed appearance, but afterwards, as the respiration becomes more injured, assuming a purple or livid hue,—are signs of great practical importance, and of a constancy more ap- proaching to that of the physical signs. They do not, however present themselves in the early and more tractable stages of disease; and they are always less distinct in pallid persons with small superficial vessels. . ^ • ■ ., Intimately connected with the state of the circulation is the symptom of general fever, or increased heat, which attends many diseases of the chest. It depends on increased force and rapidity of the circulation, with diminished perspiration. When the per- spiration is restored, the heat always falls. This exhalation of fluid not only lowers the temperature by its physical agency of evaporation, but being in itself a sign of a relaxing of the super- ficial vessels, it implies an abatement of the vital irritation. In the more transient forms of fever, such as the intermittent and hectic, the profuse perspiration sometimes reduces the animal heat to below the natural standard, just as the circulation is pro- portionately enfeebled; and the same chilling influence is illus- trated by the cold sweats which succeed to temporary and irre- gular excitement. There are degrees of vascular irritation in which the increased heat of skin is partial, and determined by the structure of particular parts. Thus in the asthenic excite- ment of hectic fever, the heat is most felt in the palms of the hands and soles of the feet, because the circulation is not strong enough to drive the perspiratory excretion through the thick cuticle of those parts, which become consequently dry and hot. The same thickness of cuticle, on the other hand, when once imbued with perspiration, often keeps these parts soft and moist, when there is no sensible perspiration on other parts. Not unfre- quently the unequal state of the circulation is exhibited in febrile and inflammatory disorders by the heat of the abdomen, back, chest, or head, whilst the extremities are cooler than usual; and occasionally the same locally increased action is manifested by partial sweats, which prevent the increase of heat, and tend to reduce the excitement. We have known a patient with pleurisy perspire profusely only from the affected side, for several days; and nothing is more common, in slight, abdominal inflammations, than to find the pungent heat of the belly relieved by a perspira- tion equally confined to that part. But we practice on the same principle, in applying to irritated or inflamed parts poultices, fomentations, and partial baths, which tend to bring the skin and superficial vessels to the same relaxed and expanded state which they have in a perspiring part. Heat of skin, therefore, is an uncertain symptom ; for it de- FEVER. 69 pends on a condition of the superficial circulation that is by no means constantly associated with disease of the internal organs. When present, it may as much result from a general cause—an idiopathic fever—as from a local inflammation; and cases are not uncommon in which severe, and even fatal, visceral inflam- mations are attended, through a great part of their course, by free perspiration ; nay, the same may be said of some fevers which are called idiopathic. Still the heat and condition of the skin become valuable guides, when taken in conjunction with other signs, inasmuch as they indicate the constitutional disturbance, which is an important part of the disease, and which is some- times as much to be considered in the treatment as the local disease which has excited it. So, likewise, when the presence of a disease has been established by other signs, the condition of the skin may prove a measure of its increase or diminution more delicate and sooner appreciable than can be found in the physical signs. Thus an increased heat of skin, coming on during a bronchial or pulmonary inflammation, either indicates an increase of that inflammation or the addition of some abdominal or other irritation, which tends to aggravate the condition of the patient. So, too, perspiration breaking out in the hitherto dry and hot skin of a pleuritic patient, occasionally does prove critical, whether that word be applied to the excretion as a cause or as a sign of the amendment. Where there is disorder of the circulation, especially of a febrile kind, we may well expect alteration of the secretions, which are so intimately connected with it: hence we find the urine is scanty and high-coloured, and the secretions of the liver and intestines variously deranged. As a natural consequence, too, there will be disorder of the digestive and nutritive function : the tongue will be furred, or florid: the appetite will fail; the stomach will cease to digest; thirst will torment; the blood, no longer fed with chyle, will not duly nourish the textures, nor support the functions : the strength will fail; absorption continu- ing active, if time permit, emaciation will ensue ; and various complications of these disturbances may differently modify the character of diseases of the chest. The sensorial functions, too, may be deranged, either in consequence of the secondary visceral disturbances, or more rarely by a more direct influence of the imperfect respiration on the brain and nervous system. A know- ledge of the causes of asphyxia suggests also how certain states of the nervous system may tend to develop disease of the lungs. Thus insensibility, or coma, causes imperfect respiration, and consequently congestion of the lungs; and, as we shall hereafter see, a long-continued congestion of the lungs only requires the addition of vascular reaction to convert it into inflammation. Persons rarely recover from an asphyxiated state, without suffer- ing more or less from the injury which it leaves in the vessels of 10 70 D1AGNOMS Of DISEASES OF THE LUNGS. the lun<*s ; and not a few who have been recovered from sus- pended^inimation, have sunk under the pneumonia, or bronchitis, which supervened. ... We have thus rapidly glanced at some of the pathological relations of the organs of respiration to other functions, to give the reader an opportunity of considering rationally the nature and value of general symptoms. Dyspnoea, cough, pain, and signs of the circulation, with its concomitant, temperature, although often equivocal, yet when strongly marked sometimes assist us in diagnosis. It is just the reverse with the symptoms arising out of disorder of the other functions. The altered secre- tions of the kidneys, the liver, and the intestines, cannot inform us of the nature or presence of a disease of the chest; and still less will gastric derangement or sensorial disturbance. Not only will they not direct, but they tend essentially to blind us to the presence of pectoral disease; for they set up prominent symp- toms of a new character, that may take the attention entirely from the real source of disease, and fix it on the brain, the liver, the stomach or intestines, the affections of which are only second- ary, and often trivial. How often do we find peripneumony, or bronchitis, disguised by delirium or stupor, or by vomiting, a loaded tongue or diarrhosa. How often pleurisy, masked by jaundiced skin, a tender right hypochondrium, and clay-coloured fasces; or by lumbago, or nephralgia. How often tubercular consumption, obscured by sundry bilious, dyspeptic, or nervous symptoms. It will be happy for the practitioner (for his credit at least, if not always for the successof his practice) if he detect the enemy through its false colours, ere it triumph, and before the scalpel shall proclaim the delusion of his unwary mind. The physical signs will enable him to do this, and again we recom- mend them to the best attention of the student. On taking a rational review of the general symptoms in comparison with the physical signs, we must come to the conclusion that as diagnostic means, the general symptoms fall far short of the physical signs. But it is not to be supposed that, because the general symp- toms are often comparatively of little aid in diagnosis, we are to neglect the study of them. They are almost always of great importance in prognosis and practice. The physical signs more surely show how the pectoral organs suffer; but having dis- covered this, to the general symptoms we must look for how the system suffers ; and as the symptom often closely sympathises with the injured organ, we may through them often watch the first turns of the disease before the change in the organ becomes physically appreciable. In the general symptoms we seek for those critical phenomena, which, although sometimes deceptive, yet generally announce the tendency of the disease to one or other mode of termination. In them we study the vital forces LARYNGITIS. 71 and properties with which nature works, and the signs of what nature can do; and in our methods of treatment these become the standards to which we direct, and by which we modify, our remedies. When we treat a patient with peripneumony or catarrh, we do not apply our remedies merely to the local lesions, inflamed vessels, or a discharging membrane; we study the sys- tem at large, we examine other functions through the general symptoms, and we direct our treatment with due reference to indications from all these several sources. We see, then, that the mere stethoscopist is but ill-fitted to practice medicine. He may justly boast of his skill in diagnosis; his place of triumph will be the dissecting-room, where he can show the lesions that he had detected ; but his practice at the bed-side will be unsuc- cessful in proportion as local lesions vary in their general rela- tions, and in the conditions of the constitution, or of other func- tions that may accompany them. The judicious physician will not omit to study the condition of the vital properties, which are exhibited in the general symptoms, as well as the local physical changes which have been already produced ; and whilst he chiefly confides in the physical signs to indicate and measure the present local lesions, he carefully watches in the general symptoms the tendencies of those properties and functions which are capable of increasing or modifying these lesions, and are equally liable to be affected by them. The general symptoms being less intelligible and certain than the phj'sical signs, need more experience to enable us to appreciate them ; but we have found that even these also may be rationally studied, and may derive a light from a knowledge of physiology and the physical signs, which experi- rience alone could never throw on them. ----U^" LARYNGITIS. General observations.—Two forms of laryngitis—the Acute and the Chronic.— Symptoms of the acute.—Anatomical characters.—Diagnosis.—Causes— Prognosis.—Treatment.—Chronic Laryngitis—its symptoms.—Anatomi- cal characters.—Diagnosis.—Causes.—Prognosis.—Treatment. Mucous or catarrhal inflammation not unfrequently affects the larynx, and is the cause of the hoarseness which often attends both mild and severe bronchitis. There are, however, other in- flammatory affections of the larynx of a very serious and fatal tendency—those, namely, in which the inflammation affects the submucous cellular membrane, and causes cedematous effusion into this tissue. The swelling which results, narrows the caliber of the larynx, particularly at the glottis, impedes the respiration, 72 LARYNGITIS--ACUTE. and often destroys life. To this form of inflammation the term Laryngitis is generally restricted. It may occur under the different forms common to other inflammations, varying accord- ing to its exciting causes, and to the state of the constitution. Dr. Cheyne has specified no fewer than nine varieties of Laryn- geal inflammation, including the catarrhal form. For practical purposes, however, and "or the sake of conciseness, we shall com- prehend all the varief under the Acute (which may be sthenic or asthenic) and the < ironic. I. Acute Laryngitis. Symptoms. The sthenic form of acute laryngitis often begins with symptoms of tonsillitis, with difficulty of swallowing and fever, which is generally preceded by rigors. In this case the extension of the inflammation to the larynx, or its establishment in other cases, is announced by hoarseness, a frequent husky, and sometimes convulsive cough followed by tenderness, pain and constriction in the larynx itself, with difficult, prolonged, and sonorous inspiration, the chest being free from signs of disease. On examination the fauces generally, but not always, are red and swollen, and sometimes, by pressing the tongue forwards and downwards, the epiglottis may be seen erect, thickened, and of a bright or deep red colour. In this state the epiglottis no longer protects the glottis from the contact of matters passing into the pharynx; hence the act of swallowing not only is painful, but often causes convulsive fits of coughing, and increased difficulty of breathing. At first the fever is decidedly inflammatory : the face is flushed, the skin hot, and the pulse full and hard ; but this state is soon changed under the depressing influence of the ob- structed state of the respiration. A frightful train of symptoms then ensues, induced by the rapidly increasing impediment to the supply of air. The countenance becomes anxious in the extreme, and pallid ; the lips livid ; the eyes staring and watery ; the nos- trils raised ; the voice is reduced to a whisper; the integuments in the fore part of the neck are sometimes oedematous ; the pulse becomes quicker, feebler, and less uniform. To quote the ex- pressive description of that experienced observer, Dr. Cheyne, "the patient is restless and apprehensive, often changing his position, in the va n hope of obtaining relief; walking, or rather staggering to and 'ro in great distress ; feeling that he is on the point of suffocatio , he cannot be ignorant of the danger to which he is exposed ; h -ce he is willing to submit to any means of relief, and is impa ent of delay. In this stage the sufferer seldom sleeps for many m,notes at a time; when he begins to dose, he starts up in a state of the utmost agitation, gasping for breath, every muscle being brought into action, which can assist respi- ration, now a convulsive stru gle. He is quite enfeebled, be- laryngitis (Causes). 73 comes delirious, drowsy, and at last comatose, the circulation being more and more languid, and he dies on the fourth or fifth day of the disease, or even earlier." Death has been known to take place seven hours after the attack; in some cases it has been delayed for two or three weeks... The asthenic form of laryngitis differs from the sthenic in the absence of symptoms of inflammatory hyer, and sometimes of pain in the larynx and difficulty of deglu^'on. In other respects the symptoms are similar; with th.e samv^Jioarseness and cough at the commencement, difficult and stridu^js respiration, rapidly amounting to a feeling of strangulation, as if the upper part of the windpipe were closed, often with fits of convulsive coughing and increased difficulty of breathing, apparently of a spasmodic kind ; and after inducing symptoms of partial asphyxia in one of these paroxysms, the disease may prove fatal suddenly or more gra- dually, by the patient after repeated attacks falling into a state of insensibility. In one of the. asthenic forms of laryngitis, the inflammatory symptoms are by no means prominent; and the affection has long been termed oedema of the glottis, because an effusion of serum or pus into the cellular tissue of the lips of the glottis is the destruc- tive lesion, and few other traces of disease are found after death. In other cases, particularly those arising from erysipelas, whether propagated from other parts or at first attacking the throat and larynx, and those of laryngitis supervening on continued fever, small-pox, scarlatina and measles, the symptoms of local inflam- mation are more severe, pain and difficulty of swallowing are present, and after death, the epiglottis and other parts of the larynx are found inflamed and swollen by the effusion of lymph or pus into their cellular texture. The course of all these forms of laryngitis may be as rapid as that of the sthenic kind, but it is seldom so uniformly progressive, particularly in the cedematous variety, in which the attacks of difficult breathing are sudden and rather severe at first, and may prove rapidly fatal; or they may subside for a while after the expectoration of a little glairy mucus, and recur again with increased severity; in the interval the breathing being pretty free, but the voice still hoarse, and the sensation of a tightness or lump in the throat remaining. In the cases in which the obstruction is chiefly cedematous, it generally occupies the cellular tissue of the glottis, andifrom thence to the ventricles, the epiglottis being comparatively -ee, and there being little or no difficulty of deglutition ; but in thessrysipelatous cases, as in the sthenic form, the epiglottis is frequently thickened, the patient experiences difficulty and pain in swar .owing, the attempt to swallow liquids sometimes causing a spasm so violent as to resemble that of hydrophobia. Causes. Acute laryngitis may follow exposure to cold and wet. It may originate in cynar^he tonsillaris, and, according to 14 laryngitis--ACUTE. Dr. Stokes, in cynanche parotide** which he has found to be inflammation of the cellular membrane only, and not of the parotid gland itself. Acute inflammation of the larynx has been brought on bv swallowing scalding or corrosive liquids by the convulsive action which these excite in the throat; they are in part thrown on, and even into the glottis. Children accustomed to drink from the mouth of a tea-kettle or tea-pot have often attempted to do this when these vessels contained scalding water; the result has been violent inflammation of both pharynx and larynx. Instances of this accident were first recorded by Dr. M. Hall. Mr. Porter observes, that when a person attempts to drink by mistake a corrosive liquid, a similar convulsive action takes place, closing the pharynx and throwing the offending matter violently backwards through the mouth and nostrils, under the epiglottis, and thus this accident becomes a cause of acute inflammation of the larynx. Mr. Ryland has with good reason placed the inhalation of flame or of very hot air among the causes of acute inflammatory injuries of the larynx. Persons who die from severe burns, if it be only about the head and face, generally suffer from severe dyspnoea, and the mouth and larynx are found in a highly inflamed and congested state : these effects he very rationally ascribes to the great heat of the air inhaled at the mo- ment of the conflagration. The inhalation of very acrid vapours might possibly have the same effect. As exciting causes of asthenic laryngitis, erysipelas, scarlatina, small-pox, and measles, have been already mentioned ; and we may add, that inflammation of the tongue from the excessive use of mercury, and diffusive cellular inflammation from punctured wounds, have been known to ex- tend to the cellular tissue of the larynx and cause death. M. Bayle and Dr. Tweedie have noticed that cedematous laryngitis sometimes suddenly supervenes without any obvious cause during and after typhoid fevers. It occurs also not unfrequently in the course of chronic disease of the larynx, and is sometimes the cause of death in these cases. We have known it to come on and hazard life in a patient with aneurism of the arch of the aorta, before the tumour had well shown itself outwardly : Mr. Lawrence has adverted to similar cases. Habitual intemperance, long courses of mercury, frequent and long-continued exertions of the voice, are supposed to predispose persons to attacks of laryngitis. Except in case of scarlatina, measles, and small-pox, and of the accidents before alluded to, laryngitis never attacks children ; and of those advanced in life, Dr. Cheyne states that it most frequently occurs in such as are liable to indigestion connected with a disordered state of the liver. In most instances, the subjects of it had previously been liable to sore throat. Anatomical characters. The effects of laryngitis are commonly found in the red injection and thickening of the lining membrane laryngitis (Diagnosis). 75 of the larynx, and an cedematous state of the cellular tissue un- derneath, particularly at the upper portions, from the epiglottis to the ventricles, the parts beneath being nearly or quite free from disease. In the more sthenic cases especially, the epiglottis is very red, thickened, and erect, instead of lying over the glottis. The folds forming this chink are generally also red, and much swollen. On cutting into them, serum, or if the disease have not terminated very rapidly, a sero-purulent liquid or pus, exudes. In a few instances, lymph has been found in the cellular textures, and in two or three there have been small patches of lymph on the glottis and under surface of the epiglottis. Rarely these parts have been found ulcerated, even in acute cases. In the erysipe- latous disease, and that arising from diffusive cellular inflamma- tion, the matter effused in the submucous tissue of the epiglottis, vocal ligaments, and ventricles, is a sloughy kind of lymph with serum, sometimes mixed with pus ; and the longer the case has lasted, the more purulent the liquid is. This effusion is often found to extend to the cellular texture at the root of the tongue outside the larynx, and even among the muscles of the neck and throat. In the cedematous variety the epiglottis is nearly free from disease ; the mucous membrane is little injected, but the folds of the glottis are so distended, as nearly to close the orifice, and on cutting into them a clear or purulent serum flows out. It can scarcely be doubted, that in most cases this serous effusion is the result of a low form of inflammation; but it may be fa- voured by the existence of a dropsical diathesis, or by the pressure of a tumour on the neighbouring venous trunks: to the latter cause we would chiefly ascribe the laryngeal symptoms which occasionally show themselves in cases of aneurisms of the great vessels or other tumours at the lower part of the neck. Dr. Stokes notices the occurrence of oedema of the glottis in a patient labouring under a cancerous tumour below the jaw. Diagnosis. The symptoms of acute laryngitis are generally sufficiently characteristic to separate it from other diseases af- fecting the breathing. The stridulous or hissing inspiration, heard most distinctly at the larynx, which is drawn down at each act, the seat of the sensation of pain or constriction at that part, often the visible condition of the epiglottis, and the absence of pec- toral signs, suffice to distinguish it from diseases of the chest. Abscesses external to the larynx and compressing it, may cause difficulty of breathing and swallowing: sixteen years ago we saw a fatal case of this kind, which was mistaken for laryngitis, until the first incision of the throat after death gave issue to a quantity of pus which had formed among the numerous muscles of the tongue and larynx. A careful examination will generally dis- tinguish these cases by the partial or general swelling at the upper part of the neck, often with tenderness, and an inability to open the jaw. Mr. Porter thinks that they differ from those of 76 LARYNGITIS--ACUTE. laryngitis in the breathing, although obstructed, being less sibi- lous, and more gradually oppressed, and in the diminished mobi- lity 'of the larynx when pressed from side 1o side against the spine. We should conceive that the absence of the peculiar cough and hissing hoarseness of laryngitis might in some cases better assist the diagnosis. Spasmodic affections of the larynx may generally be distinguished by the complete absence of fever and by the suddenness of the attack; but they may not be so easily distin- guished from the cedematous laryngitis supervening on chronic diseases, which is in effect generally combined with spasm: still in this case there is usually a previous slight access of fever and increase of the chronic symptoms. Spasm of the glottis is a very rare affection in adults, and occurs only in hysterical or highly nervous subjects. Prognosis. Laryngitis has been considered by Dr. Cheyne and others to be the most fatal of all the inflammations. Of seven- teen cases observed by Bayle during six years only one reco- vered. Of twenty-eight cases collected from various authors by Mr. Ryland, ten recovered, which he justly considers to be above the average. In most of the fatal cases, death took place be- tween the first and fifth days. The prognosis must therefore in all cases be unfavourable; and the more so, as the disease has lasted longer and with progressive increase of the difficulty of breathing. When the face loses its colour or becomes livid, and the faculties obtuse, from the circulation of black blood, the danger is extreme. On the other hand, decrease of the difficulty of breathing and of swallowing, a returning freedom of expectora- tion, with an improved expression and colour of the countenance, give rational hopes of recovery. Treatment. In no disease is an early and energetic use of remedial measures more essential to their success, than in acute sthenic laryngitis. There is a period during which free blood- letting and the administration of calomel and antimony may arrest the inflammation before considerable effusion has taken place; but this period is very short, and has often elapsed before me- dical aid is resorted to; and when once the effusion has taken place, antiphlogistic measures become worse than useless, and unless artificial means of supplying air to the lungs be employed, the disease generally destroys life before there is time for ordinary curative measures, however energetic, to produce their effect. The chief indications of treatment, therefore, are,— 1. To prevent effusion by reducing inflammatory action:—2. Effusion having taken place, to prevent the obstruction which it causes to respira- tion from producing mortal injury to the functions:—3. To pro- mote the removal of the effused matter. 1. In endeavouring to fulfil the first indication by free blood- letting, we cannot do better than by quoting the directions of Dr. Cheyne. He recommends free bloodletting but not to syncope, laryngitis (Treatment). 77 as advised by Dr. Baillie, for this may deprive the patient of strength sufficient to struggle against the next spasmodic parox- ysm of dyspnosa. "We would bleed the patient freely during the first twenty-four hours:—we should be disposed to do more: as long as the complexion of the patient is good, we would have recourse to venesection, keeping a finger on the artery while the blood flows, and closing the orifice when the pulse is reduced ; we would have leeches applied or blood removed from the nucha by cupping; and we should be disposed to bleed again or even a third time, so as to abstract forty or fifty ounces of blood, and at the same time let the patient have a powder containing two or three grains of calomel, three or four of Pulv. Jacobi Verus, and one-half or one-third of a grain of opium should be taken every third or fourth hour till the gums become affected." We would not hesitate to give double this quantity of calomel. Dr. Cheyne justly objects to blistering on account of its trifling advantages in comparison with the additional suffering which it occasions, and possible interference with the operation of bronchotomy. Per- haps the same objections would not apply to the speedy and ener- getic counter-irritation by the strong liquor ammonias, which, if applied at the side of the neck in the manner directed by Dr. J. Johnson, may produce vesication in two or three minutes. Dr. Cheyne also deprecates the use of tartar-emetic, lest it should excite vomiting, which with the erect state of the epiglottis would throw matters on the unprotected glottis, and cause a frightful convulsive irritation. For a similar reason we would object to the direct application of leeches to the tonsils, a measure proposed by Dr. Cheyne. We can testify of its utility in tonsillitis, for which it was first recommended by Mr. Crampton; but the irri- tation from the bites, and the blood proceeding from them, could scarcely be tolerated with an exposed glottis. Active depletory measures employed early may for a time re- lieve the symptoms without removing the inflammation: they often only delay the effusion, which with its resulting permanent in- crease of difficulty of breathing and appearance of lividity, instead of taking place in the first day, may not come on for several days. Hence the importance of attempting, from the first appearance of the disease, to fulfil the third indication by the free use of mercury both by calomel internally and by external in- unction ; for if the gums can be made sore, a secretion from the throat is established which generally reduces the swelling of the glottis. We have more confidence in the power of mercury to cure laryngitis than in that of bloodletting ; and would consider the great utility of the latter to be in so far retarding the pro- gress of the inflammation as to enable the mercury to act before a fatal obstruction is produced. Some few cases have yielded to bleeding alone, and its employment should never be neglected when the strength can bear it, and the conditions so well stated 11 78 LARYNGITIS—ACUTE. by Dr. Cheyne indicate it. But if the strength have already failed, or these conditions cease, and the undiminished dyspnoea and com- mencing lividity announce the approach of asphyxia, bloodletting becomes worse than useless, and the second indication by the ope- ration of bronchotomy must then be attempted without delay. Dr. Baillie considered it advisable to resort to bronchotomy if no con- siderable reiief be obtained from other measures in thirty hours. Dr. Cheyne more rationally takes as a criterion the condition of the patient rather than the period; and says that if the symptoms be such as to contraindicate bleeding and yet asphyxia is imminent, thirty minutes' delay may be too much : but if the complexion is good and asphyxia not threatened, the operation may be delayed thirty days. Surgical writers strongly urge the early performance of the operation. Louis observes, "as long as bronchotomy is con- sidered an extreme measure (a dernier resort) it will be always performed too late ;" and Mr. Lawrence says that it should be done, " as soon as the symptoms enable us to determine the nature of the disease." It is because we are convinced that it should be resorted to early, that we have included it in the second indi- cation. If free bleeding produce no relief, or be not borne, and serious difficulty of breathing have become established, we would not wait for the appearance of pallor or lividity as recommended by Dr. Cheyne, and still less for the lapse of a certain number of hours as proposed by Dr. Baillie, but we would urge the performance of bronchotomy without delay. To defer the operation on ac- count of the difficulty or danger attending it, is most unreasonable; for experience has proved that these are increased rather than diminished by delay, and the danger from the operation is at no period to be compared with the danger from the obstruction to the breathing that it is calculated to remove. Laryngitis de- stroys life, not by the extent or the vitality of the organ which it occupies, but by closing as it were the door of the breathing ap- paratus : by opening another door we render the disease com- paratively trivial; and it may then be deliberately attacked by mercurial and other remedies, or, if slighter, even be allowed to run its course, which commonly ends in muco-purulent secretion. When the operation has been delayed until asphyxia approaches, it will have less chance of success ; but should still be tried, for a very few instances are on record where it succeeded at almost the last extremity. It is not within our province to give directions for the mode of performing the operation ; but we may state that we have seen reasons for making a free incision between the thyroid and cricoid cartilages, and keeping them separated for the first half hour by the thin handle of a scalpel, and afterwards by a short tube half an inch in diameter, with a projecting rim to button into the opening, and a ligature passing round the neck to prevent its slipping in too far. Such a tube may be made in a few minutes of a piece of hollow reed or elder stick, by winding laryngitis (Treatment). 79 a few turns of waxed twine around the end to be inserted, and passing the ends of the twine through the two holes bored across the outer extremities of the tube, whence they are passed and tied round the neck. The less of the tube that is introduced within the windpipe the better ; for the presence of a foreign body often excites terrible paroxysms of coughing. The act of expectoration is often impossible with the opening free; it should therefore some- times be closed after a long inspiration, that the patient may for- cibly expel the accumulating matter by a full expiration through the glottis, which is sufficiently free to the exit of air: varying the posture will aid this act. Until and after the mercurial action is established, it is often useful to apply leeches or a blister, or other counter-irritants, to the upper part of the chest; for there is a tendency to bronchitis as the laryngeal inflammation subsides ; and this extension of dis- ease has, in not a few instances, caused death where bronchotomy had saved the patient from the laryngeal affection. The treat- ment of the after stage of laryngitis is much the same as for the same period of bronchitis. The great difference to be remarked in the treatment of acute asthenic laryngitis, whether of the cedematous or erysipelatous kind, is in the total absence of a phlogistic period in which general bloodletting may do good. Leeches freely applied to the sides of the larynx, and speedy blistering the sides and back of the neck by the strong liquor ammonias or acetum lyttas, may sometimes diminish or retard the effusion until the system can be brought under the influence of mercury, which here, as well as in the sthenic form, is the only remedy to be relied on for dispers- ing the swelling. But if, as it more commonly happens, the pro- gress of the disease towards causing a fatal obstruction be more rapid than the influence of the remedies, the obvious resource will be in the early performance of bronchotomy. These cases will bear even less delay than those of the sthenic disease; for besides that they are still less under the control of remedies, they occur in weakly subjects, which are sooner injured by an ob- structed state of the respiration : and it has repeatedly happened that a late operation has relieved the breathing, but the patient has sunk from the injurious influence of imperfectly arterialised blood, which had already circulated in the lungs, brain, and other organs. Hence too even if this influence be not immediately fatal, it may lead to secondary congestions of these organs, which in the form of asthenic bronchitis, pneumonia, or arachnitis, may ultimately endanger, and even destroy life. In case of the secondary laryngitis, supervening in erysipelas, scarlatina, measles, typhus, and other febrile diseases, due regard must be paid to the original disease, which, according to cir- cumstances, may require a stimulant or an opposite plan of treat- ment. 80 LARYNGITIS--CHRONIC II. Chronic Laryngitis. This form is of more frequent occurrence than the acute, and presents itself in a great variety of degrees. As acute laryngitis is a comparatively trivial disease as long as it is confined to the mucous membrane, and produces no swelling of the tissues be- neath, so chronic inflammation may affect the internal surface of the larynx for many months, and produce little inconvenience ex- cept hoarseness, habitual husky cough, and perhaps some feeling of soreness at the top of the windpipe. This affection not unfre- quently succeeds to a neglected catarrh, especially in those persons who are continually exposed to cold and wet, and are habitually intemperate; for example, hackney-coachmen and street porters. The purple faces of many such individuals give evidence of a congested condition of the capillaries, that in all probability ex- tends to the lining membrane of the larynx; increasing its sensi- bility and injuring its nice adjustments in the production of the voice. This form of disease may exist long without inducing further change, and tends rather to induce thickening of the mem- brane and vocal ligaments, than to end in ulceration. It is different with the serious disease which more commonly goes by the name of chronic laryngitis, or phthisis laryngea, which, like the acute disease, reaches to the submucous cellular tissue, from whence it may extend to the other constituents of the larynx, and involve them in the intractable and destructive effects which inflammation induces in these less vital textures. The chief of these are, erosion and ulceration of the mucous and submucous tissues; softening, thickening, oedema, induration, contraction, and dissecting abscesses of these textures, and of the ligaments and muscles attached to them ; ossification, caries, and necrosis of the cartilages; warty and fibrinous excrescences ; scirrhous and tuberculous formations in the different structures. These several lesions may be variously combined, and produce disease of very different degrees of severity, those being the worst forms in which the cartilages are diseased, or extensive ulceration of the other tissues already produced. These more destructive changes may follow simple inflammation; but they are more commonly either the result of a scrofulous diathesis, and often complicated with tuberculous disease of the lungs and other parts; or they are the product of a syphilitic taint, or much more rarely of scirrhous or other malignant disease. Symptoms. Chronic laryngitis is generally a very insidious disease, often beginning as a common catarrhal cough with hoarseness, and not attracting particular attention until it has lasted for a long time, and seriously injured the general health as well as the tissues in which it is seated. The chief symptoms are hoarseness, a husky dry cough, with soreness or pain in the larynx, laryngitis (Symptoms). 81 felt sometimes on pressure, or rubbing it against the spine, some- times only in the act of swallowing. Of these, the most constant sign is the change of the voice, which varies very much in degree and kind. The dry, stridulous, or squeaking kind of hoarseness, if permanent, generally implies a worse form of disease than the deep, loose, or mucous hoarseness which may proceed more from relaxation: sudden loss of voice may occur with slight diseases affecting the thyro-arytenoid ligaments, or a nervous affection of the muscles, and may not be permanent; but where a voice gradually becornes more and more cracked until it is at last lost, there is probably a progressive destruction of the vocal apparatus. In some cases the defect of the voice is perceptible only on speak- ing loud, or in any attempt to vary the tone ; for the patients in- stinctively acquire the habit of speaking in that tone and degree in which the voice is best produced. Pain is so uncertain a symptom, that Trousseau and Belloc state than in more than half the cases of laryngeal phthisis which fell under their observation, there was no pain throughout the disease. There is, however, generally increased sensibility of the larynx, so that the inhalation of cold air, or any hurry of the circulation, very readily excites coughing. The cough, which in the early stages is commonly short, dry, and hacking, is described by MM. Trousseau and Belloc to assume in some instances in the later stages a very peculiar loose continuous character, like eructation or belching, which they ascribe to an inability to close the glottis, its closure being the first act of an ordinary cough. As the disease ad- vances, there is often abundant purulent and sanious fetid expec- toration, sometimes streaked with blood; but not unfrequently the sputa are scanty and chiefly mucous. The occurrence of purulent expectoration is sometimes accompanied by relief to the breathing, although the voice may suffer more, and there may be more pain or soreness in coughing; this marks the formation of an ulcer, the discharge from which diminishes the constriction of the air-passage. Instances have occurred of the expectoration of dead and ossified portions of the arytenoid and cricoid car- tilages, and of calcareous concretions formed within the larynx ; and in more than one case, such solid fragments have fallen back into the trachea, and caused much irritation and consequent dis- ease in one of the large bronchi. The respiration generally be- comes affected sooner or later in chronic laryngitis ; the difficulty of breathing commonly coming on in the night, and on any ex- ertion sometimes in very severe spasmodic paroxysms, leaving the patient only with a short breath in the interval. The attacks of dyspnoea afterwards increase, and prevent the patient from lying down ; and in the interval, the hissing sound of the laryn- geal breathing indicates some degree of permanent impediment to the passage of the air. After the orlhopnoea has once com- menced, death generally ensues in a fortnight or three weeks ; but at an earlier period the patient may be suddenly carried off' 82 LARYNGITIS--CHRONIC. by an attack of acute cedematous inflammation of the glottis. Of nine fatal bases of oedema of the glottis, examined by MM. Trous- seau and Belloc, five occurred in the course of chronic laryngitis. In many instances, chronic inflammation and ulceration of* the larynx are accompanied by progressive emaciation, hectic fever, night-sweats, and other signs of phthisis, without marked dyspnoea; and the patient is ultimately worn down by cough and weakness, and is perhaps carried off by diarrhoea or some other superadded disorder. In by far the greater number of these cases, tubercles are formed within the lungs, either before or after the laryngitis begins, and become the chief cause of the decline, although too gradual in their effect to affect the breathing in a marked degree. In a few instances recorded by Trousseau, Belloc, Ryland, and others, the laryngeal lesion was uncomplicated with any pulmo- nary disease, the consumption having been purely laryngeal. In most of these cases the cartilages of the larynx were diseased. Chronic inflammation and ulceration of the larynx and trachea are very common with tuberculous consumption of the lungs, and are the cause of the loss of voice, and smarting or pricking sen- sation in the larynx, so often occurring in the advanced stages of phthisis. Ulceration was found by Louis in upwards of a fourth of the cases of phthisis noted in his work. Causes. Chronic laryngitis may succeed to the acute disease; but it much more commonly arises from the frequent recurrence of catarrhal inflammation, particularly in those who are addicted to ardent spirits. Excessive exertions of the voice, repressed eruptions, wounds or contusions of the throat, foreign bodies in- troduced into the larynx (among which may be mentioned the habitual inhalation of air loaded with dust), and the extension of syphilitic disease from the throat, may be enumerated as occa- sional exciting causes. A scrofulous or tuberculous constitution particularly predisposes to laryngeal phthisis. The excessive use of mercury, habitual intemperance, and other debilitating in- fluences, are also supposed to render persons more liable to chronic inflammation of the larynx. The disease appears to be most common at the middle period of life. According to Mr. Ryland, it affects women more frequently than men, but this is at variance with the experience of MM. Trousseau and Belloc. Anatomical characters. We have already enumerated the principal lesions which chronic laryngitis induces. They are very various, and have been minutely described by Porter, Lawrence, Stokes, Ryland, and Trousseau and Belloc, to whose work (par- ticularly the last) we refer for details. The simplest effect of the chronic inflammation is, 1. Redness of the mucous membrane in patches; even when not ulcerated, it has often a rough granular appearance, from the irregular enlargement of the mucous folli- cles. 2. Thickening of the submucous tissue: this is frequently observed in the epiglottis and the lips of the glottis, causing en- laryngitis (Anatomical Characters). 83 largement and diminished mobility of these parts: the ventricles of the larynx are sometimes nearly obliterated from the same cause. 3. Contraction of the ligaments, wasting, induration, and fibrous degeneration of the muscles which move the cartilages of the larynx: this is a common result of chronic inflammation on fibrous and muscular textures, and must in this case impair or destroy the mechanism of the voice. Contraction, together with partial thickening affecting the epiglottis, renders it curved or corrugated, so as to defend the glottis very imperfectly. 4. Ul- ceration of the mucous and submucous textures: this is a com- mon result of chronic inflammation, and presents itself in great variety as to form and seat, of which the following are the most remarkable: the ulcers are sometimes small and round, but con- fined to the mucous membrane: in other cases they have been known to penetrate to the cartilages or ligaments ; and M. An- dral notices a solitary case in which one perforated the thyroid cartilage, just above the insertion of the vocal ligaments. In this case the voice was unaffected. When these ligaments are in- jured, the voice is generally destroyed. When again the ulcers are large and superficial, denuding but not injuring the vocal cords, there is commonly hoarseness, but not aphonia. It is between the vocal ligaments and the epiglottis that ulcers are most commonly found, but they are often met with in other parts of the larynx and trachea. They are frequently seen on the laryngeal surface of the epiglottis, and sometimes at its margin; it is only in case of syphilitic disease that the upper or lingual sur- face is found affected. Considerable parts of the epiglottis, as well as of the arytenoid and cricoid membranes and cartilages, have in a few instances been found destroyed by ulceration. 5. The ulceration, however, does not frequently extend to the car- tilages except in young subjects. MM. Trousseau and Belloc do not consider the cartilages of the larynx sufficiently vital to take on the process of ulceration or caries. The common effect of ulceration of the adjoining textures on them is in the first place ossification, and afterwards necrosis. The cricoid and thyroid cartilages naturally become ossified in advanced life; but chronic laryngitis of two years'duration produces the same change in young persons. This is in conformity with a law well-developed by Andral, that a certain degree of irritation accelerates in tis- sues those changes to which time would naturally bring them. The osseous matter is deposited in irregular places on the surface of the cartilage, and sometimes quite encases it. Instances of necrosis of the cricoid, arytenoid, and even of the thyroid car- tilages, have been recorded by Porter, Lawrence, Cruveilhier, Ryland, and Trousseau and Belloc. The last authors state that they have found this lesion in more than half of the fatal cases of laryngeal phthisis which they have examined. In this state the cartilages are denuded of their perichondrium, and are of a dirty 81 LARYNGITIS--CHRONIC. dull hue without ther natural lustre. The sequestrum of dead cartilage is not readily thrown off; but there is often fetid pus in the cellular texture near it. These abscesses may open and dis- charge their offensive contents, and even the dead portions of the cartilage, either into the larynx, or outwardly through the integuments of the neck, or into the oesophagus. It can readily be conceived how much local and constitutional irritation these dead matters may produce before they are discharged, and how in the very act of separation, acting as foreign bodies, they may produce suffocation. Diagnosis. The most characteristic signs of chronic laryngitis are the permanent change of the voice and the peculiar cough before described, with hissing breathing and pain or tenderness in the larynx when these happen to be present. Except in syphilitic cases where the fauces are also diseased, little is to be learnt from examination of the throat; for it is impossible to see or reach further than the epiglottis, and to get a view of this is a matter of difficulty. Neither is crepitation felt on pressing the larynx to be depended on; for, according to Trousseau and Belloc, this may be produced in a healthy larynx. Dr. Stokes describes, as a stethoscopic sign of chronic laryngitis, a harshness in the sound of the air passing through the larynx, giving the idea of a roughness of surface, perceptible even when the breath- ing is not distinctly stridulous. In a few cases he observed above the thyroid cartilage a rhonchus, like the sound of a valve in rapid action, combined with a deep humming. We much ques- tion that the latter sound was seated in the larynx, for such a sound is often produced in the jugular veins. When the laryngeal constriction is considerable, the peculiar sound of the passage of air through it will sufficiently distinguish it; and where it is slight or altogether absent, laryngeal disease may yet be known as the cause of the cough and other symptoms, by the negative indica- tions of the thoracic organs, the sound of percussion and of re- spiration being good throughout the chest. But pulmonary tubercle is very commonly conjoined with laryngeal disease, and the two affections are apt to disguise each other. The noisy laryngeal respiration, and the absence of the voice may destroy the chief distinctive signs of phthisis in its early stages; but as the disease advances, the dulness on percussion and perhaps cavernous rhonchus in some part of the chest, particularly under a clavicle or scapular ridge, with a more copious purulent expec- toration, night-sweats, and more rapid emaciation, sufficiently announce this most destructive complication. When the breath and sputa in laryngeal disease are very fetid, it maybe suspected that some part of the cartilages is dead. This is generally the case where a chronic abscess opens outwardly about the thyroid cartilage. Prognosis. The milder and simple forms of chronic laryngitis laryngitis (Treatment). 85 are by no means incurable; in fact they generally yield to judi- cious treatment; and were it not for their liability to exacerba- tions from acute cedematous inflammation and to complications with pulmonary disease, they could hardly be called dangerous. Both these destructive complications may be apprehended when the disease has continued long, with increasing serverity of symp- toms of the voice and respiration, with a change of the cough from dry and ringing to loose and undivided, with increasing purulent expectoration, and particularly if the disease has re- sisted treatment. If from the history of the individual there be any suspicion of a scrofulous tendency, and particularly if symp- toms of pulmonary disease, such as slight cough, shortness of breath, pains in the chest or shoulders, quickened pulse, &c, pre- ceded those of the laryngeal affection, the prognosis is unfavour- able ; and if there are found any physical signs of phthisis, such as dulness under a clavicle, the case of the patient must be con- sidered almost hopeless. Fcetor of the breath and sputa, imply- ing mortification of the cartilages, is also very unfavourable ; but it is more probable that the dead portions of these may be thrown off, than that tuberculous disease of the lung combined with a laryngeal lesion may be cured. In all doubtful cases, particularly those of a syphilitic origin, the state of the general health and strength, as well as the degree of the local affection, must be duly taken into account in estimating the probable issue of the case. Treatment. The curative indications are, 1. To subdue the chronic inflammation and to promote the removal, as far as pos- sible, of its effects on the structure; 2. To relieve urgent symp- toms as they arise; 3. To improve the condition of the general health. 1. It is necessary to premise, that as a condition essential to the success of any mode of treatment, the diseased parts must be kept as much as possible in a state of rest by suspending the ex- ercise of the voice, which is the work of the larynx ; and to effect this it is sufficient to limit the patient to speak in a whisper only, which exerts the larynx no more than respiration does. This restriction is a more practicable one than that to absolute silence. The protection of the parts from the irritating influence of cold air, smoke, dust, &c. is also very necessary. This may sometimes be effected by means of a respirator, without con- fining the patient to warm rooms. As is generally the case in chronic inflammations, general bloodletting is useful only to re- lieve temporary congestions, or in plethoric subjects to prepare for the better action of other remedies. Local bleeding, especi- ally by leeches, is more frequently beneficial, particularly in case of temporary increase of the local symptoms, when the cough is more troublesome than usual, with pain or increased tenderness in the larynx. They should be applied to the sides of the 12 80 LARYNGITIS—CHRONIC. larynx or under it; and if they give relief they may some- times with advantage be repeated in small numbers, every two or three days for some length of time. In a greater number of instances, however, more benefit will be derived from continued counter-irritation at the sides of the neck or upper part of the chest; and for this purpose the tartar-emetic solution or ointment, or a caustic issue, or well-managed seton, will answer better than blisters. A succession of pustular eruptions, or a discharge of pus from beneath the cutis, has an influence over an established chronic inflammation of a submucous tissue far greater than serous discharges. To modify the action of the diseased textures, and to promote the absorption of the solid matter effused in them, no measure has been found so efficacious as a mild mercurial course, varied to the extent of affecting the gums. Unlike in the acute disease, there is time enough to produce this effect without giving very large doses ; and as soon as it takes place, there is generally a diminution of the pain and constriction in the larynx, improve- ment of the voice, and a loosening of the cough. If the disease be not of long standing, and there be no extensive ulceration, or disease of the cartilages, the means already named will often effect a cure. But where the disease has lasted long and induced considerable local lesions and constitutional derangement, other measures, both local and general, should be employed. In cases where the influence of mercury might be hurtful, as in those of a strumous diathesis, a course of hydriodate of potash with an excess of alkali will sometimes prove very beneficial. The in- halation of steam, in some cases rendered slightly stimulant and alterative by the addition of camphor, turpentine, or a balsam, has been found useful in promoting the secretion of the diseased mem- brane. MM. Trousseau and Belloc place much confidence in medicaments applied directly to the diseased part, and some of those which they recommend are of a very energetic kind, such as nitrate of silver, corrosive sublimate, sulphate of copper, &c. They may be applied either in solution or in powder. The solu- tion which they have found most effectual is that of nitrate of silver in the large proportion of from one to two parts in four parts of distilled water. This solution may be applied to and behind the epiglottis, by a small roll of paper bent at its moist- ened end. A more effectual mode is with a small round piece of sponge fixed to a long rod of whalebone bent, at an inch from the sponge, to an angle of eighty degrees. The patient's mouth being opened wide, and the tongue pressed down with a spoon, the sponge is passed to the top of the pharynx; as soon as it reaches the fauces, a movement of deglutition takes place, which carries the larynx upwards, at which moment the sponge is brought forward and squeezed under the epiglottis, and the solu- tion freely enters the larynx. Convulsive cough and sometimes vomiting ensue ; but the application causes no pain. A less dis- laryngitis (Treatment). 87 agreeable mode of applying the solution is by a small silver syringe, filled one-fourth with the solution and three-fourths with air. To this is affixed a tube five inches long, bent at the free end, which being carried beyond the epiglottis, the syringe is forcibly discharged, and in consequence of the air in it throws the solution not in one stream but in a fine shower, part of which enters the larynx. The patient is then made to rinse his mouth with and swallow salt water, or water acidulated with muriatic acid, which decomposes the remains of the nitrate; the same precaution should be used where this agent is applied in sub- stance. MM. Trousseau and Belloc found this application (which they term cauterisation) highly beneficial in several casesof chronic laryngitis. In cases of aphonia, probably dependent or relaxation rather than inflammation, it effected a cure in a few days; in some worse forms of the disease, with probably ulceration of three or four years' standing, its repeated application during five or six weeks was successful; and it produced considerable tem- porary improvement in three cases which proved afterwards to be tuberculous. Solid substances may be applied to the larynx in powder by insufflation, as recommended by Aretasus for angina maligna. The powder is put into one end of a reed or glass tube, and the other is carried back as far as possible into the mouth: after a full expiration the patient closes his lips around the tube, and inspires suddenly and forcibly through it, by which some of the powder is carried into the larynx and trachea. The cough which is excited should be restrained as much as possible, to prevent the too speedy expulsion of the medicine. The powders used by MM. Trousseau and Belloc are sub-nitrate of bismuth, which may be used pure with safety and advantage in most forms of chronic laryngitis, even that accompanying phthisis ; calomel with twelve times its weight of sugar; red precipitate, sulphate of zinc, and sulphate of copper, each of which must be mixed with thirty-six times its weight of sugar; alum with twice its weight, and acetate of lead with seven times its weight of sugar; and nitrate of silver with twenty-two, thirty-six, or seventy-two times its weight of sugar. The last is said to be most effectual in erythematous laryngitis with erosions or ulcerations. Calome and red precipitate have proved beneficial in ulcerations, whether syphilitic or not, but they should not at first be repeated oftener than twice or thrice a week. The others may be used twice or oftener daily, according to the nature of the case. The powders should be impalpably fine ; the least roughness or perceptible frag- ment of a crystal excites such efforts to cough as insure the ex- pulsion of the powder. This description of the treatment of MM. Trousseau and Belloc is taken from an abstract in the British and Foreign Medical Review by the writer, and appears to be well- worthy of the attention of British practitioners, in proving the safe direct application of powerful agents, which as in ex- 88 LARYNGITIS--CHRONIC. ternal diseases are likely to improve the action of the diseased parts. 2. The second indication—to relieve urgent symptoms, espe- cially requires attention, when the attacks of difficult breathing or of cough are very urgent. These arise in some degree from spasm, and may often be relieved by sedatives and antispasmo- dics, such as belladonna, camphor, ether, and opium, both taken internally and applied by inhalation in the steam of hot water. Drs. Graves and Stokes recommended particularly the use of a belladonna plaster to the external throat, and a hot pediluvium. If, however, the more gradual supervention of the dyspnoea, with feelings of increased uneasiness in the larynx, and perhaps some fever, indicate that the aggravation of the symptoms is produced by an attack of cedematous inflammation, and this be not speedily relieved by leeching, it may be necessary to adopt the surgical means of relief recommended for that affection, avoiding dan- gerous delay after the character of the attack has been clearly made out. 3. The third indication—to improve the condition of the gene- ral health, is in many cases a point of the first importance ; and until it be fulfilled, any other measures may be of no avail. No particular rules can be laid down for this purpose ; but the prac- titioner may well be guided by the state of the constitutional symptoms. To preserve a due balance of the secretions, to im- prove the nutrient functions by a well-regulated mode of diet and regimen, aided by mild alterative tonics, such as sarsaparilla and saline chalybeate waters, and especially to assist both nature and art by placing the patient in a salubrious and congenial climate, are the objects chiefly to be aimed at, in order to fulfil this indi- cation. When the disease has a venereal origin, a proper course of mercury will generally be indicated; but this will often fail, unless measures be at the same time taken to improve the general health ; and if this have already suffered much from mercury in repeated or ill-directed courses, or in a strumous habit, it will be necessary, for the time at least, to use the iodide of potassium and other general measures, with whatever local treatment the nature of the case may admit. In such cases, fumigation of the fauces with cinnabar (sublimed from a hot plate, or a laundry iron) will sometimes improve the character of the local disease. Chronic laryngitis is interesting on account of its relation to pulmonary phthisis. This may be stated in three different ways :—1st. It is a cause of phthisis if accidentally developed in healthy individuals ; that is, if the chronic laryngitis continue very long, tubercles are generally developed in the lungs. 2d. It occurs nearly at the same time with tubercles in the lungs, or a little before them, in persons of a scrofulous constitution and already strongly predisposed to phthisis. 3d. The laryngitis occurs as a mere secondary lesion, ong after phthisis has set in. The last variety is strictly a consequence of tracheitis (Symptoms). 89 the disease of the lungs, and is in itself of little consequence. The other varieties are so far important that they should always excite the attention of the physician, and induce him to be guarded in his prognosis: as many of these cases terminate in consumption of the lungs, although for a long time no local evidence of phthisis should be present. Should phthisis not super- vene, chronic laryngitis is still a serious affection, and in not a few in- stances terminates fatally, but there is always a much greater chance of re- covery than if complicated with phthisis. TRACHEITIS, OR CROUP. Symptoms of its various forms.—Anatomical characters.—Nature.—Diagno- sis.—Causes.—Prognosis.—Treatment. This disease has been described under a variety of names: Tracheitis; croup; cynanche vel angina trachealis; cynanche stridula infantum ; angina polyposa, membranacea vel exudato- ria; tracheitis infantum, Sec. Its essential pathological cha- racter is inflammation of the trachea, attended by swelling of the tissues, and often by the exudation of a concrete albuminous mem- brane, which, by the spasmodic contractions which its presence excites in the windpipe, occasions difficult and stridulous breath- ing. This disease, so serious and destructive in early life, has been the subject of several able treatises; and although its exist- ence was scarcely recognised till the middle of the last century, it is now as well understood as other diseases of the air-passages. In the history of the usual form and progress of the disease, we shall often avail ourselves of the descriptions given by the latest writers, Dr. Cheyne and Dr. Copland. Symptoms. For practical purposes rather than because they are in an obvious degree so presented in nature, it is useful to divide the symptoms into, 1. Those of the invasion ; 2. Those of the developed stage; and, 3. Those of the collapsed or suf- focative stage. 1. The first symptoms of an attack of croup are by no means distinctive ; they are commonly of a catarrhal kind, but with more fever, perhaps a more hard hollow cough, with alternate chills and heats and flushing, a loaded tongue, hoarseness, heaviness of the eyes, fretfulness, restlessness at night, and sometimes a mani- festation of uneasiness in the throat, by the child frequently put- ting the hand to it. The presence of bronchial inflammation at this time is shown by the sonorous and sibilant rhonchi heard in many parts of the chest; but the tracheal breathing is not yet stridulous. 2. The developed stage of the disease is manifested by stridu- 90 TRACHEITIS. lous inspiration, which is like a sonorous or sibilant rhonchus, only much louder; it can be heard through the stethoscope or ear applied to the neck, before it is otherwise distinct: the oough is of a peculiar rough barking or ringing kind, followed by an inspiration more hissing and sonorous than usual: hence the com- bination of the cough and inspiration has been compared to the barking of a puppy or the crowing of a young cock : the voice becomes decidedly hoarse: the pulse is frequent and hard : the carotids beat strongly, and the pulsations of the heart are heard all over the chest; the skin is hot; the face flushed; the eyes watery and injected; the head thrown back ; and the child is ex- tremely restless and indicates pain or uneasiness about the trachea and larynx, which is often slightly swollen externally, and tender to the touch. These symptoms generally come on at night, and may somewhat subside in the morning ; but the quickness of pulse, stridulous breathing, and hoarseness continue. The remission may last until the evening, or until the patient falls asleep, when the symptoms soon return, and become more severe than ever; the difficulty of breathing, with its accompanying distress, being in- creased. The cough is more harassing and convulsive, and threatens suffocation; the respiratory muscles are thrown into their fullest action ; and whilst the whistling inspiration shows the constriction of the upper portion of the air-passages, the indis- tinctness of the respiratory murmur in the chest, and the concave state of the intercostal spaces at each inspiration, show how little air enters the chest. All these symptoms become more and more urgent, particularly the state of the breathing and the cough, which now sometimes ends in vomiting or in the expectoration of viscid phlegm, occasionally streaked with blood, or containing shreds of opaque albuminous matter, and, in rare cases, a tubular mould of the trachea formed of this matter, like a piece of soft- ened macaroni. The voice, too, by this time has become changed to a hoarse whining note, and afterwards is suppressed ; the pulse becomes excessively frequent, and sharper and smaller; the face and neck become more swollen, and either purple or pallid, es- pecially during the fits of coughing. During the intervals, the child remains in a half stupid state, the whole strength being given to the act of respiration. The disease may reach the acme of this stage within twenty-four hours, in rapid cases ; but in those of slower progress, in which there have been several remissions, perhaps following the expectoration of the viscid or albuminous exudation before noticed, this stage may be protracted through several days; and, in favourable cases, terminate in recovery without passing to the third stage. 3. The third or collapsed stage is marked by a general failure of the vital powers, the difficulty of breathing being undiminished. The pulse becomes extremely weak, thready, and irregular; the cough more suppressed ; the voice gone; the face swollen and tracheitis (Symptoms). 91 pallid, or with the lips slightly livid ; the neck full, the superficial veins distended, the skin cold and perspiring, and the efforts of the poor little sufferer to get breath are most painful to behold; they become weaker and weaker, and at last cease; or, in the case of infants, they are sometimes cut short by a fatal convul- sion. From this stage, recovery can take place only in the rare event of free expectoration of the albuminous exudation. The noisy state of the tracheal breathing renders it difficult to investi- gate the state of the chest; but there may sometimes be heard, especially after coughing, a general mucous rhonchus throughout the lungs; and in some instances the chest becomes partially dull on percussion. Such is the common course of croup in its severe forms : but as in the case of other inflammations, the disease may vary in intensity; and, instead of being precisely of the character described, it may exhibit sthenic, asthenic, and catarrhal varie- ties in regard to the fever and inflammation ; and it may be more or less complicated with a spasmodic tendency. The sthenic form attacks plethoric and robust subjects, with high fever, strong pulse, hard cough, pain in the larynx, with little or no remission in the stridulous constricted breathing; and, unless very promptly treated, passes into the stage of collapse, and proves fatal in from twelve hours to five or six days. The asthenic form occurs in debilitated or cachectic subjects, especially those reduced by previous disease : the fever is low, and the progress of the disease more tardy; but the stage of collapse supervenes early, if the disease be severe. The albumi- nous exudation often extends to the throat and fauces, and is then identified with the Diphtheritis of Bretonneau, especially in the asthenic form of croup, which occasionally comes on in connec- tion with scarlatina and cynanche tonsillaris. The catarrhal variety of croup is by no means uncommon, and forms the link between the plastic and mucous inflammations. It is attended with much cough, and various rhonchi in the chest, and, from the extent of the inflammation, is often of a very serious character, its favourable issue depending on the free expectora- tion of tenacious bronchitic mucus. Like both croup and bron- chitis in children, it is liable to remissions and exacerbations, dependent partly on the subsidence or increase of the inflamma- tory swelling, and afterwards of the secretion within the air-tubes, and partly on temporary spasmodic constriction induced in the upper portions. This form of croup may supervene on ordinary bronchitis, adding to its symptoms the stridulous inspiration and ringing cough indicative of the constriction of the trachea and larynx. The addition of croupy symptoms to bronchitis, or of general bronchial inflammation to croup, must be considered a serious aggravation of the simple disease. The spasmodic form of inflammatory croup is that which, 92 TRACHEITIS. occurring in irritable children of a nervous temperament, and disposed to nervous affections, presents a preponderance of spasm in the constriction causing the difficult breathing: hence the attacks are more sudden, and may be very severe; but they are succeeded by more complete remissions than in the purely in- flammatory form. There may be every degree of combination of the nervous with inflammatory symptoms ; the most inflam- matory kind of croup is not free from some admixture of spasm, particularly in its advanced stages; and the asthenic and catarrhal varieties generally evince, by the sudden character of the exacer- bations and remissions of difficult breathing, that the muscles of the larynx and trachea are thrown into a temporary spasm. But there are cases in which there are few inflammatory symptoms; and the more nervous the subject, the more readily may even slight bronchial and tracheal inflammation excite this spasm. So it may happen, too, that mere nervous irritations, such as from teething, disordered bowels, worms, &c, may, without any in- flammation, cause spasmodic constriction of the windpipe, and thus imitate croup ; this is the true spasmodic croup, which will be noticed hereafter. Anatomical characters. On examining fatal cases of croup, there are generally found a variety of lesions in the respiratory organs, indicating the effects of different degrees of inflammatory action. In the instances in which death has occurred early, the mucous membrane of the trachea, and generally of the larynx and bronchi, is found to exhibit bright vascular redness, continuous or in patches; and it is often covered with a viscid mucus, some- times tinged with blood. The submucous tissue between the rings of the trachea, and in the looser parts of the larynx, is often much swelled : at a more advanced stage, is mixed with an opaque yellowish or gray-white albuminous matter, in films or patches, often tinged with blood, adhering to the mucous membrane; and in the sthenic cases that have run their full course, this is of such abundance and consistence as to form a false membrane or a tubular mould of the trachea, in some instances extending to the larynx or bronchi. This is obviously the product of the inflamed membrane; and it is remarkable that in the most sthenic cases, or purely inflammatory croup, it is usually thickest and most consistent, but confined to the trachea ; whereas in asthenic cases it is thin, loose, and often extends to the bronchi. In some of the severest and most speedily fatal cases, the albuminous matter is found in a semifluid state intermediate between lymph and pus; and this matter has been sometimes expectorated when the dis- ease has not proved fatal. The membrane is neither so red nor so much swelled as in the earlier stage, before the albuminous effusion has taken place. In catarrhal croup this effusion is in smaller quantity, and mixed with an abundant viscid mucus. In the more spasmodic forms, a false membrane or opaque exuda- tracheitis (Nature). 93 tion is seldom found, but merely viscid mucus covering patches of vascular redness, especially in the larynx. In most instances that have lasted for some days, and in all of the catarrhal variety, the bronchi exhibit the marks of acute bronchitis, and contain much viscid mucus. Sometimes, too, in such cases, portions of the lung have been found in the state of inflammatory engorge- ment and hepatisation; and signs of inflammation are now and then seen in the pleura. Interlobular and subpleural emphysema are also occasionally met with. Nature. The nature of croup has been the subject of much discussion. In Dr. Copland's Dictionary, the reader will find an account of the various opinions which have been held respecting it. Our limits do not permit us to enter into these ; and we shall only give that view which, in the present state of our knowledge, seems most tenable, and which best comports with the whole history of the disease and the effects of remedies on it. These indubitably prove true croup to be essentially an inflammatory disease of the air-passages, especially of the trachea and larynx. But why does it differ from the catarrhal or bronchitic inflammations which we find to occur in the same parts? Many authors seem to consider its seat to be the same as that of catarrhal inflanv mation, and that the difference of its product (lymph instead of mucus) is to be ascribed to the early age at which it most fre- quently occurs. But this is insufficient; for, at the same age, we meet with bronchitis affecting every portion of the air-tubes, yet without constituting croup. Others again, and among them Dr. Copland, refer the peculiarity of the product to an excess of albumen in the blood; but even this, although it probably has a share in determining the amount of membranous or other solid formations within the air-tubes, does not alone seem sufficient to cause it; nor can it be ascribed to the intensity of the inflamma- tion ; for although the albuminous effusion is generally thickest and most tough in sthenic cases of croup, yet it is pretty abundant in asthenic cases; so much so, that Andral and Gendrin consider plastic inflammations of mucous membranes to be rather of the subacute than of the most acute kind. To say that the inflam- mation is one of a specific character, throws no light on its na- ture. But does not the pathological and anatomical history of croup seem to point out that the seat of its inflammation is deeper than that of bronchitis? The distinct and circumscribed posi- tion of the inflammation and painful constriction in the most marked cases; its fixedness in this part, not wandering or creep- ing about, as catarrhal inflammation does ; the tenderness, and sometimes the swelling of the trachea and larynx externally; the nature of the product of the inflammation, which is coagulable lymph, as from serous or cellular membrane; the thickened state of the submucous texture found after death in the earliest stages, and the tendency of this texture to suppurate in chronic cases, 94 TRACHEITIS. where the subject approaches adult age,—seem to render it pro- bable, that the inflammation owes its peculiar character and results to its being more deeply seated, more of a phlegmonous character than mucous inflammations, and involving essentially the submu- cous cellular tissue. This view has not been generally held ; Mr. Ryland alone distinctly inclines to it, when he remarks, that " the inflammation of croup appears in the first instance chiefly to affect the cellular tissue that enters into the composition of the mucous membrane, and not the muciparous follicles themselves; and the albuminous exudation is poured out by the secernent ar- teries of the cellular structure." Dr. Stokes remarks, that no satisfactory explanation of the greater frequency of croup in the infant has been given; and he seeks to account for it by the general fact of the predominance in the young subject of white tissues, which reproduce their kind. This idea may lead to an explanation, but it does not set it forth; and it leaves still a mys- tery why croup differs from bronchitis in the same subject. But if we examine the air-tubes of young subjects, we find in them, as in other parts, an abundance of the fine submucous cellular tissue, whilst the mucous membrane is more fine and less complex than it becomes in after life, when, from the continued irritations to which it has been exposed, its follicular apparatus attains its full activity and development. The blood, too, in the young subject, abounds with'the plastic material of nutrition, which is more abundantly thrown out under the influence of inflammation, than in the adult. Yet, as long as the inflammation, even in young subjects, is confined to the mucous membrane, the disease is simply catarrhal or bronchitic, and its product mucous or purulent. But the inflammation may readily reach the active and vascular sub- mucous tissue, and then it has the more fixed character of the inflammation of croup, the product of which easily transudes through the fine mucous membrane; and, as in the analogous case of serous inflammations, which are also seated chiefly in the subserous tissue, the product is coagulable lymph. In adults, where the mucous membrane is more developed, and the sub- mucous tissue less so, inflammation is less likely to reach the latter: when it does, it attacks the looser parts of the larynx, and, modi- fied by the active mucous secretion, its product is pus instead of lymph ; or it may be confined to the tissue, and cause the oedema, thickening, or purulent infiltration of laryngitis. The pathological history of croup is quite intelligible. The inflammation may commence at first in the submucous tissue, or it may have been first catarrhal, in which very common case, catarrhal symptoms precede those of croup. The inflammation immediately causes increased sensibility of the contractile fibres, and interstitial effusion in the lining of the trachea and larynx: hence results the constriction, partly spasmodic, partly from swelling of the air-tubes; and hence the croupy inspiration and cough, and the hoarseness. Afterwards lymph is poured out in a tracheitis (Diagnosis). 95 liquid state, and becoming concrete, forms the false membrane, another cause of obstruction to the passage of the air, both di- rectly by its bulk, and also by the spasmodic contraction which its presence causes in the muscular fibres of the tube. The latter cause acts especially when the false membrane reaches to the larynx, and excites its very irritable muscles; in such cases, the paroxysms of dyspnoea and cough are frightfully severe and suffo- cating. The share which spasm has in causing the dyspnoea may be inferred from the fact, that in no case have the air-passages been found so much blocked by the albuminous secretion as to account for the amount of the obstruction ; and in many cases the constriction has appeared greatest, where little or no exudation was found after death. It must not be forgotten, however, that cedematous swelling, like that of erysipelas, may disappear after death. The separation of the concrete matter from the tube, and the prevention of its becoming permanently adherent and organ- ised, is doubtless owing to the mucous secretion and the continued motions of the tube. In cases where the albuminous effusion is less plastic, or the follicular mucous secretion more abundant, the mat- ter may be liquid and purulent; and this generally takes place in the bronchitic variety. The collapse which takes place towards the fatal termination of croup is, like that in bronchitis, to be ascribed to the imperfect state of the function of respiration, and the consequent injurious effect on the vital powers. The lividity, coldness, occasional attacks of convulsions, &c, are the result of the circulation or stagnation of imperfectly oxygenated blood. From the sameeause arises, also, the congestions in the lung, which may in parts take on the irritation of inflammation and become hepatised. The emphysema occasionally detected in the lungs, is plainly produced by the violent efforts of breathing. Diagnosis. The very peculiar sound of the breathing and cough, and altered voice, are generally sufficient to distinguish croup from other diseases; and it is important to know that the stridulous inspiration may often be detected through the stetho- scope applied to the trachea, before it is otherwise distinct. A ringing cough, like that of croup, is often present during the early stage of measles, before the eruption has come out, but it soon becomes catarrhal, and is unattended by the croupy inspiration. In the advanced stages of croup, when the respiration is become so feeble as to loose much of its peculiar character, it may be more difficult to determine whether the obstruction be in the wind- pipe or in the chest; but then the comparatively good sound on percussion of the chest, and the concave state of the intercostal spaces at each forcible inspiration, showing that there is room in the chest for the air if it could find its way in, will generally suffice to distinguish croup from diseases of the chest. Such diseases being, however, a common concomitant of croup, the existence of the signs of bronchitis or pneumonia does not dis- prove the existence of croup. The loud sound of the tracheal 96 TBACHEITIS. breathing of croup may in great measure obscure any signs of disease within the chest; but, as Dr. Stokes has remarked, this is seldom the case constantly, particularly at ihe early stage of the affection, or after the act of vomiting, when, the tracheal sound being less, the sonorous and mucous rhonchi of bronchitis, and the crepitation of pneumonia, would be heard if they were present. From spasm of the glottis, or purely spasmodic croup, and hys- terical affections simulating it, inflammatory croup may be dis- tinguished by the presence of febrile symptoms, the less sudden and more permanent character of its attack, and other points in its history. Causes. Exposure to cold and damp is supposed to be one of the most common exciting causes of croup. It prevails most generally in cold climates, especially in damp situations exposed to the east. In England, it is a far more common disease near the eastern than the western coast. Nothing is more apt to bring on croup in children predisposed to it, than exposure to a keen east or north-east wind. This wind is remarkable for its dry- ness ; and we are inclined to think that the influence which damp situations seem to have in favouring its occurrence, is that of a predisposing rather than of an exciting cause. There can be little doubt that residence in low, humid, and ill-ventilated places gives to children an increased susceptibility to the influence of cold and other morbific causes ; so that this and other inflamma- tory diseases may be more readily excited in them. Hence it prevails in the clay-bottomed valleys of chalky districts; in the more exposed parts of fenny countries; in some of the deep valleys of Switzerland, through which, low and damp as they are, the cutting winds from the snow mountains sweep in great severity. As it may, from these causes, be endemic in particular situations; so, from the prevalence of cold east winds, particularly after relaxing damp weather, it may be epidemic at particular seasons. The ages at which croup most commonly occurs, are from one to six years; it is rarely met with before and after these ages. There are very few cases on record, of true inflammatory croup in the adult. Diphtheritic affections, on the other hand, frequently occur in mature age. We have before mentioned that croup may supervene as a sequel or concomitant of other diseases, such as bronchitis, measles, scarlatina, small-pox, &c. It also comes on from too early exposure during convalescence from febrile disorders. In some families there is a strong predisposition to croup; which fact is not more extraordinary than analogous tendencies to catarrh, quinsy, &c; and its inflammatory or spas- modic character depends on the prevalence of the phlogistic or nervous diathesis, which may attach to families as well as to individuals. Prognosis. Croup is a most serious disease : if not arrested by tracheitis (Treatment). 97 treatment, it generally leads to a fatal termination, and it often baffles the most active measures. According to the statements of M. Double, the mortality in the present day is nearly one-half of the whole nunibers attacked: formerly, when the treatment of the disease was less understood, it amounted to nearly four-fifths. Whenever, therefore, the disease has declared itself by the croupy inspiration and difficult breathing, the patient is to be considered in great danger; and this danger is increased in proportion to the time during which the breathing continues to be oppressed. The supervention of convulsive paroxysms of cough, also, brings the patient into immediate jeopardy, either of sudden suffocation or convulsions, or of speedy and often fatal collapse. The pro- portionally small size of the larynx in children, compared with adults, no doubt adds, as Dr. Copland remarks, to the danger of the disease; but we cannot admit that it is a predisposing cause, as Dr. Cheyne has supposed. In the confirmed stage of croup, the chief hope is in the removal of the albuminous exudation by coughing and vomiting, or by the free expectoration of muco- purulent secretion. The vital forces are not often sufficient to accomplish this; but cases have occurred, in which by these means children have been snatched from the jaws of death, and recovered speedily or slowly according to the bodily strength and the freedom of the organs of respiration from remaining disease. The coexistence of bronchial or pulmonic inflammation much increases the danger of severe croup; but it does not ren- der the case quite hopeless ; and the slighter attacks of croupy inflammation supervening on bronchial inflammation, are less dangerous than the severe forms of the simple disease. Treatment. The curative indications in croup are well stated by Dr. Copland. 1. To diminish inflammatory and febrile action when present, and to prevent, in these cases, the formation of a false membrane, or the accumulation of albuminous matters in the air-passages: 2. When the time for attempting this has passed, or when it cannot be attained, to procure the discharge of these matters: 3. To subdue spasmodic symptoms as soon as they appear: and, 4. To support the powers of life in the latter stages, so as to prevent the recurrence of the spasms, and to enable the system to throw off the matters exuded in the trachea. (Diet. ofPract. Med.) If the disease is in its earliest stage, described as that of in- vasion, the first indication should be pursued with promptitude and energy. An emetic of tartarised antimony or ipecacuanha is the first and best remedy in all cases ; and in the slighter ones it may cut short the disease, especially if followed by a warm bath and a dose of calomel and James's powder, repeated every two or three hours, and carried off, if necessary, by a dose of castor oil. In general, however, the relief is not complete, and the pulse becomes harder and the countenance more flushed after the 98 TRACHEITIS. oneration of the emetic. If there be considerable fever, and the other symptoms of the invasion be pronounced, it is proper at once to resort to bloodletting with as much freedom as the strength of the patient will bear. Dr. Cheyne recommends vene- section to be practised (in the jugular vein of very young children) ten minutes after the exhibition of the emetic : by this mode, the loss of a few ounces of blood induces vomiting followed by faint- ness, which lasts for some time, a powerful impression being made at a small expense of blood. For severe cases he advises a repetition of the bleeding in two or three hours; and leeches, if necessary, afterwards,—avoiding their application to the larynx, because, in case of excessive bleeding, pressure cannot well be applied there. Dr. Copland thinks that, for town prac- tice, bloodletting by cupping between the shoulders or to the nape of the neck, or leeches to the top of the sternum, is prefer- able to venesection; and he states that the loss of little more than an ounce or an ounce and a half of blood for each year of the patient's age can well be borne, whilst the nausea from the emetic continues. M. Guersent recommends the bleeding before the emetic, for which he prefers ipecacuanha. As it appears to be a great object to reduce the inflammatory action without an excessive loss of blood, and as bloodletting alone is rarely suffi- cient to cure croup, the plan recommended by Dr. Cheyne is to be preferred ; but we think with Dr. Copland, Goelis, and other writers, that local bleeding will generally be sufficient in young children, and all that are not plethoric. In the second stage, when the symptoms are fully developed, and the stridulous dyspnosa permanent, bloodletting is less effectual, and not so well borne: it can, therefore, only be used at the earlier period of this stage, and then with caution : the albuminous effusion having then taken place, which bloodletting will not re- move, our endeavours must be also directed to fulfil the second and third indications ; and these are, in the first instance, still best pursued by remedies called antiphlogistic. Of these, the most powerful are antimonial and mercurial medicines. Dr. Cheyne first recommended tartar emetic in 1801 ; and stated, in 1832, that he had found no other remedy worthy of confidence in the second stage of croup. The dose is from a quarter of a grain to half a grain repeated every half hour or hour, until it induce sick- ness; and then hourly whilst the inflammatory symptoms continue, as long as the strength of the patient will admit. Dr. Stokes and Mr. Porter follow Dr. Cheyne in recommending this remedy as the chief one in croup: the former places it above blood- letting. The late Professor Hamilton of Edinburgh, J. P. Frank, Mi- chaelis, and others, depend chiefly on calomel in large doses, as first recommended by Dr. Rush of Philadelphia. The lono- and extensive experience of the former physician at Edinburgh, where tracheitis (Treatment). 99 the disease prevails much, entitles his advice to our attention. He recommends large doses to be given and repeated at inter- vals of one or two hours, until they cause dark green stools: a very large quantity is sometimes required to produce this effect, relief generally ensuing on their appearance, but not before. The remedy thus given, sometimes causes great exhaustion, which is to be counteracted by wine or other stimulants. After venesec- tion and an emetic in the first instance, Dr. Hamilton places im- plicit confidence in calomel, which he considers to have a spe- cific operation, and not that of a purgative or derivative merely. We have found this remedy a most valuable one, especially in the less sthenic and more spasmodic form of the disease; but we do not consider its operation to be different from that in other diseases of children, such as pneumonia and hydrocephalus, in which, as soon as it affects the system, it causes copious spinach- like evacuations. It probably acts both by derivation and by diminishing the albuminous contents of the blood, as well as by the peculiar alterative or sorbefacient operation which it exerts in inflammatory diseases, when it affects the system, and which is visible in the case of iritis. In all severe inflammatory cases we confide in tartar emetic and calomel used conjointly, rather than on either separately. The tartar emetic may be given in the manner recommended by Dr. Cheyne, taking care to watch in very young children against the symptoms of sudden depression that sometimes come on during Its use. The calomel is best given in large doses, once, twice, or thrice in the day, so that it may act freely on the bowels. From two to four grains for children below the age of two years, and from four to twelve grains above that age, according to the strength of the subject, and the violence of the inflammation, are more effectual than smaller doses more frequently repeated. If the bowels are irri- table a minute quantity of opium in Dover's powder, or in the Pulvis Opiatus, should'be added; and if there has been diarrhoea, the Hydrargyrum cum Creta in double quantity may be substi- tuted for the calomel, but is much inferior in antiphlogistic power. Blisters have been generally recommended immediately after blood-letting; but their application requires caution, particularly in very young subjects, in whom they are apt to cause sloughing. In such cases, silver paper or gauze moistened with oil should be placed between the blister and the skin, and the blister should not be left on for more than three or four hours. The nape or side of the neck is the best place for applying them, and not the throat, for this is too near the inflamed part. In consideration of the deep-seated character of the inflammation, we should anticipate a more effectual result from counter-irritation by tartar emetic, which has a deeper and more permanent operation than blisters. The sides of the neck should be rubbed downwards with a brush or coarse flannel until they are red, and then with a sponge or ^ -J/etcv «. ^/t**~^£ 100 TRACHEITIS. flannel dipped in a saturated solution of tartar emetic for five or ten minutes: this leaves a vivid erythema, which in the course of a few hours forms a great number of small pustules, which dis- charge a sero-purulent fluid for several days. A more speedy mode of counter-irritation, and one well suited to the spasmodic variety of croup, might probably be found in that by strong liquid ammonia, in the manner described by Dr. Johnson : he found that, by two minutes' application of lint moistened with this liquid, and covered with a wooden pill-box, or a wine-glass, a number of small vesicles were produced ; and by this means a suppurating surface could be quickly obtained. The second indication to procure the discharge of the products of inflammation in the trachea, is to be attempted through the operation of emetics and expectorants. The tartar emetic before recommended is the most suitable medicine whilst the pulse re- tains its force and regularity ; and it may be pushed to the extent of inducing vomiting two or three times in the day, if the hourly doses should be insufficient to have this effect; but this must not be done without caution and due regard to the strength of the patient. When the inflammatory symptoms have in great mea- sure subsided, and the continued croupy breathing is caused by the false membrane with spasm, a less debilitating emetic, such as tincture of squills (3ss ad 3j) with sub-borate of soda (gr. x ad gr. xx), in warm decoction of senna or infusion of chamomile, ■ or ipecacuanha wine (3ij ad |ss) with ammoniated tincture of valerian (n\,xv ad 3SS) hi some convenient vehicle. Looseness and fluidity of the secretion of the air-tubes, and a consequent facility to expectorate it, are materially promoted by alkaline medicines, which seem to possess considerable attenuant power. Hence, probably, the efficacy of warm alkaline baths, which have been recommended by several authors, and which are useful ad- juvants to the other remedies both in the early and later stages of croup. In the early stage, the temperature may be about 92°; but when the inflammatory stage has subsided, it should not be less than 96°; and this heat should be kept up during the whole time of immersion, which may be from half an hour to an hour, or even more, if it afford marked relief. It has been advised by some writers to promote expectoration by means of inhalation of the steam of hot water, rendered stimulant and antispasmodic for the after stages by additions of camphor, asther, and ammonia. The application of these remedies is not easy in young subjects, especially when the breathing is already so embarrassed ; but they may be sometimes advantageously used, particularly in the more spasmodic cases, by holding under the patient's mouth a jug of very hot water with the medicines added. The use of a ster- nutatory, in form of strong snuff gently blown into the nostrils, has also been found to aid the removal of the albuminous deposit from the air-passages, and in a measure to relieve the symptoms. tracheitis (Treatment). 101 We have already mentioned some of the means calculated to diminish the spasm which so commonly adds to the constriction of the air-passages ; and when, from the more remittent character of the croupy breathing, this spasm seems to be a chief cause of the difficult breathing, besides emetics, which are the most effec- tual, antispasmodics, assafcetida, aether, musk, camphor,andopium, may be employed with some benefit; but they must be given with caution, and still in combination with calomel and ipeca- cuanha. Counter-irritation of the sides of the neck, by means of flannel wetted with oil of turpentine and asther, or even the strong liquor ammonias, and covered with oiled silk, or a glass vessel inverted over it, to prevent evaporation, is a powerful means of relaxing spasm, and one that causes less risk than internal sti- mulants. In the last stage of croup, when the inflammatory symptoms have given place to those of prostration and collapse, the effects of unsubdued disease and of the unsuccessful lowering treatment, the only resource is in stimulants and cordials, by which the powers of life may perchance be excited until the respiration be re- stored to a better state. Dr. Cheyne remarks, that this is " a time when we may with advantage lay aside all lowering reme- dies, and give burnt brandy and ammonia, to which may be added calomel with a minute quantity of opium, and the application of spirit fomentations to the surface. Gasping, failure of the pulse, a pallid or livid and clay-cold surface, show that our only faint hope is in cordials: it must be admitted, however, that a clear discovery of the point at which this change of treatment ought to take place, is the reward of clinical experience alone, and cannot be made in the closet." {Cyc. Pract. Med., art. Croup ) It is unnecessary to dwell on the modifications in the treat- ment required in the varieties of the disease which have been noticed; they will be suggested by the character of the symptoms. Thus, cases of the asthenic form of croup will ill-bear blood-let- ting ; and, should the disease be unsubdued, may very soon re- quire the exhibition of stimulants in addition to the other reme- dies. Both in it, and in the catarrhal varieties, blisters are more beneficial than in the sthenic form. In catarrhal croup,also, pur- gatives are useful throughout the disease; and they do not, as in the bronchitis of adults, tend in any degree to check the expecto- ration. The expediency of using antispasmodics, in the more spasmodic form, has been already adverted to. It is not necessary to discuss the question of the propriety of resorting to tracheotomy in croup ; as it has been decisively nega- tived by Dr. Cheyne, Mr. Porter, and other of the best authori- ties. The trachea of young subjects is so small, vascular, and difficult to open, and, above all, the obstructing matter of croup so frequently extends into the bronchi, or cannot be dislodged, even from the trachea, through an incision, that the dangers are 14 102 LARYNGISMUS stridulus. many, and the chances of success so few, that in general it can scarcely be said that the performance of the operation is justi- fiable. The subjects of croup are very liable to a relapse during their recovery from the disease. The increase vascularity of the sub- mucous tissue, and the augmented irritability of the muscular fibres of the trachea and larynx, may continue, although not to sufficient extent to cause croupy symptoms; but whilst this is the case, slight exposure to cold, the too early use of animal or stimu- lating food, or the hasty suppression of a free action of the bowels, or of a discharge from a blistered surface established for the cure, may excite the inflammation afresh, and bring back the stridulous breathing. In these relapses, the disease has commonly more of a spasmodic character than in the first instance, the phlogistic condition of the body having been reduced by the previous .treat- ment. It is of great importance to watch patients during their recovery, and to guard against the recurrence of the disease, by continuing to give occasional moderate doses of mercurial pur- gatives, and an expectorant mixture with an alkali; and to main- tain some degree of counter-irritation in the vicinity of the neck, by means of tartar-emetic solution or an ammoniated liniment. Even after apparent recovery, the child should be kept warmly clothed, and not be permitted to venture out of doors, until the season becomes mild, and there is no easterly wind. It may often be requisite to remove to a warmer climate, especially to a southern or western coast. When the season is warm, however, and the complaint entirely gone, relaxing heat is to be avoided ; the throat and chest should be daily sponged freely with vinegar or salt and water, and afterwards the whole body well rubbed with a coarse towel. / LARYNGISMUS STRIDULUS. History and causes.—Nature.—Diagnosis.—Prognosis.—Treatment. Or spasmodic affections of the larynx, the most remarkable is that which affects infants, and has been called Laryngismus Stridulus—Asthma Infantum—the Crowing Disease—Spasm of the Glottis—Spasmodic Croup, fyc. History and causes. In the first instance, the attacks generally come on during sleep : the child starts suddenly, and, instead of crying as usual, struggles for breath, the face becoming flushed, swollen, and even purple : after repeated efforts a long inspiration takes place, often accompanied with a hooping or crowing noise, and the child then recovers its breath and voice, and generally bursts into a fit of crying, sometimes remaining dull and heavy laryngismus stridulus (History and Causes). 103 for two or three hours after. These attacks are apt to come on more frequently during sleep, and whilst the child is awake, par- ticularly on being irritated, or too suddenly tossed in nursing, or on being exposed to a cold wind. The infant will then throw his .head back, and struggle for breath, recovering it with the noisy inspiration before described. This noise is not however constantly observed, and depends on the partial opening of the rima glottidis ; in some cases it is opened completely, and there is no crowing, just as the hooping is occasionally absent in per- tussis. In the intervals there may be no disorder of the breathing orof the general health, but more commonly it attacks children that are delicate and irritable with disordered bowels. It is apt to occur during the period of dentition in children who are badly fed and much confined in too warm or ill-ventilated rooms. In severe cases it may return several limes in the day, and as the fits become more frequent, they last longer, sometimes pass into general convulsions, and have in many instances proved fatal. According to Drs. J. Clarke, Cheyne, and Marsh, this affection is often accompanied with a convulsive contraction of the hands and toes, the hands being clenched on the thumbs, and the great toes drawn in: these circumstances, together with the fact that general convulsions sometimes succeed, have induced these writers to consider the crowing disease as symptomatic of in- cipient disease of the brain. Dr. Cheyne relates three cases in which examination after death discovered such lesion: in one, scrofulous tumours in the brain: in another, venous congestion and serous effusion ; in the third, induration of the brain and oblit- eration of the convolutions. In two fatal cases Dr. Merriman found no trace of cerebral lesion, but only a collection of enlarged glands in the lower part of the neck, which appeared to have pressed on the par vagum. The late Dr. Ley was led by these and similar cases to ascribe the crowing disease to the influence of enlarged glands or other tumours compressing and partially paralysing the recurrent or inferior laryngeal branch of the par vagum. Frank and Kopp in Germany have found an enlarged state of the thymous gland in some cases of this disease; and the latter has therefore named it asthma thymicum. They appear to refer it to direct pressure on the air-tubes, but it is more pro- bable that an enlarged thymous gland would at first act by com- pressing the recurrent nerves. It had long been known that the section of this nerve or of the par vagum above its source occa- sioned a permanent contraction of the glottis, sufficient to suffo- cate quickly. Magendie and others concluded from this experi- ment that this nerve supplied the muscles which open the glottis, and that those which close it are influenced by the superior laryn- geal nerves. Dr. J. Reid has however lately shown that the latter are chiefly sensitive, and not motor nerves, and that nearly 104 LARYNGISMUS STRIDULUS. all the motions of the larynx are affected by the recurrent nerves. We cannot then explain'lhe closure of the glottis on the division of the recurrents, without referring it to a reflex action on the constrictor muscles through the sensitive nerves. The facts however that division of the recurrent nerves causes closure of the glottis, and that aneurisms and other tumours pressing on them have been known to occasion fits of difficult laryngeal breathing, form so far a fair ground for the view of Dr. Ley, that we may admit that enlarged lymphatic glands may sometimes have a similar effect. It has been objected by Dr. M. Hall, that were paralysis the cause, the affection ought to be permanent and not in fits; but this objection is not valid, for the paralysis is not supposed to be perfect, but that the muscles which it affects are unable to antagonise the constrictors of the glottis only when these are unduly excited by the immediate cause of the paroxysm. The effect of such a pressure as can be exerted by enlarged glands would be a weakening of the motory power of the recur- rents, rather than a paralysis ; and its influence would be mani- fest in the power to keep the glottis open, failing only when the act of crying, vomiting, a sudden fright or the like cause, tends to close it with more force than usual. But although disposed to admit the condition described by Dr. Ley as a common cause of the crowing disease, particularly in its milder forms, we think that there is sufficient evidence to show that it is sometimes symptomatic of cerebral disease and the forerunner of convulsions, or some other formidable symptom o cerebral disease. The cases of Dr. Cheyne point to this cone' sion ; and we may men- tion one of a child long under our care, which, after being subject to attacks of this affection for nearly two years, became idiotic. The muscular apparatus of the glottis is so nicely adjusted, and the aperture so narrow in children, that any disease of the nervous system affecting the motory apparatus is very likely to be mani- fested first here; afterwards as it becomes further advanced, by contraction of the hands and feet; and ultimately by more general convulsions or by paralysis, according to the nature of the lesion. But we do not consider that slight attacks of the croupy inspira- tion are always to be referred either to pressure on the recurrent nerves or to any permanent lesion of the nervous system. The crowing noise which many quite healthy children make on being too abruptly tossed in the air, or on being exposed to a high wind, obviously proceeds from a momentary contraction of the glottis under the excitement of the sudden motion. This shows how readily this contraction may be excited; and it is rational to suppose that other causes of mere irritation to the nervous system, such as dentition, disordered bowels, and worms, may occasionally produce the same effect, without inducing any further mischief. Like other spasmodic affections, spasm of the glottis may be in- laryngismus stridulus (Diagnosis—Treatment). 105 duced by temporary irritations as well as by permanent changes of different parts of the nervous system. Diagnosis. The absence of fever, the suddenness of the at- tacks and of their cessation, and the freedom of the respiration in the intervals, distinguish this affection from croup. The ab- sence of cough prevents it from being mistaken for hooping-cough. The character of the crowing sound, and the absence of signs of any disease of the chest, distinguish it from all other affections of the respiratory organs. Prognosis. From what has been stated as to the nature of the affection, it may be inferred that it varies greatly in its import- ance. When it proceeds from teething or disorder of the bowels, it may cease as soon as the source of irritation is removed. The fits themselves may prove fatal by lasting so long as to cause asphyxia; but we apprehend that this will rarely happen unless there be some permanent disease or great weakness of the system. But if the fits recur frequently and are excited by slight causes, there is considerable danger of cerebral congestion or effusion and convulsions being induced by the frequent interruptions to the respiration and circulation. For this reason the frequent recur- rence of the fits is dangerous, even if there be no sign of perma- nent disease in the system. If there be contraction of the fingers or toes, the case is still more formidable, but still not hopeless ; for even this symptom may be caused by temporary irritation of the nervous centres. If the affection can be traced to glandular swellings in the neck, o o similar or thymous tumours within the chest, it may genera, ' be removed by prompt and judicious treatment; but if neglected and allowed to become habitual, it may soon destroy the general health, and prove fatal either of itself or by inducing other disease. Treatment. The paroxysm is of so short a continuance, that there is scarcely time for the application of remedies to remove it. If it threaten suffocation before the crowing inspiration an- nounces its decline, it may be useful to dash cold water in the face, or to blow forcibly into the ear of the little sufferer: these impressions will often succeed in relaxing the spasm, although they are sufficient to excite it when not present. Antispasmodics have very little effect. When the fits come on very frequently, the warm bath may be used, if it can be done without fretting the child, which must be avoided as much as possible, as tending to excite the fits. Dr. Marsh mentions a case of a child two years old, in which very frequent attacks complicated with general convulsions were stopped and suspended for a month after the administration of a tobacco enema (v gr. infused in 5j of water). The most important part of the treatment is that directed to remove the causes of irritation, to improve the general health and the tone of the nervous system, and thus to prevent the re- 106 LARYNGISMUS STRIDULUS. currence of the paroxysms. When the affection is connected with teething, the gum should be divided in any part where it is hot or swollen, whether a tooth be pressing or not. Teeth often irritate long before they are cut; and although the incision of the gum over them do not effect their extrusion, and may by taking blood from their capsules even retard this process of dentition, it relieves the irritation which they occasion. A judicious course of purgative medicines will be found useful in almost every case, beginning with mercurials followed by castor oil, and keeping up their action by daily doses of rhubarb and magnesia or sulphate of potash, or by some of the stronger purgatives if the bowels are torpid, recurring occasionally to the mercurials whenever the excretions are clay-coloured or too dark. Dr. Merriman recom- mends that aperients be used so as to produce at least two full evacuations daily. Dr. Joy mentions a case in which, after pur- gatives and change of air had failed, the affection was removed on the occurrence of a spontaneous diarrhoea. Whenever there is any appearance or suspicion of the existence of glandular swell- ings as a cause of the disease, it will be proper to exhibit a course of alkaline medicine with small doses of the hydriodateof potash. Dr. Merriman found that the continued use of soda, or a strong infusion of burnt sponge, materially contribute to the cure of the complaint; and this is quite in accordance with the view that he and Dr. Ley have taken of its nature. In case of convulsions or an approach to them shown by contractions of the fingers and toes, strabismus, &c, it may be necessary to draw blood from the temples and nape by leeches or cupping, and to apply cold to the head, while the lower extremities are bathed in warm water. But it often happens that there is an atonic or anasmic state of the system rather than plethora: in such cases bloodletting is eventually hurtful; and much benefit may be derived from the judicious administration of tonics, preceded by and combined with aperients. All writers agree in considering the management of the regimen and food of the greatest importance in this disease. Change of air is often of more avail than any system of medication; and the child should be carried out into the open air as much as pos- sible, only avoiding cold winds; and its apartments should be well-ventilated without exposure to partial currents. If it do not bring on the attacks, free sponging of the body with cold salt water every morning should be practised; or if the child be very delicate, it may be used tepid. The clothing also requires particular attention ; in cold weather, a sufficiency of warm woollen clothes must be worn, and on no account should the arms and chest be left uncovered from October to June; the neglect of this precaution through the vanity of mothers, has occasioned the sacrifice of many children. The food should be nutritious but simple, given at regular hours and not more in quantity than NERVOUS AFFECTIONS OF THE LARYNX. 107 the stomach can digest: if the child is under twelve months of age, it is by far the best plan to nourish it by the breast only to the sixteenth or eighteenth month, due attention being paid to the health of the nurse and changing her if necessary ; but when this cannot be accomplished, the best first substitute is asses' milk or cows' milk, a little sweetened and diluted with half its bulk of lime-water or pearl-barley gruel. For children above the age of two years, milky and farinaceous food with a little meat or broth alternately once a day, will generally be most suitable. NERVOUS AFFECTIONS OF THE LARYNX, IN THE ADULT. 1. Spasmodic affections of the larynx in the adult are generally connected with some inflammatory or organic disease there, or by the presence of a foreign body; but occasionally they occur as the result of more distant spinal or nervous irritation, under the garb of hysteria. The sensation called globus hystericus is sometimes distinctly attended with a spasmodic constriction of the glottis, which is probably excited by wind in the stomach or even in the oesophagus, for it is generally relieved by flatulent eructation. The choking sensation produced on swallowing too large a morsel is also in part owing to spasm of the glottis: all these associations of symptoms are rendered more intelligible by the experiments of Dr. Reid, which prove the sensations and motions of both pharynx and larynx to depend on the same nerve —the vagus. More rarely the constriction is of a more enduring kind, and accompanied by fits of croupy breathing and a con- vulsive ringing cough. Like the crowing inspiration of infants, this may arise from temporary irritation, or from more perma- nent disease of the nervous centres. Dr. Stokes mentions cases in which spasmodic affections of the larynx terminated in inflam- mation of, and effusion under, the membranes of the brain. The same writer describes another case in which a patient, long tor- mented by all kinds of hysterical disease, with occasional ob- stinate fits of laryngeal spasm and cough, died suffocated by an abscess involving the cricoid, without any other organic lesion. May this abscess have originated in a tumour, which caused by reflected spinal irritation the long train of spasmodic symptoms from which this patient had suffered 1 Nervous affections of the larynx chiefly affect females, and may present all the degrees of inconstancy and intractability which disorders called hysterical often exhibit. If not rendered inveterate by indulgence or habit, they may sometimes be resisted by an act of the will: we have 108 NERVOUS AFFECTIONS OF THE LARYNX. known a most violent form of convulsive cough with stridulous breathing, which had resisted every kind of treatment, cured through the patient's hearing the actual cautery prescribed for the next attack. The treatment of spasmodic affections of the larynx is to be generally conducted on the usual principle, of giving antispas- modics to remove or prevent the attacks, and improving the tone of the muscular system and diminishing nervous irritability by tonics, regular exercise in the open air, and other suitable means. Foreign bodies in the larynx and even in the oesophagus may excite violent and fatal spasm of the glottis. The treatment of this subject belongs rather to surgery than medicine. 2. Atonic or paralytic affections of the larynx are chiefly known by the symptoms of aphonia, hoarseness, or some other altera- tion of the voice. This symptom is commonly connected with inflammatory or structural disease of the vocal apparatus : but even in these the sudden exacerbations show that much of it is nervous: and in nervous and hysterical subjects we not unfre- quently find affections of the voice independent of any other dis- ease of the larynx. Some persons not unfrequently lose their voice from sudden mental emotion, taking particular articles of food, menstrual irregularities, and other causes which operate on the nervous system ; and the sudden manner in which they often regain as well as loose the voice, sufficiently points out the nature of the affection. We had the care of a lady, who from such causes is liable to lose suddenly not only her voice but also her power of articulation for days together, and to regain them as suddenly. For some time relief was instantaneously given, merely by her taking an electric spark with her fingers. This at last lost its efficacy, and even shocks failed ; subsequently it was found that holding a lump of ice in the mouth was quite effectual. The complaint originated in a low fever, and the liability to its recurrence has diminished with the improvement of the general health under the use of mild metallic tonics with change of air. At present the attacks are rare, of short duration, and may be removed by drinking a little wine. The affections of the speech often preceding and accompanying general paralysis, are those of articulation rather than of the voice. But the voice is often changed or suppressed in attacks of violent palpitation, and par- ticularly in cases of aneurism involving the arch of the aorta, the innominata, or right subclavian artery; and this circumstance is obviously referrible to the manner in which the recurrent nerves are stretched or compressed by these tumours. Nervous aphonia is generally symptomatic of some other general or local disease: its treatment therefore must vary according to the nature of the primary affection. In the purely nervous or hysterical cases, the fetid gums and other stimulants as temporary means, and a course of steel and other tonic medi- CATARRHAL INFLAMMATIONS. 109 cines, with free exposure to a healthy air, the shower or plunge bath, and corresponding regulation of the mode of living, com- prise the measures most likely to be successful. But sometimes either with or without those more remote causes, the local affec- tion depends in great measure on relaxation or weakness of the muscles concerned in the formation of the voice. In such cases stimulant and astringent gargles, as of port wine, alum, infusion of rhatany root, or even a weak infusion of galls, will prove useful. The injection of a solution of sulphate of zinc or of nitrate of silver in the manner recommended by Trousseau, and described in the treatment of chronic laryngitis, would probably be still more efficacious. We have known several instances of clergymen, whose vocal organs have been weakened and relaxed by over-exertion, in which much benefit was derived from the use of astringent gargles. A piece of camphor kept in the mouth for some time before speaking is also of use. In some cases, the relaxation may be removed by the internal use of the balsams of copaiba or Peru. But unless there be a temporary suspension of all extraordinary exertions of the vocal organs, the effect of all these remedies will be very transient. CATARRHAL INFLAMMATIONS. Acute Catarrh. General observations on catarrhal inflammations.—Symptoms of Acute Catarrh__Coryza.—Mild Bronchitis.—Physical signs.—Causes.—Treat- ment. By Catarrhal Inflammations of the air-passages is meant, those affections which are attended by an increased and altered secre- tion from the mucous lining of the tubes. From their most fre- quent cause they have received the common name of colds ; and they are further distinguished according to their seat. Thus, in the nasal canals, the complaint is called a cold in the head, coryza, or nasal catarrh: in the fauces, it is catarrhal sore throat, or cynanche ; whence it may branch off by the Eustachian tube, causing deafness and earach; or by the lachrymal duct, causing catarrhal ophthalmia, or a cold in the eyes. In the larynx and trachea, and its branches, it constitutes a catarrh or cold in the chest; in which case, from its most prominent symptom, the complaint is called a cough. Although, by a few writers, this affection of the mucous membrane of the air-passages has been considered not to be essentially inflammatory, we do not hesitate to class it as such, for its course and phenomena are undoubtedly 110 CATARRHAL INFLAMMATIONS. those of inflammation ; and to reckon it otherwise, because there may be something specific and non-inflammatory in its origin, would be to follow a doubtful hypothesis, rather than plain fact. The divisions which we purpose to adopt, are made with a view to important practical distinctions, rather than because they exist naturally ; for the different affections, thus separated, pass by im- perceptible gradations into one another. The more acute catarrhal inflammations of the air-tubes, present especially two forms, which vary greatly in their severity, on account of their difference in extent and the situations which they occupy. 1. Acute Catarrh, which in the nasal passages is Coryza, and in the upper parts of the air-tubes a form of Mild Bronchitis; and, 2. Bronchitis, which affects the air-tubes more extensively, and by its effects interferes with the function of the lungs. Symptoms of Acute Catarrh. The first symptom of catarrh, or, as it is popularly termed, a cold, is generally a feeling of fulness or obstruction in one or both nostrils, or a sense of tickling or relaxation in the throat, with an uncomfortable sensation in the stomach, approaching to nausea, and attended with flatulence; or, in those more liable to cough, it may begin with tightness and uneasiness in the chest, with slight hoarseness, and irritation of the glottis. Any of these are commonly accompanied by some feeling of chilliness, occasionally with slight rheumatic pains, which are sometimes the first symptom, and indicate the general disturbance which precedes the localisation of the disease. As yet it may be uncertain what form the complaint may assume, although most individuals know from experience the course which it is likely to take in their own persons. When it becomes developed as a Coryza, or cold in the head, there is a sense of fulness and obstruction of one or both nostrils, accompanied by the secretion of a thin colourless fluid. This flux comes on from time to time in an increased quantity, and the increase is always attended by an aggravation of the uncom- fortable feelings of fulness and tickling, with frequent sneezing, and copious flow of tears from the eyes, which are full and in- jected: these effects show an acrimony in the discharge, as well as an increased sensibility of the pituitary membrane lining the nasal fossas: this is further evinced in the progress of the disease, by the redness and excoriation of the end of the nose, and the skin above the upper lip. The senses of smell and of taste are always impaired, the latter often quite destroyed ; there is often headach, or a sense of weight and heat over the brows, supposed by some to be occasioned by the catarrhal inflammation affecting the lining of the frontal sinuses. The partial or complete ob- struction of the nasal passages, although caused entirely at this stage by the swelling of the membrane, gives the feeling of their being plugged up: and the same obstruction often renders the voice thick and nasal; subsequently it becomes husky from the catarrhal inflammations (Symptoms). Ill swelling of the laryngeal membrane. If the attack be severe, there is fever, with loss of appetite, and pains of the back and limbs; and in almost every case an unusual degree of chilliness and sensibility to cold. The disorder is at its height generally about the third day, and then begins to decline ; the flow from the pituitary membrane becomes more scanty and viscid, and less acrid, the lachrymation ceases, the swelling and obstruction diminish, while the headach and other symptoms proportionately abate, and between the fifth and seventh day the disorder may be entirely removed. Not unfrequently, however, fresh cold is taken from the slightest cause, and the coryza, with its attendant symptoms, is kept up for a longer time ; and so long as the secre- tion is copious and thin, no amelioration of the other symptoms takes place. Still more commonly, as the irritation of the nasal passages subsides, that in the throat and larynx begins. The in- flammation seems to be of the creeping or erysipelatous kind; and may wander along the Eustachian tube, causing dulness of hearing, perhaps with earach ; along the fauces, causing sore throat; and down the oesophagus into the stomach, occasioning slight gastritic dyspepsia. Its more common course, however, is down the air-tubes, giving rise to the bronchial form of catarrh to be presently described. Coryza not unfrequently attacks infants, and so obstructs the nostrils, as to interfere with the process of sucking, in which nasal respiration is necessary. The child leaves off repeatedly, becomes fretful, and sometimes purple in the face, in a few seconds after each time of taking the nipple. In children pre- disposed to convulsions, these efforts, and the disturbed circula- tion ensuing from them, sometimes prove the exciting cause of a fit. When catarrhal inflammation extends to the upper bronchial tubes, constituting a form of mild bronchitis, it commences with coryza, or sore throat, and increases as the latter affections diminish ; but in persons who are liable to coughs, it often is the first effect of exposure to cold. The first symptom is sometimes a feeling of coldness at the top of the sternum, with roughness or dryness in the throat, which occasions frequent attempts to scrape the throat. Then follow sensations of heat, tightness, soreness, or pain in the same part, with a cough, which is at first short and dry, but soon becomes longer, more urgent, and ac- companied by the expectoration of a glairy, saline tasted, trans- parent mucus. This secretion, so far from relieving the cough, obviously aggravates it by tickling and irritating the glottis, and probably possesses somewhat of the same acrid quality with that of coryza. This acrimony may be owing to the increased pro- portion of saline matter, which not only is evident to the taste, but has been chemically shown by Messrs. Brett and Bird to exist in the expectoration of bronchitis. The full development 0/ 112 catarrhal inflammations. catarrhal inflammation in the air-tubes is usually attended, espe- cially towards evening, with quickened pulse, hot skin, and scanty high-coloured urine, with some degree of fever, and some shortness of breath. The physical signs more clearly mark the condition of the bronchial membrane, In the earliest stage, perhaps, before any cough or other symptom of pectoral disease, various dry rhonchi, the sonorous and sibilant, with a diminution of the respiratory murmur, announce the narrowing of some of the air-tubes. More rarely, a total absence of sound in a part of the chest shows that the obstruction there is complete ; while the unimpaired sound on percussion proves that the vascular structure is free. These obstructions, no doubt, arise chiefly from the swelling of the mucous and submucous tissues, as we find the same take place in the nasal canals, when they are the seat of the kindred affection—coryza. Dr. Stokes supposes that a spasmodic con- striction of the circular fibres, rendered irritable by the inflam- mation, contributes to the coarctation of the tubes. The bron- chial tubes do not remain long in this dry state; the secretion commencing first gives a roughness to the other sounds, then adds to them a sound of bubbling, which is the mucous rhonchus; but this-is seldom so" loud as the other sounds, and when the disease occupies only the deep-seated tubes, it may scarcely be heard at all. According as the liquid is in the large or the small tubes, the bubbles, and the crackling which they produce, will be coarse and unequal, or fine and more uniform. The usual seat of all these sounds, in the milder forms of bronchitis, is in the middle parts of the chest, whether in front, behind, or at the sides, where the larger bronchi lie. The lower tones imply an affection of the larger tubes ; but the acute notes do not indi- cate that the finer tubes alone are diseased, for they may be pro- duced in the large tubes also, when the obstruction is considerable ; and when there is heard an acute or whistling note prolonged through the whole act of inspiration or expiration, it may be known not to be produced in the finer tubes, because the air is not so long a time passing through them. The deep sonorous rhonchus, like the note of a violoncello, is probably seated at the branching off of a large bronchus; and so strong are its vibra- tions, that it may be often felt by the hand applied to the exterior, or by the patient, who can point out the spot where it is produced. These various sounds may accompany either the inspiration, ex- piration, or both. The decline of this mild form of bronchitis is announced by a looser character of the cough, and a change of the expectoration to an opaque, thick, less coherent phlegm, which is generally first perceived in the morning, that being the time when most inflam- matory and febrile diseases show a tendency to remission. With this change, there is a general amelioration of the symptoms. catarrhal inflammations (Causes). 113 The constriction of the chest is diminished or removed, the pulse loses its frequency, the skin becomes cooled by perspiration, the urine more copious and deposits an abundant sediment, and the decline of all the tronblesome symptoms very generally cor- responds with the altered character of the expectoration. This seems to have lost its irritating quality; is more tasteless; and comes up by easy coughing, indistict pellets of opaque yellowish- white or greenish-white mucus, to which the soot and smoke of the air in large towns often give a gray tinge. Sometimes the sputa assume a consistent form without opacity, which renders the cough and expectoration easier, but it is not accompanied by the general improvement so remarkable when the sputa become simply opaque. In either case, the inspissation of the bronchial secretion causes some change in the physical signs; the bubbles are heard to break more rarely, and give more of a whistling or ticking sound ; and the sibilant and sonorous rhonchi become remarkable; but they change with every cough or forcible act of breathing. The same clots of mucus that by this partial ob- struction to the air cause these rhonchi, sometimes block up entirely one or more of the tubes, and stop the sound of respiration in the part to which the tubes lead. But this stoppage is seldom permanent; and a cough or deep inspiration will often open it or shift it to another situation, and the air is then heard to enter with a whistling or a clicking noise, where all had been silent before. The sound on percussion is still uniformly good ; and this circum- stance, with the varying respiration and rhonchi, characterises bronchitis in this stage. Such is the ordinary course of the slighter cases of mild bron- chitis, which may last from a few days to two or three weeks, but if neglected may continue for a much longer period, and assume a chronic form. Causes. The most common exciting cause of acute catarrh, whether affecting the nasal passages or the air-tubes, is exposure to cold or sudden transitions of temperature. This cause is always more effectual when it is partially applied, as by standing or sitting in a draught of air, especially if the body be heated; by wet feet, or wearing damp clothing. Acute catarrhal affec- tions often prevail epidemically, probably depending on sudden atmospheric changes, some of which are, obviously enough, those of temperature, but in other cases they are of a less intelligible kind, being perhaps connected with electric conditions of the air that elude our scrutiny. Certain it is, that the most severe and universal forms of epidemic catarrh have occasionally appeared without being preceded by equally remarkable transitions of tem- perature. An opinion prevails among many persons, that catarrh is infectious; this rests on the equivocal evidence of their so fre- quently affecting, consecutively, the different members of a house- hold. A catarrhal affection of the eyes, nostrils, and upper 114 CATABRHAL INFLAMMATIONS. portion of the air-tubes, very generally accompanies measles, and more rarely small-pox and scarlatina. Irritating gases, vapours, or dust, may excite catarrhal inflammation of the pituitary and bronchial membrane; but it is of a slight kind, and soon passes away, unless the cause be reapplied. The only complication of acute mucous catarrh of the air- passages, which it is necessary to notice, is that with disorder of the gastro-hepatic function : in which, in addition to the catarrhal symptoms, there are headach" thirst, a loaded tongue, loss of appetite, occasionally nausea, or even vomiting, sometimes with tenderness at the pit of the stomach, or in the right hypochon- drium ; sometimes a slightly jaundiced skin and conjunctiva; and bowels constipated or irregularly loose, with dark or clay-coloured dejections. Dr. Copland mentions rheumatism as a disease with which catarrh is sometimes complicated, to which, he thinks, it bears some affinity. We have not observed this complication; and although there are occasionally slight wandering pains, like rheumatism, in the early stages of catarrh, they rarely take the course of true rheumatism. Treatment. " A cold," which is one of the most common of all diseases, is rarely considered an object of more than domestic treatment; yet, trivial as it is, it is often formidable in its conse- quences. The ordinary method of treating a cold is, certainly, rather palliative than positively curative; but it generally miti- gates its severity, and hastens its termination. A brisk purgative, conjoined, if there be febrile disturbance, with a moderate dose of calomel and James's powder, or tartarised antimony (the mer- curial being increased and repeated in case of gastro-hepatic disorder), a hot pediluvium at night, confinement to a room of moderate temperature, or to bed in order to increase the perspira- tion, which may be promoted by warm diluent drinks, will gener- ally serve to moderate the complaint. Temporary relief may sometimes be given to the headach and severe catarrhal irritation of the nasal passages, by holding the face, with the head covered with flannel, over a vessel of hot water; and, in the case of the coryza of infants, the repeated application of a sponge squeezed out of hot water will often succeed in freeing the air-passages for a time, and in thus enabling the infant to suck. The cerebral symptoms which under these circumstances are sometimes developed in children, are quite serious in their character. Besides using the remedies pointed out by the author, it is often of great service to place a cup filled with tar, which is kept hot by being suspended in a larger vessel of water kept at the boiling point; the vapour of the tar facilitates the secretion from the nostrils, and often greatly relieves the child. Holding the head of the child for a few moments over a vessel of hot water, or of hot vinegar, is often of great benefit, and above all a repeated change of position is advisable so that catarrhal inflammations (Treatment). 115 by inclining the head forwards the flow of mucus may be facilitated. The coryza of young children is often an affection which causes great annoyance and sometimes danger. When the catarrh extends to the air tubes, the same mild anti- phlogistic plan may be pursued, with the addition, in more severe cases, of leeches above the top of the sternum, or a blister or tartar emetic liniment to the upper part of the chest, and the frequent use of a cough mixture, to diminish irritation and pro- mote expectoration. Various combinations may answer for this purpose. Mixtures containing antimonial or ipecacuanha wine (ttlx to n\,xx) with tincture of hyoscyamus or conium (rt\,xx to n\,xxx) or hydrocyanic acid ("lj), for the early stage, and with tincture of squill (rrtx to n\,xx) and compound camphor tincture (nixx to ^ixl), for the subsequent periods, generally answer well. But the efficacy of these remedies is decidedly increased by combining them with an alkali. From i^lx to tn,xx of the Liquor Potassas, or an equal number of grains of carbonate of soda, or in more asthenic cases rr^xx or ftixxx of the Sp. Ammonias Arom., are sufficient: in the greater number of cases, such alkaline reme- dies quiet the cough and promote expectoration far better than the oxymels and acid linctus or lozenges that are commonly in use. To have their full effect, cough medicines should be taken frequently, at least four or five times a day; for, besides that their object is to increase continually the secretion of the bronchi through the circulation, they seem to act, in some measure, directly on the glottis and its neighbourhood ; and in the intervals it is useful to have in the mouth a demulcent substance, such as gum arabic, the solution of which tends, also by continuity, to sheathe these same irritated parts. In order to insure the success of this mode of treating catarrh, more or less nursing and confinement is essential. To give dia- phoretics and diluents, and at the same time to expose the body to transitions of temperature, which are almost unavoidable with- out confinement, will tend rather to increase a cold than to diminish it; yet few persons think it worth while to confine themselves for the sake of a cold, and thus either let it run its natural course, or make an even worse compromise, by nursing and sweating during one part of the day, and exposing and chilling themselves at another. Now, as these ordinary antiphlogistic means are inconvenient, and do not succeed in cutting short a catarrhal inflammation, there are other measures, which, if used at the outset of the disease, within a day or two of its commencement, often prove prompt means of arresting it altogether, or of bringing it to a speedy termination. One of these methods is, by taking at bedtime, at the earliest stage of the cold, (whether the affection be felt in the nasal pas- sages, the throat, the chest, or in the system generally,) a full 116 catarrhal inflammations. dose of opium in some form, following it the next morning by a brisk cathartic. From ten to twenty grains of Dover's powder, or two grains of opium with two of ipecacuanha or a quarter of a grain of tartar emetic, or half an ounce of compound tincture of camphor, are the most eligible forms of opiate. It is safer to add a few grains of calomel or some milder mercurial, to prevent the restringent effect of the opium on the secretions. When the remedy acts well, the patient sleeps soundly, generally perspires freely, and awakes in the morning free from his cold, but often with some headach and nausea. These are generally relieved by a brisk purgative, and no further ailment is felt than a degree of languor which another night's rest may remove. This remedy seems to operate by deadening the morbid sympathies, and thus breaking the chain of actions on which the process of inflamma- tion depends; as we find it cut short, in some cases of more serious inflammations, after the general vascular action has been reduced by bloodletting. Somewhat in the same way may be supposed to act the hot, spirituous, and vinous remedies which are popularly employed to check a cold ; and which, hazardous as they are, were in some measure commended by Laennec. This kind of treatment may, however, prove injurious, where the digestive organs are weak, or where a tendency to other in- flammations exist; and, by suppressing the expectoration, may change a bronchial catarrh into pneumonia. Another method of stopping a cold is by abstinence from all kinds of liquid. This plan originated with the writer, who has practised it in his own person for the last twelve years, with such success, that colds and coughs that used to continue for several weeks, have been generally cured in two or three days. It was first adopted especially in the treatment of coryza, in which, as the earlier stage of catarrh, it is the most successful; but is was soon found to be of great utility in catarrhal bronchitis. About six years ago, M. Piorry also recommended this plan as a means of diminishing the expectoration in various forms of bronchial disease; but it does not appear that he adopted it with the view of removing catarrhal inflammation. The great effect of abstaining from liquid food is promptly to reduce the mass of the circulating fluids. The natural fluid secretions continue, although in diminished quantity; the urine is still excreted, but its watery part is decreased ; the skin continues to perspire, either insensibly, or obviously under the influence of increased warmth or exer- cise. This is not the case with the morbid secretion from an irritated membrane: the irritation is lessened with the decreasing fulness of the bloodvessels; the scantier circulating fluid being now taxed for the habitual and necessary secretions too closely to supply it, the morbid flux soon ceases, and the diseased mem- brane, no longer irritated by its own secretion, is restored to a healthy condition. If liquid be freely taken too soon, before the catarrhal inflammations (Treatment). 117 membrane has lost its diseased action, the discharge will return, and the complaint be as severe as ever. But if, when the discharge has ceased after twenty-four or thirty-six hours of abstinence from liquids, means be taken to keep up the natural secretions, as by exercise, with a warm state of the surface, a little liquid may be taken with impunity, the bulk of the circulating fluid being still below the amount at which it can readily supply any demand from the irritation of the diseased membrane. This is probably the physiological principle of the curative influence of the dry treatment on catarrh. 'It is very essential for its success, that it should be applied in the early irritative stage of the com- plaint; and it is most effectual when the catarrh affects chiefly the nasal membrane. If there be any fever, and especially if the state of the bowels require it, an aperient with an antimonial should be given ; for this favours that free state of the secretions on which, as we have seen, the efficacy of the dry plan depends. In milder cases, this is not necessary. For similar reasons, it is desirable that the solid food be not of a too rich or heating kind; for this, undiluted by liquid, might be apt to disagree. Bread, or any consistent farinaceous food, with a little butter, vegetables, white fish, white or gelatinous meats, light puddings, and dried fruits, are suitable articles for a dry diet. Although a total abstinence from liquids is the most effectual, yet, taking about a tablespoonful of tea or milk with breakfast and the evening meal, and a wine-glass full of water on going to bed, does not prevent the success of the plan, whilst it diminishes its discomfort. But the suffering from this voluntary privation is trifling in comparison with that from a severe cold ; in fact, except with those who are habitually thirsty, it is rather negative than positive, arising from the imperfect enjoyment of eating without drinking. A great advantage of this plan is, that it does not interfere with common active pursuits, and needs no nursing or confinement. In fact, if care be taken to prevent the surface from being chilled, exercise in the open air promotes the success of the plan, by favouring the natural secretions. On the other hand, those who treat their colds by slops and diluents, which act chiefly by increasing the perspiration, will suffer from the least transition of temperature, which will have a greater influence on a freely perspiring surface. The time necessary to effect a cure by the dry plan will vary in different individuals, according to the present quantity of their circulating fluid, the activity of their secretions, and the intensity of the catarrhal disease; and also, somewhat according to the hygrometric state of the air, longer time being always required when the weather is cold and damp. On the average, forty-eight hours of abstinence will be sufficient. We have known thirty- six hours enough; but some severe and obstinate cases require three days. The period may generally be somewhat shortened by exercise and warm clothing, or lying in bed, or by commencing 16 118 BRONCHITIS--ACUTE. with a purgative, or by any other dry means of increasing the natural secretions. The catarrhal affection is generally much relieved at the end of the first day, and only troublesome at times; but the cure is not complete till all stuffing is gone, and nothing but a consistent mucus is formed, without irritation in the nasal or bronchial passages. Sometimes this secretion continues for a few days ; but, unless fresh cold be taken, it causes no incon- venience, and soon ceases. In these cases, it is generally prudent to take an aperient and diaphoretic on returning to the use of liquids, which it is always best to begin at night, when there is less risk of relapse from fresh exposure. There is a chronic variety of coryza which is very troublesome ; it occurs chiefly in persons of a scrofulous constitution, and although it is not in itself attended with much danger, it is often difficult of cure. The mucous mem- brane of the air passages, that is, of the nasal fossae, is thickened and secretes a large quantity of mucus, which is sometimes altered in its quality and more opaque than usual. The coryza is unattended with pain, but the inflammation in many cases extends to the throat, and then becomes a variety of the chronic pharyngitis which is so common amongst clergymen. The best means of treatment are the alteratives and tonics; that is, the preparations of iodine and sarsaparilla, and stimulant inhalations, especially the vapour of chlorine, tar, and vinegar. These may be alternated with soothing remedies, as the vapour of water. y BRONCHITIS. Acute Bronchitis.—Sthenic and asthenic forms—Symptoms.—Physical signs. —Infantile bronchitis.—Causes.—Symptomatic bronchitis—Anatomical characters.—Diagnosis—Prognosis.—Treatment of the sthenic and asthenic forms—of infantile bronchitis—of the various forms of symptomatic bron- chitis.—Chronic Bronchitis.—General observations on chronic inflammation of the air-passages.—Characteristic symptoms of chronic bronchitis.— Causes.—Anatomical characters.—Prognosis.—Treatment of chronic bron- chitis.—Diet and regimen. Acute Bronchitis. The more intense form of acute bronchitis differs from the milder kind already described, in the greater extent of the bron- chial tubes which it occupies, rather than in pathological character. Its local nature and signs are the same ; but its general symptoms differ, inasmuch as the system suffers more from the greater intensity and extent of the inflammation and of the functional bronchitis (Symptoms). 119 disorder. This disease presents itself under two forms, long dis- tinguished by the terms sthenic and asthenic. In sthenic bronchitis, inflammatory symptoms are marked from the commencement: there are generally pain, and constriction across the sternum ; hard severe cough, with glutinous expectoration; much fever, heat of skin, thirst, headach, and scanty urine ; white tongue, with red edges ; quick and often hard pulse ; hurried breathing, often accompanied with a feeling of great oppression ; and cough on the least exertion. The pain in the chest is commonly referred to the sternum, and is more obtuse than the pain of pleurisy. The expectoration is usually scanty at first; afterwards it becomes more copious, glairy, frothy, sometimes streaked with blood, and its expulsion gives but little relief to the cough and breathing : it is compared by Andral to white of egg in different degrees of dilution, and from chemical analysis appears to contain free albumen, which is not present in healthy mucus: its quantity increases in the evenings, when there is a general aggravation of all the symptoms, more especially of the fever, dyspnoea, and cough. The physical signs are similar to those of the mild form ; but they are here heard more extensively throughout one or both sides of the chest. The rhonchi are at first sibilant and sonorous ; afterwards mucous and submucous, reaching to the inferior por- tions of the lungs, with a weakened respiratory murmur, announc- ing the presence of the inflammatory mucus even in the smaller tubes ; but the clear sound on percussion declares the vesicular structure still free. If relief be not afforded by expectoration, perspiration, or prompt remedial measures, the disease soon shows a change of character, from the increased -dyspnoea, and symptoms of partial asphyxia that ensue. Then come on feelings of great depression ; the pulse is weak, as well as very quick, and often irregular; the functions of the sensorium are impaired or disturbed ; the muscular strength is much reduced ; the countenance becomes anxious, and pallid, or partially livid, according to the quantity of blood in the system; partial sweats appear; the pulmonary congestion becomes evident, by the slightly diminished resonance on percussion in the postero-inferior regions of the chest. The continuance of this state, and the imperfect arterialisation of the blood, further disturb other functions; the secretions become more scanty and vitiated; the tongue is loaded with a brown fur; the thirst is intense; and all these disorders concur in reacting on and aggra- vating the original disease, and in injuring the natural powers. Such is the loss of balance that results from the disturbance which severe bronchitis makes on the important function of respiration. The share which this function has in giving character to the constitutional symptoms, is seen in the fact, that very similar effects are met with in persons who have been subjected to an asphyxiating influence. The step from this condition to death is 120 BRONCHITIS--ACUTE. but a short one. In favourable cases, the disease declines between the fourth and the eighth days ; the dyspnoea is diminished, and is confined chiefly to the evening, when there is almost always some tendency to exacerbation. The expectoration becomes opaque, and less glutinous and frothy; and on being voided, gives more relief to the cough and dyspnoea. The breathing becomes less laboured ; the countenance improves, and resumes its proper colour ; the symptoms of fever abate ; and the disease either entirely subsides, or passes into a chronic form. The chief difference presented by the asthenic or humid form of bronchitis (peripneumonia notha, as it was formerly termed), is, the early appearance of signs of depression, generally attended with gastric derangement; quick, wiry, often irregular and unequal, pulse ; hot skin towards evening ; headach, and thirst. Oppression of the breathing is here one of the earliest symptoms, accompanied by a peculiar wheezing; and, on auscultation, we find in the universal mucous rhonchus the proof of the early presence of a profuse secretion in all the tubes. The dyspnoea is liable to temporary exacerbations, which are often so severe as to prevent the patient from lying down, and are accompanied by extinction of the voice. During these attacks, there is some- times some dulness on percussion, and occasionally even broncho- phony in the posterior region on one side, which is removed with the decrease of dyspnoea. These probably depend on the quantity of liquid mucus in the bronchial tubes and cells; and on a tem- porary pulmonary congestion. The expectoration may be scanty at the outset, but afterwards becomes very copious and frothy. This form of bronchitis commonly attacks' elderly people, those of a lax phlegmatic habit, and such as have habitually a cough with copious thin expectoration. In young children, a very fatal kind of bronchitis of the asthenic kind sometimes comes on in a most insidious manner. It may at first present the aspect of a common catarrh with coryza, without pain, much fever, or marked derangement of the functions. On attentive observation, however, the breathing is observed to be frequent, accompanied with wheezing, particularly before and after the fits of coughing; while the pallidity of the countenance, and heavy state of the child's spirits, indicate something more than a common cold. The cough is not always present; and as children do not expec- torate, the disorder in the chest may escape remark, until the dyspnoea suddenly comes on and renders the danger imminent. Causes. The most common exciting causes of severe bron- chitis are the same as those of the milder form of the disease, from which, as we have before observed, it differs rather in degree than in kind: cold, particularly conjoined with moisture, applied locally or generally, as by wearing damp clothing, or exposure to a cold, moist, variable atmosphere, especially after the body has been heated by exercise or crowded rooms. Par- bronchitis (Anatomical Characters). 121 ticular conditions of the atmosphere may excite sthenic bronchitis in those of an inflammatory habit; and the humid form of the disease in those of a more relaxed constitution. A severe kind of bronchitis often accompanies some of the eruptive fevers, measles, erysipelas, small-pox, and scarlet fever, and causes the chief danger that accompanies them. In some cases, the recession of the rash is followed by great increase of the bronchial affection, which is announced by sudden and oppressive dyspnosa. From the suddenness of the production and disappearance of this symptom, which is occasionally observed in these cases, it is very probable that they are rather congestive than inflammatory ; although, if the congestions continue, they take the form of bron- chitis. Of the same character is the symptomatic bronchitis of continued fevers, in which the symptoms of the local disease are often so obscured, that it may run on to a fatal termination without being discovered, till its nature has been revealed by dissection after death. Auscultation in such cases, however, generally reveals the lesion—the sibilous, sonorous, and submu- cous rhonchi being heard in every part of the chest. Bronchitis supervening on erysipelas sometimes depends on the propagation of the inflammation by continuity, and may prove rapidly fatal. Erratic gout may manifest itself also in the form of bronchitis, which may be dangerous if the attack be sudden: in general, it vanishes quickly on the appearance of gout in an extremity. The anatomical characters of acute bronchitis, as far as they present themselves, correspond with the indications of the phy- sical signs. The lungs do not, in general, collapse on opening the chest, the escape of air being prevented by the obstructions in the bronchial tubes. These tubes, in most instances, con- tain a quantity of frothy fluid, similar to expectoration, before death: not unfrequently it is sanguinolent; but as this appear- ance is not often observed in the sputa, even at the last, it proba- bly arises from an exudation of the colouring matter from the congested pulmonary plexus of vessels at the time of, and after, death. Purulent matter is frequently mixed with the mucus, especially in very acute sthenic cases, which have proved fatal in a few days. The bronchial mucous membrane presents various shades, from a light pink or crimson, to a deep or brownish-red, either generally diffused, or in patches. It is oc- casionally found partially thickened, but much less commonly than might be expected from the character of the physical signs, which so generally indicate constriction of the tubes ; but it is to be borne in mind, that the vascular injection and effusion, which chiefly constitute these constrictions, probably resemble those of erysipelas, which, it is well known, disappear after death. Oc- casionally the mucous membrane is somewhat softened, so that it may be easily abraded ; but this change is found by no means so frequently as in the gastro-intestinal mucous membrane. 122 BRONCHITIS--ACUTE. Diagnosis. The distinctive characters of acute bronchitis are to be found in the leading general and physical signs of the dis- ease. Its most important symptoms arise from its interfering with the function of respiration, and occasioning the circulation of dark blood through the system, with corresponding changes in the hue of the lips and cheeks, which result sooner from bron- chitis than from other inflammatory affections of the chest. It should be kept in view, that more or less bronchial inflammation always accompanies these other pulmonary affections in their more serious forms, and is often the immediate cause of death. One of the most rapidly fatal forms of tuberculous disease, is that of abundant miliary tubercles, attended by a general bronchial inflammation, the secretion from which is the chief cause of the dyspnoea and suffocation which ensue. So also in continued fevers, as it has been pointed out, a secondary bronchial inflam- mation or congestion and effusion become a chief source of danger, although it may be difficult to distinguish it among the symptoms of the primary disease. On the character of the sputa, a diagnostic between bronchitis and pneumonia has been founded: those of the former, although sometimes very viscid, wanting the rusty tinge which is presented by the expectoration of peripneumony. We shall see, hereafter, that hasmorrhagic engorgement, or a highly congested state of the lungs from organic disease of the heart, may add even this character to the sputa of bronchitis. But in bronchitis the air is not expelled from the vesicular structure, as in the effusions of pneumonia and pleurisy : hence, although, from temporary congestion, the sound of the chest on percussion be sometimes impaired, it is not so to a great extent, or for a continuance; neither is there such condensation of the tissue, as to transmit the sound of bronchial respiration or bronchophony. The absence of the fine crepitation of pneumonia is a more equivocal test; but if observed, for two or three days, without dulness on per- cussion and rusty tinge in the sputa, it may be considered as pretty surely indicating that the parenchyma is not influenced. It is important to bear in mind, notwithstanding the artificial distinctions insisted on by Laennec and others, that the physical conditions of a congested lung with acute bronchitis, and of a lung in the first stage of pneumonia, are the same as far as re- gards their signs, and can be distinguished only by the different courses which they take, and which will depend on the degree of inflammatory tendency present, as indicated by the cough and general fever. Prognosis. The tendency of acute bronchitis may be judged by the extent and stage of the disease, and the general strength and condition of the patient. When the inflammation is partial, affecting a few bronchi only, as in common mild cases, and with- out much dyspnoea and fever, it may terminate in a period vary- bronchitis (Prognosis—Treatment). 123 ing from six days to three or four weeks ; and its disposition to pass off is indicated by the expectoration becoming opaque and more clotted, and gradually diminishing in quantity. This change is always first seen in the morning; the evening exacer- bations often restoring the thin glairy character to the sputa, even in cases tending towards convalescence. A relapse is marked by the expectoration resuming this condition, which is always accompanied by an increased hardness of the cough and fever. In the more extensive attacks of inflammation, where the dyspnoea is oppressive and constant, and particularly where the fever is high in the beginning, the prognosis must be very doubt- ful. If the acute symptoms have already yielded to the state of collapse, it may be feared that the power of the system will be insufficient to restore a function on which the disease has made a serious inroad. The extreme anxiety of the pallid countenance, with more or less lividity of the lips, of the face, and hands, cold- ness of the surface, and a rapid fluttering or thready pulse, an- nounce the asphyxiating effects of this stage of the disease ; and the universal mucous rhonchus becoming coarser and more gurg- ling as expectoration fails, with little or no respiratory murmur heard on applying the ear to the chest, gives direct evidence of impending dissolution. In the severe bronchitis of children, the real amount of danger can seldom be estimated by the general symptoms, in time for the effectual application of remedies ; but where auscultation dis- covers, from a widely diffused mucous rhonchus, that the inflam- mation is extensive, and occupies both lungs, great danger may be apprehended, whatever be the amount of dyspnoea and other symptoms at the time ; for frequently these come on in paroxysms only, or are scarcely remarked in the somnolent state in which the child lies during the remissions. The chief danger in asthenic bronchitis arises from the weak- ness or age of the patient. As long as expectoration continues free, and the strength keeps up, the lungs may be cleared of the secretion fast enough to maintain their functions ; but the disease is often fatal to the weak, and especially the aged, whose lungs are generally more or less emphysematous, and therefore can ill afford any infringement on their function. One of the most fatal forms of bronchitis is that supervening on a suppressed eruption, or on erysipelas. Treatment. As long as the sthenic character of bronchitis continues there can be no doubt of the propriety of bleeding, more or less freely, by venesection, cupping, or leeches, accord- ing to the intensity of the symptoms, and the strength of the patient. In bronchitis, occasional moderate bloodletting (from 12 to 20 oz.) generally gives speedy relief, by removing the con- gested state of the lung ; and in this respect bronchitis differs from pneumonia, in which this congestion is a more fixed part of the 124 BRONCHITIS —ACUTE. disease. It is desirable, however, to produce an impression on the pulse, which often increases in fulness as the blood flows, while the temporary congestion is relieved. But inflammation of a mucous membrane is rarely removed by bleeding alone ; it in- volves a certain structural change, probably interstitial effusion, that can be relieved only by a free secretion from the inflamed membrane. Expectoration is a necessary process during the remainder of the disease, and the strength should be saved for this purpose. In many cases, the local is preferable to the general abstraction of blood ; and often they may be combined with ad- vantage. The local abstraction of blood should be performedon the side in which auscultation discovers the greatest obstruction to the passage of the air. In the earliest stage of the disease, the exhibition of a brisk purgative, containing calomel, is useful in assisting the antiphlo- gistic effect of the bleeding ; but at a later period, strong purga- tives do not act so favourably, and seem in some degree to check expectoration : a mild mercurial aperient every night is, however, generally useful. To aid the antiphlogistic measures already named, certain internal medicines, which act especially on the vascular system, are of considerable efficacy. Tartarised antimony, in doses of from one-eighth to one-half of a grain every three, four, or six hours, with a drop or two of hydrocyanic acid, ten or fifteen drops of tincture of digitalis, or twenty drops of colchicum wine in camphor julep or other more agreeable vehicle, greatly con- tribute to reduce the intensity of the mucous inflammation, and to hasten its termination by expectoration. The efficacy of tar- tarised antimony in bronchial inflammation is much insisted on by Cheyne, Badham, Stokes, and others. If the cough is very hard and harassing, and is not sufficiently allayed by the remedies just named, it may be expedient to add something to diminish the nervous sensibility, such as hyoseyamus, conium, or bella- donna. These drugs produce little effect, unless given in pretty large doses. Opium and the salts of morphia are not well suited to the early stage of bronchitis, as they tend to check expectora- tion. This objection does not, however, apply to the combina- tion of opium with calomel, which is so efficacious in various in- flammatory diseases. We have not found it equal to tartarised antimony, as a remedy for acute sthenic bronchitis; but it is a valuable resource where the latter disagrees on account of irri- tability of the stomach or great debility, and is more eligible where the bronchial affection is complicated with hepatic con- gestion and intestinal disorder. From one to three grains of calomel, or double thatquantity of blue pill, or Hydrargyrum cum Creta, with from one-fourth to one-half of a grain of opium, and a grain or two of ipecacuanha, every three, four, or six hours, according to the symptoms, may in such cases be substituted for bronchitis (Treatment). 125 the liquid remedies; using, in addition, merely a little mucilagi- nous mixture, or some mild slightly alkaline linctus, for the cough, in which, if there be fever, a few grains of nitre and citrate of potass may be dissolved. The mercury may be withdrawn as soon as the gums show signs of its having affected the system, or it may be confined to a single dose at bedtime. Blisters are not eligible for the early stage of sthenic bronchi- tis from their liability to excite the whole vascular system before they rise, and consequently to increase the fever and bronchial inflammation. This effect is less likely to be produced by the tartar emetic applied externally, the operation of which, by par- ticular management, may be so hastened as to be made available in acute diseases. For this purpose, the vessels of the surface should be excited by friction with a coarse flannel or a flesh brush, or by the application of cloths rinsed out of hot water, or by a short application of a mustard poultice. The tartar emetic should then be immediately rubbed in, either in the form of a warm saturated aqueous solution, or in that of an ointment com- posed of one part of tartar emetic and two or three of lard ; and the application may be repeated in an hour, if a strong effect is desired. In this way, a full pustular eruption may generally be excited in as short a time as that required for the rising of a blister. We have often seen produced, in two hours, an intense exanthematous redness, which in another hour or two became a thick crop of pimples, speedily running into vesicles and pustules. This form of counter-irritation is more intense and lasting than that from a blister, and is especially suited to give relief in the more sthenic form of bronchitis with very viscid expectoration. It is probable that a minute quantity of the antimony enters the circulation, for nausea is sometimes felt; this result, instead of proving injurious, may be highly salutary. When free secretion from the bronchial tubes has been fully established, and especially if it be more or less opaque, we may venture on remedies which are hazardous at the onset of the inflammation,—blisters and expectorants, even of a somewhat stimulating kind. The propriety of this change in the treatment has been ably pointed out by Dr. Stokes. Expectoration now becomes the chief mode of relief; and to facilitate this, the decoc- tion of senega, with acetate or muriate of ammonia and tincture of squills, may be added to the tartar-emetic or ipecacuanha mix- ture before in use. Should a state of collapse come on, or symp- toms of increasing debility threaten inability to expectorate, it is necessary to resort to more decided stimulants. Of these, the carbonate of ammonia is the most appropriate, as it rapidly enters the system, and seems peculiarly to assist expectoration. It may be given in doses of from two to five grains in decoction of senega, as frequently as the urgency of the symptoms indicate ; 17 126 BRONCHITIS--ACUTE. and it should be withdrawn if there be a return of hardness of the pulse, or heat of skin. The tincture of the lobelia inflata may sometimes be advantageously added, in the dose of ten or twenty minims; but its action is uncertain, both in kind and in degree. The good effects of the treatment will be apparent in the general symptoms, before they are evinced by the physical signs. The breathing becomes less laboured, the countenance improves, the pulse becomes more steady and full. On observing and listening to the chest, we may perhaps find that the air enters more freely into the lungs ; but the mucous and other rhonchi are still present, and continue for some time ; and it is only when the improvement is considerable, that we perceive that they diminish, and that the obstructions become less general; that, instead of bubbling over the whole, or a considerable portion of the chest, the respiratory murmur is heard, still mixed with clicking, whistling, and hum- ming sounds. In the asthenic form of bronchitis, the antiplogistic treatment can be employed only to a limited extent; and the measures for the after stages of the sthenic disease may be used from the first. Bloodletting is scarcely borne, or only by leeches and moderate cupping. Dry cupping is occasionally useful; but the most avail- able external remedies are blisters, which should be of large size. The mercurial or antimonial remedies, used in moderation, together with decoction of senega, an ammoniacal salt, squill, and compound camphor tincture, constitute the chief internal remedies useful in such a case. Where the depression is great, and the power of expectoration fails, besides the carbonate of ammonia it may be necessary to give other stimulants, such as asther, brandy, or hot coffee. In these cases, likewise, a certain degree of absti- nence from liquids is expedient, not only by diminishing the mass of blood that has to pass through the clogged lungs, but also, as in acute catarrh, by reducing the quantity of the bronchial secre- tion. Dr. Badham recommends assafoetida in the occasional aggravations of the dyspnoea, which he supposes to arise from a temporary spasm in the bronchi. The asthenic form of bronchitis often leaves great weakness ; and it is generally necessary to use tonics. If an irritable cough remain, it may be allayed by opium. Change of air will sometimes answer both purposes. In the bronchitis of young children, emetics and mercurial purges are peculiarly serviceable. The former must not be too frequently used, as they cause considerable determination to the head, and exhaustion ; but they are eminently successful in empty- ing the bronchial tubes of their secretion ; and they probably do this, not only by the action of the external muscles of respiration, but also by exciting the bronchial muscles to contract, as we know that the glottis is forcibly closed during the act of vomiting. It is generally necessary to be particularly energetic in the BRONCHITIS--CHRONIC. 127 treatment of bronchitis supervening on suppressed discharges and eruptions. Extensive counter-irritation with tartar-emetic is especially indicated in these cases. In case of retrocedent gout, means should be taken to bring back the inflammation to the extremities, by hot pediluvia and mustard poultices ; but these measures alone are not to be depended on; and it is proper to use colchicum with other internal medicines. The bronchial affections occurring in the course of continued fever, are often rather congestive than inflammatory; and although they may greatly embarrass the breathing, the depressing tendency of the general disease prevents the employment of bloodletting to any extent. Leeches to the chest may be used in the early stages; but subsequently, when the low fever requires wine and other stimuli, the chest affection can only be treated with dry cupping, sinapisms, and blisters, and with moderate doses of tartarised antimony, or of mercurials, according to the symptoms. Chronic Bronchitis. Before entering on the consideration of chronic bronchitis, we shall make a few general observations on chronic inflammation of the air passages. These are not separated from the acute by any very distinct line ; although, when well marked, they differ much from each other. The two forms may pass gradually into each other, and are often conjoined ; for although acute bronchitis fre- quently exists alone, chronic bronchitis is rarely free from an admixture of acute inflammation. Neither is the long duration of the disease always a proof that it is not acute; for, in some cases, attack may succeed attack for weeks and even months, yet never lose the acute character. The character of the expectoration gives some proofs of the state of the membrane; and by its hetero- geneous nature in chronic bronchitis, we may form a notion of the different pathological conditions simultaneously affecting the bronchial lubes in different parts of the lung. Perhaps the best test of the existence of chronic inflammation is that proposed by Andral—the continued presence of opaque matter in the expecto- ration, such as we have classed under the head of albuminous, whether it be muco-purulent, purulent, fibrinous, or caseous; whether these occur separately, or, as is more usual, are variously combined, of different degrees of consistence and colour, and occasionally mixed with a thinner and more transparent liquid of a mucous or serous quality. The catarrhal inflammation of the nasal passages does not often present itself in a chronic form. If it continue, it loses the cha- racter of inflammation, and rather tends to become a kind of gleet or pituitous discharge,—a disease of secretion, coming on at intervals under the influence of various constitutional causes, 128 BRONCHITIS--CHRONIC. in the manner of pituitous catarrh, which we shall afterwards describe. Sometimes we find persons complaining of an habitual stuffing or cold in the head, occasionally accompanied by a dis- charge of a sanious or puriform fluid ; and, on inspecting the nostrils, the membrane is found red and thickened ; but generally there is something to keep up this irritation, such as polypous growths or small ulcerations, which render the affection distinct from catarrhal inflammation, although it may occasionally ori- ginate in repeated attacks of this complaint. When the discharge has a fetid odour, it falls under the description of the disease called ozcena. This is, however, more commonly of specific origin, fre- quently depending on ulcerations, or changes in the membrane of a syphilitic or herpetic character, from which, together with the continued action of the air, the fetor of the discharge proba- bly arises. In young children, the coryzal inflammation shows more tendency to become chronic. It generally terminates in the formation of a thick sulphur-coloured mucus, which may con- tinue for a considerable time, now and then becoming more liquid, and either glairy or puriform. In infants, this complaint often causes great inconvenience and mischief, by interfering with the process of sucking. The slighter forms of chronic bronchitis is indicated only by habitual cough and expectoration, which are increased by sudden changes of the weather, and generally prevails most in winter and spring. It is most common in advanced life; in fact, few old people are perfectly free from it: in its slighter degrees, it may continue for many years, without materially injuring the constitution of the patient. The more severe forms may succeed to an attack of acute bronchitis, which has lasted long enough to injure permanently the vessels of the bronchial membrane, its effects not having been controlled by treatment,or various causes having kept up a local irritation at the stage in which the membrane was relieving itself by an unusual secretion. In such cases, although the sputa have become partially opaque and clotted (or concocted, as the old writers termed it), and the usual mitigation of the fever and other symptoms have accompanied this change, yet the complaint then becomes stationary, with a lower febrile and inflammatory cha- racter, but with unsubdued and more paroxysmal cough, often with dyspnoea, soreness, tightness, and wandering pains in the chest, and more or less derangement of the general health. The sputa become diffluent, or of different degrees of consistence, and mixed with opaque clots of a yellowish or greenish colour, often with decided pus; sometimes they are streaked with blood, or of a dirty gray or brown colour, and partially transparent. When the expectoration is purulent and copious, there is usually much prostration of strength, and some loss of flesh ; in some instances, with evening hectic, night-sweats, and other symptoms resembling bronchitis (Symptoms—Causes). 129 those of pulmonary consumption,—but the physical signs are wanting. The chest, in simple chronic bronchitis, still expands equally, and sounds well on percussion : the respiration and cough are heard with various rhonchi,—mucous, sonorous, sibilant, and clicking,—which are continually shifting and changing. There is no bronchial or cavernous respiration ; no permanent absence of respiration in a part: no unusual resonance of the voice; and, in spite of the continuance of the copious and puriform expectora- tion, on listening day after day, there are found no signs of a cavity, viz., cavernous rhonchus or pectoriloquy. Under these circumstances, whatever be the general symptoms, it may be pretty confidently pronounced that the disease is not tuberculous consumption, but simple chronic bronchitis. It is not, however, always very easy to get this perfect degree of negative evidence ; and it requires much experience in auscultation, as well as repeated examinations, to pronounce confidently the diagnosis. In such and all doubtful cases, we should take also into consider- ation the history of the attack, the constitution of the patient, and such of the general symptoms as may serve to throw light on the prevailing tendencies of the system. The more profuse the ex- pectoration, particularly if it be very purulent or otherwise albuminous, the less likely is the case to be one of phthisis, if no signs of this disease be found ; and it may be the more readily inferred, that the sputa only proceed from a diseased membrane. But there may be another change induced, in consequence of long-continued inflammation of the bronchi, namely, dilatation ; and this may produce physical signs, which may imitate those of phthisis. Causes. Chronic bronchitis commonly arises from long-con- tinued or repeated attacks of the acute disease, in the way already mentioned ; but in old persons it may originate without any distinct prior acute attack. An inveterate and formidable kind of chronic bronchitis is excited by the habitual inhalation of air loaded with dust. Needle- pointers, stone-cutters, those who powder and sift the materials for making porcelain, leather-dressers, and workers in artificial hair and feathers, are particularly liable to this affection. In these cases it begins with dyspnoea, which may continue for a considerable time before the disease declares itself. In the course of a few months, however, the dyspnoea is increased, and accom- panied by severe cough and copious expectoration, sometimes mixed with pus and blood. Not unfrequently the cough is accompanied with a profuse haemoptysis. At this time the con- stitution suffers much : the pulse becomes quick ; thirst and fever come on ; the tongue is loaded ; and the dyspnoea is more and more urgent, often attacking in paroxysms, attended by swelling and lividity of the face. The lesions in these cases, although beginning as chronic bronchitis, generally affect the structure of 130 BRONCHITIS—CHRONIC. the air-tubes and pulmonary tissue, and terminate ultimately in various forms of pulmonary consumption. Unless the disease be early relieved by remedies, and a total abandonment of the unhealthy occupation, they become worse; the expectoration increases to a great extent, and becomes more purulent; hectic, with night-sweats, succeeds; and the patient ultimately dies with most of the symptoms of tubercular phthisis. When chronic bronchitis occurs in early life, it generally follows hooping-cough, measles, small-pox, or some cutaneous eruption, and does not often succeed to the acute disease. It is generally a serious affection in young subjects, and is probably always accompanied or followed by considerable changes of structure in the bronchial tubes. Anatomical characters. The mucous membrane of the air- tubes is frequently found of a deep red colour, which is either diffused or in patches, and of a more livid or violet tint than in the acute disease. Not unfrequently, however, there is very little redness: sometimes the membrane is even paler than usual; and this, in cases where there has been copious purulent expec- toration. It is often thickened, particularly at the branching of the tubes, and the longitudinal and circular fibres under it irregu- larly enlarged in the manner to be afterwards described. Ulcera- tion is not common in the smaller bronchi, except in cases of the disease arising from the habitual inhalation of dust, in which the whole mucous membrane of the air-passages is both ulcerated and thickened to a greater degree than in any other case. Prognosis. The prognosis in chronic bronchitis depends very much on its origin, and on its being complicated or not with other disorders. When succeeding to an acute attack, and when unattended with much derangement of the general functions, it does not tend to a fatal termination. Even should there be purulent expectoration and some signs of hectic, a strong con- stitution and favourable circumstances often bring about a cure; and slighter forms of the disease, though obstinate and lasting for years, seem scarcely to abridge life. But in its worst cha- racter, with constant dyspnoea, copious purulent expectoration, hectic, and emaciation, especially if attended with symptoms of confirmed disease in the abdominal mucous membrane, in the liver, or in the heart, it is nearly as fatal as tubercular phthisis. In complicated cases, the bronchitis is often secondary ; and there are abundant examples which prove that it may disappear entirely, if the primary disease be of a tractable nature and yield to treat- ment. In many instances, the prognosis must in great measure depend on the physical signs : the disease is itself an attendant on phthisis; and if these give the least suspicion that tubercles are present, the case must be considered of doubtful issue. The cases of simple bronchitis that prove fatal, are those in which the mucous membrane and other structures of the tubes have become bronchitis (Treatment). 131 so altered in texture and function, that the oxygenation of the blood is permanently impeded, whilst the copious secretion, and the perpetual wearing efforts to expectorate it, waste the body and reduce the strength. Such cases generally occur in aged persons, and in those already reduced by fever or some other severe disease. The imperfect oxygenation of the blood that results from extensive chronic bronchitis, occasions congestions in the lungs and heart: hence organic diseases of the heart, with effusions of serum and of blood, not unfrequently supervene on its long continuance. Treatment of Chronic Bronchitis. In the administration of remedies in this, as in all chronic diseases, regard must be paid to the time required for the cure, and the strength economised accordingly. Unless in case of a temporary increase of pulmonary congestion or aggravation of the inflammation, bloodletting is not necessary, for it has little power to control the action of vessels under the influence of chronic inflammation. Where needful, a few leeches under the clavicles, to the top of the sternum, or cupping between the shoulders, will generally suffice ; or the existence of pain on either side may direct the place for bloodletting. The most generally useful class of remedies are counter-irritants conjoined with mild alterative tonics. Friction of the chest with an oily liniment containing various proportions of tartar"-emetie, tincture of cantharides, the essential oils, am- monia, or acetic acid, or a diluted mineral acid, according to the effect desired, or a succession of mild blisters ; or, in less severe cases, wearing an ample pitch or mercurial plaster, with a small portion of cantharides in it will furnish a choice of means applicable to every case. The methods by friction are prefera- ble to the use of plasters, for they tend to promote the respiratory movements; whereas plasters, unless they be supple and carefully applied, may somewhat restrain the expansion of the chest. To avoid this, the patient should be desired to take long deep inspi- rations when the plaster is first applied ; and if its material be rigid, long cuts should be made in it, from the middle to the margin, corresponding with the intercostal spaces from the sternum to the sides. Dr. Stokes strongly recommends the fol- lowing liniment as a rubefacient in chronic bronchitis:—R Sp. Terebinth. 3iij; Acid. Acetici gss ; Vitellum Ovi j; Aq. Rosas §iiss ; Olei Limonis 5J. We have used it with good effect; but have found a combination of ammonia with similar ingredients a still more permanent and energetic counter-irritant, such as the following:—R Lquoris Ammonias gss ad §j, Olei Amygdal. gss ; Olei Terebinth, giss ; Aquas Font, ^ij; Olei Rosmarin. vel Limo- nis 5j. M. We have sometimes employed with benefit a counter- irritant lotion, composed of a saturated solution of tartarised antimony with hydriodate of potash, in the proportion of half a 132 BRONCHITIS--CHRONIC. drachm to the ounce, adding a little oil of turpentine or lemon to distinguish it as a liniment. With external counter-irritation it is generally expedient to join such internal remedies as may seem best calculated to improve the condition of the diseased membrane, and of the func- tions generally. These must vary in different individuals; and although, in all these cases, the same local disease—chronic bronchitis—exists, yet they may be relieved by the most opposite means. Mild tonics, such as calumba and cascarilla with nitric acid, sarsaparilla, and taraxicum, are very commonly useful to improve the state of the secretions and functions in general; and where the expectoration is profuse and even purulent, without much vascular excitement, the mineral acids and metallic astrin- gents in some cases, in others myrrh, copaiba, the balsam of Peru, or benzoic acid, prove occasionally useful. Many of these are safe and beneficial only when combined with external counter- irritation. With this safeguard, we have found that even steel medicines, particularly that most valuable preparation, the iodide of iron, may be borne, and have sometimes been very salutary in improving the general health and strength, without increasing the cough. The hydriodate of potash has been also found of service in some instances: it seems to restrain low degrees of inflammation affecting the fibrous parts of the air-tubes, and probably may in some degree retard the processes of induration to which they tend. Of late years much has been said for and against the direct application of remedies to the bronchial surface, particularly of the vapour of iodine and chlor: by inhalation. This treatment, proposed some years ago by . Gannal, a French chemist, has been used with some advant; s by several practitioners. The chlorine or iodine is put in a mid state into an inhaler contain- ing hot water, and the air c} wn into the lungs through a thin layer of this water is imprcc) ted with an amount of chlorine varying according to the proportion of the ingredients used. In several cases in which we have seen this plan tried, the result has been unfavourable, the stimulating properties of the vapour exciting fever and cough, r ;d the effort of inhaling fatiguing the patient. For this method X inhalation might be substituted the diffusion of iodine or chlorine combined with aqueous vapour, either in the apartment of the patient, or, what would be more practicable, in a small room or closet, cleared for the purpose, in which half an hour or an hour could be spent twice a day. This plan has been also proposed by Dr. Murray. Iodine or chlorine may be readily dispersed in any quantity through a room, by placing a few grains of the former, or a solution of the chloride of lime or soda, in a saucer floating on hot water. The quantity should be determined by the effect on the patient, always bronchitis (Treatment). 133 keeping it below that which causes much coughing or accelera- tion of the pulse. The inhalation of tar vapour has had repeated and extensive trials, since Sir Alexander Crichton first directed the attention of practitioners to it, and there has been some evidence in favour of its beneficial effects in certain cases of chronic bronchitis. As it is of a stimulating nature, like the balsams, it proves useful only in cases free from irritability or tendency to active inflammation: it is important to watch its effects when first employed, and to diminish or withdraw it alto- gether, if it continue to aggravate the cough and quicken the circulation. The utility of expectorants in the chronic form of bronchitis has been questioned, because it is supppsed that they might in- crease the secretion that is already redundant. But they probably exert, in many instances, an alterative rather than a stimulant operation on the bronchial membrane. Thus ipecacuanha, which seems to increase the expectoration in acute bronchitis, modifies and facilitates it in the chronic disease. In some cases, it may be given with great advantage in emetic doses repeated every two or three days: in some obstinate examples of the milder form of the disease attacking persons of robust habit, this practice has effected a cure. As an expectorant, it may be given in the dose of a grain or two of the powder or twenty or thirty drops of the wine, repeated several times a day, combined with squill, colchicum, camphor, and opium, or any other combination that the symptoms of the case may indicate. Squill is very useful in chronic cough unattended with purulent expectoration ; and, in combination with colchicum, ipecacuanha, and a small quantity of opium, is often very serviceable in facilitating the expectora- tion and quieting the winter cough of old people. When the ex- pectoration is viscid, an alkali should be added ; and with a feeble state of the circulation, th"—Hirbonate of ammonia is the best. The tincture of the lobelit: roflata has sometimes proved very beneficial in the occasional aggravations of chronic bron- chitis, by relieving the breathing, and facilitating expectoration : but its operation varies greatly, sometimes causing giddiness and faintness in a dose of ten minims, so. betimes giving relief only in doses of a drachm. ° To diminish morbid sensibility, and allay that mobility of the muscular system on which the length and frequency of the fits of coughing depend, narcotics must often be combined with the preceding remedies. Unless for the sake of procuring a nio-ht's rest, opium should not be given alone, but combined with ipeca- cuanha, colchicum, or some of the other drugs which in some measure prevent its astringent effect on the secretions. The salts of morphia, liquor morphice bimeconatis, or the Tinct. Cam- phoras Co., are in many cases more suitable than solid opium or its tincture. Conium in its extract is a very useful narcotic in 18 131 BRONCHITIS--CHRONIC. chronic bronchitis, particularly combined with ipecacuanha, and, if the secretion be excessive, with benzoic acid also. The extract or tincture of conium has been sometimes used by inhalation: Dr. Stokes recommends ten or fifteen grains of the extract to be added to hot water in an inhaler, and the inhalation practiced for a quarter of an hour once or twice a day. The extract or tinc- ture of henbane, and the extracts of stramonium and of belladonna, are likewise occasionally beneficial. The latter is particularly serviceable where the cough has a convulsive character; and it should be given in large doses, such as a grain or two. In these convulsive cases, assafoetida and valerian have been found very serviceable. Hydrocyanic acid, the oil of bitter almonds, and laurel-water, which seem to owe their power to the same principle, also sometimes give great relief to the cough of nervous subjects; but we have found them very uncertain. Besides the means directed against the bronchial disease, it is of great importance to attend to the state of the functions in general. In febrile cases, the daily exhibition of a saline purga- tive is advisable. Should there be any complication with abdo- minal disorder, it is obvious that this should be attended to. Thus, when pain of the right side and shoulder, with perhaps fulness and tenderness in the right hypochondrium, stools of unnatural colour, a loaded tongue, and turbid urine, indicate disordered function of the liver and alimentary canal, it will be desirable to put the patient under an alterative course of blue pill and mild aperient medicines, in order to improve the functions of these important organs. Again, where a florid tongue, tender epigas- trium, frequent thirst, dry skin, and nightly accessions of fever, indicate that the disease extends to the mucous membrane of the stomach and bowels, it is quite apparent that many of the reme- dies directed against the bronchial disease will not be borne, or will prove injurious, until the gastric disease be relieved by leeches and blisters to the epigastrium, followed by the mildest alterative aperients, with small doses of castor oil, and rigid regulation of the diet. Until this gastritic affection be sub- dued, the action of most internal remedies, even colchicum or opium, may be irritating. If due attention be paid to the re- moval of such complications, and if the disease do not present a decidedly inflammatory character, the weakness of the system may be combated by tonics, such as the sulphate of quinine, and the others before named. Diet and regimen. The diet, in all cases of chronic bronchitis, should be mild and simple, and as nourishingascan be borne without disordering the digestive organs, or increasing the bronchial dis- order. Farinaceous and milky food, with a little chicken or white fish, is best adapted to the plurality of cases; but those whose frames have been much weakened by age or by excesses generally require more substantial animal food, with a certain BRONCHORRHffiA (Symptoms). 135 proportion of wine, which, like tonics, may be allowed with most safety where a counter-irritant is habitually used. It is scarcely necessary to insist on the importance of avoiding extremes and sudden changes of temperature, insufficient or damp clothing, and all those circumstances that are frequently in themselves exciting causes of the disease: when re-applied, they must neces- sarily prolong it; and not a few instances are met with, in which, owing to the nature of our climate, it is impossible entirely to avoid them. In these cases, in spite of the most careful adminis- tration of remedies, the disease persists; but a perfect cure may be effected by simple removal to a more genial climate. A warm sea-coast residence is the most beneficial, especially if the patient use regular and moderate exercise in the open air. When the circumstances of the patient do not permit the measure to its full extent, a change of air to the distance of a few miles may often do good, always preferring a sheltered situation with a dry soil. The careful regulation of the air in the apartments to which he is confined during the winter months, must be the resource of many in this country ; and this can now be effected with the greatest precision and economy by means of Dr. Arnott's stove, one of the most valuable inventions of the present age. There must, however, be additional means to insure the ventilation of the rooms, which may be safely effected by a smalll fan-wheel in a window or door, so placed as to direct the current of fresh air to the ceiling, where it would mix with the warm air of the room, and occasion no draft. In those predisposed to bronchial inflammation, the practice of daily sponging the chest freely with vinegar, or salt and water, contributes much to diminish the susceptibility to cold; and in the winter, the chest should be well-protected by a leather vest, as well as a long-sleeved flannel waistcoat. BRONCHORRHGEA. Symptoms, general and physical.—Causes.—Hay-asthma.—Anatomical characters.—Prognosis.—Treatment. The mucous membrane of the air-tubes may be disordered in its function of secretion, independently of the process of inflam- mation ; and, by the effects of the altered secretion as well as by the condition of the membrane itself, various groups of symp- toms are induced. The most remarkable are those accompanied by excess and defect of the watery part of the secretion, consti- tuting Bronchorrhaa, or Bronchial flux. That with excess is the 136 bronchorrhoxa (Causes). Humoral Asthma of the older writers, and the Pituitous Catarrh of Laennec. Symptoms. Bronchorrhoea generally comes on without any fever, in paroxysms of asthmatic or oppressed breathing, with cough, and the subsequent expectoration of an abundant thin frothy liquid, which appears to be the natural mucus diluted with a considerable addition of the watery part of the blood, with some portion of its saline matter. In some instances the affec- tion extends to the nasal membrane, causing sneezing and a dis- charge from the nostrils, similar to that of a cold in the head ; sometimes the bronchial and nasal affections alternate. The attack generally comes on rather suddenly in the evening, some- times twice or oftener in the day, and may last from a few minutes to several hours: the dyspnoea is sometimes extreme; but the strength of the respiratory forces being unimpaired, the fluid is discharged by violent coughing as fast as it is secreted, and comes up clear, slightly viscid, and frothy, to the amount of a pint or more, leaving the patient almost free from complaint. On applying the ear to the chest at the commencement of the attack, various kinds of whistling, cooing, and sonorous rhonchi are heard; a little later, these become mucous and crackling or bubbling, and very little of the natural respiratory murmur is heard. The sound on percussion is generally pretty good; but in severe cases this is also impaired by the profuse quantity of liquid, which from the submucous and subcrepitant rhonchi may be known to extend even to the smaller bronchial tubes. As the coughing discharges this fluid, the respiratory murmur gradually returns; but even after the paroxysm is over, a good deal of whistling and wheezing may be heard in the chest. Causes. This affection commonly occurs in persons of a relaxed habit, who have a languid circulation and are little dis- posed to inflammation. It appears to be frequently connected with long-standing disorder of the digestive or biliary organs. Laennec remarks that it is common in gouty subjects advanced in age, in whom the gout has become irregular and slight in its effects on the extremities. The causes which generally excite an attack are, exposure to sudden transitions of temperature, espe- cially when the body is perspiring, disorders of the stomach and bowels, particularly from acid or acescent drinks, and other circumstances that tend to disorder the balance of the secretions and of the circulation. It sometimes arises from the unknown atmospheric influences, which develop common catarrh or bronchial influenza: in these diseases the pituitous catarrh often forms a most prominent and important pathological part, and it may remain after the febrile symptoms have subsided. The summer catarrh, hay-fever, or hay-asthma, as it is termed from its supposed connexion with the effluvium of new hay, com- bronchorrho3A (Anatomical Characters—Prognosis). 137 monly-presents the features of pituitous catarrh in the periodical and intermittent character of its attack. After one attack, pituitous catarrh is very apt to recur ; very slight causes, such as peculiar odours, close rooms, and trivial irregularities of diet being sufficient to re-excite it. In many cases however—from our own experience we should say in a considera ble majority—bronchorrhoeal discharges are secondary on organic disease of the heart, tubercles of the lungs, or some other organic lesion, causing obstruction in the circula- tion through the lungs, the flux being a natural mode of relief to the over-distended vessels. Not unfrequently it accompanies or follows dry catarrh or bronchial congestion ; and we shall pre- sently find that the pathological difference between the two affec- tions is not great. Anatomical characters. The examination of the air-tubes of those who have died during a paroxysm of pituitous oatarrh, discovers little or no trace of inflammation in the bronchial mem- brane. It is sometimes a little thickened and softer than natural, from the infiltration of serum ; sometimes it is perfectly pale; sometimes a few lines or patches of vascularity are seen. The heart is commonly found more or less diseased, especially at the left auriculo-ventricular orifice; sometimes there is merely thin- ning of the walls. More rarely miliary tubercles are found in great abundance; and we have seen an instance of pituitous catarrh in connexion with malignant disease of the bronchial glands, which seemed to press on several of the great pulmonary bloodvessels. These several results, together with the transitory character, but long-continued recurrence of these attacks, the nature of the discharge, the absence of febrile and inflammatory symptoms in the subjects whom it affects, lead us to consider pituitous catarrh as a profiuvium depending on a laxity, want of tone, or a mechanical obstruction of the pulmonary and bron- chial vessels, rather than on an inflammation. Prognosis. The importance of this affection varies much according to the state of the individual. When it attacks a subject enfeebled by age or disease, it may prove fatal in a few hours, there not being sufficient strength to discharge the suffocating accumulation of fluid in the air-tubes. Again, its long con- tinuance, when it has by habit become established in the system, may waste the body, and by the struggle caused by its frequent attacks it may aggravate or induce disease of the heart, and lead to dropsical effusions and other serious symptoms of a breaking- up of the constitution. In other cases where the body is strong, or the disease slight, it may go on for years, impairing the com- fort rather than destroying the general health of the individual. Its occasional occurrence may even prove salutary in cases of diseased heart, by unloading the engorged pulmonary vessels, and averting more formidable evils. Andral records an instance in which a sudden temporary attack of pituitous catarrh with 138 bronchorrhosa (Treatment). very profuse discharge was attended with the removal of hydro- thorax. In all cases the condition of the general health and of other organs, especially the heart and lungs, must be duly considered before a prognostic of the probable issue of the case can be safely given; and if there be found by physical examina- tion that there is considerable disease of the heart, or a proba- bility of the presence of tubercles in the lungs, the case will assume a proportionately unfavourable aspect. Treatment. This affection is sometimes very obstinate, particu- larly when it has become established in the habit. The treatment should be considered in relation to the attacks of dyspnoea and expectoration, and to the condition of the system, and the pulmo- nary and general circulation, with a view to prevent the recur- rence of the attacks. The chief indication, when an attack comes on, is to shorten its duration by diminishing the pulmonary congestion as far as possible by means of derivatives, and pro- moting the relief of what remains by measures which assist ex- pectoration. From what we have already said of the nature and subjects of the disease, it may be inferred that bloodletting is rarely indicated. Immersing the hands and feet or even the whole body in hot water, or still better in a vapour bath, will sometimes, by deriving freely to the surface, much relieve the paroxysm of dyspnoea, and diminish the quantity of secretion which accompanies it; but to take effect, such measures should be employed at the earliest feeling of the asthmatic attack, and before the secretion commences, otherwise they only weaken the patient and scarcely shorten the attack. An emetic will often relieve an attack by determining freely to.the surface, and by facilitating the discharge of any fluid which may have already been secreted in the air-tubes; and some cases have been sig- nally benefited by the repeated use of this remedy. Its violent and disagreeable action, however, precludes its employment in many cases; particularly in the weakly, and those labouring under organic affections of the heart. Laennec found tartar- emetic in large doses effectual in two cases in which suffocation was threatened. Ipecacuanha is however on the whole pre- ferable, and when it cannot be borne as an emetic, it is sometimes useful in equalising the circulation and in promoting expectora- tion and perspiration. When the cough is very violent, it may be advantageously combined with hyoscyamus, conium, or small quantities of opium. In a few cases we have known great relief from the tincture of the lobelia inflata, in the dose of from twenty to thirty drops every hour or two hours, and increased according to its effects ; but it is a very uncertain remedy, some- times causing a most unpleasant giddiness and sickness in the dose of ten drops. In subjects that are very weak, with languid circulation, it may be necessary to give stimulants to support the powers of expectoration during the paroxysm. Of these, strong bronchorrho2a (Treatment). 139 hot infusion of coffee is the best and the most harmless, but it is apt to lose its effect; and it may be requisite to substitute com- binations of ether, ammonia, and camphor, with one of the reme- dies before named. The most important object of the treatment is to prevent the recurrence of the attacks; and for this purpose constitutional measures are of more avail than those directed particularly to the lungs. Of the latter it may however be mentioned, that the habitual promotion of moderate expectoration by small doses of ipecacuanha and the balsam of copaiba or Peru, with alkaline attenuants and other remedies, recommended for bronchial con- gestion, may sometimes prevent that accumulation in the vessels that is apt to end in an asthmatic paroxysm. The occasional application of a blister will sometimes withdraw the irritation and flux from the bronchial surface. A course of aperients may also give temporary relief, particularly where the complaint originates in a torpid state of the bowels; but drastic purgatives should be avoided, for although they may for the time remove the pulmonary symptoms, they injure the tone of the digestive organs and insure the recurrence of disorder. In gouty subjects it is useful to increase the urinary secretion by a moderate use of col- chicum with alkalies. But these measures are of little avail, unless attempts be made to improve the tone and balance of the vascular system by a mild but tonic diet and regimen. The diet should be mild and nutritive, consisting chiefly of farinaceous food and plain meat taken at regular hours and in moderate quantity. Spirituous and fermented liquors should be taken as sparingly as the previous habits of the patient and the present strength will allow. Liquids of all kinds should be used with limitation, and with due regard to the activity of the renal and cutaneous excretions. These should be promoted by regular exercise in a bracing but not a too cold air, care always being taken that the clothing is sufficient to maintain the temperature of the surface. Such measures will generally do more than drugs; but where they prove insufficient or cannot be fully adopted, benefit may sometimes be derived from a course of some mild tonic, such as columbo, cascarilla, or even quinine with a mineral acid, or the sulphate of zinc in small doses, or one of the milder preparations of steel. In cases of hay-asthma, Dr. Elliotson recommends the diffusion of chlorine in the air of the patient's apartment, by placing in it saucers, &c, containing chlorides of lime or soda. In three out of four cases, this measure afforded signal relief. 140 BRONCHIAL congestion. BRONCHIAL CONGESTION. Its symptoms and physical signs.—Causes.—Anatomical character.— Prognosis.—Treatment. Bronchial Congestion, or congestive asthma, inaccurately termed by Laennec dry catarrh, is another affection which exem- plifies altered secretion of the bronchial membrane without in- flammation. It is known more as an asthmatic than as a catarrhal affection. The symptoms vary much according to its extent. In its slightest degrees it is experienced by many individuals, who only in the morning on waking feel their breath rather short until they have coughed up a little thick, tough, gray, semitransparent or dirty-looking mucus. In its severer degrees, that is, when more of the bronchial membrane is affected, the shortness of breath may amount to asthma, which comes on in paroxysms ending with hard dry cough and the expectoration of the scanty mucus before mentioned. Occasionally there may be also a thin mu- cous secretion; but this is not constant, and is obviously not the general cause of the dyspnoea. Sometimes there is little or no cough; and the dyspnoea or rather shortness of breath is not in fits, but may last for months and even years without other pec- toral symptoms. If an attack of bronchitis supervene, there is a great aggravation of the dyspnoea, often amounting to severe asthma, and the symptoms of the two complaints are conjoined. But in simple bronchial congestion there is no fever, or sign of inflammation, but sometimes a sense of heat and constriction, or rather of stuffing, in the chest. There is often however much gastric disorder, with swelled and slightly furred tongue, relaxed uvula, and congested tonsils. The physical sign of this disease is a more or less complete suspension of the respiratory sound in the part affected, whilst the chest at that point sounds well on percussion. This suspen- sion is caused by the tumefaction of the bronchial membrane, which either of itself,or assisted by the scanty thick mucus before- mentioned, obstructs the passage of the air in ordinary respi- ration. Sometimes during coughing, or violent efforts of respira- tion, a clicking, wheezing, or sibilant sound announces that the obstruction is not quite complete ; and some of the tubes will generally yield some of these rhonchi in common breathing. These signs, together with the character of the expectoration, will suffice for the diagnosis. Causes. Excesses in diet, the sudden removal of cutaneous eruptions, suppressed gout, and sudden checks given to perspira- tion or any other free secretion, occasionally excite this affection. BRONCHIAL CONGESTION (Prognosis). 141 These causes operating on systems not much disposed to inflam- matory reaction, such as those of a torpid habit of body, destroy the balance of the capillary system, and occasion an undue dis- tension or congestion in certain parts of it. The same kind of passive congestion is sometimes more directly occasioned by organic diseases of the heart, particularly those in which there is some obstruction in the left ventricle; and these cases fre- quently are accompanied by the symptoms of dry catarrh. Anatomical character. The membrane of the air-tubes is gene- rally found of a deep red or violet colour, and sometimes panially tumefied, but without softening or ulceration. These circum- stances, together with the sudden and intermitting character of the disease in some instances and its long stationary duration in others, seem to indicate that the affection rather belongs to the class of passive congestions which may be produced and re- moved, or endure for an uncertain period without that tendency to definite terminations which inflammations manifest. This congestion may doubtless sometimes originate in inflammatory affections of the same part; but according to our experience it is more commonly, as already stated, the result of disorders of the digestive or other organs, which tend to injure the tone of some or other part of the capillary system ; and when from prior tendency the bronchial membrane becomes its seat, its secretion is impaired and the symptoms above described are induced. Oc- casionally bronchial congestion is conjoined with bronchorrhcea : but according to the view which we have taken of that affection, the pathological causes of the two do not very widely differ, the same circumstances which cause a loss of tone in the capillaries being capable of either relaxing their exhalations, or dilating their caliber; or, what is more usually the case, some parts of the membrane are affected with one, and some with the other, and the result is the expectoration of much thin glairy fluid, with little pellets of tough mucus in it. So too by a modification in the properties of the congested vessels they may be excited or relaxed, and relieve themselves by the exhalation of their watery contents; and we accordingly sometimes find an attack of catarrh or asthma, at first quite dry, and devoid of any but the tough expectoration, suddenly relieved by a copious discharge of a thin frothy fluid. This happens commonly where the conges- tion is a mechanical result of organic disease of the heart. Prognosis. Dry catarrh, although sometimes severe and dif- ficult to remove, is rarely a dangerous disease, except in so far as it may be connected with organic lesions of the heart or ex- treme general debility. According to the extent of the bronchi affected, the disease varies from a degree not interfering with the general health to one amounting to severe asthma. Andral records two instances in which fatal asphyxia was caused by tough mucus that plugged up one of the great bronchi, and which 142 bronchial congestion (Treatment). no efforts of coughing were able to remove; but these are to be considered as accidental cases ; and generally the expectoration comes at last, to the temporary relief of the breathing even in the most severe cases. But the continuance of the disease tends to induce permanent lesions of the pulmonary texture, particularly dilatation of the tubes and cells, which tend more constantly to injure the function of respiration, and sometimes eventually to destroy life. Treatment. Depending, as this affection generally does, on constitutional causes, it requires general treatment as well as mea- sures calculated to improve the condition of the affected mem- brane. A due management of the diet, avoiding all acid, rich, and irritating articles of food, the promotion and regulation of the excretions by the appropriate combinations of mild aperients and diuretics, such as blue-pill, ipecacuanha, rhubarb, aloes, nitre, colchicum, &c, followed by mild alterative tonic medicines and suitable exercise, are the measures best calculated to restore and maintain that balance and tone of the sanguiferous system, which is incompatible with the congestive distensions of its parts. With regard to the remedies directed to the congested mem- brane, it is not found that those useful in bronchitis are of much avail here. Bloodletting produces little impression. Dry cup- ping and other means of derivation are occasionally of more use. Stimulating applications to the surface of the chest, such as tur- pentine and vinegar or ammonia embrocations, or pitch plasters, or even dry rubbing, are frequently of temporary advantage. There are however means of increasing the bronchial secretion, and thus reducing the congestion, which, as temporary remedies, have considerable efficacy. We have before noticed the pro- perty which alkalies seem to possess, of determining to the bron- chial surface; and we have now to notice in addition their attenuant or dissolving power, which diminishes the tenacity of the bronchial secretion, augments its quantity, and thus facilitates its expulsion. Their action is probably in great measure chemical. We know that alkaline remedies render the urine alka- line, and therefore increase the alkaline quality of the blood. Now there is no solvent of mucus more powerful than alkalies; and it is easy to conceive that an alkaline state of the blood can scarcely be compatible with the formation of tough solid mucus. Having followed the example of Laennec in using this class of remedies, we have found them very beneficial in promoting expectoration, and relieving the dyspnoea of dry catarrh. The Liquor Potassas (n\xx to xl), carbonate of soda (gr. x to xx), or carbonate of ammonia (gr. iij to vj), may be given three or four times a day, with squill, ipecacuanha, or colchicum, and some narcotic, according to the general state of the system and the prevalence of particular symptoms. Laennec recommended also the use of alkaline baths, and of sulphur baths in cases compli- spasmodic asthma (Character and History). 143 cated with cutaneous eruptions. The inhalation of the steam of hot water, alone or with camphor, tar vapour, ammonia, or any other volatile matter which may render it slightly stimulating, is sometimes of use. Some patients derive benefit from smoking tobacco or stramonium, particularly when there is also a tendency to spasm in the bronchi. ,^ SPASMODIC ASTHMA. Character and history.—Causes.—Diagnosis.—Prognosis.—Treatment.— Atonic or paralytic dyspnoea and its treatment. The air-tubes are throughout endowed with nervous and muscular fibres, the functions of which contribute to the due performance of the act of breathing. The amount of the assistance which they thus contribute in health is not well known, but a morbid defect or excess of their operation is the cause of a peculiar class of affections of the respiratory organs of a nervous or spasmodic character, including Laryngismus Stridulus (Spasm of the Glottis), which has been already described, Spasmodic Asthma and Atonic or Paralytic Dyspnoea, Hooping-cough and Neuralgia or Morbid Sensibility of the Air-tubes. Character and history of asthma. The term asthma is generally given to dyspnoea occurring in paroxysms. We have seen that attacks of bronchial congestion and bronchial flux may come on suddenly, last a longer or shorter period, and cease in such a manner as to merit the name of asthma; by which in fact they are generally known in this country. ^ln the greater number of *-" cases of asthma, there is reason to suppose that one or other of these affections or some degree of inflammation is present, and, by increasing the irritation or the irritability of the bronchi, causes an undue contraction of their circular fibres. An increased vascu- larity of the bronchial membrane may heighten its sensibility, and augment the contraction of those fibres that are in relation to it; and the same effect may ensue from the irritation of an unusual quantity or quality of the secretion within these tubes. So on the other hand the continuance of inflammation, the thick- ened and altered condition which it induces in the membranes, may tend to impair their sensibility, and injure in proportion the contractility of the air-tubes. In all these cases, the modification of the sensibility and contractility of the air-tubes is secondary to«. other lesions that are more essentially vascular. J But there are also cases of asthma of a purely nervous cha- racter; and this is sufficiently pointed out in the temperament of the patient, the nature of the exciting causes, the very sudden 144 spasmodic asthma (Character and History). attack and removal, and the irregular duration of the affection. Thus it commonly occurs in nervous or hysterical subjects. The attacks are excited by strong or peculiar odours (such as the smell of a stable or of ipecacuanha), close rooms, sudden changes or particular conditions of the atmosphere, irritations of the stomach, mental emotions, disordered menstruation, and the like. These causes often suddenly bring on an attack, which, if severe, obliges the patient to assume a remarkable and very characteristic attitude. The body is bent forwards, with the arms resting on the knees; the chest is contracted, with the feeling of a tight cord or heavy weight upon it; the face is suffused, accompanied with an expression of great anxiety and distress; the veins are turgid, and the perspiration copious, whilst all the muscles of respiration, ordinary and supplementary, are brought into full action in order to introduce air into the chest. With what amount of success these efforts of respiration are made, may be known by applying the ear to the chest, where, in spite of the force of the motions, scarcely any sound of passing air is heard. The contractions of the muscles often give an external muscular sound ; but within the chest there is only a very faint respiratory murmur, with occasional whistling or wheezing. The violent action of the muscles of inspiration seems to diminish rather than to increase the entrance of air : but when the efforts are less violent, especially towards the end of the paroxysm, now and then the air is heard to enter freely, as if the obstacle were suddenly removed, but at the next breath there is the same obscurity as before. At these temporary returns of the respiratory sound we must suppose that the spasm of the bronchial muscles is for the moment relaxed; and Laennec has pointed out a method of causing at will this relaxation, the consideration of which may be useful in enabling us to discover the nature of the disease. If we desire a patient who labours under the asthmatic spasm to restrain his efforts of breathing, and to hold his breath altogether for a few seconds, or, what amounts to the same thing, to count with his voice as many numbers as he can without taking breath, and then as quietly as possible to breathe again, the air wiil be heard to enter freely into every part of the lungs, but in a breath or two after the spasm regains its hold, and the respiration becomes as obscure as ever. Laennec used to say by way of explanation that the spasm was thus overcome by surprise ; but this expression gives no distinct physiological reason for the phenomenon. It does not seem to be explicable without assuming that there is a temporary relaxation of a tonic spasm of muscular fibres; and this relaxation we would ascribe to an increased degree of the same cause which usually induces the contraction of the same fibres. It js probable that the contraction of the circular fibres of the bronchi, excited by a certain degree of foulness of the air that is within them, is spasmodic asthma (Symptoms). 145 an essential part of natural expiration. Now the foulness of the air being increased by holding the breath long would stimulate these fibres to their utmost contraction, a contraction even beyond that of asthmatic spasm: their irritability is thereby for the moment exhausted, the spasm becomes consequently relaxed, and the air is heard to enter freely ; but after a few moments' relaxa- tion, the irritability is again restored, and, the exciting cause of the spasm remaining, the next breath may find the contraction as strong as ever. The distinctive physical sign then of spasmodic asthma is imperfect sound of the respiratory murmur, except after holding the breath, when it becomes as loud as, or louder than usual. The bronchial spasm is often of long duration ; but it is liable to temporary increase, causing more decided fits of asthma in which the symptoms before described are manifested in the highest degree, and on their subsidence the patient is only short-breathed. When the bronchial spasm is considerable, especially in the paroxysms, the chest may sound ill on percussion, not with the absolutely dull sound produced when solid or liquid occupies the chest, but a short tight sound, like that which the chest yields on a forced expiration. This is caused by the contracted state of the lungs when under the influence of the bronchial spasm; the walls of the chest therefore being forced inwards by atmospheric pressure, are not so free to vibrate as usual, when this pressure is more nearly balanced on either side. A better sound may generally be obtained by striking on a finger or pleximeter pressed on the chest strongly enough to exceed the contraction of the lungs. This contraction when excessive sometimes causes the diaphragm to rise higher than usual in the chest, leaving a remarkable hollow in the epigastrium, and gives to the whole chest a tight and contracted appearance. We have remarked that those who suffer much from spasmodic asthma are seldom free from a shortness of breathing in the intervals ; and the frequent recurrence of the paroxysms generally increases this habitual dyspnoea. If weexamine their chests, we find the same diminution of respiratory sound as during the paroxysm, but in a less marked degree ; and the test of holding the breath proves that the spasm exists here also, having in a measure become habitual. The frequent recurrence or long continuance of these spasmodic contractions of the tubes must lead to permanent diminution of their calibre, and the other tissues become changed, and fix the tubes in this constricted size. We see the parallel of this in the irritable bladder, which, after long-continued attacks of spasm, at last becomes permanently contracted. Where the disease is purely spasmodic, this more lasting change might not ensue for a very long period ; but with the spasm there is so com- monly associated, either as cause or effect, congestion, irritation, 146 spasmodic asthma (Causes). or inflammation, that the phenomena and effects of these patho- logical conditions are very commonly combined with those of spasmodic asthma. Thus in asthmatic subjects, an attack of bronchitis, bronchial congestion,or bronchorrhoea, will be attended by spasmodic exacerbations; and a fit of nervous asthma which first comes on suddenly as a spasm, often terminates in a copious catarrhal secretion. The spasmodic constriction of the bronchial tubes, and the consequent violent yet ineffectual respiratory efforts, produce a congested state of the pulmonary vessels and partial obstruction of the circulation, which disorder the action of the heart, and may not be relieved without a free watery discharge from the bronchial membrane. On the other hand, asthmatic paroxysms are frequently associated with organic diseases of the heart. The congestion which these determine in the membranes and structure of the lungs, increases their sensibility and irrita- bility; and where the circular fibres are naturally disposed to spasm, this congestion readily excites it; and the spasm may not be entirely relaxed until the congestion is relieved by free secretion from the bronchial membrane. So also, irregular gout, or the sudden suppression of an habitual discharge or secretion, or of a cutaneous eruption, may determine an irritation and con- gestion of the bronchial surface, accompanied by an asthmatic spasm. Causes. In the preceding sketch of the history and pathology of the disease we have adverted to some of the causes which occasionally excite asthmatic spasm. But when the disease is purely nervous, there must be a condition of the nervous system in general, or of the nerves of respiration in particular, which gives the bronchial muscles unusual irritability. The nature of this condition is involved in#much obscurity ; but it may be classed with that which gives rise to many spasmodic affections of other muscles, which are called nervous or hysterical, and which not unfrequently occur in the subjects of spasmodic asthma. Hence violent mental emotions, long-continued illness, especially such as in itself or by its treatment tends to depress the tone of the system, menstrual irregularities, and particular states of the atmosphere, are among the circumstances which may predispose to, and even produce, spasmodic asthma; the predisposition is in some instances distinctly hereditary. In a few instances, spas- modic asthma has been more satisfactorily traced to a local cause of irritation, such as a tumour pressing on the pulmonary plexus, or on the par vagum, in some part of their course. Probably the remarkable influence which the state of the stomach and digestive organs often exerts on asthmatic affections maybe also referred to irritation reflected through these nerves. In some instances too a source of irritation has been found in a diseased state of the upper part of the spine, occasioning pressure on the spasmodic asthma (Diagnosis—Treatment). 147 medulla or on some of those spinal nerves which, communicating with the great sympathetic, are also in relation with the nerves of the lungs. Diagnosis. The sudden attack and removal of the paroxysms, together with the assemblage of physical signs before described, constitute the distinctive character of the disease. The slighter tonic or permanent spasm which may remain in the interval, and cause an habitual shortness of breath, may also be known by the respiration becoming distinct, not on increased effort, but after holding the breath, as well as by the absence of the signs of other lesions of the lungs or heart. The absence of fever also serves to distinguish it from inflammatory diseases. For spasmodic affections of the larynx, it may be known by the absence of the peculiar hissing or stridulous sound resulting from the passage of the air through the constricted glottis. We have before remarked that bronchial spasm is generally associated with a congested state of the bronchial vessels, ending in secretion; and it there- fore rarely happens that during the paroxysm, and especially towards its termination, there are not present also many of the signs of catarrh. So likewise where the asthma is symptomatic of disease of the heart, the signs of this, and of its various patho- logical effects, are combined with the asthmatic affection. Prognosis. Spasmodic asthma, although most distressing and alarming in its attacks, is seldom fatal when uncomplicated with organic disease. It is probable that the spasmodic constriction, . although sufficient to cause a painful feeling of suffocation in the lungs, which are perhaps unusually sensitive, always yields before the system can become injured by the imperfect oxygenation of the blood. The view which we have given of the temporary relaxation of the asthmatic spasm favours this supposition, and explains the well-known fact that spasmodic asthma is more distressing than dangerous. But as it is often complicated with other affections of the lungs and heart, or its frequent recurrence may tend to induce them, particularly dilatation of the air-cells, pulmonary congestion and hasmorrhage, dilatation and hyper- trophy of the heart, &c, we are not to regard asthma as free from dangerous tendencies. We have known more than one case of hereditary asthma occasionally attacking an individual from the age of childhood to manhood, and terminating at the age of between forty and fifty in pulmonary consumption. In such cases tuberculous disease probably existed in a limited extent from a very early period : the asthmatic spasm occasion- ally supervening on it, and tending to increase it. Treatment. This is to be considered in relation to the pa- roxysm and to the general state of the system in the intervals. The first indication is to counteract the exciting cause of the spasm, the second to remove this cause altogether or to lower the irritability on which it operates. 1. To relax the spasm of 148 spasmodic asthma (Treatment). the bronchial tubes various measures may avail according to its immediate cause : when this is chiefly nervous, with little bron- chitic or catarrhal complication, such antispasmodics as ether, valerian, assafoetida, opium, belladonna, and especially the fumes of stramonium, or tobacco, inhaled into the lungs, will sometimes succeed ; each of these has proved more successful than the others in particular cases, but seldom retains its efficacy long. A more generally and permanently successful remedy is strong infusion of coffee, long ago recommended in this country by Pringle, and much extolled by Laennec. We have known some asthmatic patients, who relied so much on its efficacy, that the very idea of being out of the reach of it would be enough to bring on a fit; and they scrupulously avoided using coffee as an ordinary beverage, lest the habit of taking it should impair its efficacy as a remedial agent. This is a good rule, for this remedy is not free from the tendency of antispasmodics and narcotics, in general, to lose their power by frequent exhibition. In most cases it is easier to avert an asthmatic paroxysm than to stop or to shorten it when it has once begun. Hence, after previous experience has indicated the usual times and signs of its approach, the remedies before- named may be given with best advantage in anticipation of the attack. This is especially the case with the smoking of stramo- nium, which we have often found useful in this way, and rarely so after the fit has begun. In some cases sudden strong impres- sions on the system, such as dashing pails of cold water on the body, or passing slight electric shocks through it, have been known to stop a fit of asthma. Strong counter-irritants and revulsives, such as mustard poultices to the epigastrium, hot turpentine fomentations to the chest, and irritant pediluvia, in some cases give relief, but in others aggravate the symptoms. Emetics have the same uncertainty of effect. If the asthmatic spasm be complicated with an inflammatory or congestive state of the bronchial or pulmonary vessels, which is very frequently the case, the treatment recommended for these conditions may be advantageously combined with some of the antispasmodics just mentioned : and when the nervous affection does not form the chief part of the complaint, it is probably dependent only on the altered condition of the membrane, which is either inflamed or con- gested ; and to this condition therefore the remedial agents must be chiefly addressed. Under such circumstances depletions and other antiphlogistic measures which are rarely useful in purely spasmodic asthma become the best remedies. 2. The fulfilment of the second indication, to diminish exces- sive irritability of the bronchial muscles, and to remove the causes of irritation by which they are excited, will be best aimed at by various means which tend to restore a proper balance of the func- tions of the whole system, and to improve the general health. Of these the most effectual are those of diet and regimen. Particu- spasmodic asthma (Atonic or Paralytic Dyspnoea). 149 lar rules can scarcely be laid down, and the experience of the patient is required to give a clue to the most eligible plan; but generally, a simple, light but nourishing diet, with great regu- larity as to hours, and moderation as to the quantity of food, will be the most suitable. The daily use of cold sponging to the chest, or the shower-bath if it can be borne, and of moderate exercise in the open air, avoiding walking against a strong wind, is gene- rally beneficial. Of medicinal agents, besides those necessary to regulate the secretions, which always need attention, the metallic tonics sometimes prove useful in diminishing the morbid irrita- bility of the bronchial muscles, or of the nerves that influence them. We have found in various instances the oxide and sulphate of zinc, the sub-nitrate of bismuth, the nitrate of silver, the milder preparations of iron, severally, beneficial in diminishing the tendency to the recurrence of the paroxysms. Probably these remedies act through the nerves of the stomach, which are supplied by the same trunk (the par vagum), with those which influence the bronchial fibres; and they may do this directly, or indirectly, by improving the condition and function of the stomach, disorders of which in some form or other are commonly associated with spas- modic asthma. The signs of improvement are (besides the less frequent occur- rence and diminishing severity and duration of the paroxysms) a more free state of the respiration in the intervals, so that the vesi- cular murmur is pretty audible without much wheezing, through- out the chest, and is increased in loudness by quicker and deeper inspirations, not stopped or impaired as during the continuance of the asthmatic tendency, when additional effort will often at any time excite the spasm. In the cure of this, as of other spasmodic disorders, it is very necessary to study the circumstances that excite the paroxysms in each case, in order to be able to avoid them ; for the frequent occurrence of spasm increases the facility of its return, until it becomes habitual and may be excited under almost any circumstances. The evil of an habitual asthma is not only the inconvenience and distress occasioned by the paroxysm itself, but also the permanent changes which it may induce in the structures of the lung, such as contraction and rigidity of the air-tubes, congestions, emphysema, and other lesions of the parenchyma, and diseases of the heart and whole circulating system. Atonic or Paralytic Dyspnoea. Hitherto we have considered only the spasmodic form of asthma, or that dependent on an excessive contractility of the bronchial tubes : but as in examining the elements of dyspnoea we found that defect of these properties would disorder the process of breathing, we are led to inquire whether there may not be a nervous asthma or dyspnoea of this kind from weakness or paralysis of the circular fibres, or of the nerves which regulate their contractions. We have parallel 20 150 spasmodic asthma (Treatment). affections of the alimentary and urinary passages, when from local or general causes their moving fibres become torpid or paralysed ; and if we are right in supposing that the action of the circular fibres, as well as the elasticity of the longitudinal fibres of the bronchi, be essential to the effectual performance of the act of expiration, defects of the properties of these tissues must cause a proportionate imperfection in this act. We meet with instances of dyspnoea generally accompanying chronic bronchitic affections, but sometimes in hysterical females and other nervous subjects, in which this difficulty of expiration is the prominent feature ; this part of respiration being wheezing, pro- longed and attended with effort, whilst inspiration is compara- tively short and easy. So also we see the defective action of the contractile fibres of the intestinal tube arise sometimes from pre- vious over-irritation, and sometimes from more directly weakening or paralysing causes, and sometimes from that irregular distribution of nervous influence which produces the phenomena commonly called hysterical. Nay, if we consider that irritations first exalt, and afterwards injure, the contractile properties of hollow organs or tubes, and that these irritations or inflammations affect succes- sively different parts of the same tubes, we can understand that spasmodic and relaxed asthma may co-exist in the same person, one part of the bronchial tube§ being unduly contracted, and another unduly relaxed, from an irregular distribution of the property of irritability. This subject will be noticed again under Dilated Bronchi and Air-cells. Treatment. Depending as this affection usually does on pre- vious inflammatory or congestive affections of the air-tubes, the remedies generally useful at the decline of those lesions are such as may be supposed to act in some measure by stimulating or giving tone to the bronchial fibres. Thus ammoniacum, benzoin, myrrh, the balsams of Copaiba and Peru, and the inhalation of tar and other stimulating vapours, besides their operation on the secerning function of the air-tubes, may probably have an influence of this kind on their moving fibres; and they may thus improve their powers in relation to the act of both expiration and expec- toration, the difficulty of which often forms the most prominent feature of many protracted inflammatory and congestive disorders of the air-tubes. hooping-cough 'Syrpgtoms). 151 HOOPING-COUGH. Symptoms—Division into three stages.—Varieties and complications.— Causes.—Anatomical characters.—Nature.—Diagnosis.—Prognosis—Treat- ment. The disease known by the names hooping-cough, pertussis, chin- cough, convulsive cough of children, and which generally occurs once only during life, seems to combine several of the characters of inflammatory affections of the air-tubes with those of a nervous description, already adverted to, and, from its occasional severity and frequent complication with other serious diseases, merits careful consideration. Symptoms. The simple or uncomplicated form of hooping- cough generally exhibits three stages: in the first it is inflam- matory, a bronchitis or catarrhal inflammation; in the second it is both an inflammatory or at least congestive and nervous affec- tion ; in the third it is entirely nervous, although it may in some cases be complicated with alterations in the pulmonary structure. The first stage commonly begins as an ordinary cold, often accom- panied with coryza, but there is more headach, languor, and often more febrile disturbance than usual; these symptoms sometimes precede the cough, which however begins earlier than in an ordi- nary cold. The general symptoms vary greatly in degree; being in some cases very severe, in others very slight, and not sufficient to require treatment. In the former case the pectoral symptoms are also very severe at first, with pain, soreness and oppression of the chest, dyspnoea, and other symptoms of severe bronchitis. The cough is at first hard, short, and ringing, being apparently excited by the irritation of a thin saline-tasted mucus in the glottis. The transition to the second stage, which com- monly takes place in from four to eight days, is marked by the cough coming on more in fits and of a more violent character. The tickling in the throat is less constant, but when it comes it cannot be borne an instant, but excites an uncontrollable cough, consisting of many repeated violent expiratory efforts followed by a long inspiration, which, by the hooping or crowing noise often accompanying it, may be known to be drawn through an imperfectly opened glottis. The hooping depends on an undue irritability of the laryngeal and bronchial muscles, so that they do not relax, as usual, during the act of taking breath. But this sonorous back draught is not always heard in this complaint, particularly if the subject be not 152 hooping-cough (Symptoms). very young; and on the other hand it often accompanies other severe kinds of cough in children, in whom the aperture of the glottis is small and disposed to contract. This is further illustrated by the result of auscultation. On applying the ear to the chest of a child during a fit of hooping-cough, one is surprised to hear so little sound of respiration within the chest with all the violent external motions; and during the sonorous back draught,there is scarcely any sound of air entering trie pulmonary tissue. This is to be ascribed to the continued contraction of the glottis and large bronchial tubes preventing the air from penetrating to the vesicular texture with sufficient force to produce the ordinary respiratory murmur; for in the convulsive cough of adults there is no obstructed hooping inspiration, but a full forcible one which is heard loudly in all parts of the chest. The other physical signs of pertussis do not differ from those of mild bronchitis; there being often variable sonorous, sibilant, and mucous rhonchi in the upper and middle parts of the chest. The fits of coughing generally terminate in the discharge of a thin glairy mucus; and such is the violence of the action of the abdominal muscles that the con- tents of the stomach are often forced up by it. The termination of the cough in vomiting is merely the result of the violence of the action which produces the cough: as soon as the muscular efforts have compressed the chest as far as it will yield, their force falls on the stomach, and in proportion as the cardiac orifice yields is the completeness of the act of vomiting. This dis- position is increased by habit; and consequently as the disease advances the fits of cough often terminate more frequently and speedily by vomiting or retching. The violent and convulsive character of the cough is its most characteristic feature; the face and neck become red or purple, and turgid; the eyes are injected; the throat, chest, and abdomen are quite sore with straining, and the whole frame is so shaken, that the child is obliged to lay hold of something to afford support, and seems to be on the verge of suffocation. It is no wonder, that with such straining the expec- toration should be sometimes streaked with blood, or that blood should flow from the nose ; yet this does not. happen very often, but chiefly in the plethoric, or in those predisposed to epistaxis, and, if not excessive, is salutary. No wonder too that convul- sions, coma, and other cerebral affections, are sometimes induced in young and delicate subjects. At this time the violent parox- ysms of cough sometimes cause mechanical injury of the apparatus of respiration and circulation: the air-tubes and cells become partially dilated or ruptured, the passage of the blood through the lungs is impeded, congestions are produced, the action of the heart is disordered, the foramen ovale may sometimes be re- opened, giving rise to blue discoloration and oedema of the surface, etc. At this period in severe cases also there is often remittent hooping-cough (Varieties). 153 fever at night; and with it there may be combined the various inflammatory complications in the chest, head, and abdomen, which constitute the chief source of danger in these cases in pertussis. We shall advert to these hereafter. In slight cases there may be no fever, and little functional disturbance in the intervals of the cough; but the common presence of the sonorous and mucous rhonchus, particularly before and after the cough, and the mucous expectoration in which the cough generaly termi- nates, indicate that in all cases it is still a bronchitic or catarrhal as well as a nervous affection: and in fact, as this stage declines, the expectoration generally assumes the more consistent and opaque form which characterises the concocted sputa of a termi- nating bronchitis. . , This change, which may occur from the third to the sixth week after the commencement of the disease, marks its transition to the third or purely nervous stage. There is great variety in its severity in different subjects : in some the convulsive cough may only come on twice or thrice in the twenty-four hours, and cease in the course of a few days: in others it rapidly loses its convulsive character and subsides like a common cougn; in the maiority of instances, however, it retains its convulsive character to the last, but becomes less frequent in its attacks, and ceases from six to ten weeks from the commencement of the disease. Delicate nervous children often suffer long and severely in this last stase, which assumes somewhat the form of a chronic con- vulsive disease; and even after it has itself ceased, for a long times it gives its character to any fresh cough that may be con- tracted from other causes. Varieties and complications. The first or febrile stage of the disease is complicated occasionally with extensive bronchitis, and more rarely with pneumonia, pleurisy, or croup. These compli- cations generally occur at times of the year, and in situations, in which such affections prevail; or they, as well as other complica- tions, may be the result of individual predisposition developed by the fever which accompanies the disease. The greater intensity of the inflammatory and febrile symptoms, the more continued oppression and pain in the chest or throat, permanent frequency of the breathing and pulse, with the physical signs distinctive of these several affections, mark their occurrence. The cough becomes less violent and sonorous, but still frequent, and in the intervals the mucous or crepitant rhonchus is heard in the chest or there may be partial absence of the respiratory murmur, with dulness on percussion. Less commonly the membranes of the Drain are affected, and the grinding of the teeth the rolling of the head, intolerance of light, contracted pupil, followed by squinting, vomiting, screaming, &c, indicate the presence of acute hydrocephalus. 145- hooping-cough (Causes). With any of these complications unsubdued by treatment the disease may prove fatal in the course of a few days with the usual symptoms of these affections. In the second stage the most fre- quent complications are partial pneumonia, hydrocephalus, and gastro-intestinal inflammation. Circumscribed or lobular peri- pneumony is a very common and fatal complication of severe hooping-cough among the children of the poor. It causes con- tinued dyspnoea with quick pulse and hot skin, and crepitation or obstructed respiration and dulness in some part of the chest. Effusion in the brain may be apprehended when convulsions come on, or when between the fits of coughing the child rolls his head from side to side, with moans indicative of pain, or when he lies in a lethargic or half comatose state, with dilated or contracted pupil, strabismus, and paralysis or contraction of some of the limbs. This formidable complication is by no means uncommon in young children during the period of dentition. Gastric mucous inflammation is marked by the characteristic appearance of the tongue, continual thirst, occasional vomiting not excited by the cough, pain or tenderness at the epigastrium, looseness of the bowels, the stools being offensive, dark or clay-coloured: or in some cases constipation, scanty high-coloured urine, with burning heat coming on at night, followed by perspiration, progressive emaciation, &c. These signs of gastric irritation are sometimes combined or followed by those of inflammation and effusion in the head; or if this organ escape, and the abdominal irritation proceed, accompanied by the cough, it may terminate in tuber- culous disease of the lungs or of the mesenteric glands. In these complicated cases, if the patient survive the dangerous lesions until the usual period of the third or nervous stage, the phenomena of this stage vary much according to the nature of the compli- cation, the convulsive cough being cometimes absent and some- times unusually severe in the cephalic cases; whilst those, in which the gastro-intestinal membrane or the lungs take on per- manent disease, in some instances retain the convulsive character, and in others they present merely that of chronic cough. Causes. Hooping-cough may occur epidemically, sporadically, or it may be propagated by infection. The latter cause is ques- tioned by some writers, but there is as much evidence in favour of the infectious properties of this as there is of any other disease, it having been known to spread among a family and neighbour- hood from one case brought from a distant part; and its extension to other children being often prevented by their removal. It resembles the other contagious diseases of children in its rarely occurring more than once in the same individual. Like these, however, the disease spreads more rapidly under certain unknown epidemic influences; and passes by individuals in a manner that proves some bodily predisposition to be necessary for its production. hooping-cough (Anatomical Characters). 155 Its epidemic prevalence has been frequently observed to accom- pany that of measles; the one disease sometimes succeeding to the other. The period of life in which it most commonly occurs is be- tween the ages of two months and twelve or fourteen years, but it occasionally happens before and after, and a few individuals escape it entirely. On the other hand, when it has occurred during infancy, it occasionally though very rarely recurs in after life. This happened to the writer, who suffered severely from a second attack in Paris in 1826, having probably contracted it during his attendance at the Hopital des Enfans Malades. Mothers have also been known to have the disease a second time when suckling a child labouring under it. We have seen many instances in which adults, who in early life had pertussis, contract a cough of a convulsive character during the prevalence of the disease among children in the house. It has been occasionally observed when hooping-cough attacks adults, the paroxysms recur during the night only, interrupting sleep and exhausting the strength. In children also the paroxysms are often more fre- quent and violent during the night. The infectious properties of the complaint probably last during its two first stages, but this is very uncertain. Anatomical characters. As hooping-cough rarely proves fatal, except in consequence of its complication with some other disease, it is not easy to learn from anatomy its essential effects. Most writers agree, however, that the lining membrane of the wind- pipe, from the epiglottis to its larger branches, is more or less injected and often covered by a thick mucus, and the bronchial glands are also red and much enlarged. Dr. Copland adds his testimony to that of Ozanam of Milan that the oesophagus also bears marks of inflammation; and he mentions having observed inflammatory appearances in the medulla oblongata and its mem- branes, even when there was no other remarkable lesion within the cranium, but he does not state what these appearances were. In the complicated cases, the common effects of inflammation are found in the organs which have been peculiarly affected. Thus in the bronchitic cases the bronchial membrane is much more ex- tensively inflamed than usual, and the tubes are everywhere filled with spurious mucus, sometimes mixed with pus. The results of pneumonia are seen in the engorgement and hepatisation of portions of the lungs, in these cases often confined to lobules, par- ticularly about their margin. In more protracted cases tubercu- lous deposits are sometimes formed, and the air cells and tubes are often irregularly dilated. Various products of inflammation are, in some instances, met with in the pleura and pericardium. When the head has been affected, serous effusion and opacity of the membranes have been seen in the brain, and rarely softening of its substance. When there has been remittent fever the mucous 156 hooping-cough (Pathology). membrane of the ileum, caecum, and colon is found inflamed, and occasionally ulcerated, and the mesenteric glands enlarged ; in prolonged cases with a scrofulous tendency, tuberculous matter is deposited in these glands. In cases of hooping-cough which terminate quickly in death, there is no pro- minent lesion ; the brain is a little more livid than usual, both in its cortical and medullary portion, but there is no effusion of serum, and its consistence is not materially affected. The bronchial tubes contain a thick mucus, and are rather bluish than reddened. If the disease continue for a long time, the bronchi are dilated and filled with the same viscid secretion : the dilatation evidently arises from the repeated attacks of cough, and tends to retard the recovery of the patient. The complications which may occur in the course of the disease are very numerous; they are inflammation of the lungs and brain and tuberculous formations, especially the minute semitransparent granulations and tubercles in the bronchial glands ; they are of course extremely variable. Pathology. There has been a great diversity of opinion respect- ing the nature and essential seat of pertussis. Cullen, Guibert, Hoffmann, Hufeland, and most other German authors, consider the disease as essentially nervous, depending on irritation (not in- flammation) of various parts of the nervous system, particularly the phrenic and pneumogastric nerves, and causing spasmodic action of the larynx, diaphragm, and stomach. Leroi, Webster, and Begin ascribe the disease to inflammatory irritation of the brain and its membranes. Watt, Badham, Dawson, Dewees, Guer- sent, Laennec, and most other French authors hold the disease to be essentially bronchitic or catarrhal, with the addition of convulsive action of the diaphragm and larynx, excited, according to some, by an excessive sensibility of the inflamed bronchial membrane. A third view, particularly maintained by Desruelles, is that hoop- ing-cough depends on inflammation of the bronchi speedily caus- ing irritation in the brain, whence is reflected convulsive excite- ment of the diaphragm, muscles of the larynx, &c, which gives to the cough its peculiar character. Dr. Copland considers the disease to be essentially a nervous irritation, commencing in the respiratory surfaces, and through the nerves, chiefly the pneumo- gastric, transferred to the medulla oblongata, whence it again affects the respiratory apparatus and sometimes the stomach ; and that predisposing or concurrent causes may readily convert this irritation, at either of its seats, into inflammation. In reference to these different views we may remark that in many instances they do not sufficiently regard the physiological character of those morbid motions which form the chief feature of hooping-cough. Thus we find much ascribed to the phrenic nerve and diaphragm, when it is obvious that these agents of inspiration are little, if at all, concerned in the motions which con- stitute the cough. We regard hooping-cough as originating in hooping-cough (Diagnosis—Prognosis). 157 a specific irritation (almost always inflammatory at first) of the lining membrane of the upper portions of the air-passages. This irritation is in the first stage constant, and accompanied with cough and expectoration, like those of common inflammatory catarrh ; but in the second stage it peculiarly increases the irri- tability of the laryngeal constrictor and bronchial muscles, and of the nerves which excite the contractions of these as well as of the expiratory muscles which are sympathetically associated with them—those in fact which are concerned in the act of coughing. The peculiar cough of pertussis resembles that excited by a foreign body directly irritating the glottis ; in fact it is properly called pertussis, for it consists of an exaggeration of all the actions of an ordinary cough and of nothing more; and there is no more reason for seeking its cause in the brain or spinal marrow, than there is for referring excessive vomiting or dysenteric straining to this seat. It is unnecessary to go further than the respiratory apparatus for an explanation of the phenomena of hooping-cough. The irritation which at first extends to the vessels and is more constant, becomes afterwards purely nervous, and like other local nervous affections, such as neuralgia, spasms, nervous colic, &c, manifests its effects only occasionally, perhaps under the influence of some additional exciting cause. The various complications which so much increase the danger of hooping-cough, we would regard chiefly as the effects of the violent cough, sometimes assisted by predispositions to particular diseases or by co-operating causes. Any one who has witnessed the severe paroxysms of hooping-cough can scarcely wonder that it may produce in the head, in the lungs, and in the abdomen, serious congestions, which previous tendencies, or additional exciting causes, may readily convert into inflammation and its effects—hydrocephalus, pneumo- nia and intestinal disease. Diagnosis. The convulsive character of the cough, consisting of a rapid succession of violent short expirations, followed by a long inspiration, which is hooping in young children, forms the most distinctive feature of pertussis. Its termination in the dis- charge of glairy mucus, or of the contents of the stomach, also seldom happens habitually in other coughs. The convulsive or hysterical cough of adults sometimes exactly resembles pertussis even in the hoop; but the history of the case, and the alternation of the affection with other nervous complaints, will serve to dis- tinguish it. Prognosis. Hooping-cough, when occurring in children pre- viously healthy, and not disposed to visceral disease, and when unattended with high fever at its commencement or with great violence and frequency of the paroxysms afterwards, is not a dangerous disease. But it is highly dangerous and destructive when, either from the delicacy or previous tendency of the sub- ject, or from the violence of the cough, it becomes complicated 21 158 hooping-cough (Treatment). with inflammatory or congestive lesions of the head, chest, or abdomen. When, therefore, it attacks young children, under two years old, who are under the additional influence of the irri- tation of early dentition; or when it attacks children who are delicate from constitution or prior disease, or who belong to a family in which hydrocephalus or scrofula has prevailed ; or when it comes on in any subject with high fever, difficult breathing, and other signs of complications : or when from the extreme vio- lence and frequency of the cough these may be expected to ensue, —the prognosis must be expressed in terms of uncertainty. Treatment. The three stages which the disease presents, form the ground of indications of treatment, varying as the complaint advances; and the complications, when present, will also furnish further indications. In the first stage moderate antiphlogistic measures ; in the second, these in combination with expectorants and sedatives to allay the nervous and muscular irritability; and in the third stage, antispasmodics and nervous tonics,—form the chief indications of treatment of simple hooping-cough. In the milder cases, very trifling measures, such as an occasional emetic and mild aperients, and avoiding imprudent exposure, when the weather is variable, may suffice ; and, except in the early stages, confinement is unnecessary: in the severer forms, however, close attention to the symptoms will be required throughout the complaint. The first stage is to be treated much in the same way as ordinary catarrhal bronchitis, which it resembles. Bloodletting only in the plethoric or when inflammation runs high, antimonial expectorants, and occasional mild mercurial and other aperients, are the chief remedies. If there be much heat of skin, a few doses of James's powder, or of an antimonial saline with nitre, should be given. In the second stage, the antimonial expectorant may be con- tinued with advantage ; but it must now be combined with a sedative, to diminish the violence of the paroxysms of cough. These paroxysms generally terminate with the expectoration of glairy mucus ; and, by favouring this secretion, antimonial or ipecacuanha wine in small doses, combined with an alkali, as in bronchitis, will generally shorten the duration of the fit. Full emetic doses have been very strongly recommended with the same view; but, except in case of accumulated bronchial secretion, we consider that equal benefit may be derived from expectorant or slightly nauseating doses, for they are far less weakening, and are quite sufficient to induce vomiting if that be desirable. Of sedatives, those most recommended are hydrocyanic acid, bella- donna, and opium. The first has been highly extolled by Drs. Granville, Elliotson, and Roe; but its administration demands great caution, especially in young children, for its sedative influence affects the heart as well as the muscles and nerves of hooping-cough (Treatment). 159 respiration; and the circulation of very young subjects, if sud- denly depressed, does not readily recover its power. Belladonna has been much recommended by several continental practitioners. We have found it more safe and more effectual than prussic acid ; and its dose may be considerably increased without any real risk. We have given a quarter of a grain three times a day to a child of two years old, half a grain to one of four, and a whole grain to one of eight years of age; and increased these quantities to double and more when they ceased to relieve. These doses generally cause dilatation of the pupil; and we conceive that the remedial agency of the drug depends on the same power to diminish the irritability in the laryngeal and bronchial nerves and muscles, which is thus evinced with regard to the iris. In a few cases there have been some feelings of heat and dryness in the throat, giddiness, and pain over the eyes; but these symptoms soon cease when the medicine is discontinued. They are more alarming than dangerous, for instances have occurred of upwards of a drachm of the extract being taken without any bad effects further than the continuance of these symptoms for a day or two. Belladonna often signally diminishes the violence and frequency of the paroxysms of cough ; but as it is liable to lose its efficacy by constant use, it is better to intermit it for a few days, and then resume it. In the more violent cases, it is necessary to resort to the stronger sedative—opium. It is best given in form of solution of one of the salts of morphia, combined with ipecacuanha and small occasional doses of calomel or hydr. cum creta. Its administration requires much caution in very young children and those with cephalic symptoms: in these it should be always combined with calomel. Syrup of poppies is objectionable on account of the uncertainty of its strength. At the early part of the second stage, blisters are often bene- ficial, especially if there be more than usual bronchial inflamma- tion : with young children they should not be left on for more than three hours. Afterwards stimulant and anodyne liniments rubbed over the whole chest occasionally prove useful. Cam- phorated liniment, with additions of oil of turpentine or amber and ammonia, may be applied. Tartar-emetic ointment has also been recommended for the same purpose; but it is less eligible, for the painful pustules which it excites prevent the con- tinuance of the daily friction to which embrocations seem to owe much of their efficacy. In the third stage, when the complaint is purely nervous, be- sides the sedatives and-antispasmodic embrocations, another class of remedies becomes of great utility—tonics and even stimulants. Bark, myrrh, preparations of iron, arsenic, suphate and oxide of zinc, nitrate of silver, assafoetida, musk, tincture of cantharides, and many other medicines of this class, have been much extolled by different writers; and each, perhaps, is occa* 160 hooping-cough (Treatment). sionally useful in particular cases. In the choice of them, the practitioner must be guided by general principles or analogies. Thus in cases presenting a periodic character attended by debility, bark or arsenic may be most suitable : in those of a more con- vulsive type, assafoetida, musk, or tincture of cantharides, fol- lowed by the preparations of zinc or silver, may be found useful; whilst in cases decidedly asthenic, steel medicines are far more effectual. Of the latter, the ammoniated iron and carbonate of iron are generally the best preparations. M. Lombard of Geneva has recently written strongly in favour of the carbonate of iron, which he uses to the extent of twenty-four to thirty grains in the day even for very young children. In the employment of this and other tonic remedies, it is important to keep the excretions free; and to withhold the tonic, if there be any signs of obstruc- tion, inflammation, or vascular irritation. Diet and regimen, In the early stage the diet must be light, consisting of milk and farinaceous food. In the second stage white meat or jelly may be allowed ; and children who are pallid may sometimes with advantage be permitted to take meat and the more nourishing articles. In the third stage the diet may be as in health. In the first or inflammatory stage of hooping-cough the child should be confined to the house and warmly clothed; and exposure of every kind should be avoided as much as in bronchitis. But towards the end of the second stage, when all feverishness and sharpness of the pulse have subsided, much benefit may be derived from the open air, and especially from a change of air. In the last stage, a change of air is almost a specific; any kind of change, and although only to the distance of a few miles, will sometimes entirely remove a cough that has baffled all medicines. Treatment of the complications. When in the early stages of the disease, connected with its febrile onset, there are signs of inflammation in the head or chest, the appropriate antiphlogistic treatment must be employed, but not with the same freedom as if this inflammation were the only lesion. No antiphlogistic treat- ment will stop the course of hooping-cough; and a certain amount of strength must be reserved to support the patient through it. With this qualification we may refer to Acute Hydro- cephalus and Pneumonia for the treatment proper in these compli- cations. The congestive and inflammatory complications arising in the second stage from the violence of the cough and other concurrent causes, may be more successfully guarded against than cured. A few leeches to the head or chest, when any signs of congestion or irritation show themselves there, the occasional exhibition of mercurial aperients, the removal of dental irritation by free scarification of the gums, and the continued use of measures calculated to diminish the violence and bad effects of the cough, constitute the chief means of preventing the produc- neuralgia op the air-tubes (Symptoms). 161 tion of serious disease. Of these, none is more important than the precaution of raising the child to a proper posture when attacked by the cough. It is a case in which a careful nurse is invaluable. The child should never be allowed to lie, or to hang its head down, during the severe fits. The paroxysms when very severe, and causing great turgescence and lividity of the face, may often be cut short by dashing cold water on the face, or by blowing into the ear. When once hydrocephalus or pneu- monia has been induced, it must be treated, as far as the strength will bear, in the usual way ; but from the weakness resulting from the previous disease, and from the repetition of the cough which it yet induces, these secondary forms of lesions are more fatal than when they occur idiopathically. Remittent fever, or other symptoms of gastric irritation, must be treated on the usual plan of mild alterative aperients, a strictly regulated diet, occasional warm baths, &c. In case of chronic bronchitis, pneu- monia, or pleurisy, which in some instances succeed to hooping- cough, the treatment recommended for these affections must be adopted. The convulsive cough of adults, not of a specific nature, is generally associated or alternated with other forms of spasmodic or convulsive disease, in which there is a great mobility of various muscles, an exaltation of the natural relation which subsists between certain nerves and. the muscles which they influence. In several such cases, we have found extract of belladonna with the pilula aloes and assafoetida, and a galbanum or pitch plaster to the chest or back, give most effectual relief. Where the com- plaint is more obstinate, a course of the metallic salts, subnitrate of bismuth, nitrate of silver, sulphate of zinc or ammoniaret of copper, is often successful in removing it. They may generally be mupti aided by the shower-bath, country air, exercise, and othep/means which diminish the mobility of the nervous system. / Neuralgia, or Painful Sensibility, of the Air-tubes. A pain in the larynx or under the sternum is sometimes pro- duced independently of inflammation or any other affection. It is most commonly excited by breathing cold air, but sometimes comes on independently of any such cause. This morbid sensi- bility, although often, is not invariably accompanied by increased contractility. Spasmodic asthma, or spasm of the glottis, may be unattended with any other pain than that common to dyspnoea; and on the other hand, the weak or relaxed state of the bronchial tubes, marked by difficult or imperfect expiration, is sometimes accompanied by an increased sensibility of the bronchial mem- brane, so that the breathing of cold or irritating air becomes unusually painful. Under such circumstances the pain may be considered as nervous, depending on an excessive sensibility of 162 STRUCTURAL lesions of the air-tubes. the sentient filaments of the par vagum, like the gastrodynia and morbid sensibility of its gastric branch. Treatment. The direct application of narcotics, by inhaling their vapour or smoke, will sometimes relieve nervous pain of the air-tubes. The vapour of hot water charged with camphor or conium with an alkali, smoking a cigar, or even holding in the mouth a lump of camphor or a warm aromatic lozenge, a bit of ginger, or a clove, will in some cases remove the pain, and enable the individual to lake breath freely. Where cold air only excites the pain, a respirator, or some warm porous material held to the mouth, will prevent it. But it is better to attempt to reduce the morbid sensibility by the daily use of the shower-bath, or by freely sponging the throat and chest with vinegar or salt water, at first tepid, but after a few days quite cold. STRUCTURAL LESIONS OF THE AIR-TUBES. Hypertrophy and induration—Dilatation, Contraction and Obliteration.— Ulceration.—Tumours. Hypertrophy and Induration of the Air-Tubes. Changes of structure in the bronchial tubes are most commonly the result of inflammation, or of some kindred modification of the nutritive process. Frequent recurrence or long continuance of inflammation of the bronchial membranes, as in other structures, changes their condition, and the mechanical forces to which they are subjected in the function of respiration may variously modify this change. The most simple change of structure is a mere thickening of the mucous and submucous tissues. This generally in some degree accompanies acute inflammations, but is then only temporary, and subsides as the secretion becomes free and albuminous ; being caused, probably, by only an infiltration of he pores of the tissue with soft lymph, which, as the inflamma- tion subsides, is eliminated and expectorated with the mucus of the membrane. The deposits that are the most readily produced by inflammation in highly vital tissues, are also the most readily removed ; and thus it is that the soft albuminous matter that is effused by acute inflammation in cellular textures and in paren- chymatous organs in general, if it be not so abundant as to air-tubes (Hypertrophy and Induration). 163 compress the vessels, becomes absorbed as the inflammation subsides. But it is otherwise when the inflammation recurs frequently, or lasts long ; for it then causes an effusion less susceptible of absorp- tion, involves the less vital structures; and as the changes induced are slow, so they are more permanent, because they become identified with the nutritive or reparative functions of these tissues. A degree of hypertrophy is then produced of some or all of the various tissues composing the tubes. Sometimes there is extraordinary thickening of the mucous membrane, so that it forms projections within the tube. More commonly, however, it is the harder and less vital textures that undergo the change, and its effects is to increase the rigidity of the tubes, so that there is a diminution of their expansibility and contractility. Nothing is more common than to find the air-tubes of persons who have long suffered from bronchitis, presenting an unusual development of the longitudinal elastic fibres. In other cases, the outer cellular coat of the larger bronchi is thickened and in- durated, and their cartilages are sometimes partially ossified. Any of these changes has the effect of rendering the lungs less easily expansible in respiration : the first in particular is a com- mon cause of the short breath from which persons frequently affected with bronchitis generally suffer; and although not often serious in itself, yet it may so abridge the sphere of the function of respiration as to make its increased exertion, during bodily exercise, a matter of difficulty and disorder, and to render it ill able to bear any other disease, to which the lungs can in general adapt themselves by supplementary efforts. The chief sign of hypertrophy of the longitudinal fibres, and of increased rigidity of the tubes generally, is difficulty of inspira- tion, which is short, quick, and performed with an effort, espe- cially on making any exertion; whilst the expiration is compa- ratively easy: but both acts are often accompanied by wheezing sounds from irregularities in the calibre of some of the tubes, and frequently from partial congestion or inflammation, from which tubes thus diseased are rarely free. The vesicular mur- mur is impaired, and the expansion of the whole chest is per- ceptibly limited. These signs resemble those of spasmodic asthma, except that they are permanent, and are not removed as the latter may be, for an instant, on breathing after holding the breath in the manner before described. Inasmuch as these lesions seem to arise from continued inflam- mation, it becomes of the more importance to direct remedies against those forms of bronchitis that are habitual or frequently recurring. An imperfectly cured cough will often harass a patient for months, and even for years. In process of time the breathing becomes permanently shortened, and an irritation is often fixed in some of the tubes, manifesting its effect on their secreting function by habitual expectoration, generally thin and mucous, 164 structural lesions of the air-tubes. sometimes mnco-purulent. This affection varies greatly in degree. We have known several cases of habitual dyspnoea, pre- senting the characters now described, ultimately prove fatal, and after death no other lesion discovered than a general redness of the membrane lining the larger tubes, and an extraordinary de- velopment of the longitudinal fibres. There is one point with regard to treatment particularly suggested by a knowledge of this change of structure, that not only should the practitioner persevere in the use of the means which tend to eradicate the low degrees of inflammation that produce it, especially alkaline expectorants and counter-irritants, but he should also endeavour to Countervail, by mechanical means, that mechanical limitation which this change induces in the size of the tubes. If the patient use no exertion and give his lungs little play, any increase in the rigidity of the tubes will more readily fix them in their present contracted state; but if he take moderate exercise, increased as habit improves his power, the lungs will be kept in that free mobile condition that is least favourable to rigidity or deposition of any kind. Probably special efforts of inhalation would be useful with the same view; and as this might be combined with some mildly stimulating vapour, such as that of water impregnated with tar or camphor, it might be also serviceable in improving the secreting properties of the membrane. It is obvious, how- ever, that great discretion is necessary in the employment of these mechanical means, for if they strain the tubes beyond the due limits, they may cause a morbid yielding of the walls, and increased inflammation ; and if exertion be used beyond what the function of circulation can readily support, it will occasion con- gestion in the lungs, which may aggravate the original disease, and induce lesions of other kinds. These mechanical measures are more adapted for young than for old subjects; because in the latter the change is more likely to be permanent, under the influence of that general law by which, as age advances, fibrous tissues tend to assume a cartilaginous hardness, and cartilage becomes rigid with osseous matter. Dilatation, Contraction, and Obliteration of the Air- Tubes. On examining the lungs of patients who have long suffered from complaints of the chest, it is not uncommon to find the bronchial tubes, when laid open by a pair of scissors from the large to the smaller branches, exhibit dilatations of different kinds, the enlargement being usually most apparent in those parts of the tubes where the cartilaginous plates are small and few; but occasionally the larger tubes are also dilated, their rings only here and there limiting their dilatation. Sometimes the dilata- tions are pretty uniform through some length of a tube; in other air-tubes (Dilatation, Contraction, etc.). 165 cases they form irregular roundish cells or pouches, freely com- municating with each other, from which other tubes arise either dilated or undilated. The tissues surrounding the tubes are gene- rally more or less altered. They are least so in the uniform or tubular form of dilatation, in which the coats are often quite thin, and the longitudinal fibres distinct, although occasionally enlarged. But in the more globular or cellular dilatations, the walls of the tubes are commonly much altered; they are irre- gularly thickened, the thickening being formed in part by hyper- trophy of the mucous and submucous tissues lining the tubes, and partly by a dense tissue on their outsides, probably consisting of the parenchyma of the lung compressed by the encroaching tube. There is little or no trace of the longitudinal or circular fibres in this form of dilatation, and the lining membrane is generally in a softened state and of a red colour, whilst some parts of the tubes are quite rigid. We shall better understand the pathology and signs of these lesions by examining a little into their causes. Laennec, who first described dilatation of the bronchi, ascribed it to the frequent accumulation of mucus in the tubes, causing their mechanical distension. He considered that they were formed especially by long-continued chronic bronchitis, and that the continual recurrence of the same distension of the tubes led to their permanent dilatation. But this view is by no means suffi- cient to account for the remarkable changes which we frequently see in the structure of the dilated tubes; nor do these lesions constantly occur where the bronchial secretion is copious, and most calculated to cause distension. M. Andral takes a more rational view in ascribing these lesions to a modification in the nutrition of the textures composing the tubes; but he does not attempt to explain the mode in which the change is effected. If, however, we bear in mind the details of the internal mechanism of respiration, and the manner in which they may be deranged by disease in the various textures concerned in them, we shall find no difficulty in tracing several causes of dilatation of the air- tubes, as well as an explanation of the changes in their tissues and those of the surrounding parts. A mutual pressure is con- tinually exerted between the interior of the bronchial tree and the air: in inspiration, by the air which enters to distend the tubes; in expiration, by the tubes contracting to expel the air. In forci- ble acts of respiration, such as coughing or energetic breathing, this pressure is increased ; but in the normal condition of the tubes when they all equally and freely convey the air to and fro, and meet the pressure with a well-proportioned degree of elasti- city and contractility, this pressure is balanced and borne well. But if in any way the equality of this pressure be disturbed, or those elastic and contractile properties that are opposed to it be deranged, it becomes converted into a cause of unnatural disten- sion in some parts, while it does not reach others with sufficient 22 166 STRUCTURAL LESIONS OF THE AIR-TUBES. force. There are several conditions which may cause these disturbances, and they are especially to be met with in those dis- eases which are known to lead to dilatation of the air-tubes. Bronchitis may act in both these ways: by thickening of the membranes or by viscid secretions, it may cause partial or com- plete obstructions, which, by preventing the free entry of air into some tubes, increase its pressure into others, which become dis- tended in consequence; and it may alter the condition of the tissues composing the tubes, so that, losing their elastic and con- tractile properties, they yield to the pressure and become fixed in this dilated condition. Perhaps, as Dr. W. Stokes has sug- gested, the mere loss of contractility may in itself be sufficient to cause dilatation of the bronchi; but our view will be more satis- factory if we take into consideration that this distending force is applied to textures softened and otherwise modified by inflamma- tion, and that the change may thus become perpetuated and com- bined with other alterations in the textures affected. Hence the lesions are often not simple dilatations of the tubes, but compre- hend also irregular softenings and indurations, atrophy and thick- ening of their several textures : so that when the lung is cut open after death, it may be at first difficult to discover that the irre- gular cavities and indurations which it presents are formed by dilated tubes. Then in the production of these dilatations we are not to forget the influence of violent acts of respiration. They have been observed to succeed to hooping-cough, and other bronchial affections in which the cough is particularly violent and long-continued. But we have met with cases of dilated bronchi in which there had been very little cough, and none of any violence; and here we must suppose that the other causes, the irregular introduction of air, and the partial yielding of the tissues, were more exclusively concerned in the production of this lesion. Of this kind are the following cases. In pleuro- pneumonia, the lung is inflamed and at the same time compressed by an effusion in the sac of the pleura: if it remain long in this state, the smaller air-tubes and cells become obliterated by the adhesion of their sides, so that when the liquid is removed from the pleura, they will not expand again with the enlargement of the chest; but the large and middle-sized bronchi are not obli- terated,—they bear the whole force of the inspired air, and be- come consequently dilated by it. These cases, although not uncommon, were not noticed by any writer, until described in the author's lectures published in the Medical Gazette. Dr. Corrigan has since described cases of dilated bronchi, which seem to be of the same character, although he refers them to the production in the lung of a new contractile tissue, like the cirrhosis of Laennec. We doubt the propriety of giving such a name to a lesion which seems to be the result rather of inflammation modified by the circumstances of compression or of slow progress, than of a pecu- air-tubes (Dilatation, Contraction, etc.). 167 liar production like the cirrhosis of the liver. Other lesions which cause the obliteration or obstruction of a considerable number of tubes and cells, tend to produce dilatation of the adjoining tubes, on which the motions of the chest act with aug- mented force. Thus it was observed by M. Reynaud, that when bronchial tubes become obliterated in consequence of the effusion and organisation of lymph within them (a result connected with pneumonia rather than bronchitis), they are sometimes dilated up to the obstruction, and the neighbouring tubes and cells com- monly so. The same result is not unfrequently observed in con- nexion with tubercles which press on some tubes or obliterate the cells to which they lead. Larger tumours, such as aneurisms and cancer of the bronchial glands, pressing on one of the great bronchi, in a similar way cause unusual distension of those parts of the lung to which the other bronchus leads. The symptoms produced by dilatations and contractions of the bronchi vary accordingto the extent of the lesions. Slight degrees of them are met with in the bodies of persons who had not during life manifested any prominent disorder of the respiration ; and their simpler forms may exist to a greater extent without producing other effect than a liability to attacks of bronchitis. But where many tubes are affected, their structure modified, and much of the vesicular parenchyma obliterated in consequence, there are then produced habitual dyspnoea, with more or less cough and muco-purulent expectoration, which is often remarkable for its fcetor. The ordinary symptoms of severe chronic bronchitis, from which some of the affected tubes are scarcely ever free, are generally present; and the permanency of these symptoms, together with a degree of lividity, dropsical effusion in different parts, and cachectic condition of the whole frame induced by the crippled state of the lungs, constitutes the usual general character of the aggravated forms of dilated bronchi. The physical signs of dilated bronchi are very intelligible. The air passing through them in respiration causes a louder, hollower, more blowing sound than in those of the natural dimen- sions; hence a kind of tracheal or cavernous respiration is heard over them in regions where naturally the respiration is vesicular ; and if, as it frequently happens, there be liquid in the tubes, the bubbling into which it is thrown will be coarse and gurgling, instead of the finer mucous rhonchus of common bronchitis. So also the voice may be powerfully transmitted through these enlarged tubes, not as usual in a diffused fremitus, but loud and startling, as if issuing from the spot; in some cases cracked and jarring as in bronchophony ; in others more articulate, and with a snuffling or hollow sound, as in pectoriloquy. These however are also the signs of tubercles and excavations in consumption, with which the lesion under consideration is commonly con- founded ; we must therefore seek for other distinctions. Besides 16S STRUCTURAL LESIONS OF THE AIR-TUBES. in the history of the case, and in the character of the constitu- tion, these are sometimes to be found,—in the situation of the sounds, which in phthisis is usually in the upper parts, but in dilated bronchi in the middle regions of the chest; in their cha- racter in relation to time, those in phthisis tending to increase and spread as the excavations proceed, whilst those of dilated tubes will remain nearly stationary for weeks and months; in there being less change in the shape of the chest with dilated bronchi than with phthisis, unless they have succeeded to pleuro- pneumonia, in which case the change is different; and, finally, in the nature of the sound on percussion, which in phthisis is more dull chiefly under the clavicles, whereas in dilated tubes, if any dulness exist, it is generally in the mammary, lateral, or scapular regions of the chest, and is often accompanied by a peculiar hollow sound, which, from its resemblance to that produced by mediate percussion on the trachea, or by tapping with the finger on the mouth of a phial, we have called tracheal or amphoric. We shall have occasion to mention this sign in treating of pleurisy and pneumonia. The differential diagnosis between dilated bronchi and phthisical cavities will be better understood when the signs and symptoms of the latter have been fully described. We shall only add here, that when a case presents itself in which there have been cough, long continued with ex- pectoration, dyspnoea, loss of flesh and strength, hectic fever, and even some of the physical signs of cavities in the lungs, the prac- titioner should be cautious in pronouncing it to be tubercular, if it be qualified by all or most of the following conditions:—If no proofs of a scrofulous habit can be traced ; if the complaint have originated in a long-continued and violent cough, or in an attack of pleuro-pneumonia, and, considering its duration, emaciation have not proceeded far; if the purulent expectoration have been fetid and sanious, rather than flocculent or caseous; if the bronchial or cavernous respiration, or voice, be heard rather in the middle than in the upper portions of the chest, and be there spread over a considerable extent of surface; if these middle portions chiefly sound differently on percussion, being dull when the rest of that side sounds pretty well, or amphoric when the side is generally -dull and contracted ; and if, although the cough and expectora- tion continue undiminished, these signs remain stationary for many weeks together. In such a case the strong probability is in favour of its being one of dilated bronchi, and not phthisis. It is obvious that dilatations of the bronchi, when once formed, can be little under the influence of medicine. The profuseness of the secretion may sometimes be restrained by acid mixtures; and we have known the nitro-muriatic acid in a few instances for a time remove its fcetor. Probably inhalations of chlorine or iodine would be useful in such cases. Where the cough is violent and troublesome, it should be allayed as much as possible by air-tubes (Ulcerations, Tumours, etc.). 169 sedatives, such as hyosciamus,belladonna, conium,and particularly opium or some of the preparations of morphia; due attention being at the same time paid to the state of the excreting functions and the general condition of the system, which may need various kinds of treatment in different cases. The co-existence of chronic bronchitis often renders external counter-irritation of service, and other antiphlogistic measures are occasionally required for super- vening acute inflammation. It is, however, from preventive measures that we may expect more success; and our knowledge of the causes and tendencies of this lesion suggests the inexpediency of abandoning the treatment of cases of bronchitis, pertussis, and pleuro-pneumonia, until the cough and physical signs have been satisfactorily removed. Most of the severe cases of dilated bronchi that have fallen under our observation, we have traced to imperfect treatment in former inflammatory attacks, especially those affecting the parenchyma of the lungs, which have yet been disguised under the name of a severe cold or influenza. Ulcerations, Tumours, etc, of the Air-Tubes. Ulcers seldom originate in the bronchi, but in connexion with some cause which concentrates inflammation in a peculiar manner on the bronchial membrane, and carries it to the submucous tissues, such as the habitual inhalation of irritating particles of dust, in the occupations of needle-pointers, stone-masons, and leather-dressers, the continued passage of tuberculous matter in phthisis, and occasionally the specific influence of measles, scarlatina, small-pox, and syphilis. We can describe no signs by which the presence of ulcers in the bronchi can be distinguished: but they rarely, if ever, exist without similar lesions in the larynx, in which case the voice is often impaired or lost. Ulcerations of the trachea and larynx are very common in phthisis, and from the observation of Louis, seem to be in some degree caused by the contact of the matter expectorated, for he found them par- ticularly on that side of the windpipe on which the lung was most excavated. Ulcers of the larynx are commonly the effect of chronic laryngitis, which has already been described. Tumours of various kinds are occasionally developed in the windpipe, and others external to the tube may press upon it and interfere with its function. The most common seat of the former is in the larynx: if small, they may continue long accompanied with violent cough and fits of stridulous breathing from spasm like chronic laryngitis: if large or of rapid growth, they may speedily occasion suffocation, preceded by the symptoms com- mon to irritation and obstruction of the larynx. External tumours pressing on the air-tubes are not of a very uncommon occurrence. Of those situated in the neck, bron- chocele sometimes has this effect; but, as Dr. Stokes has observed, 170 STRUCTURAL LESIONS OF THE AIR-TUBES. it is chiefly by tumours originating within the chest, where the wind-pipe is surrounded by an unyielding frame of bone, that compression of this tube is produced. Such are aneurisms of the aorta and innominata, various tumours of the deep-seated cervical and bronchial glands, and enlargement of the thymous gland. We have met with instances of all these lesions, except the last, inducing pressure on the windpipe or one of its branches, and inducing dyspnoea, which in some cases was the obvious cause of death" In two cases the tumour was encephaloid, originating apparently in the bronchial glands,.and surrounding the trachea at its bifurcation, both of the branches in one instance, and one in the other, being considerably compressed by it. In one of these cases the bloodvessels, although passing through the tumour, appeared to be quite free; in the other, the vena innominata was partially compressed. In a case of aneurism of the ascending aorta the right bronchus was compressed. In another of aneurism of the innominata the trachea was com- pressed at its bifurcation. The signs of aneurisms compressing the air-tubes have been particularly described by Dr. Stokes. The general symptoms are dyspnoea, generally accompanied by acute bronchial irritation and a sense of constriction under the sternum, occasionally dysphagia, distension of the jugular vein chiefly on one side, oedema of the face, and other signs of venous compressions. The chief physical signs are hissing or sonorous respiration heard best at the top or on one side of the sternum, with weak vesicular sound on that side, various signs of displacement of the wind- pipe, the lung, and the clavicle, dulness on percussion, and occa- sionally projection of some of the upper portions of the chest, generally most on one side, in which in cases of aneurism, and sometimes of other tumours, there is a double or single pulsation. This is not the place for entering into details with regard to the signs of substernal aneurism; but we may remark that in more than one case we have observed slight oppression of the breathing at a very early stage, before there were signs of bronchial com- pression ; and we are disposed to attribute this, as well as the paroxysmal attacks of dyspnoea occasionally occurring in the further progress of aneurismal and other tumours in this region, to an irritation, of the vagus and its recurrent branch, which these tumours generally affect; and we agree with Dr. Stokes that the alterations of the voice are referable to varying irritation of the recurrent nerve. But the laryngeal constriction is some- times also complicated with inflammation, to which the air-tubes are particularly subject under the influence of aneurismal irrita- tion. We lately witnessed a case in which a patient with a substernal aneurism was at the point of death from spasm of the glottis with stridulous breathing, which afterwards assumed the form of acute laryngitis, and was relieved by free expectoration pleurisy (Pathological History). 171 after venesection and the prompt administration of mercury. In two instances we have observed dyspnoea, or rather oppressed breathing, for a time in connexion with scrofulous enlargement of the lymphatic glands, manifest in those of the neck and axilla, and supposed to reach to the chest, yet without the hissing breathing in the trachea or the deficiency of vesicular sound in the lung, indicative of bronchial compression: the symptom here was probably from irritation of the pneumogastric nerve. The treatment of tumours affecting the air-tubes is to be conducted on the general principles of counteracting as far as possible the irritation which they produce in the vessels, nerves, and muscles of the respiratory organs. Hence, according to symptoms, antiphlogistics, sedatives, and antispasmodics may be useful. Except in the case of enlarged lymphatic glands, it is of little use to attempt the cure of the disease itself. In that case a judicious course of alkalies and hydriodate of potash, with some mild tonic and sea air, will sometimes succeed in reducing the swellings, and removing the symptoms which they occasion. ^ —XP PLEURISY. Definition.—Pathological history, symptoms, and signs of acute pleurisy.— Symptoms and signs of the decline of acute pleurisy.—Chronic Pleurisy.__ General symptoms.—Pathology.—Signs of absorption of the effusion.— Empyema—its symptoms, signs, and modes of termination.—Causes of pleurisy.—Diagnosis.—Prognosis.—Treatment of acute and chronic pleu- risy, and of empyema. Pleurisy, pleuritis, mnufint (Hippocrates), are names applied to inflammation of the pleura, the serous membrane covering the lungs and lining the thoracic cavity. The leading characters of this disease are, sharp pain of the side, dry cough, dyspnoea, fever, diminished resonance of the side, with asgophony followed by enlargement of the affected side and abolition of all sound of respiration and voice. But there is so great an uncertainty in the general symptoms, and variety in the physical signs, that a satisfactory knowledge of the disease can be obtained only through a study of its pathology : a short account of this will therefore simplify the history of the disease, and render more intelligible and available the description of its symptoms and signs. Pathological history of Acute Pleurisy. The first known stage of inflammation of a serous membrane is an enlargement of the 172 pleurisy (Pathological History). vessels in the subserous cellular texture : it is these chiefly that form the striated patches or points of redness that are seen after death in the earliest stage of pleurisy, and their distension can be felt through the serous membrane, which seems slightly uneven on passing the finger over it. Perhaps at this period there is a diminution of the serous exhalation at the inflamed spot, as we know such to be the first effect of inflammation of mucous mem- branes, and probably increases the friction between the surfaces. Soon, however, the flow of serum is increased, and with it, if the inflammation continues, an albuminous matter (eoagulable lymph) is exuded. This exemplifies the most simple form of inflamma- tion. The vessels have no compound structure or secretion to complicate or modify their action; and we find their increased development attended by an exaggeration of those secreting func- tions which they fulfil in health. These functions are twofold, viz., that of liquid exhalation and that of solid nutrition: the fluid exhaled is serum; the material of nutrition is the albuminous or fibrinous part of the blood. In their natural proportion these functions preserve the membrane in a healthy state, one merely lubricating its surface with a slightly albuminous fluid, the other nourishing and sustaining the solid matter of the membrane. But when these functions are increased in activity by acute inflamma- tion, there is an overflow of their products, the liquid effusion is more or less rapid and copious, and the excess of the nutritive secretion now appears on the exterior of the membrane in various forms, and, either by itself or mingled with the liquid effusion, constitutes all the different products which are recognised as the results of inflammatory action. In its smallest proportion it is held in solution by the effused fluid, which on being drawn from the body, or after death, gelatinises from this fibrinous matter which it contains : where very abundant, it forms films or layers of lymph on the surface of the membrane ; and this lymph is generally more abundant and disposed to speedy organisation, when the inflammatory orgasm is strong, and the blood rich in nutrient matter. Following still the pathological history of pleurisy, we find in the lymph the product of adhesions; but whether or not these adhesions take place, depends on the quantity of liquid effusion between the pleuras. This effusion to a certain degree gravitates to the lowest parts of the chest, and in those parts tends to keep the membranes separate; and if the upper parts of the pleura be inflamed, they adhere the more readily, unless the liquid effusion be very abundant. But if the pleuras be inflamed only in their lower portions, a moderate quantity of liquid is sufficient to keep them separate ; and if the lymph then become organised, it forms not an adhesion but a false membrane coating the lung, which may have further effects in modifying the remains or the products of the previous inflammation. Before we consider these various pleurisy (Symptoms). 173 results of the modifying influences of time, of the degree and kind of inflammation, and of previous disease, on the pathological his- tory of pleuritic cases, we shall take a view of the symptoms and signs of acute pleurisy. Symptoms. These have been long considered as well marked by the sharp cutting pain in the side, restraining every common inspiration, and often making the act of coughing or deep breath- ing almost intolerable; the short breath which consequently results, the short dry cough, the general inflammatory fever, which with its antecedent rigor sometimes precedes the pain, but more commonly is developed with or after it, with hard quick pulse, heat of skin, flushed cheeks, and scanty high-coloured urine. But it is now well known that there may exist extensive pleu- risy and its consequences without this array of symptoms; nothing is more variable than the degree and combination in which they may occur. Pain of some kind is most frequently present; it is generally acute, circumscribed, and referred to below the breast or lower margin of the pectoral muscle; but sometimes it is lower down or shooting, or more diffused and less severe, and not seldom there is very little or no pain at all, but rather some soreness or tenderness on pressure between the lower ribs of the affected side. When the pleura covering the diaphragm is inflamed, the pain is generally acute, referred to the margin of the ribs and causes an unusual degree of distress and dyspnoea. This form of pleurisy is by no means commonly accompanied, as formerly supposed, by the risus sardonicus or delirium. The acute pain seldom lasts more than the first day or two, after which it may abate or entirely cease, although the inflammation continues, and the dyspnoea may increase with the accumulating effusion. The same remark is in some degree applicable to the fever, which is generally diminished in four or five days, assuming then a less inflammatory type. Sometimes it is very moderate, or of a remittent character; and this often happens when the effusion is most abundant. The degree of dyspnoea also varies much, being chiefly determined, first by the amount of pain, nervous sensibility, or catarrhal complication, and afterwards by the rapidity rather than the mere quantity of the effusion. The cough is a very uncertain symptom, being in some instances most distressing, in others altogether absent. In fact, so uncertain are all the general symptoms, that there are cases of what is called latent pleurisy, in which there may be scarcely a suspicion of the presence of disease of the chest, when pleuritic inflammation and its concomi- tant copious effusion have existed for many days or weeks. This is especially apt to occur in the course of fevers, or during con- valescence from them, and in persons of weak or injured constitu- tion ; but it is occasionally met with in the healthy and robust. The above-described symptoms may present themselves without 23 174 pleurisy (Physical Signs). pleurisy. Sharp pains of a nervous character not unfrequently closely imitate that of pleurisy, especially in hysterical females; and if they happen to be attended with feverish excitement, the resemblance is more complete. In fact, the greater number of symptoms commonly supposed to be distinctive of pleurisy, depend on a morbid sensibility of the pleura, which is by no means a necessary accompaniment of its inflammation ; and the symptom of oppressed breathing, proceeding from the pressure of the effu- sion, may be marked only when this effusion has accumulated very rapidly, or when the other lung has been prevented by prioi disease from supplementary exertion. Physical signs. On the other hand, the physical signs in the greater number of cases are very unequivocal, and although they by no means mark the degree or the intensity of the inflammation, they seldom fail to announce its presence, and they pretty accu- rately measure its most serious concomitant, the liquid effusion. We shall first enumerate these signs in the order in which they commonly occur, and afterwards consider the nature and value of each:— 1. Diminished motion and sound of respiration from pain; 2. Sound of friction accompanying the motions of respiration; 3. Dulness on percussion in the most dependent parts of the chest from the effusion ; 4. Diminished motion and sound of respiration from the same cause; 5. iEgophony; 6. Cessation of vocal vibration felt by the hand ; 7. Cessation of asgophony and all sound of the voice; 8. Enlargement of the side; 9. Displacement of the heart, liver, mediastinum, and intercostal spaces; 10. In- creased motions and sound of respiration on the sound side. 1. The respiratory movements are so far within the control of the will, that they are instinctively restrained in parts affected with pain; and it is obvious that the sound of respiration will be diminished in proportion. This has been noticed by M. Andral as an early sign of pleurisy ; but it is evidently a very equivocal one, since it depends on the presence of pain, which is not constant, and which may exist quite independently of inflam- mation. 2. At the first onset of pleurisy a rubbing or creaking sound accompanying the movements of the chest is sometimes heard. This may be owing to a slight roughness or defective lubrication of the pulmonary and costal pleuras at certain points, and, when combined with the general symptoms, may be considered a pretty exact sign; but it is very transient, and is seldom heard. It may be produced also by interlobular emphysema, in which case it lasts much longer. We are disposed to think that this sound is rarely produced by 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 tuberculous or other deposites. The friction sound is commonly heard about the middle parts of the pleurisy (Physical Signs). 175 chest; it generally ceases as soon as the sound of percussion becomes more extensively dull: but in dry pleurisy, and in the cases of partial pressure before mentioned, it may continue for a long time. 3. In by far the greater number of cases of pleurisy there is an effusion of serum, soon after the commencement of the inflam- mation; and the accumulation of this liquid in the chest is the cause of the signs by which pleurisy can be best distinguished. This fluid will accumulate first in the lowest parts of the chest, floating to a certain degree the lung upon it. Hence these parts will sound more or less dull on percussion, whilst the higher parts retain their usual resonance: change of posture, by changing the place of the liquid, will in some degree alter the situation of these sounds. As, however, the external vesicular structure yields more readily to pressure than the tubular parts within, the accu- mulating fluid soon mounts up in the form of a thin layer, between the lung and the ribs, to a considerable height in the chest. This thin layer slightly impairs the sound on percussion, and this more distinctly if the percussion be gentle and abrupt, as by filliping on a finger tightly applied, and comparing the sound with that of corresponding parts of the opposite side. This sign, as well as those to be next described, is liable to modifications from adhe- sions previously existing between the pulmonary and costal pleuras: these we shall notice afterwards. As the effusion increases, the dulness becomes more complete and general, the infraclavian and scapular regions being generally the last to exhibit it. It often happens, however, that when even these are dull, there is some resonance in the axilla, transmitted through the fluid from the opposite lung. Sometimes, at a particular stage of the effusion, a tracheal or tubular sound is for a day or two heard on percus- sion below the clavicles and in the axilla, arising from the larger tubes which are not yet compressed. 4. The same accumulation of liquid must diminish the extent of the motions of respiration in proportion to its bulk, which has taken the place of the most expansible part of the lung. The sound of respiration will for the same reason be weakened, and its duration shortened in the affected side. 5. About the same time at which the dulness on percussion and diminution of the respiratory murmur reach the middle regions of the chest, there is a remarkable modification of the vocal resonance. It is heard much more distinctly than is usual in those regions; and it is superficial, as if produced in the spot, separately from the oral voice, and changed to a small bleating trembling note, which so much resembles the voice of a goat, that Laennec has well-termed itasgophony (*'£, a goat, and o£», pulse) is a loss or suppression of the pulse, indicative of a failure in the action of the heart, constituting what is now known as Syncope. It is, however, universally employed at present to designate the cessation of the function of respiration (or rather, of its essential part, the aeration of the blood), and the consequent suspension of the heart's action. Preliminary observations. In order to have a clear idea of the pathological condition thus indicated,—of its causes, nature, and results,—it is necessary to take a brief survey of the character of the respiratory process, and of its connection with the other' vital functions, especially those of circulation and nutrition. This process essentially consists in the interchange of ingredients between the blood and the atmosphere, when brought within the sphere of each other's action in the organs adapted to the pur- pose. There is, on the one hand, an extrication of carbonic acid from the circulating fluid; and, on the other, an absorption of oxygen from the atmosphere. Although these are not the only changes which take place in the process of aeration, they are the most important to the present inquiry, from their immediate necessity to the continued well-being of the animal. The nutri- tive fluid, by its circulation through the capillaries of the system, undergoes gr'eat alterations both in its physical constitution and vital properties. It gives up to the tissues with which it is brought in contact some of its most important elements ; and, at the same time, it is made the vehicle of the removal from these tissues of ingredients which are no longer in the state of combination that fits them for their offices in the animal economy. To separate these ingredients from the general current of the circulation, and to carry them out of the system, is the object of the excretory organs; and it is very evident that the importance of their res- 43 334 asphyxia (Preliminary Observations). pective functions will vary with the amount of the ingredient which they have to separate, and the deleterious influence which its retention will exert on the welfare of the system at large. Of all these injurious ingredients, carbonic acid is without doubt the most abundantly introduced into the nutritive fluid ; it is also most deleterious in its effects on the system, if allowed to accumulate; and we accordingly find the provisions for its re- moval surpassing in importance that made for any other excre- tion. The two largest glands in the body appear to have for their chief object the separation of carbon from the blood; but this operation is subservient in each case to other purposes. By the liver this element is combined with others into a fluid excre- tion, which has important uses in the digestive function; whilst by the lungs (which may be certainly regarded as organs of a glandular character) it is excreted in a gaseous form, and thus made subservient, according to the laws of the mutual diffusion of gases, to the introduction of oxygen into the system, and the consequent maintenance of the animal temperature as well as of the stimulating properties of the blood. It is evident, then, that any circumstances which check the excretion of carbonic acid by the lungs, will have an immediately injurious effect upon the system at large, by causing the accumu- lation in the fluid upon which it is dependent for the performance of its vital actions, of an agent that so seriously injures its vivi- fying properties. But this is not the only mode in which the cessation of this function is injurious. The exclusion of a con- stant supply of oxygen from the blood, even though the removal of the carbonic acid were provided for by other means, deprives it of its due power of nourishing and exciting to action the tissues and organs to which it is afterwards distributed; for it would appear that this element is, throughout animated nature, a stimulant as necessary to the energy of its operations, as caloric is to all, and light to many of these. Further, we shall here- after see reason to believe that any obstruction to the due aera- tion of the blood has an immediately injurious effect upon the ^ circulation, by causing a retardation or even an entire cessation of its movement through the capillaries of the lungs; and, in consequence, a dangerous accumulation of blood in the venous system, with a proportional deficiency in the arterial. We observe, accordingly, that a provision for these changes is more universally found to exist in living beings than for any other function, save the ingestion of aliment, and the perpetuation of the race. Even in plants a true respiration analogous to that of animals is constantly going on, although its effects are some- times obscured by the converse change which is subservient to a different purpose. (Principles of general and comparative Phy- siology, p. 294.) In the lower animals the process is carried on by means which render it equally independent of any active asphyxia (Preliminary Observations). 335 movements adapted expressly to the purpose. In proportion to the energy and variety of the nutritive processes, however, does the necessity arrive for a more powerful and constant respiration; and we find in the warm-blooded Verlebrata the highest acti- vity of this function provided for by the vast extension of the aerating surface, and by the means adapted to renew both the blood and the air in contact with it. The arrangement of the circulating apparatus is such, that all the blood which has been returned from the system is made to pass through the lungs, before being again transmitted through the aorta—a provision which is not made for any other gland, the portal circulation presenting the nearest approach to it. And, on the other side, the nervous and muscular systems are adapted to keep up, with- out the intervention of the will of the individual, a constant series of movements, by which the air that has been vitiated is replaced by a pure supply. Although these arrangements will be fully explained in the physiological division of this work, it is necessary here to advert to the mode in which these constant changes are maintained, in order that the operation of various causes in the production of asphyxia may be rightly understood. , The periodic movements of the heart, by which the blood is propelled into the capillaries both of the system and of the lungs, result, there is good reason to believe, from the simple contrac- tility of its muscular structure, excited by the direct application of a stimulus. Experiment seems to have sufficiently demon- strated that, although they may be influenced by particular conditions of the nervous system, they are not dependent upon any constant influence transmitted through it, as was formerly supposed. Like other muscular structure, the parietes of the heart may be excited to contraction by stimuli of various kinds; but that which is employed in the living body is the con- tact of blood with the membrane lining its cavities. So long as the fibre retains its vital properties, will this stimulus excite it to con- traction ; but if it be deficient, and not replaced by any other, no movement will take place. In those cases in which the movements of the heart have continued for many hours after it has been removed from the body, it is probable that the admis- sion of air to the interior of its cavities has acted as the stimulus. Over-distention of the muscular tissue appears to suspend for a time its contractility; and this effect may even be produced by the accumulation of blood in excessive quantity, which prevents the fluid from exercising its usual stimulant influence. On the other hand, the movements of the respiratory muscles are entirely dependent upon the influence of the nervous system. Their ordinary actions are of the class denominated by Dr. M. Hall excito-motor, and were spoken of by Whytt and other authors as sympathetic. They result from a stimulus originating in the extremities of the nerves usually denominated sensory, but 336 asphyxia (Preliminary Observations). which may be more properly called afferent; and this, being conveyed to the spinal cord, occasions the propagation along the motor or efferent nerves of an influence which excites the mus- cles to action. The afferent or excitor nerves most concerned in producing the respiratory movements are the pneumonic por- tion of the par vagum, and those which supply the surface of the face and body. The impression of the external air on the skin (itself in some degree a respiratory organ) seems to be the sti- mulus which acts through the latter ; and it is in this manner that the first inspiration of the infant is excited. The presence of venous blood in the lungs has usually been considered as the stimulus which acts through the par vagum ; but Dr. M. Hall contends, with some apparent justice, that it is the evolution of carbonic acid which is to be regarded in this light. However this may be, it is admitted on all hands that, after the function is once actively established, the impression of the besoin de respirer conveyed by the pneumogastric is the principal source of the continuance of the movements. From the recent experiments of Dr. J. Reid (Edin. Med. and Surg. Journ., April, 1839), it ap- pears that, although they will continue after section of these nerves, they are much diminished in frequency. The great inter- change of filaments which has been proved to take place between the pneumogastric and the sympathetic, joined to certain " residual phenomena" brought to light by experiment, leaves little doubt that the latter system of nerves also is concerned in the maintenance of the respiratory movements, its function being perhaps supplementary to that of the pneumogastric. We may suppose also, without much improbability, that the besoin de respirer may be produced by impressions transmitted from other parts of the system as well as the lungs, when imperfectly arterialised blood is transmitted through its capillaries; just as the sense of hunger seems to depend, not only upon the emptiness of the stomach, but upon the demand for nutrition existing in the body at large. It will be observed that the two most powerful exci- tors of these actions, the pneumogastric and the fifth pair, ter- minate in the medulla oblongata; and that the motor nerves by which the most important of them are called into play arise in their neighbourhood. Hence respiration may continue when the portions of the nervous centres, both above and below this divi- sion, have been removed, which has caused it to be regarded as the peculiar seat of life.* A little consideration will show, however, that it is so only by furnishing the mechanical conditions requisite * In the class Tunicala there is bat a single ganglion, and this seems almost entirely devoted to the maintenance of the respiratory movements ; so that Nature may be regarded as here presenting the physiologist with an anticipation of the above experiment. (See the author's Prize Thesis on the Nervous System of the [nvertebrata, p. 61.)—Jluthor. asphyxia (Causes). 337 for the real organic function of respiration, to which the inspir- atory and expiratory movements are but superadded actions pro- perly forming part of the animal functions. We are now pre- pared to consider the causes which may operate in the produc- tion of asphyxia. Causes. The variety of conditions required for the healthy performance of the function we have been considering, involves a similar diversity in the causes which may produce its suspen- sion. These may, however, be classed under two general divisions: the first comprehending those which mechanically prevent the contact of the aeriform medium surrounding the animal with the membrane lining the lungs; and the second including those which affect the chemical processes to which this contact is subservient. I. This division embraces a great variety of causes, which must be separately considered. 1. Those which suspend the respiratory movements, by inter- rupting the nervous circle through whose agency they are main- tained. Thus, section of the eighth pair of nerves on each side may induce asphyxia, though slowly, by suspending the transmis- sion to the medulla oblongata of the stimulus originating in the lungs. If no other excitor nerves existed, there can belittle doubt that this operation would suspend the usual respiratory movements as completely as section of the motor nerves themselves, though they might still be performed by an effort of the will; but the other excitors, which have been already specified, have sufficient power to maintain these actions, although with far less than the normal energy and regularity. The asphyxia of new-born infants arises from the want of a sufficient impression upon these super- added excitors, by which the first inspiration is occasioned ; as is shown by the effect of the stimulus ofcold air on the face, or of y the smart stroke of the palm on the body, in producing this essential movement. The nervous chain may be also interrupted at the point of communication between the afferent and efferent nerves, namely the spinal cord. Any want of integrity in the portion of this central organ which is included between its con- nections with these nerves, will obviously impede the transmission of the necessary influence, as completely as lesion of the nerves themselves. This is by no means unfrequently exemplified in the effects of the disease or accidents to which this part is subject. Thus, fracture or dislocation of the upper part of the cervical vertebras may produce compression or laceration of the cord above the origin of the phrenic nerve. In this case all the respi- ratory movements of the trunk are immediately suspended, except those produced by the spinal accessory nerve, which are by no means alone sufficient to maintain the constant exchange of air which is required ; and death, therefore, very rapidly supervenes. If the affected part of the cord be below the origin of the phrenic 338 asphyxia (Causes). nerve, but above that of the intercostals, life may be prolonged for some time ; but a slow asphyxia appears to take place, since death generally occurs at an interval of from three to seven days. (Sir A. Cooper, on Dislocations, A-c.) The same effect will result from want of functional activity in this portion of the nervous centres, although no disease or injury may have directly affected it. Thus, in the ordinary apoplectic coma, as in profound sleep, the functions of the medulla oblongata being but little impaired, the respiratory movements continue almost as usual; but it, by compression or other deleterious influence, it should become less able to respond to the stimulus communicated to it by the excitor nerves, the movements will cease more or less gradually, and the aeration of the blood will be consequently prevented. A similar condition may result from the operation of narcotic poisons, by which the functional activity of the whole nervous system, but more especially of its central organs, is depressed, and the respi- ratory movements in consequence suspended for want of the maintaining power. Section of the motor nerves will of course produce a corresponding effect. If the phrenic be divided, respi- ration may be carried on for a short time by the intercostals, but not in a degree sufficient for the prolongation of life. If the intercostals be divided, the animal will respire with difficulty and imperfectly, as when the spinal cord is injured above their origin ; and slow asphyxia is usually the result. There is a difference among different species, however, as to the degree in which the movements of the diaphragm and those of the thorax are respec- tively concerned in producing the ingress of air. In birds it is entirely dependent upon the elevation of the ribs, no complete diaphragm existing in that class; and paralysis of the intercostal muscles, by the division of the spinal cord above their nerves, consequently produces immediate asphyxia. In fishes, on the other hand, the respiratory movements can only be affected by injuries of the medulla oblongata, as all the nerves concerned in them arise from that division of the spinal axis. 2. The next group of causes to be enumerated is composed of those which prevent the dilatation of the thoracic cavity by mecha- nical compression of the exterior of the body. Instances are by no means rare in which persons engaged in excavating are suddenly overwhelmed by a fall of earth which closely envelopes the body, leaving the head free. If not speedily relieved from such a situation, the sufferer dies of asphyxia ; since the descent of the diaphragm is prevented by the compression of the abdomen, as well as the ascent of the ribs by the restraint to which the thorax is subjected; and the first shock expels the contents of the lungs, and reduces the cavity to its smallest dimensions. A curious case is mentioned by Dr. Roget (Cyc. of Prac. Med., vol. i. p. 177.), in which a similar result was very near occurring to a pugilist, of whose body a cast was being taken in one piece. asphyxia (Causes). 339 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, however, was perceived just in time to save his life. The due expansion of the thoracic cavity may also be prevented by accumulation of fluid or the growth of tumours in the abdomen, by which the descent of the diaphragm is impeded ; but though a very distress- ing amount of dyspnoea often results from this cause, it is not likely ever to produce absolute asphyxia. Any disease which occasions a very painful condition of the contents of the abdomen, such as acute peritonitis, will offer a similar impediment to the movements of the diaphragm ; as will inflammation of the pleura or pericardium, or rheumatism of the external muscles, to those of the thorax. 3. Asphyxia may take place from disorder of the mechanism of respiration, without the existence of any force externally com- pressing the thorax, or of any direct impediments to the entrance of air into the lungs. These organs may be prevented from dilating by an accumulation of fluid in the pleural sacs; or by the admission of air into the thoracic cavity, either through its parietcs, or through the lungs. If an aperture be made into the cavity on one side, so that air rushes in at each inspiratory movement, the expansion of the lung on that side will be diminished or entirely prevented in proportion to the size of the aperture. If air can enter more readily than through the trachea, an entire collapse of the lungs will take place; and if such apertures be made on both sides, asphyxia necessarily results. But if they are too small to admit the very ready passage of air, the vacuum produced by the inspiratory movement will be more easily filled by the distension of the lungs; so that a sufficient amount of change takes place for the maintenance of life. Sudden death by asphyxia not unfrequently occurs from a communication being opened by disease between the air-passages and the pleural cavity, so as to check the dilatation of the lung of that side, whilst the function of the other is impeded by tubercular deposition, hepatisa- tion, or some other morbid alteration of its structure. 4. The next group of causes is a very numerous one; and those which it includes, althougii operating upon the respiratory process in the same manner, are very different amongst them- selves. It is composed of those which interfere with the admis- sion of air into the air-cells (where alone it is brought into relation with the blood), either by altogether preventing its entrance into the passages, or by obstructing its movement through them. The entrance of air into the trachea will of course be prevented by any means which produce occlusion of the orifices that lead to it—the mouth and nostrils. If these be obstructed by any solid substance applied closely upon them, death is said to take place by suffocation. If the face be immersed in water, that air 340 asphyxia (Causes). can gain no admittance to these openings, asphyxia is said to be produced by submersion. It is obviously immaterial whether the whole body be covered with water or not; many drunkards have been drowned (so to speak) in a puddle, from which they had not sense enough to withdraw their faces ; and many infants have been prevented from making the first inspiration by the immersion of the mouth and nostrils in the pool formed by the maternal discharges, or by the occlusion of these entrances by their own membranes. Air may gain admittance to the mouth and nasal passages, and yet be prevented from passing into the trachea, by meeting with some obstruction in the larynx. The rima glottidis may be closed by the oedema resulting from acute in- flammation, or by the thickening which is produced by more chronic disease ; or it may be constricted by the spasmodic affection which so often accompanies these states, and which sometimes occurs independently of them, from irritation of the nervous system by other causes; or it may be closed in conse- quence of paralysis of the dilating muscles, as Dr. II. Ley believed to occur in laryngismus stridulus.* Obstacles to the admission of air into the lungs may also exist in the trachea ; the aperture of which may be closed by external pressure, as in strangulations, or its lining membrane may be so much tumefied by disease as nearly to prevent the passage of air. The accumulation of secretions, too, which the patient has not strength to expectorate, may occasion asphyxia ; and the same result sometimes occurs in croup, from the obstruction presented by the formation of a * The pathological explanation of this disease given by Dr. Ley wa3 founded upon the supposition, that the dilators of the rirna glottidis are supplied by the recurrent laryngeal nerve, whilst the constrictors of that opening are stimulated by the superior laryngeal branch. He thence inferred that, if the functions of the former nerve were impeded by the pressure of enlarged glands or other causes, and the muscles which it supplies he consequently paralysed, the constrictor muscles would close the rima jflottidis for want of opposition. The more Tecent experiments of Dr. J. Reid (Edin. Med. and Surg. Journ., vol. xlix.), however, have shown that the superior laryngeal is almost entirely a sensory nerve, and that the recurrent is almost exclusively motor, supplying both constrictor and dilator muscles. lie slates that " severe dyspncea amount. ing to suffocation may arise both from irritation and compression of the inferior laryngeal nerves, or the trunks of the pneumogastrics. For when both or even one recurrent nerve was irritated, the arytenoid cartilages were approximated, so as in some cases to shut completely the superior aperture of the glottis." (p. 149.) When the recurrents are cut or compressed, the arytenoid cartilages are no longer separated during inspiration ; and their movements become so completely passive, that they are carried inwards by the current of entering air, which they consequently impede, whilst they are separated again by the expiratory blast. " We shall leave it," continues Dr. R. " to those who have had frequent opportunities of seeing this disease to determine which of these two causes, irritation or paralysis, will best explain its phenomena. There appears, however, to be liitle doubt that the crowing respiration and dyppniea, which accompany some cases of hysteria, depend upon a spasmodic closure of the glottis, produced by ome irritation of the recurrent nerves."—Author. asphyxia (Causes). 341 false membrane, which is often of considerable thickness. The pressure of tumours upon the trachea will often produce asphyxia, which has been the immediate cause of death in many cases of aneurism, and in some of bronchocele. In such cases this con- dition gradually supervenes ; and the difficulty of respiration is indicated by the livor of the countenance and the dilatation of the nostrils, for a long time previous to the termination of life. Some- times, however, an aneurism or abscess will burst into the trachea, and occasion immediate death by suddenly obstructing the access of air to the lungs. A frequent cause of asphyxia is the presence of foreign bodies within the air-passages, or even in the pharynx. In the former case they may occasion speedy death, even though not of sufficient size to produce material obstruction to the passage of air by the irritation they excite ; during a fit of coughing they may be driven up against the rima glottidis, which they may mechanically obstruct; or they may occasion spasmodic closure of this orifice by reflex excitement of the laryngeal nerves. The increased secretion also, which results from the irritation, adds to the mechanical impediment; so that, from a combination of these causes, death by asphyxia often supervenes where at first no material obstruction to respiration appeared to exist. The lodg- ment of large masses of solid matter in the oesophagus, as when an attempt is made to swallow hard substances which are too bulky for its calibre, will sometimes produce immediate asphyxia, as if by strangulation ; or, if a partial obstruction only be created, the difficulty may be fatally aggravated by the spasmodic action which is excited, as in the last case. These are the most frequent cases of obstruction to the entrance of air through the larynx and trachea. The bronchial tubes also may be similarly affected; but the amount of impediment thus created in the respiratory process will depend upon the proportion of the pulmonary struc- ture which the particular tube supplies. A foreign body obstruct- ing one of the passages into which the trachea primarily divides, will of course impede, more or less completely, the respiratory action of the corresponding lung, and may thus induce slow asphyxia, which will be aggravated by the spasmodic actions to which the irritation of its presence gives rise. But if it should find its way to one of the smaller passages, no immediately fatal result would probably occur; though diseased action would pro- bably be excited in its neighbourhood, which might ultimately terminate life. Several instances are on record in which such an occurrence has seemed to be the remote cause of death. A fatal result may, however, be speedily occasioned by causes which affect the bronchial tubes only, if it involve them universally or nearly so. Thus it may take place from the accumulation of secretions or fluid effusions, which prevent the entrance of air to the air-cells, even though it freely pass through the trachea. This is very apt to occur as a consequence of a congested state of the 44 342 asphyxia (Causes). pulmonary vessels brought on by other causes ; and it aggravates this very condition by the new obstacle it opposes to the respira- tory process, and to the movement of blood through the capillaries. Such a state may be artificially induced by section of the pneu- mogastric nerves; but it also supervenes, to a greater or less extent, on many pulmonary diseases. Perhaps wc may include, under this class of causes, spasmodic constriction of the bronchial tubes, which seems to be an impediment to respiration in some forms of asthma: the existence of such a state is, however, un- certain ; and no experimental proof has yet been given of the power of nervous irritation to produce it. It is, however, the only feasible mode of accounting for some of the phenomena of this disease. 5. Supposing the air necessary for respiration to have obtained free admission through the trachea and bronchial tubes, asphyxia may still take place from the lungs themselves being in an unfit state to allow the due action between their gaseous contents and the blood. Various morbid alterations of their structure, which it is needless to specify, may thus prove fatal, and this, either rapidly or slowly, according to the progress of the disease. Thus pulmonary apoplexy, a pneumonia of a few hours' duration, and a deposition of tubercular matter which has been proceeding for years, may occasion death in the same manner. It is thought by some that, independently of any change of structure, the lungs may be functionally unfit for the aeration of the blood, through a disordered supply of the " nervous influence" which is required for the process; but sound physiology does not warrant us in the belief that any such influence is necessary : nor is there any solid reason to believe that this function can be affected by any cause that does not produce a change in the physical conditions which are evidently essential to its performance. Having thus taken a general review of the principal causes which operate by physical means in the production of asphyxia, we may consider, II. The causes which affect the chemical processes, to which the physical conditions are only subservient. These may be briefly dismissed. Of the several gases which may be introduced into the lungs, there are but a small number capable of producing simple asphyxia. Most of them have an immediate deleterious action on the system, quite independent of their negative proper- ties, which consist in their want of power to afford oxygen to be absorbed or to remove the carbonic acid that is to be excreted. Hydrogen and azote are almost the only gases which can be regarded as simple asphyxiating agents. Both these may be breathed for some little time with impunity, even by man ; and cold-blooded animals will exist in them for several hours or even days. By their physical properties they are enabled to remove the carbonic acid from the blood nearly as energetically as com- asphyxia (Phenomena). 343 mon air can do; but as they afford no oxygen, the animal must sooner or later perish for want of this stimulus. Oxygen breathed alone, however, is very deleterious to the system, which it over- stimulates. Other gases act as true poisons on the system, when introduced into it through the lungs; and their effects, therefore, are of a complex nature. Phenomena. These vary, to a certain degree, with the cause //- of the suspended aeration of the blood; nevertheless, there are some which are universally witnessed, and to these our principal attention will be directed. They may be best observed when the axphyxia is gradually produced, as by a partial obstruction of the air-passages; when it suddenly comes on, they succeed one another so rapidly as not to admit of accurate observation. They may be divided into three stages. Theirs* commences with an increase of that natural besoin de respirer, which prompts to the ordinary acts of inspiration; and this increases until it amounts to a sensation of extreme distress. In respond- ence to this extraordinary stimulus, active and powerful inspira- tory movements are involuntarily performed ; and muscles are excited to contraction, which do not partake in the ordinary duty. Other instinctive movements, more remotely conducive to the relief of the sufferings experienced by the individual, are sometimes performed by him at this time. The distress, which soon amounts, if not relieved, to intense agony, is of short dura- tion ; though it lasts longer if the aeration of the blood continue to a slight degree, than if the process be entirely suspended. It gives place to vertigo and a feeling of stupidity, which soon increases to absolute insensibility, which may be regarded as characterising the second stage. The respiratory movements now become irregular and convulsive; and the other instinctive movements assume a similar character, the whole frame now partaking in them. Lividity of the countenance may sometimes be observed at the end of the first stage ; it rapidly increases in the second, and especially affects the lips, which are often of a deep purple. The veins also become turgid ; and the eyes are injected, and seem as if ready to start from their sockets. At this time the heart is found to be pulsating languidly, and the pulsation at the wrist is almost imperceptible. Very shortly all the animal functions are suspended; no further muscular move- ments are performed, nor are any capable of being excited. The sphincters give way; and the animal, if previously erect, falls completely powerless. This is the third stage. The heart con- tinues for a time to contract feebly ; but the aeration of the blood is entirely suspended, and sufficient fluid is not propelled by it into the aorta to produce sensible pulsation of the arterial trunks. The general surface now partakes of the livid tint which first showed itself in the face; the hands and feet presenting a violet hue, and patches of a similar colour existing in other parts of the 344 AsrHYXiA (Phenomena). skin. The organic functions do not entirely cease until the cir- culation of the blood has been completely suspended; and even after somatic death must be regarded as having taken place, the temperature of the body is very slowly dissipated, and the post mortem rigidity of the muscles tardily supervenes. In fact reco- very may take place even after the heart has ceased to act, if the proper means be employed. The relative intensity of these phenomena will be affected by the cause to which they owe their origin; as will also, in some degree at least, the order in which they present themselves. The preceding description applies especially to those cases in which the deprivation of air is sudden and almost complete, as when due to an obstruction existing in the air-passages. It is in these that the inspiratory efforts are most laborious, and the sense of distress the greatest. Where, however, the cause be such as puts a stop to the muscular movements concerned in respiration, the fatal termination more rapidly comes on, and there is less of general disturbance. When the asphyxia is more gradually induced, on the contrary, the sufferings are often most distressingly prolonged. Thus, where it supervenes as a conse- quence of pulmonary disease, the dilated nostrils and livid cheek often indicate for a protracted period the existence of deficient aeration, whilst the patient's complaints of dyspnoea but too truly correspond with these symptoms. The feeling of distress is often referred to the lower part of the sternal region; and we have known counter-irritants applied to the spot with the view of relieving it, when the real malady was situated in the larynx. It is a point, therefore, of considerable practical importance, not to be hastily led to infer from local sensations the cause of the diffi- culty of respiration ; this it may frequently exercise the skill of the physician to detect. It is when asphyxia slowly supervenes as a result of disease, that the greatest irregularity in the order of the symptoms is observable. A very high degree of lividity often shows itself long before the stage of insensibility has come on ; and the latter is often preceded by symptoms of irregular action of the brain, such as vertigo, tinnitus aurium, flashings of light before the eyes, and various spasmodic actions. The sub- sequent convulsive movements are less violent; and the lividity of the face never acquires so deep a tint, although the discolora- tion is more general over the body. In these cases the action of the heart usually ceases soon after the respiratory movements have come to a stand ; and this is the mode in which life very commonly terminates. The time which is necessary to destroy life by asphyxia varies much, not only in different animals but in different states of the constitution of the same. Thus, wrarm-bIooded animals are much sooner asphyxiated than reptiles or invertebrata; and, on the other hand, an hybernating mammiferous animal supports life for asphyxia (Anatomical Characters). 345 many months with an amount of respiration sufficiently low to produce speedy asphyxia if it were in a state of activity. And among mammalia and birds there are many species which are adapted, by peculiarities of conformation, to sustain a depriva- tion of air for much more than the average period. Excluding these, it may be generally stated, that if a warm-blooded animal in a state of activity be totally deprived of respiratory power, its muscular movements (with the exception of the contraction of the heart), will cease within five minutes, often within three; and that the circulation generally fails within about ten minutes. Many persons, however, are capable of sustaining a deprivation of air for three, four, or even five minutes, without insensibility or any other injury; but this power, which seems possessed to the greatest degree by the divers of Ceylon, is only to be acquired by habit. The period during which remedial means may be successful in restoring the activity of the vital and animal func- tions, is not, however, restricted to this. Cases are not unfre- quent of the revival of drowned persons after a submersion of half an hour; and more than one has been credibly recorded in which above three-quarters of an hour had elapsed. It is not improbable, however, that in some of these cases a state of syn- cope had come on at the moment of immersion, through the influence of fear or other mental emotion, concussion of the brain, &c.; and that, the circulation being thus enfeebled, the deprivation of air had not the same injurious effect as when this function was in full activity, just as in the case of an hybernating animal. Such a state has been denominated syncopal asphyxia. The reanimation of still-born infants has been successfully attempted when nearly half an hour had intervened between birth and the employment of resuscitating means; and when pro- bably a much longer time had elapsed from the pe-iod of the suspension of the circulation. Anatomical characters. In cases where death has resulted from simple asphyxia rapidly induced, the external appearances found on subsequent examination are usually very characteristic. The general lividity of the surface is not unlike that which is observed on the depending parts in other cases, but may be distinguished from it by not being confined to these situations. Moreover, it is often further characterised by the presence of deeper spots, resem- bling those of ecchymosis. These are most commonly seen in the face and neck of persons who have been hung or strangled; and, on the other hand, they are usually absent in cases of drown- ing ; but they are occasionally seen under other circumstances. The appearance seems to be the result of congestion of blood in the vessels of the skin, from which, indeed, the fluid appears sometimes extra vasated ; numerous points being observable when a section is made into the substance of that tissue. The features 346 asphyxia (Anatomical Characters). usually retain the expression of distress, and the eyes, as already noticed, continue prominent: the pupils are dilated, as in coma. The accumulation of blood in the right side of the heart, and in the vessels, connected with it, namely, the systemic veins and the pulmonary artery, and the comparatively empty state of the left cavities, as well as of the pulmonary veins and systemic arte- ries, are the appearances most characteristic of asphyxia; and they are constant when this state has been completely developed. They are best marked, however, where it has slowly terminated life ; especially when some degree of aeration has taken place up to its close, and the action of the heart has ceased within a short time. The coronary veins may often be observed to exhibit an extraordinary turgescence. Not only may the venous congestion be noticed in the vena cava and larger trunks, but it is very per- ceptible in all organs which are largely supplied with blood. Thus, the liver and spleen are in a state of engorgement; and the blood may be forced out in large drops by slight compression of their parenchymatous tissue. The intestinal membranes, too, are observed to be excessively congested, especially in the most de- pending parts; and ecchymosed spots are not unfrequently seen on the mucous membrane of the stomach after strangulation, con- stituting a variety of pseudo-morbid appearance, which the in- spector will do right to bear in mind. This tendency to conges- tion in the venous system, which so constantly accompanies deficient respiration, has a most important influence on the con- dition of various organs in the later stages of chronic diseases of the thorax ; and it readily explains the derangements which they are liable to exhibit. Even the heart not unfrequently suffers from the same cause ; a permanent distension of its right ventricle, with hypertrophy of its walls, being a frequent concomitant of obstructed respiration; of which particular instances will be here- after given. The blood is usually found fluid, or but imperfectly coagulated, if the asphyxia have been rapid; and this corresponds with what is observed after other kinds of sudden death. Where it has more slowly supervened, the blood coagulates as usual. The veins and sinuses of the head of course partake of the general venous congestion ; and, in well-marked cases, an unusual number of red points are seen on slicing the brain. The disten- sion is greatest where the previous struggle has been most severe, or where there has been a peculiar obstruction to the return of the blood from the head, as in hanging or strangulation. There is seldom, however, any morbid effusion ; but an apoplectic extra- vasation is sometimes found, though rarely as a consequence of simple asphyxia. In cases where there has been but little general disturbance, the vessels of the brain and its membranes are found to be in their natural state. asphyxia (Pathology). 347 The venous congestion is usually well marked in the root of the tongue, which often appears as if injected, the papillae being remarkably prominent. It extends also to the mucous membrane of the larynx and epiglottis, of the trachea and bronchi, which is deeply coloured by vascular turgescence, and which becomes darker as it is traced into the smaller ramifications of the bronchi. The mucus which covers its surface is generally mixed with a frothy serous exudation, usually exhibiting a sanguinolent tinge. This effusion, which is often very abundant where the obstruction to the respiration has gradually operated, seems to result from the congested state of the vessels, and not to be an altered form of the natural secretion, as some have supposed. The fibrous tissue which unites the cartilaginous rings of the trachea and bronchi is also injected with blood. The lungs themselves, if not previously diseased, are greatly distended, and expand so as to meet over the pericardium. When exposed to view, they present a dark brown, sometimes almost blackish, hue externally ; but their parenchyma exhibits a redder tint when cut into. The en- gorgement is here in the arterial system ; but it is occasioned by the accumulation of venous blood, of which large dark, thick drops flow out when incisions are made in the substance, and slight pressure employed. Pathology of Asphyxia. There can scarcely be a more remark- able illustration of that important truth that morbid anatomy furnishes but one class of the facts upon which the science of patho- logy must be erected, than that presented to us in the inquiry which we have now to make into the nature of the morbid action which results from the derangement of the respiratory function, and the mode in which this occasions death. There is no dispute as to the leading facts supplied by anotomical examination; but in the interpretation of those facts there is much scope for discus- sion. No satisfactory conclusion can be attained, unless a clear conception be first formed of the physiological or normal action of the organs whose deranged function is the subject of investiga- tion. We particularly refer to that of the capillary vessels of the lungs, the duties of which must, it is obvious, be the first deranged by any cause which obstructs the access of air to the respiratory membrane. It is in these vessels that the character of the blood is altered from the venous to the arterial; and to be subservient to this change is their peculiar function, just as the secretion of fluid is the function of the capillaries of glands, and nutrition that of the capillaries of the system in general. That the movement of the blood through them is principally dependent, in their usual condition, upon the action of the heart, does not admit of a doubt; but it seems equally certain that for the continuance of this move- ment, the continuance of the changes to which it is subservient is essential; and that not even the powerful contractions of the heart can force the blood into the pulmonary veins, when these changes 348 asphyxia (Pathology). are suspended. The condition here assigned to the maintenance of the capillary circulation does not apply to that of the lungs alone. It corresponds with that which we find by observation and experiment to hold good in reference to the capillaries of the whole system. We need not imagine that any mechanical pro- pulsory power exists in them, in order to understand how such an influence on the movement of the blood through their canals may be exercised by their parietes ; since it is easy to conceive that new attractions and repulsions between the solid and fluid particles may be created by the processes to which they are sub- ject. This is not the place to discuss such a question, however; the correctness of the view just stated, in its application to this particular topic, will, we think, appear from the facts to be pre- sently adduced ; and a fuller elucidation of it will be found in the physiological division of this work. If its validity be assumed, it will follow that the first effect of impeded respiration will be a retardation or cessation of the passage of blood through the capillaries of the lungs; and that this impediment will be the cause of all the other phenomena which are observed in the pro- gress of the complaint, and finally of its termination in death. Before proceeding to developethis view in detail, however, it will be desirable to glance at the principal theories which have been offered as explanations of the same facts, and to inquire briefly into their value. It would be scarcely necessary to mention the doctrine pro- pounded by Haller, since it received a most complete refutation from Goodwyn, were it not that he assigned the true situation for the commencement of the morbid changes, although he misunder- stood their nature. In his opinion, the stagnation of the blood com- menced in the capillaries of the lungs, and thence affected the whole venous system ; but he imagined this stagnation to arise from a mechanical impediment, produced by the cessation of the motions of the lungs themselves. It is a sufficient reply to this doctrine, that all the phenomena of asphyxia are as completely developed in an animal which is made to breathe azote, as in one which has been drowned or strangled ; and it was pointed out by Goodwyn, that after the fullest expiration, the air-cells do not return to the state in which they were in the new born child, but are sufficiently distended to permit the blood to circulate freely through them. In fact, as will be subsequently shown, any excess of distension is unfavourable to the passage of fluid through their capillaries. The theory of Goodwyn himself was, that whilst venous blood furnishes to the right cavities of the heart the stimulus which excites them to contract, the fibre of the left side requires a more powerful stimulus,—that of arterial blood ; and in default of this, ceases to perform its functions in maintaining the systemic circulation, no longer contracting upon the blood returned to it from the lungs, when this has not been artcrialized. asphyxia (Pathology). 349 This hypothesis, however ingenious, is inconsistent with several observed facts. Were it correct, the pulmonary veins and left auricle ought to be found loaded with blood, which is not the case. Moreover, the left side of the heart continues to contract upon blood which may almost be called venous, in hybernating animals, whose respiration is so trifling ; and Bichat proved expe- rimentally that venous blood might be injected into the left cavities of the heart, with the effect of exciting, not depressing, their action. He also ascertained that venous blood is propelled into the systemic circulation of an animal undergoing asphyxia; so that the doctrine of Goodwyn may be regarded as completely disproved. We do not mean to assert, however, that venous blood is as effectual as arterial in stimulating the left side of the heart; but that it is sufficiently powerful for the maintenance of the actions of that portion of the organ so long as it is supplied, is evident from the fact that its chief cavity and the vessels con- nected with it are never found to contain more than a compa- ratively small quantity of blood. The theory of Bichat is the one which, until recently, has gained the most general assent; and there can be no doubt that it is partly based on truth. That it does not accord with all the facts of the case, however, and cannot, therefore, be regarded as a satisfactory explanation, will presently appear. He ascribed the cessation of the circulation to diminished irritability of the heart, resulting, as he supposed, from the deleterious effect of its pene- tration by venous blood upon its vital properties, an effect which he proved this fluid to exert on the excitability of the nervous system. This doctrine, as well as that of Legallois (who supposed the irritability of the heart to be destroyed by the circulation of venous blood in the spinal cord), is open to the same objection as that already brought against the theory of Goodwyn; which is one that will apply to any theory which primarily refers the cessation of the circulation to want of power in the heart; namely, the empty state of its left cavities, and the renewal of its action, after it has entirely ceased, by a cause which does not imme- diately affect it. Bichat, indeed, foresaw these objections. Of the second he attempted to dispose by asserting that artificial respiration never renews the action of the heart when it has entirely ceased—a statement opposed by well-ascertained facts. Of the first, he has given no satisfactory explanation. Moreover, his opinion that the circulation of venous blood through muscles is destructive of their irritability, is contradicted by the experi- ments of Dr. Kay (Treatise on Asphyxia, p. 50), who found that the exhausted irritability of muscles was restored when venous blood was made to circulate through them, but remained extinct if no fluid was transmitted. Some of Dr. Edwards experiments also lead to a similar conclusion ; namely, that venous blood, 45 350 asphyxia (Pathology). though less powerful than arterial in maintaining the vital proper- ties of muscles, is by no means rapidly destructive of them. That the first impediment to the circulation of the blood in asphyxia is occasioned by an obstruction to its passage through the pulmonary capillaries, might be inferred simply from the pro- gressive accumulation of the fluid in the system of vessels, of which those channels form as it were the outlet; a phenomenon constantly observed in this condition, and more or less rapidly induced as the aerating process is more or less completely sus- pended. It has been maintained by some that the blood flows freely into the pulmonary veins, and is thence carried into the general current of the circulation, until its deleterious action has been exercised on the nervous centres; and that, from a sort of paralysis of the capillaries of the lungs, the flow of blood through them is then impeded. But this view is inconsistent with the fact of every-day occurrence, that a great degree of venous congestion may occur long before the blood in the arteries has become sufficiently loaded with carbon, and deficient in oxygen, to produce insensibility by its action on the brain. Moreover, the doctrine that " nervous influence" is essential to the flow of blood through the capillaries of the lungs, or of any other part, is a mere assumption, unsupported by physiological facts. On the contrary, the recommencement of the circu- lation through the capillaries of the lungs, when oxygen is brought in relation with them, before any alteration has taken place in the character of the blood in the vessels of the brain, sufficiently proves that it is in them and them alone that we are to look for the primary cause of obstruction, and the cause of the recom- mencement of the circulation. What, then, is the nature of their influence on the movement of the blood through them 1 That it is not mechanical is sufficiently proved by observation; for no regularly alternating contractions and dilatations have ever been seen by the microscope in these vessels; and the only mode in which a change in their caliber would seem to influence the current is by such relaxation as may give it free passage, or such contraction as may impede it. The latter state is the one which would seem primarily to result from the application of any stimu- lus, as is shown both by microscopic examination and by the experiments of Wedemeyer, who found that stimulating liquids injected into the arteries of living animals were much longer than mild liquids in finding their way into the veins. The state of relaxation is that which paralysis or want of tonic action would seem to produce; and it is therefore impossible to attribute to either of these causes the cessation of the movement of blood in the pulmonary capillaries, which is consequent upon suspended respiration. A more valid and consistent explanation may be found in the cessation of those changes to which the passage of the blood asphyxia (Pathology). 351 through the capillaries of the lungs is subservient. How the movement of the fluid is dependent on their continuance, it may not perhaps be easy to explain ; but the fact seems well estab- lished by direct evidence, and coincides with what we know of the laws of vital action in general. In the lower animals, as in plants and in acardiac foetuses, the circulation is almost entirely independent of any central propulsive organs, and is chiefly maintained by powers originating in the capillary vessels; and even where a distinct and powerful heart is developed, we find that the distribution of blood to different organs is governed more hy the relative activity of the processes taking place in them than by any other cause. Any circumstance which peculiarly excites the nutritive or secretory actions of a texture or gland will occasion a determination of blood towards it, which is quite independent of any alteration in the heart's action; and on the other hand, any depression of their natural actions will produce a corresponding diminution in the amount of blood transmitted through them, with which the heart has no concern. The fact, then, seems to be, that any impediment to the arterialisation of j the blood in the pulmonary capillaries will of itself impede its motion through them ; and this in proportion to the completeness of the obstruction. It is quite true that when the access of air to the lungs is suddenly and completely checked, the circulation though them continues for some little time; and that blood of a partly venous character is transmitted into the systemic arteries. But it is to be recollected that a considerable quantity of air is contained in the air-cells of the lungs; and that it is not until this has been so far deprived of its oxygen and loaded with carbonic acid, as to be unfit to effect any change on the blood, that we should expect the movement to be entirely checked. Moreover, the alteration in the character of the whole mass of the circulating fluid is effected gradually, as might be inferred from the small proportion transmitted by the heart at each con- traction ; so that, if a small stream be drawn from the carotid artery of an animal undergoing asphyxia, it will be seen to become progressively darker, from the commencement of the suspension of the respiratory movements to the cessation of the heart's action. If, then, an interruption of the chemical changes effected in the pulmonary capillaries be the cause of the stagna- tion of the blood in them, a renewal of those actions ought also to renew the movement; and this it has been experimentally demonstrated to effect, in a sufficient number of cases, and under a great variety of circumstances, provided that the suspension have not been so prolonged as to occasion a loss of the vital properties of the organism. To these cases we shall presently return. We may consider it sufficiently proved, then, that the stagna- tion of blood in the capillaries of the lungs is the primary effect 352 asphyxia (Pathology). of suspended aeration; and we have now to inquire into the mode in which this disturbance of the current rr the circulation affects other organs, especially the heart and nervous system. It is very evident that the accumulation of blood in the right ven- tricle must soon become a mechanical impediment to its contrac- tion ; and the distension at last appears to impair or even destroy its irritability, just as in the case of the bladder. There is no doubt, however, that the permeation of its texture by venous blood will affect its contractility; but that it is still able to propel its contents, if the distension be slightly relieved, is shown by the recommencement of its action when the renewed movement of the blood in the capillaries of the lungs diminishes the engorge- ment of the pulmonary arteries, and by the effect of more direct evacuation, as will be presently noticed. The left side of the heart, on the other hand, gradually ceases to act from an opposite cause—the deficiency of blood. It has been proved by the ex- periments of Drs. Williams and Kay that its contractility is retained until after the pulmonary veins have ceased to return sufficient blood to excite its action. When rabbits were asphyx- iated by tying the trachea, it was found that the flow of blood from a divided artery almost ceased at the end of the third mi- nute, and was entirely suspended at the fifth ; yet " the left heart contracted spontaneously for a very considerable period longer." And when the left auricle was examined under similar circum- stances, it was found that after a period of three or four minutes very little blood was returned by the pulmonary veins, though the heart still acted vigorously. " In general," says Dr. Kay, " the phenomena of the cessation of mo' on in the left heart in asphyxia are these:—a smaller quantity of 'ood is received into its cavi- ties, and expelled for a time vigorously into the arteries; the ven- tricle meanwhile diminishes in size, as the quantity of blood sup- plied becomes less, until at length, although spontaneous contrac- tion still occur in its fibres, no blood issues from a divided artery, and the ventricle by contraction has obliterated its cavity; after this, blood slowly accumulates in the auricle from the large vessels of the lungs; and its contractility continues for a very considerable period." (Edin. Med. and Surg. Journ. vol. xxix. p. 46; and Treatise on Asphyxia, p. 135.) So long as the con- tractility of the left ventricle is retained, although its movements may have entirely ceased, it may be excited to renewed action .f, by a supply of the necessary stimulus ; and thus it may be re i- vified, and the general circulation restored, by artificial respiration which, by unloading the right cavities, and filling the left, fur- nishes the required conditions. There is no difficulty, then, in understanding how the entire circulation may be brought to a stand by a cause acting imme- diately upon the capillaries of the lungs. We have next to inquire into the mode in which ..lose phenomena are produced asphyxia (Pathology). 353 which indicate an affection of the nervous centres;—namely, the ve.rtigo, del;-ium, spasms, and insensibility which mark the later stages of.aspnyxia. These have been usually attributed, and with much show of reason, to the circulation of imperfectly arterialised blood through the vessels of the brain and spinal cord. In most vertebratcd animals we find a provision for send- ing to the head the most highly-aerated portion of the general mass of nutritious fluid. The provisions for this purpose are most apparent in the class of reptiles; but they are also peculiarly manifest in the embryo state of birds and mammalia. It is evi- dent, then, that of all organs of the body, the nervous centres are the most dependent upon a constant supply of pure arterial blood, for the due performance of their functions. But the quantity, as well as the quality, of the circulating fluid seems to have an important influence. The brain is well known to receive a pro- portion of the whole amount of blood, far beyond that to which its relative bulk would entitle it; and any interruption to the supply is found to have an immediately injurious effect upon its functional activity. Thus, Sir A. Cooper has shown, that if the carotid arteries be tied, and the vertebrals be compressed, a state resembling syncope immediately supervenes. We may reasona- bly infer, then, that the insensibility of asphyxia may arise from the concurrent action of both these causes—deficient supply, and depravation of quality. The deleterious influence of the circula- tion of venous blood through the cerebral arteries was proved by an experiment of Bichat. He injected venous blood from the heart of one dog into the carotid of another, and insensibility was the result; but, on the other h; nd, it has been shown by Dr. Kay that large quantities of venouv blood might be injected into the carotid arteries without producing more than muscular debility and lassitude, provided the injection be made slowly and cau- tiously, so as not to produce mechanical injury of the cerebral matter, by distension of the vessels. In one of his experiments (op. cit, p. 195) an accidental circumstance occasioned the em- ployment of considerable force; the animal struggled and its limbs quivered, but it seemed to recover for a time, though it remained feeble. It afterwards exhibited symptoms of lesion of the brain, and died at the end of ten days, from the effects of an abscess in one of the hemispheres. There is no difficulty, then, in accounting for the immediate insensibility produced by Bichat's inj ctions. From the results of Dr. Kay's experiments it may be inferred, that " though venous is a much less stimulating fluid than arterial blood, it may circulate through the cerebral mass without producing by its contact with the brain-a sudden suspen- sion of the functions of the nervous system. I conceive that it must be regarded as a fluid capable of only slightly nourishing and stimulating the nervous system. Its presence in the vessels y of the brain, even for a short tiine, occasions languor and feeble- 354 asphyxia (Pathology). ness; and if its circulation were prolonged, we may imagine that sensation and voluntary motion would become still further impaired; but it does not destroy life by contact with the brain, and in asphyxia small quantities of it are transmitted, and for a short period only, to the cerebral structure." (Op. cit. p. IDS.) The sudden insensibility of asphyxia is, therefore, to be in part attributed to the rapid diminution in the amount of the blood sent to the brain; and a state by no means dissimilar is often wit- nessed in cases of hemorrhage, in which deficiency of the nutri- tious fluid is the only cause in operation: neither change alone would produce the train of phenomena formerly described ; this results from a combination of both. We have alreadv observed a similar combination of influences in the suspension of the heart's action ; and our attention is thus forcibly directed to the fact that when any link in the chain of vital phenomena is broken, and the equilibrium of the whole disturbed, the derange- ments which ensue are so various and complicated, that it is difficult to assign to each its peculiar agency in finally producing the fatal termination. It is obvious that the state of deep coma, once induced, will hasten death in those cases in which a small amount of respira- tion was previously going on, by the suspension of the muscular movements necessary to it. But even after this has supervened, and the animal life of the being has ceased to manifest itself, the organic life may be maintained for a considerable period ; its duration depending upon the intimacy of the connection between the two classes of functions at the time. Thus, although the destruction of the brain and spinal cord (by which a state cor- responding with profound coma is induced) occasions speedy death under common circumstances, Dr. M. Hall has shown that it may be performed in an hybernating animal, without extin- guishing the heart's action, for many hours. Again, this con- nection cannot be said to be established in the new-born animal until the first respiration has taken place; and before this has occurred, life may be prolonged for a considerable time under submersion in warm fluid. Thus Buffon found that greyhound puppies appeared to have suffered little, after being immersed in warm milk for half an hour; and Legallois found the mean dura- tion of life in full-grown foetuses of rabbits, immersed in water, to be twenty-eight minutes. After the animal has respired for a short time, however, this power of resisting the want of air diminishes very rapidly; and in those species which generate a large amount of heat soon after birth, such as the guinea-pig, this power is scarcely, greater in the new-born animal than in the adult. These different conditions, natural to the lower animals, find a parallel, to a certain degree, in peculiar states of the human economy induced by disease, especially those in which syncope partakes. asphyxia (Pathology). 355 When the causes of asphyxia were being enumerated, it was pointed out that it is the natural tendency of many internal dis- eases, as well as of various external agencies, to induce this condition. We may now go further, and state what will to many appear startling, that in a very large proportion of deaths, natu- ral as well as violent, gradual as well as sudden, the event is either immediately or remotely attributable to this cause. It must be remembered that, so long as the circulation is main- tained, the life of the system must be regarded as continuing, even though the animal functions should have ceased to manifest themselves ; and if the causes which can operate in suspending this movement be considered, they will be found to act in one of three ways; either by destroying the moving powers, which have their seat in the heart and capillary vessels: by occasioning an obstruction in some part of the channel, which shall affect the whole current, and not a part of it merely: or by withdrawing the vital fluid itself. In the first of these cases, death is said to take place by syncope ; and the same term includes the last also. Few causes but asphyxia can operate in the second mode, since no stagnation of blood in any other organ than the lungs can suspend the general current of the circulation, and a similar effort could only be produced by a complete obstruction of the aorta or pulmonary artery. It is therefore desirable to review briefly the principal morbid conditions which terminate in death through the medium of asphyxia, as well as to notice others which the continuance of imperfect respiration would be liable to produce. Of the former, one of the most common is the state denomi- nated coma or stupor, which results from some change in the healthy condition of the brain and spinal cord. When this is profound, it suspends the respiratory movements, as formerly mentioned, by interrupting the channel through which the stimu- lus conveyed by the afferent nerves acts in producing them. All diseases and injuries which terminate in coma do in reality, therefore, occasion death by asphyxia. This principle is a very important one, since it leads us to take means for the mainte- nance of respiration when the cause of the stupor is temporary only;—an indication which has been successfully acted upon. Thus, Sir B. Brodie found that animals rendered insensible by narcotic poisons might have their lives preserved by artificial respiration, kept up until the functions of the brain were restored ; and the same expedient has been practised with success on the human subject. Although it would be evidently useless where coma is a result of permanent organic lesion, it is by no means impossible that it might be successful in some cases of insensi- bility with convulsions in children, resulting from some tempo- rary cause, which might subside if the circulation could be carried on for a sufficient length of time, especially if life were enough prolonged to allow of the operation of remedial agents. 356 asphyxia (Pathology). It must not be supposed, however, that all causes acting through the nervous centres produce death through the medium of as- phyxia : since there are many which rather occasion syncope, depressing the general vitality of the system, destroying the con- tractility of the heart, and the peculiar properties of the capilla- ries, as by a sudden and general shock, which seems diffused through the nervous trunks to every part. It is in this manner that concussion, and other violent mechanical injuries to the brain, occasion the immediate cessation of the movement of the blood, which is not prolonged for an instant beyond the cessation of the movements of respiration. There is a form of apoplexy, the apoplexia fulminans of old authors, denominated by French writers apoplexie foudroyante, in which the effusion of blood acts instantaneously in the same manner as a mechanical shock; whilst the mode in which this disease ordinarily becomes fatal is by suspending the respiratory movements alone. It seems pro- bable that when death results from exposure to cold, it is at last by asphyxia induced by coma. It does not appear very clear, however, to what the coma is to be attributed; nor is it certain that the injurious influence of cold as a sedative to all vital actions is not directly exerted in checking the circulation, by depressing the powers of the heart and capillaries. The connection of obstructed circulation through the lungs with diminished sensi- bility of the nervous centres, should not be forgotten in the con- sideration of the phenomena of fever. It is well known that in typhoid states of this disease, in which coma is threatened, dys- pnoea is a very frequent occurrence, and that this is accompanied by a considerable effusion of fluid into the parenchyma of the lungs, without any decided symptoms of active disease in these organs. The continuance of this state will of course favour the complete production of coma ; but a sound pathology will teach us to direct our remedial means rather towards the head than the chest. The diseases which have a tendency to produce asphyxia by directly preventing the access of air to the blood have already been pretty fully indicated : but it must be remarked, that when these are very chronic in their form, they do not produce death by asphyxia simply, but by such a general wasting of the powers which move the blood, that it may be said to partake of the nature of syncope. It is in cases of violent and sudden death that the distinctions above made are most easily recognised; the termination of protracted disease, if observantly watched, will generally present phenomena partaking of all the forms which may separately manifest themselves in particular cases. The intimate dependence of all the organic functions with one another, and the degree in which every one may be influenced by the nervous system, often cause them to be affected by disor- der of any one, in a manner which at first sight appears anoma- lous, but which a little consideration will generally elucidate. asphyxia (Pathology). 357 We have hitherto considered asphyxia only in' its fully deve- loped form, and examined only its fatal termination. It must not be forgotten that imperfect respiration has a tendency to produce various diseases, although it may not be sufficient for the imme- diate extinction of life. The recent experiments of Dr. J. Reid (Edin. Med. and Surg. Journ., April, 1839) have shown that, when the number of inspiratory movements is greatly diminished by section of the pneumogastrics, the sanguineous engorgement of the lungs which is thereby produced is very apt to pass into the state of inflammation ; and that the various stages of pneumonia, and even gangrene, are very commonly witnessed in animals which have lived sufficiently long after the operation for these changes to take place. The most constant result of this engorge- ment is an effusion of serous fluid into the air-cells and passages, which, of course, adds to the difficulty of respiration. It may, then, be reasonably surmised that there is a tendency to similar morbid changes in other cases of obstructed respiration ; and this has been noticed in a variety of instances. Thus, when foreign bodies have remained impacted in the air-tubes, but have not pro- duced immediate suffocation, inflammation of the lungs is very apt to supervene: and bronchocele not unfrequently proves fatal in a similar manner, whilst the real obstruction is still inconsider- able and does not excite attention as the cause of the disease. The permanent congestion of the pulmonary arteries, and the demand for increased propelling force, will often occasion hyper- trophy and dilatation of the right ventricle ; and the same con- gestion, extending to the systemic veins, may be the cause of many diseases in remote organs, especially the pain, liver, intes- tines, and kidneys. Dropsical effusions, also, are very liable to occur from the same cause. It is perhaps during the progress of phthisis that we most frequently observe these consequences of partial asphyxia. The bronchitis which so commonly accompa- nies chronic tubercular disease of the lungs may be not impro- bably regarded as taking its origin in the congestion of the mucous membrane of the air-passages, which has been mentioned as a constant result of obstructed respiration ; and the attacks of active inflammation of the lungs themselves, which are so liable to super- vene whenever deposition of tubercular matter has taken place, may, without doubt, be in part attributed to a similar predisposi- tion. The diarrhoea which so commonly occurs in the later stages of the complaint may be accounted for in a similar manner. It is often found on post mortem examination that no morbid change has taken place in the mucous membrane of the alimentary canal or in the intestinal glands ; and its functional disorder may be attributed to the irritable state induced by the congestion which has affected it during life, and which has been mentioned as often so remarkable a feature in the appearances found after death from asphyxia. Even where ulceration of the intestinal glands, and 46 358 asphyxia (Treatment). softening of the mucous membrane, are found to have taken place, they may be regarded as having had their origin in the disturbance of the circulation so often alluded to. Treatment. The ideas which are entertained of the nature of asphyxia must necessarily have an important bearing upon the principles of treatment. Those which will be here stated have been for the most part fully sanctioned by experience ; and will, at the same time, be found to harmonise well with the theoretical views formerly stated. It is rarely that this condition comes under the notice of the physician in any other form than as secon- dary to other diseases ; but as he should not be ignorant of the share it has in various kinds of violent death, wc shall presently consider the principal forms under which it may present itself, and the treatment specially adapted to each. The first object in the treatment of asphyxia will evidently be to remove its cause; since, as long as this continues to operate, no permanent relief can be procured by any means whatever. This precept will apply not only to the removal of direct or mecha- nical obstructions, but to the abatement of all sources of inter- ference with any of the operations naturally concerned in the function, and especially those of the nervous system. When the derangement has not advanced so far as to occasion cessation of the respiratory movements, it will usually be found that this mea- sure will restore the due action of the whole train in a very short time, provided that no organic lesion, such as extravasation in the brain, has taken place. But where these have been suspended. more active means become necessary. It will be remembered, that not only is there a suspension of activity under such circum- stances, but an absolute diminution of the vitality or irritability of all the organs concerned, ocasioned by the previously insuffi- cient supply of blood, and by the want of oxygenation in that which has been last transmitted. The indications of treatment, therefore, are two; the renewal of the respiratory actions, and the excitement of the low irritability of the system by unusual stimuli. The first is effected by artificial respiration, which is undoubtedly the most powerful means in our possession of restor- ing suspended animation under such circumstances. Its success, however, will mainly depend upon the care and judgment with which it is employed. As little time as possible should be lost in putting this measure into execution ; but whatever interval should from necessity occur, may be advantageously employed in other ways to be presently noticed. Until more appropriate means are available, the natural movements of respiration may be in some degree imitated, by compressing the chest and abdomen, so as to diminish the cavity of the thorax, and to expel from the lungs as much as possible of their contents, and then allowing them to recover their former dimensions by their natural elasticity. Al- though but a poor substitute for the natural process, even this asphyxia (Treatment). 359 trifling assistance may be of the utmost benefit, if given at the critical time when the heart's action is nearly suspended, and the vital powers rapidly sinking. Where no bellows can be procured, the insufflation of the chest from the mouth of another is the best measure that can be adopted. It would, in fact, be preferable, on account of the higher temperature at which the air is thus intro- duced, and the security which is afforded against the employment of an injurious degree of force, were it not for the partial carbo- nisation and abstraction of oxygen which this air has undergone. The insufflation is performed by applying the mouth of the opera- tor to the mouth or to one of the nostrils of the patient, closing the other apertures, and making a forcible expiration, so as to dilate the chest which is then to be emptied again by gentle pres- sure. The insertion of a short tube into the nostril, if of sufficient bore, will much facilitate the operation. It will be desirable that an assistant should at the same time gently press the larynx backwards and a little downwards upon the vertebras, so as to oppose the passage of air through the oesophagus into the alimen- tary canal. When a pair of bellows is employed, the air should be injected through one nostril, whilst the mouth and the other nostril are closed: the latter is then to be opened for the expira- tion of the air,* and the process repeated about fifteen times in the minute. With regard to the amount of air to be thus intro- duced at each stroke, there is some difference of opinion. Good- wyn, although he estimated the quantity naturally taken in at each inspiration to be no more than twelve cubic inches, recom- mended that a hundred cubic inches should be thrown in by the bellows, for the dislodgement of the impure air from the air-cells and smaller bronchial tubes, which he thought could not be other- wise effected. There is no doubt, however, that if this principle were followed, irreparable injury would result from it to the tex- ture of the lungs; indeed, there is reason to believe that many individuals have been sarificed by injudicious insufflation who might otherwise have recovered. Leroy discovered that brisk inflation of air into the trachea killed rabbits, foxes, goats, sheep, and other animals, even when the force employed was that of an expiration from the human being; and the recent experiments of Dr. Southwood Smith (Philosophy of Health, vol. ii. p. 75,) have shown, that though a moderate inspiration favours the passage of the blood through the lungs, great distension of their cavity checks almost entirely the circulation of fluid through them, by the me- chanical compression of the vessels. According to Leroy, the quantity injected ought to be the same as that naturally inspired ; and this is the safest rule. A few repetitions of the process will soon produce an entire exchange of the air contained in the lungs, * The bellows constructed under the direction of the Royal Humane Society is provided with an additional valve for this purpose, which prevents the necesT sity of the alternate closure and unclosure of the nostril.—Author. 360 asphyxia (Treatment). by the tendency to mutual diffusion of which all gases partake; and it is better that no risk should be run of doing mischief where the organs concerned are of so delicate a conformation. More- over, the insufflation of too large a quantity of air will diminish rather than increase the development of caloric ; and this is the explanation of the results which have led to the belief, that arti- ficial respiration has no power of maintaining animal heat. The respiratory movements may also be excited by galvanic action on the muscles, in the method proposed by Leroy and approved by Magendie (Journ. de Physiologie, torn, ix.); and there can be no doubt that the penetration of a fresh atmosphere into the air- cells will be more facilitated by such a process, than by insuffla- tion. This method requires little skill for its employment, and is unattended with any danger; and it is thereby superior to that of Dr. Ure, which can only be carried into effect by a person pos- sessed of considerable anatomical knowledge. Leroy introduced acupuncture needles a short way into the fibres of the diaphragm on each side, in such a direction that they might be easily con- nected with the opposite poles of a galvanic battery. When the galvanic circle was completed, the diaphragm contracted and enlarged the cavity of the thorax: when it was interrupted, the weight of the abdominal viscera, assisted by gentle pressure on the surface, caused its return; and thus alternate movements of inspiration and expiration were produced, and maintained until the natural movements supervened. A small galvanic apparatus only is sufficient for this purpose. The second indication for treatment is the exhibition of various stimulating agents, both internally and externally. Amongst the most powerful and useful of these is warmth ; but some judgment is required in its application. If the circulation have ceased, and the temperature of the body be much lowered, no attempt should be made to raise it suddenly; since experiment shows that when such attempts are made on animals in a state of torpor, they are often fatal. Warmth may be gradually communicated by means of a warm bath, or by warm applications, especially to the region of the stomach; but no fluid of a temperature above 98° or 100° should be employed. Rubefacients also may be applied to the skin with advantage, and friction employed, when it has in some degree recovered its sensibility; but they are previously useless. Warm stimulating fluids in moderate quantity should be injected into the stomach or rectum, and stimulating vapours applied to the nostril. When not only the respiratory movements but the actions of the heart have ceased, the case becomes much more serious, but it is not entirely hopeless. It has been already stated that arti- ficial respiration has proved successful in renewing the circulation by unloading the right cavities of the heart and transmitting the necessary stimulus to the left. But this is unfortunately not often asphyxia (Treatment). 361 the case; and it is therefore to be considered what auxiliaries can be employed. Slight shocks of electricity, or a current of galvanism, transmitted through the regions of the heart, would appear the most likely means of re-exciting its contractions. Another method has been pointed out, however, which is well deserving of trial. Professor Coleman found that after animals had been asphyxiated, and the right auricle had lost its irrita- bility, the detraction of a small quantity of blood from one of its veins occasioned it in few minutes to respond to the application of a stimulus. (Wilson on the Blood, p. 131.) A similar fact was observed by Dr. J. Reid in experimenting upon the action of cer- tain poisons. A slight incision into the auricle itself appeared most effectual; but the opening of the jugular vein generally produced the same effect. This measure is likely to be useful in more ways than one, since it will relieve the congestion of the cerebral veins, and thus promote the recovery of the sensibility. It is not a step, however, to be indiscriminately adopted. The inquiries of Mr. King (Safety-valve Function of the Heart, in Guy's Hospital Reports, vol. ii.) leave us no difficulty in under- standing how an abstraction of blood from the jugular vein may relieve the distension, not only of the right auricle, but of the ventricle, since the tricuspid valve does not close so as to prevent regurgitation, when the accumulation of blood is considerable. The effect of an electric or galvanic stimulus should be first tried; and if it fail, the experiment should be repeated after the abstraction of a little blood from the jugular vein as low in the neck as possible. Attempts at resuscitation should not be abandoned as hopeless until many hours have elapsed, unless evident indications of death present themselves; nor should the employment of remedial means be discontinued at too early a stage of recovery. The condition of the patient, even after the natural movements of respiration have recommenced, and the circulation has been renewed, is very precarious, and requires watchful attention for a considera- ble time. Many lives have been sacrificed by too early neglect. The object of the preceding sketch has been rather to give a general view of the whole subject of asphyxia, and especially to exhibit the connection of this pathological state with other morbid conditions of the system, than to pursue any department of it into details. We shall now inquire how far it is concerned in two of the most common forms of violent death,—strangulation and sub- mersion : these, however, will be here considered simply in a pathological view; their juridical relations will be fully treated of in the division of this series appropriated to forensic medicine. One form of asphyxia which has been but slightly adverted to in this article, the Asphyxia neonatorum, will be more fully treated of among the diseases peculiar to infants. 362 asphyxia (Strangulation). We shall now consider the phenomena attending certain forms of violent death, in the production of which asphyxia is principally or solely concerned. Strangulation. By this term is understood forcible compres- sion of the neck by a ligature, to such an extent as to impede or prevent respiration. Suspension is, therefore, but one variety of strangulation, the peculiarity of which consists in the traction of the ligature being produced by the weight of the body. In the simplest form of suspension the phenomena are precisely the same as those of ordinary strangulation; this takes place where the body is lifted from the ground by traction of the cord, and where no violent jerk is given to the neck. But this seldom happens; for in most cases of suspension the body has been made to fall more or less violently, so as to occasion other injury be- sides the simple compression of the neck in which strangulation properly consists. We shall first, then, consider the phenomena of death by strangulation simply; and afterwards those which often attend death by suspension. If the compression of the neck affected only the trachea, it is obvious that death would be produced by asphyxia solely ; and in this manner it has been occasionally brought about,—some firm substance, like the cushion of a tourniquet, having been ap- plied upon the windpipe. A mode in which infanticide has been sometimes perpetrated—the firm and continued pressure of the thumb upon the trachea—operates in precisely the same manner, although hardly referrible to the head of strangulation, from the absence of ligature. On the other hand, it is easy to conceive that a ligature may be applied around the neck in such a manner as to make injurious pressure on the jugular veins, so as to occasion death by cerebral congestion, or by apoplexy simply, without materially obstructing the respiration. And again, it is sufficiently evident that, in most cases of strangulation, both these circumstances will operate in producing the fatal result. Ac- cordingly it is found, by examination of the bodies of those who have died by strangulation, that in a few cases the signs of as- phyxia alone are present; in some those of apoplexy alone are very decided ; and in a large proportion the appearances indicate that both states have existed. Out of 102 cases collected by Remer (Annales d''Hygiene, torn. iv. p. 179), unequivocal signs of apoplexy were found in nine ; the appearances resulting from pure asphyxia in six; a combination of the two in sixty-eight; and in the remaining nineteen the proximate cause of death was not substantiated. More recently Dr. Casper (Wochenschrift fur die gesammte Heilkunde, January, 1837,) has given a similar collection of the results he has obtained, of which the following is a summary. Out of 106 cases, death appears to have taken place by apoplexy in nine; by simple asphyxia in fourteen; by both conditions in sixty-two; from neither in five; and the num- asphyxia (Strangulation). 363 ber of unexamined bodies was sixteen. In several of the cases attributed by Remer to apoplexy, there seems to have been (although not distinctly stated by him) an extravasation of blood in the brain, as well as congestion of the cerebral vessels: in those related by Casper, on the other hand, the congestion alone seems to have been too much relied on as a sign of apoplexy, since it is to be recollected that distension of the veins of the brain occurs in asphyxia. It can scarcely be doubted that these varia- tions depends principally on the mode in which the ligature is applied to the neck; and a series of experiments upon his own person was performed by Dr. Fleischmann (Annales d'Hygiene, torn. viii. p. 432), with the view of elucidating this question. Although not entirely satisfactory, they afford some important results, of which we shall give an abstract. 1. If the neck be encircled with a ligature placed between the chin and the os hyoides, so as to rest upon the sides and angles of the lower jaw, the principal vessels are but slightly compressed, and the cord may be drawn tightly without any material impe- diment being offered to the respiratory actions. After a short time, however, a flushing of the face and a prominence of the eyes are perceived ; the head becomes unusually hot; a sensation of weight is perceived in its interior, which increases to great oppression almost amounting to insensibility; and a noise in the ears suddenly commences. When this symptom developes itself, M. Fl. remarks, it is high time to give up the experiment, as a few moments longer would be fatal. The compression may, however, be borne for as much as two minutes with impunity. There is evidently a tendency to the production of apoplectic congestion; but the vessels are not sufficiently compressed for this condition to be immediately induced. The account given of these sensations by persons who have recovered after suicidal, accidental, or experimental suspension (instances of the last being by no means unfrequent), does not materially differ from that just quoted. A peculiar feeling of a pleasurable nature is first expe- rienced ; then imperfection of the sight, with flashings of bluish light; and these are rapidly followed by insensibility. 2. Similar consequences will follow the application of the ligature upon the larynx; but here the respiration is more impeded. Scarcely half a minute expires before the noise in the ears, and a sensation in the brain which it is difficult to describe, give warning that the experiment must be discontinued. It is obvious that, in this position of the cord, the vessels are no longer protected by the angles of the jaw, and will therefore be more completely com- pressed, so that death will result from the concurrent effect of apoplexy and asphyxia. 3. If, on the other hand, the ligature be placed between the os hyoides and the thyroid cartilage, or upon the os hyoides, and rests upon the angle of the jaw or the mastoid processes, the vessels will be almost entirely protected from com- 364 asphyxia (Strangulation). pression, and the respiratory acts will alone be affected. Occlusion of the rima glottidis is produced by the depression of the epiglottis, which is forced down by the displacement of the mass of flesh that forms the root of the tongue. In this case death will be almost purely owing to asphyxia. 4. Lastly, if the cord be applied over the trachea, the passage of air will be completely checked, and asphyxia will soon result; the event will be less rapid if the ligature cross the cricoid cartilage. The vessels will, of course, be also compressed when the cord is thus fixed: and the signs of apoplexy will be found more or less coexistent with those of asphyxia. It is to be recollected, in making such distinctions, that con- gestion of the cephalic veins is an ordinary appearance in cases of simple asphyxia ; so that it might seem unfair to consider it of an apoplectic character in any instance in which there is not actual extravasation. But the value assigned to it will depend upon its amount when compared with that of other portions of the venous system, and upon the comparative state of the right and left sides of the heart. If the pulmonary arteries, the right cavities of the heart, and the great veins leading to it be all gorged with dark blood, whilst the left cavities and their vessels are flaccid, it is evident that the congestion of the brain is only a part of the general result of the cessation of the respiratory function. But if, as sometimes happens, no such general congestion is found, and the right side of the heart is not peculiarly distended, whilst the veins and sinuses of the brain are loaded, we may regard the latter as an apoplectic condition not immediately dependent upon obstructed respiration, though aggravated by it if it co-exist. And here it is necessary to remark, that although in cases of apoplexy with gradually increasing coma, asphyxia seems to be generally the proximate cause of death, there are many instances in which the fatal result occurs too rapidly for it to be thus accounted for, and in which it seems rather due to a sudden violent impression transmitted through the nerves to every part of the system, destroying the vitality of the whole at once, and putting an immediate stop to the motion of the blood. It is this kind of impression which is produced by concussion of the brain, by blows on the epigastrium, by a violent electric shock, and other similar causes which check at the same time the action of the heart and that of the capilliaries, producing death by ? y ucope. It is well known that in the lower animals the circulation will continue after the gradual removal of the whole of the brain and spinal cord : whilst sudden violent and extensive injuries of these centres, such as crushing the brain, or breaking down the spinai cord, entirely check it. This fact appears to indicate the actual propagation of an anti-vital influence (if we may be allowed the term) along the nerves in cases of this nature, since the mere suspension of the function of the nervous centres cannot prove asphyxia (Anatomical Characters). 365 similarly fatal. In this manner only can we account for the suddenness of death in the apoplexia fulminans ; and the same view seems applicable to several cases of death by hanging, in which the appearances are very different from those of the more common forms of apoplexy or of asphyxia, as will presently be pointed out. The obstruction to the passage of air through the air-tubes, and the pressure upon the bloodvessels of the neck, are not the only causes of death by suspension, although it is probable that they are alone in operation when the cord has been tightened simply by the weight of the body. When greater violence has been used, it is not unfrequently found that the vertebral column has been injured, so as to compress or lacerate the spinal cord. This injury may be of several kinds, but it is generally confined to the first and second cervical vertebras. Sometimes the odontoid process has been displaced from the atlas, with rupture or laceration of the ligaments which confine it, and has been forced against the spinal cord. In other instances it has been separated from its own vertebra; and these displacements of the atlas upon the dentatus may happen in various ways. Again, the two first vertebras have been separated from the rest of the column, by rupture of the intervertebral substance, and of the spinal ligaments. Other fractures of these vertebras have been seen; and in all, the spinal cord was more or less injured. But even where no evident displacement is found, there is often an appearance of straining of the ligaments; and in such cases the spinal cord must have received a severe shock, which will obviously aid the other causes of death, if not itself competent to produce it. Anatomical characters. From what has been stated as to the operation of several causes, singly or combined, in producing death by strangulation, we shall be led to expect a considerable variety in the morbid appearances afterwards found ; and, indeed, it is almost only from the observation and comparison of these appearances, that our knowledge of the action of these causes is derived, since the means of observing them during life are so restricted. The description given by the older writers of the signs of death by strangulation will only apply with strictness to a limited number of cases. Indeed it may almost be asserted, that some of the appearances mentioned are incompatible with each other, and that the description must have been drawn up by combining observations made upon several dissimilar cases. The following have beeen specified:—" Lividity and swelling of the face, especially of the lips, which appear distorted. The eye- lids are swollen and of a bluish colour ; the eyes red, projecting forwards, and sometimes forced out of the orbitar cavities; the tono-ue enlarged, livid, and compressed between the teeth, or fre- quently protruded. A sanguineous froth about the lips and nostrils. A deep and ecchymosed impression around the neck, 366 asphyxia (Anatomical Characters). indicating the course of the cord, the skin being sometimes ex- coriated; laceration of the muscles and ligaments in the hvoideal region; laceration or contusion of the larynx, or of the upper part of the trachea. There are also commonly circumscribed ecchymosed patches, varying in extent, about the upper part of the trunk, and the upper and lower extremities, with a deep livid discoloration of the hands. The fingers are generally much con- tracted or firmly clenched. The urine, the fasces, and the seminal fluid, are sometimes involuntarily expelled at the moment of death. The body is, ceteris paribus, a much longer time than usual in parting with its heat." (Taylor's Medical Jurisprudence, vol. i. p. 165.) Some of these signs may be observed on the bodies of most persons who have come by their deaths in the mode in question ; but it must be also admitted that they may all be absent. This is especially the case where the general shock to the nervous system appears to have been the proximate cause of death. They are usually most developed where death has supervened slowly, and has been due either to asphyxia produced by the direct ob- struction of the windpipe, or to gradually increasing coma resulting from the accumulation of blood by pressure on the vessels of the neck. In either of these cases we find the mode of death indicated internally by the general venous congestion, already described as indicative of asphyxia, with more or less peculiar turgidity of the vessels of the brain. It will be desirable to examine separately each of the principal external signs, with the view of determining the circumstances under which they should be respectively relied on, or their absence made a ground of hesitation. The lividity of the face, lips, and eyelids, and the prominence and brilliancy of the eyes, are not unfrequently absent, at least for some time after death. It is somewhat remarkable that the ap- pearance of the countenance is usually least altered in suicides; its traits being frequently those of undisturbed placidity. These signs are, on the contrary, more constantly observed on the bodies of those who have been executed ; and they are still more developed where strangulation, as commonly understood, has been murderously performed. On an instance of this kind the graphic description given by Shakspeare was founded. (Henry VI. Pt. ii. Act 3. Scene 2.) It is frequently observed, however, that although the face presents no lividity, and the lips and eyelids no tumefaction, soon after the body has been cut down, these ap- pearances present themselves after an interval of some hours, especially if the ligature be allowed to remain about the neck. This was pointed out by M. Esquirol (Arch. Gen. de Mid. Jan. 1823), who was the first to draw attention to the uncertainty of these appearances in cases of hanging. Although, however, their absence cannot support a negative inference, their presence may be held as a proper foundation for a positive presumption ; that is, if a body be found hanging, or with a ligature tightly drawn asphyxia (Anatomical Characters). 367 round the neck, and these signs are present, the presumption is very strong in favour of death having taken place by strangula- tion. For they cannot be produced by suspension after death from other causes, even if this be effected immediately upon the extinction of life. This has been established by the experiments of Orfila. Sometimes lividity and tumefaction of the face will appear after an interval of some hours, even when the ligature has been removed, as was the case in some of the instances men- tioned by Esquirol; more recently this has been noticed by Fleischmann (op. cil., p. 436), who attributes it to the change of position of the body, causing the blood (remaining fluid as it does) to run towards the head, which is often in the removal the most depending part. In the case of the notorious Burke, it is stated by Mr. Watson (Treatise on Homicide, p. 136), that by changing the position of the body after the cord had been removed, the congestion of the vessels of the head and face could be made to appear and disappear at pleasure. As a general fact it may be stated, that the more slowly death supervenes, whether from asphyxia or from apoplectic coma, the more decidedly will these signs be presented ; and that, on the contrary, they are likely to be absent whenever death results from the sudden shock sustained by the nervous system, or from complete obstruction to the entrance of air into the lungs. The protrusion of the tongue has been considered by most writers (after Belloc) as dependent upon the position of the liga- ture. If this press above the os hyoides, it is stated that the tongue will be drawn backwards into the mouth ; but if below the cricoid cartilage, the laryngeal apparatus will be drawn upwards, and the tongue protruded. But it must be remembered, that this protrusion of the tongue may be found in the bodies of those who have died of asphyxia from other causes, or of other diseases. Moreover, M. Devergie states (Traite de Med. Legale, torn. ii. p. 384), that he has found the tongue protruded between the teeth, when the ligature has been applied even above the os hyoides; and that the same effect may be produced on the dead body : whilst he has occasionally found it within the mouth, when the ligature has been on the larynx or below it. According to Fleischmann, this change, like the former one, is mostly produced by the gradual approach of death; and is likely to be absent where death has been almost or altogether immediate. Further inquiry is certainly needed on this point; but in the meantime it may be safely stated, that, if a body were found with the tongue protruding between the teeth, and bearing their impressions, and other indications of strangulation were present, little hesitation need be felt in attributing death to this cause. The next point to be considered is a very important one—the mark of the ligature upon the neck. A good deal of confusion will be f£i nd in the statements of medico-legal writers on this 368 asphyxia (Anatomical Characters). subject, arising principally from the vague and contradictory significations which have been attached to the term ecchymosis. By true ecchymosis is to be understood an infiltration of blood into the internal substance of the skin and subcutaneous cellular tissue, so that thin laminae of these textures shall be found pene- trated with it. This can only be substantiated by dissection ; and from neglecting this mode of examination many observers have mistaken for ecchymosis the external discoloration which is often entirely independent of it. Thus we may account for the great diversity in the proportions given by different observers, of the instances in which ecchymosis was found on the neck after death by strangulation. Remer declares that nine-tenths of his cases presented it; whilst Klein relates fifteen cases which came under his own observation, and Esquirol twelve under like circumstances, in none of which was this lesion observed. Devergie has collected fifty-two cases in which the state of the neck was particularly observed, and in only three of these did true ecchymosis exists; and Dr. Casper (loc. cit.) states, that out of seventy-one cases, twenty-one were accompanied by true ecchymosis. Of the cases collected by Remer, many were probably furnished by persons who were unacquainted with the characters of true ecchymosis; and it is not surprising, therefore, that he should estimate the proportion so high. The discrepancy between the accounts of Klein, Esquirol, Devergie, and Casper, is however, at first sight, more striking. Still, it would probably be reconciled had we more precise information as to the mode of death in each class of cases; for it is observed that ecchymosis rarely or never occurs after suicidal hanging, where for the most part the body has not fallen violently upon the cord, whilst it is much more frequent on the necks of those who have been murdered or executed. The following curious case is related by Dr. Casper. A young man in a fit of drunkenness hung himself with a stout cord. He was cut down in about half an hour afterwards; and attempts were made at resuscitation. The cord had merely produced a slight superficial mark on the neck, destitute of any appearance of ecchymosis. Signs of returning animation began to manifest themselves; the efforts of the medical attendants were continued for several hours, but the traces of vital reaction disappeared. To the astonishment of all present, when life was about to become extinct, the mark on the neck became deeply ecchymosed ; this was verified by an examination made the next day. This case is an illustration of the physiological fact, that to produce true ecchymosis there must be a continuance, for a certain time, of the vital processes to which it is due; and that, where death is very suddenly occasioned by violence of any description, all marks of that violence may be absent. This has been repeatedly observed in cases of death from concussion of the brain, blows on the epigastrium, &c. When ecchymosed spots are found on asphyxia (Anatomical Characters). 369 the neck, their correspondence with the indentation of the ligature should be carefully examined ; since it not unfrequently happens that they result from violence previously inflicted, which the suspension has only been intended to conceal. Where a true ecchymosis is found in the line of the cord, little doubt can be entertained of the strangulation having taken place during life; since all experimental researches yet performed agree in a nega- tive result as to the possibility of any true ecchymosis being produced by the application of a ligature after death, even although but a short time has elapsed. Experiments are yet wanting, however, as to the possibility of producing a true ecchymosis by suspension immediately after death ; such a point is obviously very difficult of decision, and at the same time of the utmost conse- quence in a medico-legal view. In one instance related by Dr. Casper, the mark produced by the application of the ligature was so decided, that an individual not acquainted with the cir- cumstances would have supposed from it that the deceased had been hanged while living. But the subject had died of typhus; and although the experiment was tried an hour after death, marks of cadaveric lividity had already shown themselves; so that the tissues must have been in a state peculiarly favourable to the production of this appearance. Still, however, there was no infiltration of blood in the skin or cellular texture. The mark which is most constantly left on the neck after death by strangulation, is a line of slight brownish-yellow discoloration, along which the skin has the dryness and hardness of parchment. This is seldom absent where a cord has been applied; but where strangulation has been effected by a handkerchief or other soft material, the pressure may be diffused over so large a surface that even this may not be produced. The Thugs of Hindostan, who use their turbans for this purpose, are said to accomplish their work so dexterously, as to leave no external mark whatever of the mode in which they have destroyed life. Where an in- dentation has been produced by the ligature, its lips have a violet tinge, especially when the ligature has not been removed; and with this the paleness, which the skin of the depression presents on first being exposed, strongly contrasts. It is not until after it has been for some little time subjected to the contact of air, that the discoloration and hardening of the skin are perceived. This character was first pointed out by M. Esquirol, who regarded it as indicative of strangulation during life; but from the experi- ments of M. Devergie and Dr. Casper it appears, that it is of little or no value as a single proof, since it may be produced by suspension after death. All that is required appears to be a suf- ficient force in the application of the ligature, and its subsequent removal. But the violet tinge of the lips of the depression cannot be so completely imitated by post mortem strangulation; and even though it may show itself on the upper side, it is scarcely per- 370 asphyxia (Anatomical Characters). ceptible on the lower. Whenever this is very decided, therefore, and is presented by both lips of the furrow, it is a tolerably posi- tive indication of strangulation during life. We must not expect to find such a mark, however, all around the neck. It will be most decided where there have been any resisting points beneath the ligature. In case of death by suspension, we should not expect to find it at any great distance from the larynx, or os hyoides. Where strangulation has been practised, however, the circle will be more complete; and by a careful examination, we may thus be enabled to pronounce that the subject has been strangled first, and then hung—a mode in which attempts have often been made to conceal the first crime, by exciting suspicion of suicide. Some- times when the ligature has been hard (a piece of new cord, for example), and roughly applied, slight excoriations are produced by it, the epidermis and corpus mucosum being rubbed off. The degree of vascularity of the true skin at these spots will generally indicate whether or not the violence has been inflicted during life; and this may even be detected after the desiccation of the skin by holding it between the eye and the light. But it must be re- membered that the same cause which prevents ecchymosis may prevent any vital reaction of this kind, so that a negative infer- ence must not be drawn from its absence. Another change is produced by the forcible application of a ligature, to which also M. Esquirol was the first to direct attention. If the skin of the furrow be carefully dissected off, leaving all the cellular substance behind, a whitish silvery line will be perceived, marking its course along this tissue. This appearance seems to result from the con- densation of the tissue, occasioned by the forcing of its fluid and fatty matter into the surrounding substance. If desiccation has proceeded far, the mark will not have a glistening, but a white and dry aspect. This also is principally observed on the front of the neck, and sometimes over the sterno-mastoid muscles. A very important branch of this inquiry is that which relates to the possibility of an impression like that of a strangulating ligature being made during parturition, by the twisting of the um- bilical cord round the neck of the child, and the traction to which it will be subject if not preternaturally long. Medical jurists and accoucheurs seem pretty fully agreed as to the improbability of such an occurrence; and most authors deny its possibility. Klein, for example, states, that although he has examined a consider- able number of infants who came into the world with the cord twisted round the neck, he has never detected any traces of it, either in the form of actual ecchymosis or of any impression whatever. The importance of this question to the medical jurist is evident, from the frequency of attempts to conceal the com- mission of infanticide by strangulation, by twisting the cord around the neck, so that death may be referred to natural causes. This contrivance may often be detected by collateral evidence, asphyxia (Anatomical Characters). 371 although we may admit the possibility of an impression being produced on the neck in this manner; thus, foreign matters,such as bits of straw, fine gravel, ). air, partly from the ventricle, partly from the veins. In this way the auricle will be observed, at the instant of each relaxation, to become distended with air, which thus stops the circulation, and, of course, causes death." As to the causes to which Nystcn and Boerhaave attribute it, he does not deny the possibility of their being occasionally concerned, but successfully impugns the hypothesis of Magendie as being quite incompatible with the observed facts; for blood and air mixed continue to be forcibly ejected from the wounded vessel even after the animal has become insensible, which indicates sufficiently that the right side of the heart continues capable of powerful action.* * The occasional spontaneous introduction of air into the larger veins in the neighbourhood of the heart, during surgical operations, has excited much interest of late years since attention was first called to it by Beauchene, and more par- ticularly since the occurrence of Dupuytren's celebrated case. The experiments made before the recent Commission of the Royal Academy of Medicine, by M. Amussat, have thrown some new light on this obscure subject, from these it appears that it takes place only in that portion of the great veins which are situ- ated near enough to the chest to be the seat of the venous pulse, or that tlux and reflux of the blood taking place under the influences of the respiratory move- ments,—as the lower third of the external jugular, for instance, and the sub- clavian vein; or if such introduction of air occasionally occurs in somewhat more remote parts, it is only when the orifice in the vessel is held open, and not even then in veins which are considerably more distant, as the brachial, for ex- ample. Where air is artificially injected into the veins of the lower animals, the effect varies with the quantity introduced, and the force and rapidity with which it is thrown in. Thus, in some instances, death ensued within two or three minutes; in others, though there was an appearance of extreme anxiety, with great em- barrassment of the respiration and circulation, extreme debility, convulsions, and tetanic spasm, death did not take place for near half an hour; whilst in others again, when the quantity was very inconsiderable, little uneasiness was mani- fested, and the animal speedily recovered. The physical signs of air in the veins were a lapping or gurgling noise within these vessels, synchronous with the in- spirations, and occasionally also with the diastole of the heart, in which organ, likewise, a bellows-murmur was heard, with or without a gurgling sound. On dissection, if immediately performed, the right side of the heart and the pulmo- nary artery were found distended with frothy blood ; the left side at this period being entirely free from it, unless in such large animals as the horse, where the greater size of the capillaries of the lungs was supposed to have admitted more readily of its passage. In some instances, the veins of the brain and other parts of the body already contained air ; and it existed in them universally, as well as in the arteries, where the animal had survived the experiment, and not being put to death till some days afterwards. The proximate cause of death is supposed by the Commission to bo threefold. 1st. Enormous distension of the heart, and consequent impediment to its con- traction. 2d. Embarrassment of the pulmonary circulation by the spumous blood in the branches of the pulmonary artery. 3d. Compression of the brain by the air in its veins, in some instances. As to remedial measures, those which appear to promise most benefit are,— frequent compression of the chest, the vein being kept closed in the intervals ; the abstraction of air or froth with the syringe; and, lastly, free bloodletting, the efficacy of which was accidentally discovered by Nysten. There are on record nearly forty supposed cases of the accidental introduction of air into the veins in the vicinity of the chest, in operations on the human sub- ject; yet in very few of these is the actual occurrence of such an event satisfac- torily established. Dupuytren's, and perhaps half a dozen others, may be ad- mitted as genuine. In these there was heard either a gurgling noise, or a sound syncope (Diagnosis). 449 A large draught of cold water, taken whilst the body is over- heated and debilitated by violent exercise, has been known almost immediately and entirely to arrest the heart's action. But, of all agents, electricity in an accumulated form is that which most instantaneously and irrecoverably puts a stop to the heart's motions, seeming to act simultaneously on the nervous and muscular systems and on the blood, destroying at once the sensibility of the first, the irritability and contractility of the second, and the power of coagula- tion in the last. The cases in which fatal syncope more usually presents itself in practice are either those in which, there having been extreme previous debility, some unsuitable posture has been assumed, or some exhausting muscular effort attempted, some intensely painful operation performed, or injudicious evacuation practised; or those in which sudden and irreparable exhaustion has been induced by an inordinate loss of blood; or, finally, those in which the heart has long been suffering from a state of organic disease, as soften- ing or atrophy of its tissue, or passive dilatation of its cavities. In the last-mentioned order of cases, so great is occasionally the weak- ness of the circulation, that a portion of the blood seem sometimes to coagulate within the heart before life is yet extinct; the polypous concretion so formed becoming the immediate cause of the fatal syncope. A few instances are on record of individuals who have died quite suddenly without any sufficient apparent cause, and in whom dissection having discovered nothing besides an empty and flaccid state of both sides of the heart and of the venae cavas, we are obliged to refer the fatal termination either to deficient energy of the cardiac nerves, or to weakness of the muscular parietes of the organ, or, in short, to a species of paralysis. Diagnosis. Syncope may readily be distinguished from the partial loss of consciousness occurring so frequently in hysteria, and depending generally on temporary congestion of the brain rather than on deficient circulation within it, by the colour of the cheeks and lips in the latter affection, by the continuance of the arterial pulse, and finally by the accompaniment of other hysterical of air rushing through a narrow aperture; and this was, for the most part, almost immediately followed by fatal syncope. In one instance, death ensued almost instantly after opening the jugular vein for the abstraction of blood in a case of apoplexy. In all the indubitable examples of the accident in question, air was found in the vessels, both arteries and veins, of the brain and rest of the body, and in some of them also in the right ventricle of the heart. Still it is far|from certain that the air so introduced was always the sole or even principal cause of death ; for, in the first place, there were numerous other influential causes in operation, as loss of blood in some instances, exhaustion from pain or fear in others, oppressive determination to the head in others : and, in the second place, the symptoms and effects differ considerably from those induced by the direct injection of air in the lower animals; convulsions were not commonly present,— death was much more sudden. Distension of the right side of the heart with frothy blood was not so constantly observed, and the quantity of air introduced was apparently much less. (See a very able analysis of the evidence on this subject, in British and Foreign Medical Review, No. XII.)— Author 450 syncope (Treatment). symptoms, as globus, pain in the left side, alternate fits of laughing and crying, &c. The Leipothymy of Sauvages, or that condition which is charac- terised by the fixed eye and appearance of abstraction, or rather of impaired consciousness, by the momentary cessation of volun- tary motion and by the restrained respiration, a condition which so often ushers in the epileptic paroxysm, and which seems to consist in a passing congestion of the cerebral vessels, may be discrimi- nated at once by the pulse remaining firm throughout the seizure, as may likewise the epileptic attack itself by the same circumstance taken in connection with the violent agitations of the body, the foaming at the mouth, &c. Apoplexy, or pressure on the brain by effused blood or serum, or extreme congestion of its vessels, is sufficiently characterised by the heavy stertorous breathing, and commonly by the full strong pulse and congestion of the vessels of the face; as is asphyxia by the swollen livid features, and the dis- tension of the capillaries with unarterialised blood, indicative of the function of the lungs having ceased prior to that of the heart. And, finally, real death may be distinguished from syncope by the total and prolonged absence of both sounds of the heart, and of every trace of respiratory movement or pulmonary vapour; by the cadaveric stiffness of the limbs ; the sinking of the temperature in the interior of the body, as judged of by the introduction of a thermometer into either end of the alimentary tract, or under the axilla; the complete absence of all evidence of sensation, even on the application of the strongest stimuli to the nerves of the skin and to the other organs of sense ; by the blackish hue of the sclerotica when it has been exposed for some time to the air; by the filmy sunken appearance of the cornea; and by the bluish or reddish streaks throughout the skin, but especially on the most de- pendent parts; or, if these signs fail to force conviction, by await- ing the occurrence of the odour and discolorations of incipient putrefaction. Treatment. The objects of treatment consists in abbreviating or anticipating the attack, and, in the intervals, gradually counteract- ing the local and constitutional causes of its occurrence. During the period of the premonitory sensations, the obvious means of pre- venting the occurrence of complete syncope consist in placing the patient in the horizontal posture; the removal of all pressure of clothes, &c. on the throat, chest, and abdomen; the free admission of fresh air, to stimulate the lungs and surface of the body ; cold aspersion, to excite the cutaneous nerves and call the associated respiratory muscles into full action; together with sharp volatile errhines, a drink of cold water, or, if within reach, a stimulant aromatic draught, containing either ammonia or camphor, or a glass of wine, or other easily obtained stimulant, if there be no suspicions of inflammatory disease ; in short, all such means as are known temporarily to stimulate the nervous system, and augment the action of the heart and lungs. Tight ligatures on the limbs, so as to impede the flow of blood to the extremities,—once a popular syncope (Treatment). 451 remedy,—have been recently alluded to by Mr. Wardrop, who countenances their employment, and endeavours to account for their influence on physiological principles. When fainting has taken place outright, most of the above measures, with the excep- tion of the introduction of fluids into the stomach, will still be practicable and proper, and will ordinarily suffice to shorten the attack. The common people, in such cases, often cry shrilly in the ears, slap the palms of the hands, or use other familiar methods of awakening the dormant sensibility. In instances of obstinate and prolonged suspension of animation, it may be proper to employ, moreover, stimulant injections of camphor, turpentine, &c. together with frictions of the limbs and trunk ; to apply warm embrocations to the pit of the stomach and prascordial region; and avail our- selves of the agency of heat in a still more energetic form, as by means of the bowl of a spoon or head of a hammer, plunged for a few seconds into boiling water, and then brought into momentary contact with the cutaneous nerves, more especially in the situations just mentioned, or to the corresponding portion of the spine : and in extreme cases, which, from the prolonged silence of the heart, or unnatural and increasing interval between its sounds, seem to verge upon dissolution, the introduction of warm and exciting fluids into the stomach by means of an elastic tube, the assiduous employ- ment of artificial respiration, and, perhaps, also of electricity, should be resorted to. From analogy we should anticipate benefit, in some of these cases, from the momentary dashing of cold water, from a height, on the upper portion of the spine; care being taken not to produce any permanent or general reduction of the temper- ature of the body, inasmuch as to support the animal heat is an indication of primary importance. It can scarcely be necessary to recall to the reader's mind, that the prevention of syncope is not aways desirable; that in inflam- matory affections, for instance, when bloodletting has been prac- tised, the good effects of the operation are probably sometimes much augmented by its occurrence; whilst any attempts at pre- venting it, by the exhibition of stimulants, could not fail to coun- teract its beneficial results, and ought therefore, for the most part to be scrupulously avoided. There are, however, on the other hand many cases in which, though bloodletting in moderate quantity may promise great relief, as, for instance, in certain stages of organic affection of the heart, the supervention of syncope would be attended with extreme risk; and there are very few cases indeed, of any kind, in which we should venture to bleed to this extent in the horizontal posture. The ready occurrence of fainting on the loss of a very small quantity of blood may generally be considered as a proof of bloodletting being inappropriate, either to the disease in which it has been employed, or at least in respect to the period of its performance; and has been referred to, by Dr. Alison, as one of the means of distinguishing incipient idiopathic fever from the constitutional effects of a local inflammation. Dr. M. Hall thinks we have a criterion of the quantity of blood proper to be drawn in 452 syncope (Treatment). any disease, in the facility with which syncope is induced,—the patient being in the erect or sitting posture: and accordingly its supervention, from the loss of very moderate quantities of this fluid, is thought to indicate certainly the absence of formidable inflam- mation ; whilst, on the contrary, the tolerance of very copious evacuations of this kind is looked upon as sufficient evidence of their appropriateness. Thus, for example, whilst in a state of health, incipient syncope is induced commonly by the loss, on an average, of about 15 ounces of blood; in congestion of the brain, from 40 to 50 ounces may often be taken before the same effect ensues; in inflammation of serous membranes, from 30 to 40; of parenchymatous parts, about 30; of the skin and mucous mem- brane, about 10; in fever and the exanthemata, from \2 to It; whilst in delirium tremens, puerperal delirium, concussion of the brain, intestinal irritation, dyspepsia or chlorosis, and, above all, in cholera, the abstraction of a much smaller quantity will commonly have the same result. These views, however, have not been uni- versally adopted ; and Dr. Clutterbuck, in particular, whose expe- rience in regard to bloodletting has been peculiarly extensive, has very recently raised his voice against them. Whilst he does not altogether deny that the approach to syncope in the erect posture may be a test of the quantity of blood which can be lost with safety, he asserts that it is, alone, no true measure of the quantity proper to be taken; for the period at which syncope occurs will vary with the size of the aperture, and the rapidity with which the blood escapes, no less than with the quantity drawn ; and hence, if it flow very quickly, fainting may set in before enough has been obtained to make any permanent impression on the disease ; and if on the contrary, very slowly, an unnecessary and injurious dimi- nution of the circulating fluid may be undergone before the same state is induced. And agar the observance of the rule in question would lead very commonly. '. is asserted, to a wasteful expenditure of the vital fluid, as inflatv nations can very often be controlled without pushing depletion V> the length of syncope. In hasmorrhage from wounds, &c, fainting seems to be one of nature's remedies for promoting the contraction of the bleeding vessels, and the formation of a coagulum. When, however, mecha- nical means of commanding the hasmorrhage are at hand, and especially when the loss in this way has already taken place to a formidable extent, the judicious practitioner will not, of course, for a moment, hesitate to interfere and arrest the further flow of blood, and anticipate the occurrence of such a state ; unless under the existence of some very peculiar counter-indicating circumstances. In syncopes connected with diseased heart, or with uterine hasmor- rhage, such interposition, the peril being imminent, is loudly called for from the very first. In the former, our resources are unfortu- nately very limited, scarcely extending beyond the exhibition of diffusible stimuli, and the application of warmth and friction to the surface, and other excitants of the cutaneous nerves and capillaries, in the manner previously alluded to. In the latter, the invaluable syncope ( Treatment). 453 aid we possess in the tampon or plug, in the form of a sponge, or a common silk pocket handkerchief oiled, and gradually introduced into the upper part of the vagina, should never be forgotten, as by means of it, together with the judicious employment of opium and other stimulants, many a valuable life may be saved. In cases cf syncope originating in plethora, exciting medicines should, as a general rule, be religiously abstained from, abstraction of blood being the obvious remedy. On the contrary, in the very formidable cases of fainting connected with passive dilatation of the heart, and with lesion of its valves and orifices, bloodletting is a very doubtful resource, its use requiring the greatest caution; and being suitable, when at all, rather in the intervals than during or impending the attacks : whilst in softening and atrophy of the heart it is in the strongest degree counter-indicated, the proper remedies for a sudden sense of sinking and fainting connected with these conditions being the instant exhibition of powerful cordials, hot drinks, sinapisms to the prascordial region, active friction along the spine and on the extremities, and rigid restriction to the hori- zontal posture. In the syncope dependent on inflammation of the heart and its membranes, stimulants would be no less misplaced than depletions under the circumstances just mentioned. In this, as well as in the other cases above enumerated, the necessity for abstaining from all strong mental emotions, and all needless mus- cular exertions, is self-evident. Where a tendency to sickishness and fainting is the immediate result of a surfeit, or of something having disagreed with the sto- mach, the propriety of an emetic, at least where there is no coun- ter-indication from disease of the heart or great vessels, &c, is obvious ; as likewise in the case of poisoning by acrid and narcotic substances. The syncope which is caused by a -^rge draught of a cold fluid taken when overheated and in a statd1 of extreme exhaustion, de- mands the most prompt and energetic-measures. It is sometimes preceded by spasms of the stomach; and here the application of heat to the epigastrium, as by means of'a bladder filled with warm water, the introduction of laudanum in a large dose into the sto- mach, along with hot brandy and water and other stimulants, should be had recourse to without the loss of a moment of time. If the power of swallowing is already lost, by the intervention of the stomach-pump and stimulant injections we may still make an effort to save the sufferer's life. We have known a person to drop down insensible in the street, immediately after drinking a bottle of soda water; the seizure, however, being momentary, and not giving rise to any subsequent ill effects. In such a case we must suppose, either that the sudden distension of the stomach by the liberated gas arrests the heart's action through the medium of sympathy or pressure, or else that the obstruction of the great vessels produces a state of extreme but temporary congestion of the brain. The rapid secretion of gas in enormous quantity into the stomach 58 454 syncope (Treatment). and intestines, and the consequent impediment to the motion of the diaphragm, the compression of the heart, and impairment of pul- monary dilatation, have recently been adduced to explain a case of sudden death when no other morbid appearance sufficient to ac- count for the fatal event was discoverable on dissection ; and the well-known effects of speedy gaseous distension of the abdomen, on cattle which have gorged themselves with certain green foods, countenance the explanation. Instant death has been supposed, in cases of a different kind, to have been induced by the sudden over-distension of the cavities of the heart with blood ;'* and a palsied state of the organ certainly appears very rapidly to be induced in persons asphyxiated, in part by the quantity as well as by the quality of the blood with which, in consequence of the stasis in the pulmonary vessels, it soon becomes inordinately dilated. In addition to the sources of syncope already enumerated, the spontaneous development of a gaseous fluid in the blood has been recently suggested by M. Ollivier as a possible cause of the total cessation of the heart's action; acting either mechanically by inor- dinate over-distension of the right side of the heart, or as a poison if it consist mostly of carbonic acid or any equally deleterious agent (Rivue Medicate, Feb. 1838): and he adduces a case of sudden death taking place in a debilitated patient in the effort of rising, where dissection detected nothing but the gaseous dilatation here spoken of. As for the means to be put in practice, in the intervals of attacks of syncope, for the removal of the local and general conditions on which, when habitual, they depend, we must refer the reader to what has been said in the preceding sections on the modes of strengthening and regulating the nervous, muscular, and other systems. In connection with syncope, we may allude to cases in which the action of the heart may be enfeebled. The action of the heart may be enfeebled in various degrees, from a momentary flutter up to actual syncope, either from want of energy in the organ or from deficient excitement, or, finally, from the embarrassment of the circulation connected with organic dis- ease. The derangement originating in the last named cause does not fall within the scope of the present section. That such weak- ness may manifest itself in a very alarming form, altogether inde- pendently of any structural lesion of the heart, is matter of every day observation : and its source may then commonly be traced up, either to the participation of the nerves of the heart in a general depression of the nervous system; or to a deficiency, sudden dimi- nution, or impoverishment of the blood ; or to sympathy of the heart with disorder in some other organ. In susceptible individuals an apparently slight cause will often suffice to induce formidable derangement of the heart's action. Thus the pulse may become * Leuwenhoek, quoted by Elliotson in his Physiology, p. 483.—Author. angina pectoris (Symptoms). 455 not only feeble and fluttering, but of varying strength and frequency, irregular and intermitting, from a passing disorder of the stomach, or a mere flatulent distension; from the temporary oppression of the heart by too rapid an afflux of blood; or from a momentary emotion of mind, or a disagreeable impression made on the senses. Where these attacks are preceded or accompanied by a prolonged sense of faintness and anxiety, an antispasmodic or stimulant draught should be given to procure present relief, and prevent them passing into syncope; or where there is reason to suspect the pre- sence of offending ingesta in the stomach, a mustard emetic, as best suited to clear out this organ without augmenting the debility, should be had recourse to. In their intervals the tendency to recur- rence must be combated by attention to the digestive organs, by the correction of plethora or anasmia when either of these states exists, and by strictly following out the hygienic principles set forth in the last section. \y ANGINA PECTORIS. Symptoms.—Seat and Nature.—Complications.—Diagnosis.—Treatment. This severe spasmodic affection, termed also Syncope Anginosa, Sternalgia, Asthma Arlhriticum vel Diaphragmaticum, Suffocative Breast-pang, Src, for the first clear account of which we are in- debted to Heberden, consists in a sense of constriction in the pras- cordial region, and more especially under the inferior portion of the sternum, with a feeling of numbness and pain extending thence to the left arm, and is attended by apparent difficulty of breathing, intense anxiety, and apprehension of impending death. Symptoms. It makes its appearance ordinarily, for the first time, suddenly as the person is ascending a hill, especially if the wind is in his face ; or undergoing some unusual exertion soon after eating. The excessive pain and sense of suffocation and fainting, oblige him, if walking, instantly to stop, and he commonly feels as if he should die were he to persevere. By a momentary repose, his sufferings, at least towards the commencement of the disease, ordi- narily vanish for the time, leaving behind only a dull aching or uneasiness within the chest. The attacks recur at uncertain inter- vals, at first, of weeks or months, or even still more protracted periods; but become subsequently gradually more frequent, of longer duration, and sometimes, though perhaps not generally, of greater intensity. The paroxysm is, at a more advanced period of the affection, much more easily excited ; emotions of mind, intense thought, the actions of eating, coughing, or relieving the bowels, being now sufficient to bring it on. It will at this stage even occur as the individual lies at rest in his bed, and especially immediately on awaking from the first sleep; in which respect it coincides, as Heberden remarks, with many other spasmodic nervous affections. 456 angina pectoris (Symptoms). The pain, which at first was confined to the chest and upper part of the left arm, reaching commonly only as far as the insertion of the deltoid and pectoral muscles, afterwards often extends along the ulnar nerve down the inside of the arm to the elbow, wrist, or even to the fingers. It occasionally, though rarely, affects the right arm also, the neck, and lower jaw towards the ear, causing a feeling of choking and difficulty of articulation; and may even reach, though this is much more uncommon, to the lower extremities. The pain often follows the course of the anterior thoracic nerves, more espe- cially of the left side; and in females there is at times, from this cause, extreme tenderness of the breasts. In some anomalous cases the painful sensation has been known to originate in the arm, not being at all felt in the chest till a more advanced period of the disease. The duration of the seizure at the commencement rarely exceeds a few minutes, though it may last for half an hour or an hour, and in the more confirmed stage of the affection the paroxysm may be still further prolonged. The pulse is subject to great varieties, being in the slighter forms often but little affected; whilst in the protracted and more aggravated cases it is feeble, irregular, or intermittent in some, quick and strong in others; its derangements, which often continue to a certain degree in the intervals, being frequently accompanied by a marked tendency to syncope. The respiration is sometimes affected to such a degree, that the patient cannot continue in the recumbent posture: yet the difficulty of breathing, in the earlier stages more especially, is very unlike spasmodic asthma ; for the patient, by an effort of the will, is still able to take a full inspiration, and sometimes finds a momentary relief from the effort. A patient of great strength of mind has been known to persist in walking, in spite of the vehe- mence of his sufferings; and his resolution has been rewarded by their speedy cessation. Others, again, have made a similar attempt without the like result; and we apprehend that where the attacks, as is so often the case, are connected with that excited and over- loaded state of the heart induced by muscular exertion, the experi- ment cannot be exempt from hazard, and especially so if any organic disease exist. The urine during the paroxysm is commonly clear and pale, as in other affections of a nervous kind, and in some rare cases it has flowed off involuntarily. Flatulence and irritability of stomach are very frequent accompaniments of the attack, the fulness of this organ adding materially to the sense of tension in the neighbour- hood of the diaphragm. In the advanced stage of the disorder, the derangement of the digestive organs is a very prominent and dis- tressing symptom at all times. The face during the paroxysm is in general pale; and the cerebral functions are unimpaired, save in so far as the intense suffering may interfere with their exercise, or the occurrence of syncope for a time cut off the necessary supply of blood from the brain. Yet cases have been met with when, on the contrary, the action of the angina pectoris (Seat and Nature). 457 heart being violent, congestion of the head and convulsions took place. Where the patient is not previously carried off suddenlyby syncope in one of the more violent seizures, as is often the case, well-marked symptoms of structural disease of the heart often eventually mani- fest themselves; and the scene closes amidst permanent derange- ment of the circulation and respiration, serous effusions, hasmor- rhages, &c. Seal and Nature. Great difference of opinion has long existed as to the true nature of this affection, some authors looking upon it as invariably connected with organic disease, whilst others view it as merely spasmodic or neuralgic, and consider any coexistent structural changes (which, they assert, are quite indeterminate in their nature) as mere coincidences, or, if connected at all, rather related as consequents than causes. Reference to the results of the numerous post-mortem examinations recorded by various writers, shows that though organic disease of some kind or other has been found in a large proportion of cases, yet in many nothing of the kind has been delected. We are accordingly disposed to side with those who believe that angina pectoris, at least in its less inve- terate modifications, may exist altogether independent of structural changes. It is only in the more aggravated and prolonged cases that such alterations have been very conspicuous. When they occur, their most frequent seat is undoubtedly in the heart, pericardium, or great vessels. Amongst the lesions which have most frequently been met with, are ossification of the valves or orifices of the heart, of the coronaries, or of the arch of the aorta ; hypertrophy, dilata- tion or softening of the heart; excessive fatty deposition, either on this organ or in the anterior mediastinum ; effusion into the pericar- dium or pleura ; and disease and enlargement of the liver. Being comparatively a rare disease, and consequently but few cases falling under the care of any one individual practitioner, of the numerous theories, formed as to its nature and seat upon its first beginning to attract attention, most were deduced from very inade- quate premises, each observer ascribing it to that particular form of organic disease in connection with which chance had most frequently presented it to him. Thus Parry, and several others in imitation of him, referred it to ossification of the coronary arteries ;" Fothergill to deposition of fat on the heart, and in its neighbourhood; Latham, Brera, and Zechinelli, to enlarged liver, and consequent pressure on the heart, or sympathetic derangement of its function. More enlarged observation has, however, shown, that none of these appearances are essential to its production ; or, in other words, that it may exist without any of these lesions; whilst they, on the other hand, may be detected on dissection, though none of the character- istic symptoms of angina had been present during life. Heberden,though, as we have stated, the first express writer on the subject (with the exception perhaps of Sauvages), seems to have enter- tained more comprehensive and just notions of its true character than the majority of those who have succeeded him. Guided rather by the well-marked morbid phenomena which characterise it during 458 angina pectoris (Seat and Nature). life, than by the variable and uncertain structural changes sometimes found after its fatal termination, he came to the conclusion that it was truly of a spasmodic nature. Thus the attack is ordinarily sudden in its commencement and cessation, the intervals of health being, at least at the first, perfect: mental distress often induces the paroxysm, and opiates and stimulants occasionally procure relief; there is noinflam- matory quickness of pulse, and the seizures in the more advanced stage of the disease often comes on, as already mentioned, after the first sleep, as is the case with many other spasmodic affections. Our best recent authorities take very similar views of its nature : thus Laennec thinks that though it often complicates organic disease, and more especially that of the heart, it is in its nature independent of it, being essentially a nervous disorder affecting primarily either the cardiac or the pneumogastric nerves, or both, according as the heart or the lungs and stomach are affected, or all three simultaneously: that the nerves of the brachial plexus become secondarily affected, as likewise the superficial cervical plexus supplying the front of the thorax ; and sometimes, but much more rarely, those of the lumbar and sacral plexus, giving rise to pain in the lower extremities, and occasionally to pain and swelling of the testicles. The analogy of its phenomena in diseases of acknowledged nervous origin, as sciatica and tic douloureux, is, he thinks, complete; the prominent features of each consisting in numbness and pain in the course of the ner- vous ramifications, with which, occasionally, slight tumefaction is associated. M. Desportes had frequently advocated very similar views, save that he limited the source of the disease to the pneumo- gastric nerve. By M. Andral likewise it is conceived to be a mere " modification of the innervation ;" occasionally indeed accompany- ing organic disease, but then commonly only as a subsequent compli- cation, or, as he states it, an epiphasnomenon ; or else, on the other hand, obviously preceding the existence of the structural lesion, for many cases terminate fatally before any such permanent alteration has come into being. As a further evidence as to its true nature, we sometimes find it alternate with nervous affections in other parts, as withgastralgia, sciataca, tic or headach, loss of sensibility in different regions of the body, spasms of the muscles, &c. Dr. Chapman, like Desportes, conceives it to be neuralgia of the pneu- mogastric nerve originally, spreading subsequently to other nerves, and to those of the heart amongst the number; and supposes that the immediate cause of the irritation consists in irregular or mis- placed gout, inasmuch as recovery has been frequently known to ensue on the gouty action being excited in the extremities. Dr. Butter, who with Darwin fancied the affection to be placed in the diaphragm, has likewise ascribed it, as have many other writers of repute, to a gouty source. Dr. Hosack believes it to consist in a plethoric condition, more especially of the heart and great vessels; and similar views are advanced by Dr. Forbes, in his able treatise on this affection in the Cyclopaedia of Practical Medicine. Dr. Forbes argues that its seat must be in the heart, as well from the frequency of sudden death in the paroxysm, for which derangement angina pectoris (Seat and Nature). 459 of no other thoracic or abdominal organ would adequately account, as from the unquestionable frequency with which cardiac lesions are found in those who have perished by it. These lesions, it is true, are not its immediate or essential cause, which is more pro- bably some unusual irritability of the nerves of the organ ; but it is a well established general fact that diseased organs are thereby more disposed to neuralgic pains. He divides the disease into organic and functional, each of these being again subdivided into the idiopathic and sympathetic varieties. The simple functional angina he conceives to be very rare; many cases set down as such being really examples of a degree of disproportion between the cavities of the heart, which from its slightness has been overlooked. The sympathetic variety, on the contrary, or that which is called into being by the reaction of disorder in other organs, is compara- tively common. Dr. Hope thinks that any thing capable of irritating the heart, or rendering it morbid and susceptible, may suffice to produce the peculiar symptoms of angina pectoris; and hence concludes that organic disease of the heart must needs be a most influential cause. He even asserts that he never saw a very aggravated case without such organic disease. The worst cases which have fallen under his observation have been instances of osseous and cartilaginous degeneration of the heart or great vessels, and more particularly of the coronary arteries, the valves or orifices. He believes, that where the elasticity is thus impaired, any exertion which is calcu- lated to over-distend them cannot fail to be productive of uneasy sensations, the amount of which will vary with the nervous sus- ceptibility of the part and of the individual. In the less severe examples of the disorder he has often met with hypertrophy and dilatation, with or without softening of the heart; whereas in the mildest degree of all, which is very common in hysterical and hypochondriacal or dyspeptic patients, occurring in the form of spasmodic aching pain in the anterior part of the chest, extending sometimes to the neck and stomach, with or without pain in the arms, there has been no organic disease at all. It has been made probable by Dr. Corrigan that several symp- toms of the group which generally go under the name of angina pectoris,—paroxysms of dyspnoea induced by exercise, a sense of tearing asunder within the chest, together with anxiety and mental distress,—may originate in aortitis, or inflammation of the mouth of the aorta ; which will occasionally yield, even when of rather long standing, to leeching, counter-irritation, and a mild mercurial course. M. Sormani, the editor of Testa's work, likewise seems to incline to the opinion of its being occasionally of an inflamma- tory, though much more frequently of an organic, nature. No ao-e except that of early childhood seems absolutely, exempt from this disorder; in the great majority of instances, however, it does not make its incursions before the fiftieth year. Females are very much less liable to it than males in its severer form, or that accompanied with organic disease of the heart or great vessels; 460 angina pectoris (Diagnosis). though in its milder grades they often suffer from it. In estimating its comparative frequency in the male and female sex we must not be guided altogether by the printed relations of cases, as it is gen- erally only those of a more formidable character, with organic complications, which have been selected for this purpose, "it is more a disease of the higher orders, who live full and take insuffi- cient exercise, and hence have the nervous as well as the vascular system in an unhealthy state, than of the lower or labouring classes. Complications. We have already called attention to the frequent coexistence of diseases of the heart and great vessels with this af- fection, and to the powerful predisposing influence they exert in regard to it. Thinness and weakness of the parietes of the heart, and disproportion in various degrees between its several cavities, are, as Dr. Forbes has very justly remarked, amongst the morbid conditions of this organ which may most readily escape observa- tion, and which require therefore to be very carefully sought after. Dyspepsia, in some of its varied forms, is a very common pre- cursor and concomitant of angina pectoris, inasmuch as it reduces the tone of the nervous system, and so renders the heart as well as other parts prone to nervous disorder; and a temporary increase of the derangement of the stomach is, at the same time, no infre- quent exciting cause, also, of the attacks of the disorder. Diseased enlargement of the liver, commonly a secondary affection ensuing upon long continued disorder of the stomach and bowels, may, no doubt, in its turn, both by pressure and sympathy, add still further to the existing morbid tendencies within the chest, though its im- portance has been greatly exaggerated by Portal, the elder Latham, and Brera. In females, uterine and hysterical complications are not infre- quent. Both excessive and deficient menstruation exert a very powerful influence in deranging sympathetically the action and nervous sensibility of the heart. But of all the complications, one of the most frequent and important is a plethoric condition of the vascular system—a state which accounts, as Dr. Forbes has re- marked, for the frequent coexistence of angina with gout; its ordi- nary occurrence in persons at an advanced period of life, and more especially in men who indulge in luxurious living, and who, being exempt from the necessity of regular bodily labour, are prone to obesity; as well as for the striking benefit of depletion and a re- duced diet in a great proportion of cases. Diagnosis. The only disease with which angina pectoris is likely by the inexperienced to be confounded is asthma. To the mode of distinguishing them we have already alluded. It is only necessary to add here, that asthmatic attacks, from the first, mani- fest a preference for the evening or night; that dyspnoea accom- panied by wheezing and cough, is their prominent symptom; that there is a craving for fresh air which is quite peculiar; and, finally, a speedy remission of the symptoms on the occurrence of free ex- pectoration,—none of which things are commonly observed in the affection we have been considering. The prognosis in angina pec- angina pectoris (Treatment). 461 tons depends partly on the vehemence of the symptoms, but still more on the character of the complications. In the mere func- tional or sympathetic cases of hysterical or dyspeptic origin, espe- cially where the paroxysms are not of a very aggravated nature, it is comparatively favourable, as these conditions are often within the influence of regimen and medicine, and the neuralgic pain is generally of a less obstinate character. It was probably from par- ticular reference to such cases that Laennec spoke of the disorder as one ordinarily of little danger. Where complicated with obvious organic disease of the heart or great vessels, and even in cases where there remains a doubt on this point, and especially if drop- sical symptoms have manifested themselves, the prognosis should be a very cautious one. The known frequency of the occurrence of structural change at some period of the disease, as well as its liability to terminate in all its stages in fatal syncope, must ever cause it to be regarded as a very formidable affection. Treatment. This is obviously divisible into two parts,—the ob- ject of the one being to give immediate relief in the paroxysm; that of the other, applicable to the intervals, to reduce the nervous irritability of the heart and of the system generally, and where possible, to get rid of the exciting causes, and more especially of such functional derangement in other organs as is known to exer- cise a disturbing influence over the heart. The treatment proper, both during the seizure and subsequently, will in a considerable degree depend on the state of system in which the disorder makes its appearance. Where the patient is of a debilitated nervous habit, the use of carminatives, stimulants, antispasmodics, and anodynes are our chief resources, though unfortunately often very inadequate ones, during the paroxysm. The relief ordinarily ensuing on the expulsion of flatulence justifies the use of the first- named class of remedies. The presence of wind in the stomach will alone at times give rise to a painful sensation in the region of the heart, and even greatly derange its motions. The sense of pain and spasm in the prascordial region, over the chest and in the arm, together with the absence of all inflammatory symptoms, first suggested the use of the other classes of remedies just named. When opiates are had recourse to, they should be administered in a full dose to give them any chance of being useful. Many prac- titioners are, however, opposed to their employment—and perhaps with reason in such cases where there is considerable organic disease of the heart. The use of the diffusible stimulants, as ether, ammonia, or camphor,—or of antispasmodics, as castor, valerian, or assafoetida, &c.—is more universally applicable. Hydrocyanic acid, in the dose of a couple of drops, in camphor mixture, or in a solution of assafoetida, is well suited to cases connected with gastric irritation. . In cases where the action of the heart is particularly feeble, stimulant frictions to the back and chest are proper, along with sinapisms, or warm flannels, impregnated with turpentine, over the prascordial region. Stimulating footbaths and maniluvia may 462 angina pectoris (Treatment). always be had recourse to, and are peculiarly applicable to those cases where misplaced gout is suspected. A warm aperient or a terebinthinate injection should be administered in the more pro- tracted cases, particularly where the bowels have been previously deranged ; and if the stomach has been disordered by the quantity or quality of a previous meal, a mild emetic may be ventured on ; or if acidity be complained of, magnesia or an alkaline ought to be given in an aromatic mixture. In stout and plethoric patients, in whom the pulse is tolerably strong, or where if weak we have reason to think such weakness may depend on the heart and great vessels being gorged with blood, and hence unable to react freely on their contents, cautious vensection is clearly indicated, and has the sanction of Parry, Hosack, Forbes, and other practitioners of high authority. When appropriately employed, it has produced more rapid and striking relief than any other single measure whatever. In dubious cases, cupping or leeches over the chest or back may be substituted. After the employment of depletion in cases of the kind alluded to, the other remedies mentioned above have appeared of much greater efficacy than when prematurely exhibited. When, however, there is reason to suspect, from the previous history of the case, a passive dilatation of the heart or softening of its walls, we should abstain entirely from all such depletions, as a very slight depressing cause might here suffice to arrest irretrievably the motion of the heart. In those slighter neuralgic cases where the parietes of the chest seem chiefly implicated, dry cupping and acupuncturation are deserv- ing of trial. As to the treatment in the intervals, no rational plan can be formed without a correct estimate of the morbid elements present in each individual case, and more especially the recognition of organic disease where it exists, the just appreciation of associated disorder in other organs, and an accurate acquaintance with the constitution of the patient, and his habits both of mind and body. Where structural disease of the heart is ascertained as the predisposing cause of the attacks, the treatment appropriate to retarding its increase, reducing the irritability of the system, and improving the general health, of which wc shall hereafter have occasion to speak, will of course constitute the most important part of the management of the case, in conjunction with the scrupulous avoidance of all the known exciting causes of the paroxysm, and more especially of all violent exertion of the body, agitating passions, anxiety of mind, intense application to study or business. Many a valuable life has been instantly and prematurely terminated, like that of John Hunter, by a paroxysm of vexation, induced by some lamentably trivial and unworthy cause. The importance of a well-regulated mind, the result of constant moral discipline and of a studied system of self- control, tending to make the patient hang loose to the ordinary passing affairs of life, cannot be too strictly enforced. He should be made clearly to understand, that the prolongation of his life is, in this respect, in a manner in his own hands. angina pectoris (Treatment). 463 Where the disorder is purely or chiefly neuralgic, or dependent on passive enlargement or debility of the heart's Structure, the use of the carbonate of iron or of the protoxide in its nascent state (a most valuable preparation*), some of the other metallic tonics, as arsenic, or the salts of zinc, silver, or copper, bark, or the sulphate of quinine, especially where the patient has been exposed to malari- ous influences—together with a nutritious unstimulating diet, regular easy exercise, the enjoyment of a bracing atmosphere, and cheer- ful recreation of the calmer kind,—are our chief resources. Of exercise the most appropriate is that taken on horseback or in a carriage, fatigue and all undue excitement of the circulation being carefully avoided. The gentle excitement, at once of mind and body, arising from travelling by easy stages, in an interesting country, has often had a very happy influence in this as well as in so many other nervous and spasmodic affections. When the attacks are apt to take place in the night, Heberden's practice of administering an opiate at bed-time is worthy of imitation. The narcotic alca- loids, both internally and externally, have recently been much extolled; and tincture of iodine, in full doses, is recommended by Dr. Oliver, of Massachusetts. As derangement of the digestive organs so frequently complicates the other sources of this disorder, and seems not seldom in itself to be a very principal exciting as well as predisposing cause of the paroxysms, it should receive a very ample share of attention in every case where its existence, in any of its varied forms, can be detected. A temperate scale of diet, with great moderation in the use of fluids, and the scrupulous avoidance of every even occasional excess or over-distension of the stomach, together with a total abstinence from wine or other stimulants (at least in the majority of instances) ; the regulation of the bowels by the mildest aperients, or still better, if possible, by the quantity of the food; the early correction of acidity or other vitiated secretions; the gradual im- provement of the tone of the stomach and bowels; and the speedy reduction of all irritation or inflammatory action in the liver, or any other portion of the chylopoietic viscera,—are amongst the most important points in the treatment of such cases. A gouty or plethoric tendency requires the observance of a sys- tem of diet and regimen to be enforced with peculiar strictness; and regular exercise, which in a moderate form is proper in almost every variety of the disease, in order to promote the healthy play of the functions and strengthen the nervous system, without exci- ting the heart, is here peculiarly called for. The cautious employ- ment of colchicum promises to be occasionally useful; and the importance of the promotion of a free state of the bowels, with attention to the hepatic and urinary secretions, is never to be lost ^Counter-irritation in the form of issues to the thighs, frequently * For an imoortant paper on the best mode of obtaining and administering this substance, by Mr DninPovPan, see Dublin Med. Joum. for March, 1840.-^0,. 464 neuralgia of the heart (Symptotns). renewed blisters between the shoulders, tartar-emetic ointment, croton oil, a seton or perpetual blister over the region of the heart or in the epigastrium, have sometimes been of peculiar service in the moro chronic forms of the affection. The great benefit occasionally observed to ensue, upon the spontaneous occurrence of an hasmor- rhoidal discharge, or of ulcers, or eruptions on the extremities or other parts of the body, sufficiently indicates the propriety of estab- lishing such artificial drains or counter-irritations as have just been mentioned, and doubtless first led to their adoption. A very con- venient form of establishing a purulent discharge in such cases, employed by Dr. Hutchinson, as mentioned by Dr. Copland, con- sists in the application to the skin of the bark of mezereon root, soaked in water and deprived of its external cuticles, and retained in contact with the skin, by means of a large patch of adhesive plaster. It must be renewed for a day or two, till the purulent secretion is established, and this may subequently be maintained for such a period as is desirable by the occasional reapplication of the bark. M. Richard, we find, mentions other species of Daphne, which, after maceration in vinegar, are similarly employed by the people in France, and some more southern countries. The applica- tion, he adds, sometimes excites an inconvenient degree of itchiness and irritation, with crops of pustules, rendering frequent tepid ablutions, with water or a decoction of marsh-mallows, neces- sary. We have known a belladonna plaster over the prascordial region, renewed every week or ten days at furthest, to procure very con- siderable alleviation of the attacks. Respect for the name of Laennec induces us to state, before quitting this subject, that he had great faith in the application of a couple of magnetised steel plates, one over the heart, and the other with its pole opposite to it on the back, so placed with a view to causing the magnetic current to pass directly through the suffering organ. Whether the beneficial influence of this arrangement, which he states he had frequently witnessed, was not in a greater degree dependent on the reaction of the imagination of the patient on his nervous system, than on any direct magnetic agency operating on the cardiac and associated nerves, we shall not take upon ourselves to decide. Its good effects seemed occasionally to have been pro- moted, as we can well believe, by applying a small blister under the anterior plate.,. NEURALGIA OF THE HEART. Symptoms.—Nature.—Treatment. Under this title has been described, by Dr. Elliotson and other recent authors, an acutely painful, intermittent affection of the heart, obviously of a nervous character, which seems to differ from angina more in respect to the small number of parts which are drawn neuralgia of the heart (Symptoms). 465 into morbid consent with the suffering cardiac nerves, than in regard either to its nature or appropriate treatment. It consists in an acute lancinating pain, often of great intensity, darting through the prascordium from before backwards, and coming out under the left shoulder. It is ordinarily confined to the heart itself, the respi- ratory system continuing quite unaffected. Those cases in which the pain extends to the left arm and side of the neck, and still more those in which the parietes of the chest are implicated, must be referred to the head of angina. Intermediate cases, it must be confessed, present themselves in practice and baffle classification. It is of pure neuralgia of the heart, however, that we mean here to speak, or that condition which involves the sensitive function of the cardiac nerves alone. The sounds and motions of the organ are here commonly little or not at all affected, though this is not invariably the case. The attacks recur often, without any apparently adequate exciting cause, and, unlike angina in its early stages, even when the the individual is quite at rest. The intervals are various, being sometimes only of a few hours' duration, and sometimes of many days. Like other neuralgic affections, it occasionally manifests a tendency to periodi- city ; and when the acute pain of the attack has diminished, it frequently leaves behind, for a considerable lime after, an uneasiness or dull aching in the region of the heart. The anguish in the more exquisite form of the disorder is, during the seizure, often quite overpowering. In its inferior grades, however, it is merely like a stitch, or crampish pain, seeming for an instant to take away the breath, and followed by a quick forced sigh or sob: in this latter degree it is by no means an uncommon occurrence, and is one apparently of little importance, being, like other pains of a nervous character, frequently merely the result of sympathy with the stomach when distended by flatulence or irritated by acidity, though at other times it seems to be connected with over-distension of the vascular system. The duration of this complaint is quite uncertain, as it sometimes continues to recur for years in spite of all treatment. It appears most frequently to originate under the influence of long- continued over-exertion of mind or anxiety acting on an irritable and nervous temperament, and is sometimes connected with a rheu- matic or gouty tendency. A malarious source has been, in some cases, and apparently with reason, suspected. The upper part of the spine should in every case be carefully examined, as a very similar pain may arise from irritation or disease within the vertebral canal. The excessive use of strong tea, in certain idiosyncrasies, is occasionally, and not infrequently we believe, the unsuspected cause of acute pain in the region of the heart, together with a sense of faintness and impending syncope, of which a well-marked instance has been recorded by Dr. Edward Perceval. (Dub. Hosp. Rep., vol. i.) ... , Treatment. Most of what has been said in respect to the treat- ment of angina pectoris is equally applicable to this more limited affection. As, however, it seems much less commonly to be com- 466 pericarditis. plicated with structural disease of the heart, narcotics both exter- nally and internally may be more freely employed, as for example, opium in combination with camphor, or fractional doses of the narcotic alcaloids, the salts of morphia, hydrocyanic acid, *Sr-c. Ether, ammonia, and other stimulants, along with antispasmodics, may likewise be had recourse to, in order to procure relief during the paroxysm. Some of the more speedy forms of counter-irrita- tion, as by means of mustard, ammonia, or turpentine, or the local application of heat in a degree sufficient to redden or even slightly blister the skin, in the manner alluded to in the last section, should also be immediately put in practice. In the intervals a belladonna plaster should be worn, or an ointment containing veratria employed. Where these fail, as will too often be the case, wc must have recourse to some of the permanent forms of counter-irritation spoken of in a previous page, and persevere steadily in their use for a very considerable period ; whilst we endeavour simultaneously to regulate the action of the bowels, and to give tone to the stomach and system generally, as if is by such means, more, perhaps, than all others put together, that the tendency to neuralgic affections is most frequently and permanently removed. The empirical use of purgatives has, in some rare instances, been crowned with complete success ; and the trial of a mild mercurial course is justifiable in cases which have resisted other methods of treatment. When a rheumatic, malarious, or gouty origin is suspected, the treatment should be modified in reference to it. Quinine, Fow- ler's solution, colchicum, turpentine, hydriodate of potass or of iron, the corbonate of iron, and nitrate of silver, have all severally appeared useful in different instances. The disease, however, is in many cases so obstinate, that we run through all our resources in vain, and are fain at length to resign it to its course and to the slow influences of time and gradual change of constitution. Great temperance in food, and abstinence from all stimulant beverages, especially malt liquors, suit best with the majority of cases ; some, however, have, on the contrary, gone on better on a fuller diet, and a moderate use of wine; whilst change of air, cheerful recreation, and regular exercise, have appeared beneficially applicable to all. * PERICARDITIS, OB INFLAMMATION OF THE EXTERNAL MEMBRANE OF THE HEART. Anatomical characters. —Symptoms.—Physical signs. — Frequency.—Chronic Pericarditis. — Duration. — Complications. —Prognosis. — Diagnosis. — Causes.—Treatmen t. Inflammation of the external serous covering of the heart, and of the sero fibrous sac in which the organ is inclosed, the symptoms of which were reckoned so obscure by Corvisart and Bayle, and even by Laennec, has become, since the publication of a valuable pericarditis (Anatomical Characters). 407 memoir on the subject, by M. Louis, a few years ago, much better understood, more easily recognised, and consequently more suscep- tible of successful treatment. As some of the most important of the phenomena by which its presence is discovered are of a physical kind, and as the mode of their production cannot be comprehended without a previous knowledge of the anatomical changes in which they originate, we shall commence with an account of the morbid appearances usually characterising this affection. Anatomical characters. Inflammation of the pericardium, like that of other serous textures, is characterised by redness, and by effusion of coagulable lymph, and of a fluid generally of a serous nature, but varying somewhat in its appearance and composition. The redness, which may depend either on injection of the capil- laries, or on the effusion of blood into the subserous tissue, and the subsequent infiltration from that source of the serous membrane itself, assumes various forms, dotted or mottled, in stripes, or patches, or widely diffused. Yet sometimes, where the case has terminated fatally while the inflammation of the part was still in its nascent state, no redness has been found after death; probably rather, as in the parallel case of erysipelas, in consequence of the dilatation of the minute vessels not having been sufficiently long in existence permanently to overcome their contractility, than from the actual absence of such redness during life. The membrane itself is rarely notably changed either in respect to thickness or transparency, the appearances which have sometimes been mistaken for such altera- tions being really produced by the presence of a closely adhering false membrane. In the very earliest stage the serous membrane has been thought to be somewhat drier and less polished and slip- pery than natural; and at a more advanced period it becomes more easily detached from the heart than it should be. The coagulable lymph, which is partly secreted in that form, and partly a deposition from the effused serum, exists in very various quantities, sometimes covering the whole pericardium in the entire of its opposed surfaces, and sometimes confined to a limited portion •of it, dispersed at times in irregular masses, but more commonly expanded in a membranous form, and varying in thickness from the fraction of a line to several lines. The unattached surface of the false membrane thus originating differs somewhat in its external appearance from that observed on other serous membranes, in consequence of the perpetual movement of the contained organ and the incessant change of relation between the opposing surfaces of the pericardium. It has thus often an irregular areolated appear- ance, alternately compared, according to its degree of fineness or coarseness, to the reticulations of a sponge, to the cells of an honey- comb, or those in the interior of the second stomach of the cow. At other times its surface, tuberculated or studded over with slight prominences, has caused it to be likened to the exterior of a pine- apple ; or, if more jagged and irregular, to the appearance pro- duced on separating two plates between which butter of a soft 468 pericarditis (Anatomical Characters). consistence had been compressed. The false membrane may pre- sent, moreover, a rough and shaggy appearance, from being thickly covered over with flocculent shreds,or when it has been sometime secreted it may be arranged in undulating furrows or wrinkles. Where recently poured out, it is of a pale yellow colour and soft texture, like the buff or inflammatory crust of the blood, but becomes gradually firmer with time. Occasionally it has a reddish tinge, especially when any blood has been effused into the pericardium, and when organisation is commencing. Sometimes it presents the appearance of a succession of layers, ascribable to the repeated recurrence of the inflammatory process; at others the whole pericardium is strewed over with minute, softish, albuminous granulations. Where the lymph is not early absorbed, adhesions commonly take place between the opposing surfaces (if not prevented by the quantity of serum present), and thus all fur- ther continuance of the morbid effusion may be prevented, and the progress of the disease arrested—too often, however, the truce is only temporary, being succeeded, in consequence of the shrinking and condensation of the organised adhesions, by subsequent limita- tion and embarrassment of the heart's movements, and eventually by morbid alterations in its parietes or internal structure. It is only where the early and active interposition of art, or the salu- tary efforts of nature have cut short the disease in its very origin, or led to the speedy absorption of the plastic matter, as well as of the accompanying liquid effusion, that both sets of evil consequences, the immediate and the remote, are with certainty escaped from. That such a result is attainable—nay, even in a great proportion of cases actually obtained—we have evidence in the frequency with which slight traces of old pericardial inflammation are met with on dissection, though no permanent disorder of the heart's action had existed during life, nor was any other alteration of its structure discoverable after death. The white spots or patches of condensed cellular membrane, so often observed on the free surface of the pericardium, and which may, with care, commonly be dissected off, are instances of such partial and passing inflammations ; as are likewise those in its subserous cellular tissue, which, according to Dr. Hodgkin, are by no means of rare occurrence. Where adhe- sions take place, the lymph soon becomes organised and converted into cellular tissue of various degrees of firmness and condensation ; and such adhesions may ensue, as has been shown by Dr. Copland, though the lymph should originally have been effused only on one of the opposing surfaces of the pericardium, as by contact the in- flammatory action is soon excited on the other. The rapidity with which the process of secretion and incipient organisation occasion- ally takes place in pericarditis is very striking. Where the in- flammation has run very high, sometimes the external surface of the sac throws out lymph, and becomes adherent to the adjacent pleuras. In old cases the connection between the bag of the pericardium and the heart is often very close, and it is such instances which pericarditis (Anatomical Characters). 469 have probably occasionally been described by the older patholo- gists erroneously as examples of congenital absence of this mem- brane. Where the agglutination takes place in an early stage of the disease, and whilst the contractions of the heart still retain a considerable portion of their vigour, the lymph, being as yet recent and ductile, is readily drawn out into long strings or loose adhe- sions, which do not so materially impede the future movements of the organ; The closest and most unyielding ones, on the contrary, were thought by Laennec to be peculiar to the more chronic cases of the disease; in which the adhesions were, by the presence of fluid, long prevented from taking place, so that the effused lymph had, previously to such union, acquired a considerable degree of firmness and density. This, however, is not in conformity with the experience of Dr. Hope, who thinks he has observed these intimate adhesions to be the result more frequently of the more acute forms of inflammation. The liquid effusion of pericarditis in its earlier stages differs from that of hydropericardium, afterwards to be mentioned, in deviating more in its composition and appearance from the natural serous fluid, being a mixture of this with coagulated lymph, and sometimes with pus, or more rarely with blood. It is hence of various colours, more commonly of a pale greenish or yellowish hue, or a mixture of both, and has its transparency often considerably impaired by the flakes and shreds of coagulable lymph which float through it. If this latter substance be in a very subdivided form, it gives to the liquid a whey-like appearance, or even a milky opalescence. In respect to quantity, if unfortunately the patient's death affords an opportunity of examining the fluid within the first few days of the disease, it rarely falls short of eight or nine ounces, and has been known to amount to so much as three or four pounds. As the in- flammatory action begins to diminish, the process of absorption resumes its activity, and very quickly reduces the superabundant fluid, so that the coagulable lymph now comes to predominate. In some rare cases connected with previous disorder of the general health, purulent matter is secreted from the first, and almost with- out any traces of coagulable lymph; but more commonly it is at a later period that the formation of pus commences, namely, in that more advanced stage of the inflammation where, from the neglect or the inadequacy of treatment, it threatens to pass into the chro- nic stage, and where neither the absorption of the early effusion nor yet the salutary adhesion of the plastic coating has been effected. Of thirty-seven cases analysed by Louis, the effusion was sero-san- guinolent in five, entirely serous in nine, seropurulent in fifteen, and true pus in seven. Where the tendency to suppuration predomi- nates over that to the formation of coagulable lymph, the effused fluid is of a more uniform and creamy consistence. Where pericarditis occurs in a chronic form, the redness is less vivid than in the acute, but the larger vascular ramifications from which the inflamed capillaries arise are commonly more developed. The lone continued pressure of the effused fluid seems materially & 60 470 pericarditis (Symptoms). to interfere with the vigour of the heart's pulsations, the organ having from this cause often a wasted, as well as a whitish and macerated, appearance ; though this is still more common in Hydrops pericardii, in which the liquid is thin and serous. Even in the chro- nic stage there is still a possibility of the fluid being absorbed and adhesions taking place, though the chances of such a termination are very much less considerable than in the acutcr form, both on account of the nature of the effusion, the local condition of the parts, and the deeply deranged state of the general health which is com- monly induced. The formation of adhesions, however, though to a certain degree protective, does not absolutely preclude the recur- rence of inflammation in the false membranes; and the chronic form of the disease may from time to time give place to more acute attacks, which materially accelerate the approach of the fatal ter- mination. In some instances, small collections of purulent matter are met with in the interstices of the adventitious membranes; and in strumous subjects they occasionally, though rarely, become the seat of tubercular deposition, just as has been observed in the parallel cases of inflammation of the peritoneum and pleuras, occur- ring in connection with a scrofulous tendency. A slight degree of thickening may take place in the pericardium from chronic inflammation: where, however, this appears to amount to any thing considerable, an attentive examination will generally show that the change is extrinsic to it, and either seated in the subserous cellular substance, which has become hypertrophied, or that it depends on the organisation of very closely adherent, equally distributed, and smooth false membranes on its secreting surface. The false membranes of pericarditis may eventually not only become very dense cellular tissue, but even pass into a state of fibro- cartilage or bone. M. Louis has recorded a case of the latter kind where the base of the heart was surmounted by a broad osseous zone; and Burns, Laennec, Bertin, Adams, Smith, and others, have met with similar instances. Where the quantity of organised coagulable lymph is very con- siderable, its effects may be, like those from the compression by a fluid, previously alluded to, to induce atrophy of the organ ; but much more commonly, by exciting its action, they give rise to the very opposite condition, that of excessive nutrition and inordinate enlargement. The inflammatory action sometimes seems to extend its influence to the superficial fibres of the heart itself, as is manifested in the softening and increased friability of the muscular tissue, its colour being either deepened into a reddish-brown tint, or in more chronic cases diminished to a pallid yellowish hue. More rarely the heart undergoes an increase of density. Symptoms. The functional derangements in these cases are varia- ble, and, in their ordinary combinations, far from sufficient, at least without the aid of the physical signs, for the confident recognition of the disease. Amongst those most commonly present are high fever generally preceded by rigours, pain in the region of the heart, pericarditis (Symptoms). 471 irregularity of pulse, and palpitations, dyspnoea, anxiety, restless- ness, and incapacity of lying on the left side, and a peculiar expres- sion of countenance indicative of great distress. More rarely there is cough, vomiting, and difficulty of swallowing. As the disease advances there is extreme debility, suffocative paroxysms, and occa- sionally a tendency to syncope, with infiltrations of the face, or extremities, or both. The blood drawn exhibits the appearances characteristic of in- flammation in the highest degree, being cupped and buffed, with a very firm coagulum. The pulse in some rare cases is at first unaf- fected, or, according to Dr. Williams, sometimes slower than natu- ral. The irregularity or intermission often affords the earliest notice of the impending disease, though most commonly these peculiarities of action do not manifest themselves till a more advanced period. The fever, indeed, presents itself in a great variety of forms. The pulsations at the wrist, towards the commencement more especially, are ordinarily frequent, full, strong, and regular, along with a hot and sometimes a moist skin ; or they may be hard and jerking, along with violent impulse of the heart; or, again, small and wiry, and quite at variance, as it were, with the strong action going on in the pras- cordial region. At other times, and more especially at a somewhat advanced stage of the affection, the pulse is small and weak, uneven and irregular, the cutaneous surface being at the same time either dry and hot, or, more usually, cold and damp, especially in the ex- tremities. The face may be flushed, and swollen, or pallid, hag- gard, and bathed in perspiration, and expressive of intense anxiety or anguish ; and when the distressing sensations reach their acme, there is often incessant jactitation, and uneasiness in every posture. The pain in the region of the heart is increased by pressure upon or between the corresponding cartilages of the ribs, or in the epi- gastrium, especially when directed upwards, towards that portion of the diaphragm on which the heart rests. The pain occasionally shoots outwards towards the back, and upwards towards the shoul- der, and thence into the arm to near the elbow. It is very various in intensity, being in some instances so excruciating, as in the case of the celebrated Mirabeau, as to cause the sufferer to look anxiously for death as a deliverance ; whilst in others, on the contrary, it is scarcely, if at all, complained of, save whilst pressure is being made in the regions just indicated. By very many patients the pain is referred to the epigastrium or left hypochondrium, much more than to the prascordial region. Mr. Mayne, in his admirable account of this disease, states that it existed in the first of these situations, in ten cases out of the eleven analysed by him : it was ordinarily exasperated by upward pressure, and was more circumscribed than that which occurs in connection with inflammation within the abdomen ; and there was commonly less disturbance of stomach, though there were some instances where this was rather a prominent symptom. In some cases a sense of con- striction all over the left side of the chest, or a feeling of weight in the reo-ion of the heart, has been complained of, rather than actual 472 pericarditis (Symptoms). pain. Pain, in some form or other, is certainly present in the great majority of cases.*f It may be of a burning, lancinating, or a stitch- like character, as in pleurisy; and is often increased by full inspira- tion or coughing, a3 well as by extending, or lying on the left side. The decubitus on the back is generally preferred in the earlier stages. \\rhere severe inflammation of the pleuras, or acute rheu- matism of the joints, precedes or accompanies it, the pain in the cardiac region may be so much thrown into the shade as to be readily overlooked. It was, however, in the simplest cases, that is, where there was neither pleurisy nor pneumonia, that Laennec says he had observed this symptom to be most frequently wanting ; these being the instances, too, in which the affection was most apt to remain latent. Palpitations and irregularity of the pulse are likewise amongst the more frequent symptoms; but as they are of an intermittent nature, it is often necessary, in order to detect them, to examine the patient very frequently, even within the course of a single day. They are commonly greatly exasperated by the slightest movement of the body, by coughing or speaking, and are sometimes only per- ceivable after such exertions. The action of the heart, which is ordinarily so vehement at the commencement, subsequently appears unusually weak when removed from contact with the chest by a profuse effusion; and its impulse is no longer confined to a single point, but may sometimes be felt in successive mo- ments in different parts of the prascordial region. The respiration is often short and laborious, and occasionally interrupted by sighs or hiccup, especially when the inflammation has extended to the surface of the diaphragm, in which cases like- wise the risus sardonicus has sometimes been observed. The difficulty of breathing is accompanied moreover by a peculiarly deep expression of anxiety, and, when the case is very severe, and especially if a fatal termination impends, amounts to orthopnoea. Where the dyspnoea comes on suddenly, and without any discover- able disease in the lung or its lining membrane, it is a symptom of great value. " Some feeling of dyspnoea, or faintness," says Dr. Williams, " especially on moving, is the most constant symptom, and this is generally accompanied by irregularity of the pulse. The contractility of the heart, which was, in the first instance, exalted by the inflammation of its membranes, ultimately becomes impaired, the actionloses its rhythm,becomes sometimes palpitating, sometimes defective, and verges on syncope." Yet the actual occurrence of syncope appears, from the researches of Louis, to be much rarer than has been commonly apprehended; and a reference to the cases recorded by Corvisart, Bertin, and Andral, proves it to be * Chomel, after dwelling strongly on the circumstance of pain being much more frequently absent here than in any other inflnmmations, strangely adds that its intensity, where present, is rarely, if ever, augmented by pressure. (Diet, de Med.)—Author. f This is questionable: I should say it was more frequently absent than present, and very often is quite insignificant. pericarditis (Symptoms). 473 decidedly an infrequent symptom. The posture oftenest preferred by the sufferer, in the advanced stage, where the distress is extreme, is the sitting one, with the body leaning somewhat forward, or to the left side, as it were to relax the inflamed membrane. The brain here often sympathises deeply with the derangement of the heart's functions, as is manifested by the sudden starting from sleep in affright; and at other times by the supervention of delirium and total loss of rest, and occasionally by the occurrence of spasmodic twitches, or even general attacks of convulsions. Yet such violent symptoms of reaction are by no means universal; the constitutional sympathy being sometimes incredibly slight, a very inconsiderable degree of oppression having occasionally been alone complained of. Infiltration of the extremities is more peculiarly, though not ex- clusively met with in the more chronic cases; and is often associated with a pallid or livid, and occasionally a puffy, state of the face, especially the eyelids and lips, all of which are indicative of a high degree of obstruction to the course of the circulation. It has been remarked by M. Bouillaud that the cases of the greatest suffering, both general and local, are those of pleuritic complication, and especially where that portion of the pleuras which lines the diaphragm is affected; and he adds, that in those cases where there is an extreme sense of suffocation and tendency to syncope there commonly exists an abundant effusion into the pleuras as well as into the pericardium, and sometimes also polypous con- cretions within the heart. Sympathetic vomiting is one of the symptoms of nervous disturb- ance which sometimes makes its appearance, more especially in connection with inflammation of the upper surface of the diaphragm; and though doubtless ascribable in some instances to the vicinity of the peritonasum and stomach, to the inflamed pericardium and pleuras, and the propagation of the inflammatory action, yet in others again it has probably its origin solely in the connection of the nerves of those parts. Pain and difficulty of swallowing, apparently also of sympathetic origin, have been noticed in a few cases by Testa and others. Dr. Stokes, who has recalled attention to this fact, adds, that he has known the same symptom to occur in con- nection likewise with inflammation of the lungs and pleuras; and that aphonia, moreover, has occasionally presented itself under similar circumstances; and that he once observed very notable changes in the character of the voice to accompany the several stages of a pericarditis. He inclines strongly to the opinion that these phenomena are rather of vital than mechanical origin, inas- much as, in the cases in which they were met with, there was no very considerable degree of effusion, nor, consequently, of pressure ; whilst, on the other hand, they have been absent where the heart and lun^s have been most remarkably displaced and compressed by the existence of fluid in large quantity in the pleura and pericar- dium simultaneously. The great dissimilarity of the symptoms in different cases, as well 474 pericarditis (Physical Signs). as their variability in the same case, are very remarkable features of this affection, and may, in some degree, be explained by a refer- ence to the varieties of pathological condition which exist, and more especially in regard to the effusion, its quantity and nature. Thus, as Dr. Hope and Dr. Stokes have remarked, if this consists almost wholly of coagulable lymph throughout, or if the serum thrown out have been rapidly absorbed and adhesions been early effected, the circulation will be less interfered with, and less suffering will be produced than in those other more formidable cases where there is a copious fluid effusion painfully distending the inflamed mem- brane, pressing upon the heart, embarrassing its motions, and inducing weakness and irregularity of the pulse, faintness, anxiety, and a sense of suffocation, along with coldness and lividity, and incapacity of assuming the recumbent posture. The supervention of such a group of symptoms at any period of a case indicates a very serious aggravation of the state of the local affection. Yet even the effusion of coagulable lymph alone, if in extraordinary quantity, may perhaps occasionally be their source; as may like- wise the coming on of inflammation in the muscular substance of the heart. The degree of morbid alteration requisite in any of these cases to effect a certain amount of disturbance will, of course, vary with the nervous irritability of the individual. The cases in which the disease may be most readily altogether overlooked, are those where the effusion is confined to coagulable lymph, and where this exists only in very small quantity. (Stokes.) Physical signs. The impulse of the heart at the commencement is ordinarily much augmented and abrupt, accounting for that throbbing or jerking character of the pulse which has been noticed. The sounds are likewise increased in intensity, and, when endo- carditis coexists, as is so often the case, are accompanied by a bellows-murmur. Very early in the course of the disease, as on the second or third day for instance, a faint rubbing or rustling sound (bruit de frottement, or to-and-fro sound—murmur of ascent and descent, &c), such as that produced by the friction of silk- paper or parchment, is frequently audible, accompanying both sounds of the heart. This is most commonly first heard near the centre of the sternum, a little to the left of the mesial line, that is over against the base of the heart. It gradually assumes a louder, rougher character, and generally extends eventually over the whole region of the heart, and materially obscures the natural sounds of the organ, though they may still be recognised by applying the stethoscope near the top of the sternum. It has its source in the friction of the opposed surfaces of the effused lymph, which, even whilst still very thinly spread and soft, is quite sufficient for its production, as has been fully assertained by the experiments of Drs. Williams, Clendinning, and Todd. Whether the first stage, or that of simple congestion and dryness of the membrane, be capable of giving rise to it, in a minor degree, is still doubtful: the experiments of the gentlemen just named render it, indeed, very improbable that pericarditis (Physical Signs). 475 it is ever heard except in those cases where ecchymosis under the pericardium, or some slight traces of coagulable lymph on its polished surface, already exist. The rubbing sound occasionally somewhat changes its character, and becomes perfectly similar to the creaking of leather in the sole of a new shoe or saddle (cris de cuir—leather creak). This was first observed by M. Collin; and though Laennec was latterly scep- tical as to its import or reality, it has since been fully confirmed as a valuable sign of pericarditis by Stokes, Reynaud, Watson, Mayne, Bouillaud, Williams, and others. Dr. Copland has likewise noticed it, but thinks that it occurs chiefly in the chronic stage of the disease, and that it is dependent on thickening and induration of the pericardium and connecting cellular membrane; or else upon the existence of a dense and elastic false membrane. Many dis- tinguished pathologists have failed in detecting it,—probably, in part, from having confounded it with the sounds of valvular dis- ease, and partly, as suggested by Mr. Mayne, from their not having had an opportunity of examining the cases early or frequently enough. Its whole duration sometimes does not exceed a few hours, as it is necessarily put an end to, either by the absorption of the coagulable lymph, or the formation of adhesions, or, what is more frequently the case, by the effusion of fluid in sufficient quan- tity to keep the opposed surfaces apart. When the formation of adhesions is the cause of its cessation, we shall probably have neither that irregularity or sinking of the pulse, nor that prostration of strength, occurring in cases of large and rapid liquid effusion; whilst, at the same time, the sound elicited by percussion is clear, and the impulse is strong. The rubbing sound will, in these cases, continue to be heard longest, as Dr. Williams suggests, towards the apex of the organ ; whilst in those instances, on the contrary, where it disappears in consequence of the pouring out of an abundant quantity of fluid, it persists longest towards the base: in the latter cases, too, it may sometimes be momentarily reproduced by lean- ing the body forward, and so bringing the heart in contact with the interior surface of its investing sac. This distinguished physi- cian has known this sound to continue, in a few instances, for no less than a fortnight, in conjunction with the signs of a moderate effusion of fluid. The diminution of the heart's action, which is so conspicuous in the third stage of the disease, seems likewise to be sometimes concerned in the cessation of the sound in ques- tion, for it continues occasionally to recur at intervals with each casually stronger beat. As absorption makes progress, it has some- times also been known to reappear. The sensation of friction is in some well-marked cases imparted very distinctly to the touch as well as to the ear. The peculiar sound in question is commonly distinguishable from that connected with valvular disease, as Dr. Stokes many years ago pointed out, by the suddenness of its occurrence, and by the short distance from the cardiac region within which it is audible, as well as by the greater influence of treatment over it. But still 476 pericarditis (Physical Signs). there may be considerable difficulty of diagnosis where disease of the valves has pre-existed, or where endocarditis springs up simul- taneously. The rubbing sound is, however, of a decidedly more superficial and equably diffused character than the bellows-mur- mur, indicative of disease of the valves and orifices; and is more constantly double, or an accompaniment of both motions of the heart. The impulse of the heart decreases with the progress of the increasing effusion : the sounds likewise, both natural and morbid, become feebler and more distant, but may still be heard distinctly at the top of the sternum, or root of the neck, in the course of the great arteries emerging from the chest, being conveyed thither through the intervening solids, and with the arterial current. Inspection and measurement of the chest often detect, as Louis has pointed out, a fulness of the left side under the lower part of the sternum in the region of the heart, caused by the effusion within the pericardium, and partly, perhaps, also by the increased afflux of blood to the inflamed organ; and in chronic c? es, or where close adhesions have taken place, by the incipient hypertrophy of its muscular parietes induced thereby. This appearance of promi- nence will naturally be most conspicuous in subjects of tender age, in whom the cartilages are most flexible and yielding. Very soon after the commencement of the disease, a dull sound is elicited on percussion, in the situation just spoken of, the extent of which, as compared with the natural limits of deficiency of sound in the cardiac region formerly alluded to, very accurately defines, in simple cases, the degree of the effusion. The extent of this dul- ness where the quantity of fluid poured out is profuse, may be very considerable ; occupying even the greater portion of the left side of the chest, and extending moreover a little to the right of the ster- num. We must not, however, expect to meet with it in a marked degree, if at all, in the earliest stage of the disease, any more than the prominence above alluded to; and in those cases where the morbid secretion is limited to coagulable lymph, and that perhaps in small quantity, or where the fluid effusion is throughout very inconsiderable, the dulness may never be very obvious. Where, however, the quantity of effusion amounts to nine or ten ounces,—and it commonly much exceeds this,—the results of per- cussion will be usually very important, if not altogether decisive. Our conclusions may sometimes, indeed, be embarrassed by the ex- istence of pleurisy, or pleuro-pneumonia of the left or of both sides. When, however, these affections are confined to ihe right side, percussion is still capable of aiding in the recognition of pericar- ditis; and M.Louis has shown that in nt least one-half of the cases which occur it affords conclusive indications. Besides, it is to be added that the existence of dulness in the prascordial region, even though it should not be confined to that spot, is a valuable fact, inasmuch as it naturally leads to a closer investigation of the func- tions of the heart, and thus there is commonly disclosed sufficient evidence of pericardial inflammation where it really exists. In pericarditis (Physical Signs). 477 uncomplicated cases, again, the reality of its presence, being ren- dered probable by symptoms, may be confirmed materially by the disproof of all disease of the lung and its covering. If, on the con- trary, the pericardial inflammation should unfortunately be masked by the predominance of an acute pulmonary affection, the error in regara to the treatment, at least, is not of very material conse- quence. The sitting posture is one of those which afford the greatest facility for detecting the presence of a fluid within the pericardium: when the patient is lying on his back, on the contrary, its gravita- tion towards the posterior part of the chest may cause it, if small in quantity, to elude observation. The effect of the change from one to the other of these postures may assist us in discriminating pericardial effusion from a circumscribed pleuritic effusion in the same neighbourhood, tumours in the anterior mediastinum, &c. For some additional remarks on this subject, the reader is referred to what is said on percussion in the article Hydropericardium. The exist nee of false membranes and of adhesions after all in- flammatory action has ceased is commonly very difficult of detec- tion. The presence of the creaking or leather sound has occasion- ally led to their recognition; whilst a harsh grating sound has indicated a rougher or ossific state of the outer lining of the heart. Dr. Williams tells us he has sought in vain for " the jogging or tumbling motion" said by Dr. Hope to be characteristic of this restrained state of the organ ; but adds, that when the inflamma- tion has extended through to the exterior surface of the sac, and caused its agglutination to the walls of the chest, the motions of the organ become much more plainly and widely felt than usual, drawing in the intercostal spaces at each systole. The nature of the case may sometimes also be suspected by observing that change of position has no influence over the extent in which the pulsations and the dulness on percussion are perceptible. It must be admitted, however, that a similar permanency in respect to these circum- stances exists also in cases of very great enlargement of the heart. In cases of very close adhesion, each contraction of the ventricles has been observed by Dr. Sanders to be accompanied by a cor- responding retraction of the left portion of the epigastric region ; and Dr. Copland has verified this symptom in two or three instances ; yet it must needs be rare, or very obscure, as Laennec, Hope, Bouillaud and Chomel, have sought for it unsuccessfully. Much difference of opinion has prevailed as to the influence of intimate adhesions on the future health, and on the action of the heart in particular. Corvisart believed that extensive adhesion necessarily deranged the motions of the heart and diaphragm so materially, as to lead sooner or later to a fatal termination; and Dr. Hope takes scarcely a more favourable view, believing that where the adhesions are close and universal the incessant struggle and over-distension of the heart, together with the alteration in- duced in its texture by the previous inflammatory action, tend invariably to cause enlargement of the organ, and, after an indefinite ' 61 478 pericarditis (Frequency). interval of a very few years death is the almost constant result. Such patients commonly labour, ever after the original attack, under a certain degree of dyspnoea and inability to undergo the same exertions as formerly. Laennec, Chomel, and Bouillaud on the contrary think such adhesions often unimportant; and Elliotson says they do not in general produce the slightest inconvenience unless where organic disease of the heart coexists. Bouillaud believes moreover that the hypertrophy of the heart, and other formidable consequences usually ascribed to them, are referrible with much more probability to the organisation of lymph effused within the cavities of the heart, and other coexisting results of endocarditis, a disease which as is now well known often complicates pericarditis. For our part, however, it seems difficult to believe that so unnaturally shackled a condition of so mobile an organ should not very generally lead to further lesions, as it is obvious that its increased action must powerfully promote the development of any morbid tendency inherent in it. Dr. Hope has observed that the heart, though enlarged, did not in these cases beat lower in the chest than natural, but sometimes occasioned a manifest pro- minence of the cartilages of the left ribs, both of which circum- stances result obviously from its adhesions preventing its enlargement downwards or the descent of its apex. Chronic pericarditis is generally only the sequela of the acute variety. Occasionally, however, pericarditis assumes the chronic form from the very commencement, being unattended with any marked degree of fever, whilst the local symptoms are so mild as scarcely to attract notice. In such cases it is often altogether latent;—frequently, however, rather from attention not being par- ticularly called to the seat of the diseased action than from the absence of sufficiently characteristic symptoms. Thus, if in addi- tion to the physical signs indicative of effusion, as dulness on per- cussion, undulatory impulse, distance of the heart's sounds, and prominence of the prascordial region, there be some degree of pain or uneasiness in the situation of the heart, a slow fever with or without exacerbations in the evening, a general sense of oppression and debility, slight oedema of the face (which part is occasionally also of a violet tinge), and oedema of the ankles, we shall have reason to apprehend the existence of chronic pericarditis. The cause to which the indisposition is ascribed, as a fall or blow, acute rheumatism or inflammation within the chest, may throw further light on the nature of the affection. The comparative recentness of the disorder, which commonly does not date further back than a few weeks or months, taken in connexion with the advanced state of the dropsical symptoms, will aid us in distinguishing it from the results of old organic disease of the valves and orifices. Frequency. Pericarditis is a disease of rather frequent occur- rence. Louis recognised its existence on an average at the rate of four per cent, of all the dissections witnessed by him within a given time. Though an affection of the most serious nature, it is, as already pericarditis (Complications). 479 stated, now ascertained to be much less commonly mortal than it was within these few years generally supposed to be. From an estimate of the number of times that traces of it are met with in the bodies of those who have died of other diseases, Chomel is led to conclude that it does not prove fatal in above a fourth (Louis says a sixth, if uncomplicated) of all the cases in which it occurs, and even these averages are probably rather over than under the truth, as they take no account of those instances, probably not very rare, in which the disease being cut short in its earliest stages, or the absorption of all effused matters being complete, no permanent traces of its existence are left behind. Of the cases in which death takes place in the course of the disease, the fatal event is ascriba- ble, in at least one half, to coexisting complications. Where very acute, it has been known to prove fatal within thirty hours from its commencement, but this is very rare. Its ordinary duration, if acute, is, unless very actively treated, from one to two weeks; or, if subacute, three or four, within which periods it terminates in death or recovery, or else begins to assume the features of the chronic stage. The prognosis becomes much more unfavourable where a large effusion of fluid has taken place, and this in proportion partly to the rapidity with which it is thrown out; so, likewise, where cedematous swellings of the extremities make their appearance, where the action of the heart is greatly disturbed or oppressed, where the inner lining of the heart is deeply implicated, where there existed previous organic disease of the organ, or serious inflammatory complications, more especially in the lungs or pleuras, and finally where the constitution has long been in a cachectic or debilitated condition. Complications. Of all these complications, especially where the disease is of rheumatic origin, which is the case perhaps in three out of every four instances, endocarditis is the most frequent. It is indeed rarely altogether absent, and is recognised by the bellows murmur and other signs to be enumerated in a subsequent section. Pericarditis seems more frequently to excite, than to ensue upon, inflammation of the interior of the heart. Pleurisy or pneumonia are present in the greater number of instances ; Louis supposes in at least two-thirds of the whole; carditis, or superficial inflamma- tion of the muscular structure of the heart, and a similar condition of the cellular membrane in the anterior mediastinum of the upper surface of the diaphragm, or of the peritoneum, liver, or other abdominal organs, occasionally coexists. The occurrence of cere- bral excitement is, as we have already seen, not unusual. Peri- carditis frequently makes its appearance in connexion with the eruptive fevers, and more especially with scarlatina. In childhood too it forms, no less than in adult life, a very ordinary complication of acute rheumatism, and often originates in the course of neglected convalescence from various acute diseases, especially, as Dr. Cop- land remarks, amongst the children of the poor living in damp habitations and debilitated by insufficient nutriment. 460 pericarditis (Diagnosis). Death by syncope is a possible but certainly rather an unusual termination of pericarditis. Extreme dyspnoea, amounting almost to suffocation, is, towards the conclusion, the prominent symptom in most of the fatal cases. By much the most unfavourable ex- amples of the disease, and the least capable of bearing the requisite treatment, are those occurring in patients debilitated by previous illnesses, as fever, dropsy, Szc. Relapses are common even in cases of the disease which have been actively and judiciously treated ; as is likewise the recurrence of inflammation in the membrane at periods long subsequent, and especially where the organ which it envelopes is the seat of struc- tural change. Even adhesions do not, as commonly supposed, confer absolute immunity from future attacks ; for there has often been observed by Dr. Williams and others, within the agglutinated false membranes, manifest indications of the inflammatory pro- cess,—redness, softening, recent effusion of lymph or semi-purulent fluid in small quantities in their interstices, or in the adjoining cellular membrane of the mediastinum : the physical signs of effusion, such as dulness on percussion, the rubbing sound and impaired impulse, are unfortunately wanting in these cases; they may occa- sionally perhaps be suspected from the existence of local pain or tenderness on pressure, or the unusual excitement or irregularity of the heart's action. When pericarditis assumes the chronic form the prospect of recovery is much fainter; it may run on for two or three months with various'alternations of improvement and aggravation, and then pass into a slow state of convalescence, or, what is but too frequently the case, may on the other hand terminate in death, which occasionally takes place suddenly and unexpectedly, though more commonly, gradually, through the mere exhaustion attendant upon continued irritation. When the disease has lasted out some months the morbid contents of the pericardium consist most commonly either in a transparent serum, or in very thick and firm false membranes made up of many layers indicative of successive aggravations of inflammation; and in the midst of them are occasionally circumscribed purulent or tubercular deposits. In children, with all the physical signs and symptoms of profuse pericardial effusion, we have known very remarkable recoveries to ensue, and this, on one occasion, almost solely by the unaided powers of nature. Diagnosis. Where pericarditis exists in its simple state its diag- nosis has been pronounced by Louis to be no more difficult or obscure than that of pleurisy. In at least a half of all the cases analysed by him there was during life sufficient evidence of its pre- sence, from the union of a greater or less number of the following symptoms,—pain, or tenderness on pressure, oppression of breathing, palpitations, inequality or intermittence of the pulse, unnatural pro- minence, and dulness of sound over a greater extent than natural of the prascordial region, and confined to it, to which subsequent pericarditis (Diagnosis). 481 observers have added the frictional and creaking sounds already alluded to ; and all these have an additional value and clearer signification, when occurring in a patient previously healthy. Most of these signs and symptoms, it is true, are met with also in water in the chest, and some of them in aneurism of the aorta ; but the greater rapidity of the inflammatory affection, even if pain be absent, will generally sufficiently distinguish it. In the course of cases of acute rheumatism of the extremities, we should ever be on the look-out for inflammation of the surfaces of the heart, and be ready to act upon the first indications of its existence, such as the sudden supervention of cardiac pain or oppression, extreme anxiety and restlessness, with notable change in the pulse and respiration; but, above all, the characteristic auscultatory phenomena, which should be sought after frequently and at very short intervals, inasmuch as they are by far the most constant signs, and often precede, by some time, the other evidences of its existence. In pleurisy and pneumonia we should likewise be prepared for the extension of the inflammation to the heart, or its original, though it may be obscure, coexistence there. Even in the course of con- tinued fevers, the sudden supervention of irregularity of the pulse, especially if accompanied with unusual anxiety, should direct our attention forthwith to the heart, and the possibility of its having become the seat of inflammatory action. Bouillaud asserts, that dulness of sound, and prominence in the prascordial region, occurring along with the stethoscopic signs (rubbing and creaking sounds), and sudden fever in an individual who had previously no symptoms of organic disease of the heart, afford certain evidence of pericarditis, even though there be neither irregularity of pulse, dyspnoea, oppression, nor pain ; and Dr. Hope is persuaded that even with a still smaller number of signs, namely increased action of the heart, fever, and a murmur which did not previously exist, we may detect inflammation of this organ ; and that by the nature and situation of the murmur, we may generally still further decide whether the affection be pericarditis, endo- carditis, or both. Dulness on percussion, though a valuable sign, is fortunately not indispensable, being often absent, as is still more frequently prascordial prominence. When endocarditis coexists, as the researches of Watson, Hope, Bouillaud, and others have proved it to do in the vast majority of cases,—if it be so situated as to cause regurgitation through the aortic orifice, the pulse will be jerking, or even attended with a thrill in some cases; and we shall hear a valvular murmur coincident with the second sound of the heart. If the murmur be simultaneous with the first sound, on the other hand, impediment either in the auricular or aortic open- ings may be inferred. The valvular murmurs (which in themselves afford, as Dr. H. further remarks, strong presumptive evidence of pericarditis, seeing how frequently it complicates inflammation of the inner membrane), may almost always be satisfactorily distin- guished from attrition murmurs by applying the stethoscope a 482 pericarditis (Diagnosis). couple of inches or more up the aorta or pulmonary artery where murmurs connected with the similunar valves will be very distinct, whilst those originating in pericardial friction will, for the most part, be inaudible ; and also by searching for murmurs of the auri- cular valves a little above the apex of the heart, which will always be found to be their point of greatest intensity; whereas this, in respect to external murmurs, is altogether indeterminate. The attrition murmur almost invariably accompanies both sounds of the heart. In one or two instances only, Dr. II. has known it to be confined to the first sound; and in a few others, it has assumed the character of a continuous rumble, owing apparently to the churn- ing of a small quantity of fluid, in addition to the pericardial rough- ness. It is ordinarily of a rough or rustling character, and more frequently accompanied by the purring tremor than are the valvu- lar murmurs ; and varies its situation and intensity with the precise seat and progress of the inflammation. Dr. Watson has recorded a case where it was unusually loud and audible over a great part of the chest; but this is very rare. It is where the inflammatory symptoms and effusion are very slight, or where pleurisy of the left side coexists, that the recogni- tion of pericarditis is peculiarly difficult. A simple pleurisy of the left side might be mistaken for pericarditis, but only by a very careless observer. The early symptomatic derangement of the cerebral functions, evinced by the coming on of delirium, stupor, &c, throws consi- derable difficulties in the way of the diagnosis, both by taking the attention off from the true seat of the disease, and by depriving us of a knowledge of such peculiar signs of the disease (as pain, ten- derness, anxiety, sense of palpitation, &c.) as can only be ascer- tained through the rational consciousness of the patient; and such cases have actually been repeatedly mistaken by practitioners of the first eminence for idiopathic inflammation of the brain. Yet even here, if we have any suspicion of the true nature of the case, a recurrence to physical evidence will often clear away all ob- scurity. Pleurisy and pneumonia are to be distinguished from pericarditis by their appropriate signs and symptoms detailed in another part of this work. When after an accurate investigation, we are satisfied that neither of these affections exists, this negative fact may be of great value towards the establishment of the presence of cardiac inflammation, where its local symptoms are obscure. The sound of friction, sometimes heard in pleurisy, may usually be distinguished from that in pericarditis, by its ceasing on holding the breath. Yet it is just possible that the impulse of the heart against the lungs may at limes give sufficient motion to the inflamed and coated pleuras to produce this phenomenon; and when the diaphragmatic portion of the left pleura is its seat the diagnosis is peculiarly difficult. An enlarged and feebly acting heart may be distinguished from the case of a profuse pericardial effusion with weak impulse and pericarditis (Causes). 483 distant indistinct sounds, by applying the stethoscope to the supra- clavicular region, where in the latter case, and in it only, the car- diac sounds will be heard with considerable clearness in the course of the carotid and subclavian arteries, indicating that their feeble- ness in the prascordial region is the result of an obscured, rather than of an actually deficient action. When the disease is accompanied with vomiting hiccup, and epigastric pain and tenderness to the touch, great general debility, with sinking and irregularity of the pulse, and cold sweats, it may readily be mistaken, if attention be not directed to the physical signs, for acute gastritis in its fatal stage. Pericarditis in the chronic stage, accompanied with profuse effu- sion, has been known to push down the liver so far below the right hypochondria, as to give rise to the erroneous supposition of disease and enlargement of the latter organ. Such a case is mentioned by Mr. Adams in the Dublin Hospital Reports. In respect to diagnosis, the same author lays much stress on the distinction between the transient rheumatic affection of the heart, such as other muscular and fibrous organs are liable to, and the more serious inflammation of its serous membrane, occurring in connexion with acute rheuma- tism—a subject which has recently been much enlarged upon by M. Chomel. The great variability and frequent inconsistence of the symptoms have been considered peculiarly characteristic of pericarditis, as likewise the intense restlessness, the anxious, frightened look, the early supervention of weakness and irregularity of pulse, before the general strength is proportionably reduced—the intermitting nature of this derangement, and the frequent want of correspondence between the state of the pulse and that of the skin. Causes. In some instances it is found impossible to ascertain the exciting cause of this disease ; certainly, however, not so frequently as Louis is disposed to think. In far the greater number it is dis- tinctly attributable to the influence of cold, or of cold and moisture, acting on the body when overheated and fatigued, as is obvious from its ordinary connexion with rheumatic inflammation, and its frequent coincidence with pleuropneumonia,—as well as from the circumstance of its occurring more particularly during severe and changeable weather, and especially in spring. The frequency of its rheumatic origin has been recently insisted on, much and justly, by M. Bouillaud in France. This part of its history has, however, long been familiarly known to medical men in our own country. The connexion of disease of the heart with rheumatism was first noticed by Dr. Pitcairn fully half a century ago, and was soon after made more generally known to the profession by Dr. Baillie. Sir David Dundas and Dr. Wells subsequently recalled attention to it, and the latter seems with his usual penetration to have taken a just view of its inflammatory nature. Mr. Adams, in the excellent practical paper on diseases of the heart already alluded to, has dwelt particularly on the relation of pericarditis to rheumatism— yet by the French school, till very lately, all this appears to have 484 PERICARDITIS (Causes). been overlooked. Corvisart had but an obscure, or at least a very inadequate idea of the importance of the latter affection in the pro- duction of diseases of the heart; and even Louis, though so recent a writer, scarcely notices their connection. Bouillaud believes that at least one-half of all the cases of acute rheumatism occurring in practice, or what is ordinarily called rheumatic fever, are accompanied in some part of their course by an inflammation, either of the internal or of the external lining of the heart, or both, which tends greatly to the prolongation of the illness; and that these latter affections have, in fact, in very few instances any other source. He does not, however, admit that they are so often, as is commonly supposed, the result of metastasis, but asserts that they originate in very many cases simultaneously, and proceed pari passu with the articular affection. We are inclined to believe, however, notwithstanding his high authority, that the instances in which the ordinarily received opinion holds good are numerous. The sero-fibrous structure of the pericardium, and of certain portions of the interior of the heart, is precisely such as should lead us to expect intimate sympathy with the inflamed synovial and ligamentous tissues of the joints. Sometimes, though rarely, the in- flammation persists in an intense form, both in the heart and joints. More commonly, however, in proportion as it becomes more violent in the one situation, it is mitigated in the other.* Cases of traumatic as well as of spontaneous erysipelas, in which the metastasis of inflammation to the heart occurred, are alluded to by Mr. Adams. They proved fatal within 48 hours; orthopnoea, great anxiety of countenance, and other symptoms of pericarditis, having supervened immediately on the disappearance of the cuta- neous redness. Though no age is exempt, yet children, and individuals about the period of puberty, are peculiarly liable to the translation of rheuma- tism to the pericardium ; and especially in those cases where the synovial membrane is the seat of the inflammation, for, where the muscles are alone affected, metastasis is, according to the author last named, a much rarer event. Persons of a full habit and sanguineous temperament, and in the flower of life, seem most disposed to attacks of pericarditis. The gouty and the rheumatic are peculiarly prone to it, no less than to many other forms of cardiac affection. Convalescence from fever is frequently arrested by its superven- tion. It may be directly induced by external injuries, blows, falls, and penetrating wounds, and may originate also in the extension of inflammation from a neighbouring organ, more especially from the lungs and pleuras. Continued over-exertion of body and great anxiety of mind, the suppression of habitual discharges and eruptions, the inflammatory tendencies connected with measles, small-pox, and more especially scarlet fever in its convalescent period, may also be enumerated amongst its occasional causes. * Dr. Bouillaud is in the right. It occurs much more frequently during the height of the rheumatism, and only occasionally from metastasis. pericarditis (Treatment). 485 Of its predisposing causes little can be said with certainty. Ac- cording to M. Louis the male sex is more liable to it than the female, in the proportion of three to one. The period of life between the tenth and thirtieth years appears to M. Bouillaud the most prone to it. M. Louis has noted most cases of it between the twen- tieth and thirtieth years, and between the sixtieth and seventieth —the periods at which, respectively, the tendency to inflammation and to ossification and other organic changes, is most conspicuous. But the results of both these distinguished pathologists have, it must be remembered, been attained from the experience of adult-hospitals, almost exclusively. In earlier childhood it is by no means infre- quent, and extreme infancy itself is not altogether exempt from it. In respect to its very common connexion with organic disease of the heart, and especially enlargement of the organ, it exists sometimes as a cause, and sometimes as a consequence. Abuse of fermented liquors is enumerated by Dr. Elliotson amongst the sources of the insidious chronic form of pericarditis as well as of disease of the valves and orifices. Pericarditis appears sometimes to have reigned epidemically: twenty cases once presented themselves to a single practitioner, within ten weeks, in a moderate-sized town in France. Not long since the journals contained an account of an hasmorrhagic peri- carditis in Russia, of an epidemic and scorbutic character. Dr. Elliotson remarks, that the cases in which he had usually found a bloody fluid within the pericardium are those where the heart was softened. Treatment. In the acute stage, when early seen, we should pro- ceed instantly to the most vigorous employment of antiphlogistic remedies. Blood should be immediately taken fi'om the arm in con- siderable quantity, and in a full stream; and as soon as the imme- diate effects of the operation have passed away, leeches in large number (twenty to forty in strong adults) are to be applied, or cupping practised over the prascordial region. If the violence of the symptoms-persist, each of these measures must be repeated as freely, and at as short intervals as the age and strength of the patient permit, and as the intensity of the inflammation demands. Not a moment should be lost in thus reducing the quantity of the circulating fluid, and diminishing at once the natural stimulus of the organ, and, as far as possible, the quantity of labour to be done by it, and, at the same time, moderating the excited action of its capillaries; for, as we have seen, if effusion in large quantity, either of coagulable lymph, or of a more fluid character—and especially the latter—has once been permitted to take place, the chances of ultimate and perfect recovery are very much impaired; and the power of the patient to bear active treatment after such an occur- rence is no longer the same. In the earliest stage of this as of many other inflammations the tartrate of antimony in large doses, as exhibited by Laennec in pleurisy, is often a valuable auxiliary to bloodletting ; it is however far inferior in efficacy to the remedy next to be mentioned, and 62 486 pericarditis (Treatment). when not speedily very decisive in its effects should be at once relinquished. If we find that in spite of the above measures, carried as far as prudence will permit, the inflammation continues to make progress, and especially if the effusion of fluid is actually commencing, no time should be lost in having recourse to the invaluable compound of calomel and opium (for the general use of which in such cases in this country the profession is indebted to Dr. Hamilton of Lynn Regis), which exercises so remarkable an influence over inflamma- mation in serous and other analogous membranes, both checking the morbid action, and promoting the absorption of such morbid products as it may already have given rise to. Doses of from three to five grains, or upwards, of the former, guarded by from a quarter to half a grain of the latter, or an equivalent portion of Dover's powder, to prevent it running off by the bowels, should be given every fourth hour till its specific effects is manifested on the mouth, or till the disease begins to yield ; and even then the mer- curial is not to be suddenly relinquished, but on the contrary very gradually withdrawn, as well on account of the frequent tendency of the inflammation to recur, as lest any portion of the effused matter might still remain unabsorbed, and become the germ of ulterior disease. Absolute repose of mind and body, and total abstinence from food, are also very important elements in the early management of these cases. In placing bloodletting and the exhibition of mercurials so pro- minently forward, we are influenced by the conviction of their constituting incomparably the most essential and efficient part of the treatment. Where there is difficulty in bringing the system under the influence of mercury, in addition to its internal exhibition mercurial ointment should be introduced into the axillns, and left there to be gradually absorbed; and at the same time fumigations with the Hydrargyr. c. Creta or with the mercurial candle may be practised. Amongst the auxiliary remedies are to be enumerated the promotion of moderate evacuations from the bowels, especially at the commencement of the disease, by some mild aperient, avoid- ing at the same time the dangerous and absurd error of trusting, like certain empirics of our day, the cure of the inflammation of so vital an organ to purgatives chiefly or alone. WTien tartrate of antimony in the larger doses, alluded to above, has appeared inapplicable to the case, fractional doses of it, or of James's powder or ipecacuanha, to relax the skin and modify the inflammatory action, should be employed. Diluent drinks in moderate quantities, to reduce the stimulant quality of the blood, without over-distending the vessels, with the addition of the nitrate of potass in as large portions as can be borne by the stomach and bowels (as, for instance, one or two scruples to the pint), are useful adjuvants in this and other analogous in- flammations, especially if of rheumatic origin. After the first vehemence of the disorder is past, and effusion has already taken place, but not on any account previously, large blis- pericarditis (Treatment). 487 ters must be applied over the seat of the inflammation, and dressed with mercurial ointment to aid in bringing the system under the desired influence of this remedy ; and at the same period the em- ployment of sedatives, as camphor, hyoscyamus, or digitalis, prus- sic acid, or one of the salts of morphia, may be had recourse to when the excited state of the heart, and the anxiety and restless- ness continue extreme, and seem to depend rather on a high degree of nervous irritability surviving the inflammatory action than on this latter itself. Enveloping the chest in large emollient poultices is considered in France and Italy a measure of some efficacy ; and, inasmuch as it determines locally to the skin and tends to moderate deep-seated pain, it is a point of treatment not unworthy of imitation, where no inconvenience arises from the weight of the application. The importance of absolute repose is obvious from the fact that every the least movement, or the slightest effort, as in speaking or coughing, reproduces the irregularity of pulse, and aggravates the other symptoms. With regard to bloodletting, it is right to state that though all practitioners are agreed as to its importance, some difference of opinion prevails as to the most effectual and safe method of employ- ing it, and as to the extent of benefit to be expected from it. Thus M. Bouillaud, who is a great advocate for large and rapid reiterated venesections, declares that, of late years, since he adopted this method, he has scarcely ever failed to cut short any case of peri- carditis to which he was early called. He commonly takes blood three or four times from the arm, to the amount of about a pound or better each time, within the first three or four days, and employs leeches and cupping at the same time as frequently. Dr. Hope's method of employing bloodletting is very similar: blood is drawn freely from the vein by a large incision, so as to bring the patient to the verge of syncope; and this, as well as the local bleeding, is repeated twice, thrice, or oftener, at intervals of eight or twelve hours, till the pain is subdued, or as frequently as the state of the pulse, or rather the action of the heart, demands. He is however much less sanguine than the French practitioner just mentioned, as to its being adequate of itself in all cases, or even generally, to cut short the inflammation. " The antiphlogistic treatment, alone," says he, " is not to be relied on: rarely, if ever, does it in a severe case effect a complete cure." The disease too often proceeds un- controlled by it to a fatal termination: at other times it partially yields, but the heart's action long continues of unnatural strength ; and in other cases, though it may appear to have regained its healthy action, yet palpitations and symptoms of organic affection manifest themselves as soon as the patient resumes his accustomed occupations : and hence, like Dr. Latham, Elliotson, and all the best British practitioners, he has recourse early to calomel or blue pill and opium in large doses, to which occasionally mercurial in- unction is superadded, or it is altogether substituted if the internal use of the medicine disagree. Dr. Williams, whose remarks on the treatment ot diseases of the 488 pericarditis (Treatment). heart are in general in the highest degree judicious and practical, deprecates the employment of copious venesection in inflammations of this organ, unless perhaps in their very earliest period, as he apprehends that its effect where the central organ of the circula- tion is primarily implicated, must be, in the first instance, to trans- mute the inordinate into defective action, and so to augment the embarrassment of the circulation, and keep up the feelings of dysp- noea, faintness and agitation; and, in the second place, to lay the foundation of subsequent reaction—consequences which he sup- poses must more readily ensue in the case of the heart in a state of inflammation than in that of any other organ. " Whether this be the true view of the case or not," he continues, " 1 have been convinced, by repeated observations of different kinds of practice, that both pericarditis and endocarditis, and especially if connected with rheumatism, are most safely and effectually treated by mode- rate general bloodlettings, avoiding as much as possible sudden or full impressions on the circulation ; and that local bleedings, free and repeated, should in all cases be employed, as a measure of at least equal importance." We must not, however, let the irregularity of the pulse, nor its feebleness at the wrist, nor the apparent debility of the patient, prevent us from taking blood if the complaint be still of recent origin, and the pain and other characteristic local and general symptoms seem to demand it. Young practitioners should, on the other hand, be cautioned against being guided too much by the buffed and cupped appearance of the blood in this affection, for this, where the disease has a rheumatic origin more especially, will commonly persist in spite of the freest sanguineous evacuations, or will even augment under their use. If unfortunately we should not be called to the case till after it has already existed for some days, and the debility of the patient is such as to render venesection hazardous, local depletion by leeches may often still be practised with great advantage. Dr. Elliotson thinks he has observed free local bleeding to be more serviceable in all cases than general, and that calomel and opium is a still more important agent than either in the subjugation of this as well as most other inflammations, and in conformity with the opinion we have already expressed, that it is far superior to the tartrate of antimony even in the large doses in which it is exhibited in Italy and France. Colchicum also is often of decided utility, especially when the disease is of rheumatic origin, and after its first violence has been reduced. It has sometimes also proved adequate to the cure of the chronic form on persevering many months in its exhibition. When the disease has passed into the chronic stage leeches should still be occasionally employed on the revival of the pain, or other evidence of the re-excitement of the inflammatory process, and blisters must be repeatedly applied ; or, at a later period, more permanent forms of counter-irritation ought to be had recourse to, as frictions with tartar-emetic ointment or croton oil, an issue or seton, or the repeated application of the moxa, a remedy in which Baron Larrey has pericarditis (Treatment). 489 fnfl!1mmni),0Unded/0nfidence both in resPect to controlling local inflammation and producing the absorption of morbid products. in the selection and continuance of these remedies, we must of course be guided as much by their effects on the general health as by the state of the local disease, as in a prolonged affection of this kind any application which produces great irritation in the system cannot but diminish the prospect of ultimate recovery. Counter-irritation applied to the extremities may sometimes be substituted with advantage for that in the immediate proximity of the disease. Mild mercurial courses, where they do not induce too much constitutional derangement, will generally deserve repeated trial, with a view to causing the re-absorption of remaining morbid effusions, as well as to counteract the low disorganising inflamma- tory process which so often survives the more active form of the disease; especially in those cases where inflammation of the interior lining, as so frequently occurs, complicates that of the exterior. The cautious exhibition of diuretics and purgatives is also frequently called for in the chronic stage. The diet should be gradually improved, but still restrained within the strictest bounds of mode- ration, the object being to maintain just such a degree of strength as is requisite to bear the patient through a tedious reparative process, and at the same time to avoid everything which can accelerate the pulse or rekindle the local inflammation. Even in the most favourable cases the accustomed avocations and habits of living should not be returned to till after the lapse of a very con- siderable period. There is no point which should be more pressed on the mind of the patient than the absolute necessity of avoiding, for a length of time afterwards, every violent excitement of mind or body, and all excessive or prolonged muscular exertions. When tumultuous action of the heart and other symptoms of incipient hypertrophy of the organ manifest themselves amongst the sequelas of pericarditis, a favourite mode of treatment with M. Bouillaud is the introduction of digitalis by the endermic method, by daily sprinkling the skin, denuded of its cuticle by the previous application of a blister, with about ten grains of the substance in powder; whilst at the same time he cautions us against its use in those cases where, from the presence of a very abundant effusion of fluid or of thick masses of false membrane, there is reason to suspect a weak and atrophic state of the heart has been induced. Turpentine, in doses sufficient to excite some degree of urinary irritation, from its known efficacy in promoting the absorption of effused lymph, of which we have ocular demonstration in the case of iritis, is likewise deserving of trial in the chronic form of disease, and especially in cases of rheumatic complication. The hydriodate of potass, in doses of from three to five grains and upwards, in solu- tion thrice a day, has sometimes been administered advantageously with the same view and in the same stage of the disorder; and this substance may also at the same time be externally applied. The in- troduction of the alkaline subcarbonates into the patient's drinks has also been recommended as a means of promoting the action of the kidneys, favouring absorption, and modifying the composition of the 490 pericarditis (Treatment). blood; and is especially applicable to those cases where the urine exhibits an unnatural excess of acid, or where the blood coagulates too firmly, or other evidences of an inflammatory tendency exist. Where some degree of pain or uneasiness continues long after the primary attack, anodyne liniments or a plaster of belladonna, or an ointment containing a minute portion of veratria or aconitine, should be had recourse to as palliatives. When in spite of the employment of the measures above indicated there is evidence of a considerable effusion persisting long after the original inflammatory attack, and when the motions of the heart appear in consequence of its pressure to be greatly deranged, the attempt to procure relief by means of a surgical operation, to be described hereafter in the article on hydrops pericardii, might possibly, in some very rare instances of chronic pericarditis, be justifiable. Pericarditis is, as we have already seen, peculiarly apt to recur; but, fortunately, subsequent attacks are commonly very inferior in intensity to the original ones, and are much more easily con- trolled. Hence their treatment does not require to be by any means so energetic; nor, indeed, would the constitution be now able to sustain the same powerful antiphlogistic measures. A single moderate venesection, or local bloodletting alone, the cautious exhibition of mercury, and the employment of derivatives, are usually sufficient to check them, especially if the action of the bowels, kidneys, and skin be simultaneously promoted. In children, even of a very tender age, pericarditis is, as already stated, by no means a remarkably rare affection, occurring most commonly in complication with rheumatism of the joints, or with pleuritic or pulmonic inflammation, or as a sequela to the febrile eruptive disorders: its treatment in such cases is to be conducted on the principles already laid down : the early and active use of antiphlogistic remedies, bloodletting, general or local, or both; calomel, with James's powder; colchicum, purgatives, diuretics, and counter-irritants, with strict confinement to bed and a very low scale of diet, constituting the chief means for its reduction. These cases go on generally much more favourably, and are more rapidly amenable to treatment than examples of the same affec- tion in adults, and even when the effusion has already existed for several weeks its complete absorption is by no means to be des- paired of. The remarks of the author as to the symptoms and treatment of pericarditis are strictly applicable to the most violent form of the disorder, in which the dis- tress of the patient is often extreme, and the means of treatment should be of the most energetic kind. But it would be great error to suppose that in the majority of cases of pericarditis the symptoms were violent, or that the disease tended in those cases towards a fatal termination. On the contrary, the disorder is strictly latent to most physicians, that is to all who are not conversant with the pathology of heart affections, and the physical means of investigating them. Yet pathological anatomy shows us that an immense number of individuals have ENDOCARDITIS. 491 liZf "f6;,^^^113 3nd r6C0Vered' Whi,e the clinical examination of patients actually suffering frora this disorder shows us that the general signs of it are most obscure, and that, although the physical signs are pathognomonic when they exist, they are absent or badly marked in many slight cases! While the treatment of pericarditis cannot well be too energetic in severe cases, m the milder ones local bleeding and repeated small blisters are the best remedies. The remarks of the author as to the relative advantages of mer- cury and antimony in the treatment of both acute and chronic varieties of the disorder are perfectly well founded : in all serous inflammation mercury has a decided superiority not only over antimony but over all other remedies. Al- though treatment is imperatively necessary in violent cases of pericarditis, and highly useful in moderate ones, yet the greater number of cases will terminate naturally in recovery even without treatment. This may be inferred from the large number of latent cases of the disease: but if the inflammation be severe, even if recovery take place the after consequences are injurious from the forma- tion of adhesions, as already pointed out in the text: although most of the organic diseases of the heart which occur after pericarditis depend less upon the inflammation of the pericardium than on that of the lining membrane of the heart which so frequently complicates it. ENDOCARDITIS, OR inflammation of the internal membrane of the heart. Anatomical characters—in the acute stage—in the chronic, including diseases of the valves and orifices.—Symptoms and physical signs of acute endocarditis —of chronic endocarditis, and disease of the valves and orifices.—Causes.__ Complications.—Duration.—Prognosis.—Endocarditis of children.—Treatment. For our present extended knowledge of the inflammation of the inner lining membrane of the heart we are chiefly indebted to M. Bouillaud, who has devoted to its consideration a large portion of his elaborate work. It had not, however, altogether escaped the notice of previous writers, as a reference to the pages of Jos. P. Frank, Hildenbrand and Kreysig, Burns and Baillie, sufficiently testifies. But it is to the distinguished French author just named that the merit is due of having set it prominently forward as an occur- rence of great frequency, especially in connection with rheumatism, and as one of the most influential elements in the production of organic disease of the heart. Since he first fixed attention on it in his edition of Bertin's work published in 1824, it has been success- fully investigated by several of our countrymen,—Latham, Elliot- son", Watson, Hope, &c. That it should previously have attracted so little general attention is mainly attributable to the evanescent nature of several of the morbid appearances which characterise it; for though the endocardium is allied to the serous membranes, and, like other tissues of that class, secretes, when inflamed, serum, lymph or pus, yet from the contact of the secreted matters with the blood, they are commonly washed away by the torrent of the 492 endocarditis (Anatomical Characters). circulation as soon as formed, and in the greater number of instances leave no trace behind, save the slightest redness or tumefaction of the affected membrane. In some instances, however, the effused lymph seems to be of a more adhesive nature, retains its connection with the membrane on which it is formed, becomes organised, and the source of various changes of structure in the interior of the heart; especially when poured out, as is most usual, in the neigh- bourhood of the orifices and valves. But even independent of such ocular evidence as is obtained on dissection, we are now acquainted with certain auscultatory signs, which, taken along with the general symptoms, coexisting affections, and causes of the diseased con- dition, enable us to decide, even during life, with a high degree of probability, as to its presence. From the researches of M. Bouil- laud it appears that inflammation of the interior of the heart is at least as common as pericarditis, and is followed by still more important results; and though its early stage may not be attended with such incontestable anatomical evidences as the latter, yet those of its more advanced period are altogether analogous, and quite as satisfactory. In the venous system, in which the circulation is comparatively slow and feeble, examples of the organisation of coagulable lymph are still more frequently observed; and the similarity of the lining membrane of the veins to that of the heart, as well as the frequent extension of inflammation from the former to the latter, should have prepared us, prior to all positive evidence, to admit the existence of idiopathic endocarditis as not improbable. Anatomical characters. The morbid appearances characteristic of inflammation of the inner membrane of the heart are divisible into three classes: the first, or that connected with the earlier period of the affection, consisting in redness, thickening, infiltration, and softening of the membrane, along with the secretion of coagu- lable lymph or pus; the second, in organisation of the effused matter, prasternatural adhesion of the valves or narrowing of the orifices; and the third, in its conversion into a cartilaginous or bony tissue, and the consequent formation of permanent obstruc- tions. 1. The redness which marks the earlier stage exhibits various degrees of intensity, from a slight blush to a deep scarlet colour, and has, in some instances, a bluish or brownish tinge. It may be either partial or general, but is commonly most evident on that portion of the membrane which lines the valves and orifices, and not rarely is entirely confined to these situations. This redness does not, for the most part, appear to consist in any very obvious capillary injection, but chiefly rather in a dyeing of the lining membrane, which, in its softened state, is, as we should expect, more prone to imbibition. The colour is not, however, removable by washing; but continued maceration will extract it. It has been doubted by Laennec and many others, whether such redness were not rather of cadaveric than of truly inflammatory origin; but the frequent coexistence of unquestionable inflammatory products endocarditis (Anatomical Characters). 493 induces us to suspect that scepticism has been pushed too far on this point, and to assent rather to M. Bouillaud's view of the matter; according to which this redness is, at least very frequently, the result of increased vascular action; and most probably so, when met with in bodies in which putrefaction has not yet commenced, and when the coagulability of the blood has not been remarkably impaired, as, for instance, by diseases of a putrescent or typhoid tendency, and when death has not been preceded by a very long protracted suffocative struggle. It is not pretended that from the mere appearance of such red- ness we can at once safely decide on its inflammatory origin ; but from the colour, taken along with a certain set of symptoms observed during life, and afterwards to be detailed, we may often arrive at such a conclusion with a high degree of probability ; and this probability becomes converted into certainty, if there is found to coexist either thickening or infiltration of the same portion of the membrane, or if purulent matter or coagulable lymph is detected, smeared over or adherent to its surface. The simul- taneous presence of indubitable traces of inflammatory action in the great veins in the neighbourhood of the heart, occasionally affords an additional source of conviction as to the true nature of the appearances within this organ. It is chiefly where the case has lasted two or three weeks that the redness is found to be accompa- nied by a thickening of the membrane, which is commonly most obvious on the valves, inasmuch as they consist of a double layer of the serous tissue, and are most frequently the points first inflamed. In many instances they have an infiltrated spongy texture, and softening of the lining membrane is often met with in the same stage; it appears also less perfectly polished than natural, and is more easily separated from the subjacent cellular tissue. Incipient ulcerations on its surface may, moreover, be occasionally detected; and these throw light on the mode in which perforation of the parietes of the organ and of its valves, afterwards to be noticed, may often take place. The presence of purulent matter and of coagulable lymph is less frequently ascertained, they being usually, as we might expect, carried away by the passing blood as soon as formed. These substances have sometimes, however, been detected in the centre of a clot or entangled in the meshes of the columnas carneae. The coagulable lymph, from its adhesive nature, the more frequently of the two retains its hold of the surface when it has been formed, and is occasionally found attached to the valves or their tendons in the form of minute granulations; and in other instances, in that of a pseudo-membranous expansion, lining a portion of the interior of the auricles and ventricles. Sometimes too, a fragment of clotted blood becomes firmly attached to the internal lining membrane, and is eventually organised. Whether endocarditis, even in its most acute form, ever termi- nates in gangrene is dubious. M. Bouillaud inclines to the affirm- ative in respect to those cases where, on dissection, in addition 494 endocarditis {Anatomical Characters). to the peculiar morbid colour, texture and odour, indicative of this change, we find the blood unnaturally liquid or grumous, and mixed up with air bubbles; and when during life, in addition to strongly marked typhoid symptoms, there has been inordinate rapidity and irregularity of the pulse. He has not, however, adduced any very conclusive cases in evidence of his opinion. 2. Inflammation of the inner lining membrane of the heart, like that of the interior of an artery or vein, is thought by Kreysig to bestow on the contained blood a peculiar tendency to coagulation: and it has been observed that fibrinous concretions of an unusually colourless, elastic and glutinous nature, are often found in cases of acute endocarditis, adhering to the walls of the organ or to the fleshy columns or their tendons, and extending along into the great vessels. These sometimes appear to be in a state of incipient organisation, and fragments of them are not rarely attached with peculiar tenacity to the edges and base of the valves, where they con- stitute, in all probability, a frequent source of permanent organic disease, in the form of vegetations or granulations; though there is reason to think that these originate still more frequently in the effu- sion of coagulable lymph, as they are commonest in the left side of the heart, where inflammation is also most common, and where coagulation is rarest. Such appendages, which are also occasionally met with adhering to the surface of the cavities, and more especially the auricles, are divided by Laennec, in relation to their form, into the globular and the warty. The former are commonly of a softer texture, like to concrete albumen or fibrin which has as yet under- gone little change, being of a dirty white or yellowish colour, with sometimes a slight tinge of red, and resemble closely those granu- lations often found on the surface of the pleuras or peritonaeum, when in a state of chronic inflammation. The latter are of a firmer, horny, or cartilaginous consistence, and in form not unlike venereal warts, and they adhere very strongly. Each species varies in size from that of a pin's head to a small pea; and in their number, arrange- ment, and form, present great differences, being sometimes isolated, and sometimes aggregated into small cauliflower excrescences; whilst individually, they are either rounded, flattened, or elongated, and in respect to their surface either smooth and polished, or rough and irregular. They rarely exist, when of old date, unaccom- panied by induration of the valves and orifices, and when they are numerous and voluminous often contribute materially to obstruct the passage of blood through the latter as well as to impair the effi- ciency of the former. It has been remarked by Dr. Watson, that the warty vegetations on the semilunar valves affect particularly a festoon-like arrangement, being deposited in two short crescentic lines, each of which runs from the corpus sesamoideum towards the extreme point of the base of the valve, being placed some way inte- rior to its free edge,—a line which anatomical investigation shows to correspond with the outline of the fibrous matter prolonged to a certain distance into the valve from the tendinous ring at its inser- tion. endocarditis (Anatomical Characters). 495 There is sometimes a considerable shortening of the tendons of the auriculo-ventricular valves, quite capable of preventing their closure ; and yet, when existing alone, liable to be overlooked upon a hasty examination. The adhesion of a valve to the adjacent wall of the heart is a less rare occurrence than we might have expected, from the almost unremitted motion of the part and the constant contact of the blood. The valve is often in this manner so firmly glued down as to be totally incapable of fulfilling its functions, and this necessarily gives rise to great derangement of the circulation. But much the most frequent species of valvular adhesion is that which takes place between the adjacent laminae of the valve itself, especially when the calibre of the orifice to which it is affixed, has become contracted. Organised false membranes sometimes line a portion of one or more of the cavities of the heart, or, more rarely, form partial septa across them. The most common form in which they are met with, is that of whitish patches of a few lines in breadth on the endocardium, altogether similar to those so often seen on the exterior of the organ, and are, like them, generally easily dissected off, leaving the membrane beneath nearly in its natural state. Apparent thickening of the endocardium is, for the most part, due to the presence of intimately adherent layers of organised lymph. The membrane itself does, however, occasionally undergo a slight degree of hypertrophy, becoming also unnaturally opaque, and deprived of its smoothness and polish. The subserous cellular tissue, and the fibrous structure strengthening the orifices and enter- ing into the composition of the base of the valves, very frequently participate in the hypertrophous tendency ; and this holds good especially in regard to the mitral valve. 3. At a more advanced or chronic period of this affection we find almost invariably cartilaginous or osseous induration of one or more of the valves or orifices, with irremediable contraction of the latter and serious impairment of the motion of the former. The false membrane, the original product of inflammation, thus passes in process of time through a succession of changes characterised by a gradual increase of hardness ; first, assuming the form of con- densed cellular membrane, and, subsequently, a cellulo-fibrous, car- tilaginous, and osseous texture; the adjoining natural tissue either partaking in the morbid change, or being gradually supplanted by the new structures. The cartilaginous and calcareous deposits manifest a preference for the base and edges of the valves, and are of most various form and extent, sometimes occupying a mere point; at others, extending into flat patches or irregular protruding masses; and, in extreme cases, invading the entire substance of a valve and its tendons, or completely surrounding and greatly narrowing and obstructing an orifice. The calcareous matter in and around the fibrous zones is, in some rare cases, so profuse, as to extend deeply into the muscular substance of tne heart or even to protrude on 496 endocarditis (Anatomical Characters). its outer surface, and thus to give rise to a loud frictional sound of a peculiarly harsh and grating character. Where the induration of the valves is very considerable, they become in a manner fixed, and quite incapable of fulfilling their office, being often, moreover, crumpled or shrivelled up, perforated, or even torn across, and hanging like a foreign substance into the cavity; but more com- monly, as already stated, they become adherent by their adjacent edges; and this is most especially the case with the auriculo-ven- tricular valves, which may thus be seen to form an inflexible spout, as it were, projecting into the ventricle, like the rima glottidis or os tineas in miniature ; or else if flatter, an osseous partition, between the cavities, irregularly perforated in its centre, the aperture being so small in some instances as scarcely to admit the point of the little finger. Inspected from the side of the auricle, the orifice here presents a very contracted, wrinkled, or puckered appearance, and seenisconverted into a funnel-shaped passage. The aortic and pul- monary orifices, where their valves are similarly indurated and adhe- rent, assume either a triangular form, or become narrowed into the shape of a buttonhole, the consolidated valves constituting thus an imperfect septum across the vessel. The valves of the left side afford very much more frequent exam- ples of all the above changes than those of the right, which is only in conformity with the general fact, that parts of more energetic action are more prone to morbid derangement; in addition to which, the greater abundance of fibrous tissue in the latter, as Corvisart has remarked, naturally renders them more susceptible of cartilaginous and ossific degeneration. Bichat, however, was quite in error in supposing the right side of the heart entirely exempt from such changes. According to Dr. Hope's experience, as stated in the year 1832, they are found diseased in one case out of every four or five; or, according to Dr. Latham's, in so large a proportion as one out of every three instances of induration of the left valves ; but the more recent researches of the former of these writers, as well as those of Dr. Clendinning, render it now almost certain that there is a much greater disproportion than this, and that, in at least nine- tenths of the cases of valvular disease, it is found on the left side alone; in somewhere about one-fiftieth on the right alone; and in nearly one-twentieth on both sides. The pulmonic valve is even less frequently affected than the tricuspid. The morbid alteration detected is the valves of the right side is commonly only of a carti- laginous consistence. The tendency to contraction in the orifices of the heart, under the influence of chronic inflammation of their lining membrane, is but an additional example of what has been so often observed in respect to passages leading from various hollow organs within the body, as the urethra, for instance, the cervix of the bladder, the oesophagus, pylorus, rectum, Szc. It is only in the incipient or inflammatory stage, or before such organic change has established itself, that we have any great power over these morbid processes. When they have produced the permanent effects alluded to, the walls of the hollow muscular organ, behind the endocakditis (Symptoms). 497 mil rowed passage, become ordinarily increased in thickness from the constant effort to overcome the unusual opposition to the dis- charge of its contents ; and at the same time, from the frequent state of distension, one. or more of the cavities is often much dilated. Of all the orifices the aortic seems to be the most frequently the seat of obstruction, and next to it the mitral orifice. In persons who have died in consequence of a permanently ob- structed state of the circulation through the heart, there are usually found large masses of coagula within its cavities; but these, as M. Bouillaud remarks, being soft, gelatinous, and generally tinged throughout with blood, are very unlike the firm, white, elastic, ad- hesive concretions of such frequent occurrence in the acute stage of endocarditis. That the cartilaginous and osseous degenerations above described, are, in the majority of cases, of inflammatory origin (though this view of their nature was strenuously opposed by Laen- nec), has been shown to be in the highest degree probable by the researches and arguments of M. Bouillaud, who has adduced as strong proof of it, both from analogy, and from the history of the individual instances in which these appearances were met with, as the nature of the case seems to admit of. Thus chronic inflamma- tion in other serous, sero-fibrous, and allied membranes is very commonly followed by cartilaginous or osseous deposits, as we see, for instance, in respect to the pericardium and pleuras, the pe- riosteum, synovial membranes and fibrous capsules of joints. The osseous deposition in question is by no means peculiar, as so often assumed, to advanced age; a great majority of the cases of it, recorded in The Clinical Treatise on Diseases of the Heart, being in patients under fifty; nearly a fourth between sixteen and thirty; one in a child of ten years, another of seven, and a third in an infant under ten months. The frequent coexistence of traces of an old pericarditis or pleurisy along with the appearances alluded to, is also certainly decidedly favourable to the inflammatory theory of their source. Besides, in a very great proportion of these cases, indubitable symptoms of inflammation within the heart have mani- fested themselves at some antecedent period. The causes in which the disease within the heart appears to have originated, as well as the influence of an antiphlogistic treatment over its progress, con- spire still further to establish the fact of its being very frequently of a truly inflammatory nature; and if, in some of these instances, such inflammation is latent, or accompanied by no very well marked symptoms, this is no less incontestably the case, and that not very rarely, in regard to certain similar affections of the pleuras and pericardium, especially when of a very chronic type, and un- accompanied by any notable effusion of fluid. Still, however, it must be admitted, many examples of it present themselves, espe- cially in the aged, where no such source can with any probability be traced, and which seem to be connected simply with the in- creased tendency to osseous deposit so commonly observable in advanced life. n . .... c , , Symptoms. Inflammation of the interior lining of the heart com- 498 endocarditis (Physical Signs). monly gives rise to a general sense of uneasiness, with a peculiar feeling of oppression and prascordial anxiety which, if carried to its highest pitch, may be accompanied by a tendency to syncope. Pain, properly so called, is, even in the acute stage of the disease, very rarely complained of; and when it does exist, seems rather to depend on accidental complications, such more especially as pleurisy or pericarditis, than on the condition of the interior of the heart itself. In the severer forms of the affection there are generally well marked feverish symptoms, heat and dryness of the skin, thirst, restlessness, and accelerated circulation. The character of the pulse, however, often contrasts remarkably with that of the heart's action, being small and feeble, and intermitting, even at times when the latter is most violent—a disagreement which has been ascribed by some to partial obstruction of the orifices by spasmodic con- traction of the adjacent muscular fibres, but by others, on much better grounds, to mechanical impediment from congestion of the valves, effusion of lymph, or the formation of coagula within the heart; and it is at such times especially that the most formidable of the symptoms commonly ascribed to pericarditis, present them- selves—extreme anxiety, jactitation, and cold sweats, pallidness and shrinking of the features, with an indefinable expression of alarm—oppressive dyspnoea, faintness and downright syncope. Where the impediment of the circulation arrives at a great height, there is marked evidence of venous obstruction in the tumefaction and bluish colour of the lips and cheeks, and slight infiltration of hands and feet; and, apparently from the same cause, temporary convulsive seizures like epilepsy have sometimes also been observed. It is only, however, in cases where the disease exists in its intenscr form, that we are to expect to meet with such well-marked general symptoms as those detailed above.* When it is very limited in extent, or when it assumes a subacute or chronic form, they are much more obscure; and were it not for the physical signs ap- propriate to each, the discrimination between it and pericarditis would too often be impracticable. Physical signs. In simple endocarditis the action of the heart, as judged of by applying the hand to the chest, appears uncom- monly violent, and is perceptible over an unusual surface, owing, it is supposed, to the inflammatory turgescence of the organ ; and it is sometimes, moreover, accompanied by a vibratory thrill. On percussion, during the acute stage, we occasionally discover a considerable augmentation of the extent of dulness in the pras- * This affection may be anticipated, according to Dr. Hope, if a person be suddenly attacked, with three signs :— 1. Fever; 2. Violent action of the heart; 3. A valvular murmur, which is known not to have existed previously, and is distinguishable from the attrition-murmur of pericarditis. He believes further, that, in some rare instances, irregularity and weakness of the pulse and orthopncea exist temporarily, and in a moderate degree, from mere disturbance of the nervous system, before any mechanical obstruction has taken place ; an opinion in which we entirely concur.—Author. endocarditis (Physical Signs). 499 cordial region, the space in which it is now perceived being, ac- cording to Bouillaud, sometimes more than twice as great as in the natural condition. Such dulness of sound in uncomplicated cases is readily distinguished from that originating in pericardial effusion, by the beat of the heart appearing quite superficial, (a circumstance which can generally be appreciated both by the eye and by the hand,) instead of being, as in the latter case, remote and indistinct, and varying remarkably with change of posture, both as to the points and in the degree in which it is felt. It is auscultation, however, which makes known to us the ex- istence of one of the most constant and characteristic of the phe- nomena of endocarditis—the bellows-murmur—the intensity of which increases with the vehemence and rapidity of the heart's action, and is sometimes sufficient to mask one or both of the nor- mal sounds. When the impulse of the heart is very sharp the metallic ringing sound, already described, is occasionally audible. The frequency of the heart's pulsations is very remarkable in this disease, occasionally amounting to one hundred and fifty within the minute, or upwards; and they are often, moreover, irregular or intermittent, and of unequal force, some of them being altogether imperceptible at the wrist. When the intensity of the inflammation has declined, the organic changes left behind, provided the disease was not nipped in the bud, give rise to a new set of general and local symptoms. When the inflammation has assumed the chronic form (and in this it some- times appears from the first), the structural alterations resulting from it may be limited to simple thickening, or hypertrophy of the affected tissues, or else, as is the case in a great proportion of in- stances, it may give rise to their permanent induration and complete degeneracy. When induration of the valves and narrowing of the orifices have been thus produced, a permanent vibratory thrill with irregularity or intermittence, and inequality in the force of the pulsations, are very common phenomena. The contraction of the ventricles seems sometimes to be, as it were, spasmodically per- formed at two or three rapidly successive imperfect, efforts. A greatly increased extent of dulness on percussion often coexists, and indicates, for the most part, the complication of hypertrophy or dilatation, or of both. Auscultation almost always reveals the permanent existence of some of the varieties of unnatural murmur, of which we have spoken so much at large in the introductory observations. M. Bouillaud, out of upwards of one hundred cases of this disease examined by him, asserts that he never failed to detect the bellows-murmur in some of its grades, or the rasping, sawing, or musical sound, accompanying one or both of the normal sounds of the heart, save in one solitary instance, and that one was imperfectly examined. Pain is an occasional, but not a necessary nor even an ordinary, accompaniment of the organic changes under consideration: a sense of weight and obstruction, or an indefinable uneasiness in the region of the heart is sometimes complained of. Palpitations, characterised by a great increase of the force as well 500 endocarditis (Physical Signs). as frequency of the heart's action, along with a tendency to faint- ness and syncope, are very common, especially on any unusual muscular exertion, as in the act of ascending a stair or walking up a bill; and also on the occurrence of any strong mental emotion : and under these circumstances, likewise, the morbid sounds, no less than the impulse of the heart, become much more intense. In fine, when there has existed for some years, or even months, a permanent murmur accompanying the action of the heart, with or without a vibratory thrill in the pulse and prascordial region, together with frequent irregularity in the circulation, confirmed disease of the valves or orifices may be very strongly suspected; and this suspicion, according to Bouillaud, becomes changed into absolute certainty when the following general symptoms at the same time manifest themselves: namely, great contrast between the pulse at the wrist and the action of the heart; the former being very small, though commonly hard and vibrating, whilst the latter is inordinately strong; evidence of serious impediment to the course of the blood, mani- fested in the obstructed state of- the venous circulation,—as, for example, swelling and lividity of the features, congestion of the brain, lungs, and abdominal organs, passive hasmorrhage, and serous effusions into the cellular membrane of the extremities, and into the great splanchnic cavities, and, finally, dilatation of the jugular and other large veins in the vicinity of the heart. The phenomenon of a venous pulse, synchronous with the systole of the heart, and dependent on reflux from the right ventricle, is not un- frequently observed. When the auriculo-ventricular orifice is incapable of complete clo^ xre, either from its disproportionate dilatation, or from the shrivelling, or immobility, in consequence of ossification or adhesion, of one or more of the laminas of the tricuspid valves, the derangement of the respiratory organs, at first noticed as only a slight shortness of breath on exercise, gradually increases in intensity till, under the title of asthma, or in the form of orthopncea, it constitutes a most prominent and distressing part of the patient's sufferings. In such a state of things, the circula- tion within the brain becomes eventually deeply disordered, and the sufferer, after a long-continued mortal struggle, characterised by intense anxiety, jactitation, and incessant gasping for breath, at last falls for the most part into a sub-apoplectic condition, which speedily terminates his sufferings and his life. Valvular disease becomes almost always, sooner or later, complicated with morbid alterations in the cavities of the heart, in respect to size and strength ; and the general symptoms of the two sets of affections are eventually interwoven together. For their further consideration, we must refer to the sections on hypertrophy and dilatation. It is obviously much more easy to satisfy ourselves of the exist- ence of mechanical obstruction withjn the heart than to determine with certainty the particular orifice in which it is seated. The difficulty to be encountered arises chiefly from the great similarity of the abnormal sounds in the several orifices when similarly dis- eased ; from the close approximation of these apertures; and'from endocarditis (Physical Signs). 501 the liability of each, when in a certain stage of morbid change, to produce a murmur under the influence of a refluent as well as of the onward current. Dr. Hope indeed believed that he had, several years ago, succeeded in discovering a series of diagnostic marks by which this difficulty might be overcome; and that too in the great majority of cases by the stethoscopic signs and pulse alone; though, at the time, he by no means neglected the confirmatory aid of the general symptoms. Thus, disease of the aortic valves appeared to him to be characterised by the prasternatural murmur being loudest at the middle of the sternum, and by its being of a superficial and whizzing character; accompanying the first sound of the heart, if it depended on the onward current, or the second sound, if it originated in regurgitation ; in which latter case it was much feebler. Disease of the mitral valve, again, by the murmur being of a more hollow or distant character, and loudest opposite to the left margin of the sternum, between the third and fourth ribs; its coincidence or alternation with the pulse determining, as in the former instance, whether it depended on the direct or on the retrograde motion of the blood. Either set of valvular murmurs might be attended with the purring tremor: it is commonest with mitral regurgitation; but it is only where it originates in the aortic orifice that it will be communicated, in the form of a thrill, to the pulse. Regurgitation was shown to be most frequent in respect to the mitral valve; being accompanied, when so situated, by a peculiarly weak and irregular pulse. Where disease existed simul- taneously in both orifices, the circumstance would make itself known by the presence of each set oi; aigns. Disease of the pul- monic valves is excessively rare, being seldom met with, except in cases of open foramen ovale. The apparent situation of the bellows- murmur accompanying it would be the same as in affection of the aortic valves, whilst its closeness to the ear would be still more remarkable. Induration of the tricuspid valve, which is likewise very uncommon, was said to be also recognisable by the site of its attending murmur,—namely, about the middle of the sternum, and a little to the right of the mesial line. These signs, he asserted, had never, for several years, deceived him as to whether there was or was not valvular obstruction ; and " they have seldom failed to indicate, with perhaps more than necessary precision, the situa- tion and nature of the affection,"—provided he had first satisfied himself that the morbid sounds were not the result of nervous or hysterical excitement, anaemia, or loss of blood, cases in which they are transient and intermittent; nor of pericarditis, all other signs of such affection being absent; nor, finally, of hypertrophy, the murmur persisting in spite of repose, venesection, abstinence, and other methods of calming the heart's action. Such are the opinions ex- pressed by Dr. Hope, in the first edition of his valuable work on diseases of the heart. Of the correctness and importance of nearly all the signs here given there can be no doubt; but it is certain that in the hands of others, they alone were found insufficient in many cases for satisfactorily establishing the differential diagnosis 502 endocarditis (Physical Signs). of valvular disease;* and it appears to us not at all surprising that the attempt to make such distinctions, chiefly by reference to the situation of the greatest intensity of the morbid sound,—as if this corresponded immediately to the seat of lesion,—should prove abortive, especially when we consider that the most adjacent points of some of the orifices are, as we have already seen, only a very few lines apart, and that an ordinary stethoscope may be so applied as to cover at once a portion of the whole four apertures. A nearer approach to a successful method of establishing the diagnosis in question has been made by Dr. Williams, who is guided in a great degree by the direction in which the current, or column •of the blood, (or the tense walls of the vessels?) spreads the sounds, and the different manner in which they are transmitted to the walls of the chest.f Thus, murmurs generated at the origin of the great arteries are transmitted chiefly in the direction of these tubes; whilst those produced in the auriculo-ventri- cular orifices are conducted at once both by the current into the ventricles, and by the chordas tendineas and fleshy columns to the apex of the heart, and thence to the correspondent portion of the parietes of the chest. Accoidingly, in obstructive disease of the aortic orifice, the accompanying murmur, ordinarily of a sawing or grating character, and coincident with the systole, is not only audible in that part of the chest with which the heart comes into closest contact (its apex in all cases, and its body or base also, where there is great hypertrophy), but is likewise most distinctly heard along the upper half of the sternum in the direction of the innominata, and in that of the carotids, particularly the right one. The pulse is neither weak nor irregular, unless the contraction exist in a very marked degree. Regurgitant disease of the same orifice produces a murmur, commonly very loud, about the middle of the sternum, and which greatly obscures the second sound of the heart, especially when sought for at the top of the sternum, or in the carotids, situations in which it is in the natural condition very distinct; though it may still be sufficiently audible about the middle and left side of the sternum, where the action of the pulmonic valves is unimpaired. This murmur, in consequence of the smallness of the reflux current, is seldom so rough as the former: at limes it is musical in its cha- racter, and sufficiently loud. The obstructive and the regurgitant lesions are often combined, and thus give rise to a double or to- * This difficulty was participated in even by the most expert stethoscopists. Thus we find Dr. Graves and Dr Stokes, so lately as September, 1838, expres- sing their conviction " that the physical signs of valvular disease are not yet fully established ; that, taken alone, they are in no case sufficient for diagnosis ; that, even in organic diseases, the nature and situation of murmurs may vary in the course of a few days ; that all varieties of valvular murmurs may occur without organic disease ; arfd, lastly, that organic disease of the valves may exist to a very great degree without any murmur whatsoever." (See Dublin Medical Journal.)—Author. f In the third edition of his work on diseases of the chest, published in 1835, and more fully in his lectures, delivered in the winter of 1836, and published in the London Medical Gazette, in the autumn of 1838___Author. endocarditis (Physical Signs). 503 and-fro sawing murmur. The regurgitation not unfrequently stim- ulates the ventricle to a second contraction, constituting a redupli- cation of the pulse. A very remarkable condition of the arterial circulation has been pointed out by Dr. Corrigan as characteristic of aortic reflux, in which the pulse becomes momentarily hard and full; yet, in consequence of the permanent patency of the orifice, instantaneously afterwards recedes from under the finger, and so has a jerking or thrilling character; whilst the pulsation of all the arteries is from the same cause strikingly visible, the motion in these tubes exhibiting a peculiar wriggling or vermicular appear- ance, especially in the aged, in whom, having lost their dilatability, they are only capable of tortuous elongation. The value of this sign is admitted by Dr. Williams and Dr. Hope, who consider it to be almost pathognomonic of the lesion in question, when strongly marked and permanent in all conditions of the circulation.* In a slight extent it may, however, exist independent of such structural change, in consequence merely of simple excitement of the heart, especially where there is defective tension of the arterial system, as after large losses of blood, but here the pulse is invariably rapid. A new sign of inadequacy of the valves of the aorta, lately made known by Dr. Henderson, is the existence of a greatly increased interval between the systole of the heart and the pulse in the remote arteries. The musical or cooing note, taking the place of the second cardiac sound, he further asserts, is a circumstance which has hitherto only been found in cases of patency of these valves. Permanent patency of the aorta, if unaccompanied by obstruction, has, according to Dr. Hope, no systolic semilunar murmur, but only a regurgitant one. Aortic valvular disease, though in its early stage it may only give rise to slight palpitation, shortness of breath on exercising, and prascordial uneasiness, is, when extensive, one of the most formi- dable of cardiac affections, and most speedily fatal. Hasmoptysis and dropsies are thought by Dr. Williams to be quite as frequent in connection with it, as in disease of the mitral valves or of the right side of the heart. There is commonly, he believes, greater restlessness and irritability, and the features are more pallid and puffy than in mitral disease, in which there is often a considerable degree of colour in the face, with greater hebetude and torpor; the symptoms in the latter being more simply those of venous con- gestion ; but in all this there is, as he freely admits, much uncerr tainty. The mitral valves appear to be much less frequently the seat of an obstructive than of a regurgitant murmur ; which last, according to the author just quoted, in consequence of the facility with which the mechanism of the part is temporarily deranged by irregular action of the carneas columnas, &c, constitute a vast majority of * It may be neutralised, as Dr. Hope remarks, by free mitral regurgitation or great contraction, in consequence of the enfeebling effects of these lesions on the pulse.—Author. 504 endocarditis (Physical Signs). the cases of bellows-sounds occurring in women and young per- sons under twenty years of age (in whom they are, besides, more generally of a blow'ing character than either grating or whistling) ; whilst, in older persons, and those of the opposite sex, they are more frequently caused by the diseased state of the aortic valves. On account of the interposition of the lung and right ventricle, the murmur generated in the auriculo-ventricular orifice is much less distinct immediately opposite the mitral valve than over against the apex of the heart, where it is often so loud as to obscure the natu- ral sound ; this being still audible at the upper and lower ends, and to the right of the sternum, and over the carotids. Considerable enlargement of the heart, or consolidation of the lung, may some- times transmit the murmur more distinctly to the walls higher up; but percussion, as Dr. Williams suggests, would sufficiently eluci- date the nature of the case. The pulse is generally very irregular, unequal, and weak, when there is much constriction, or free regur- gitation in the mitral orifice: in the latter case, however, it has sometimes been found strong and jerking, when dilated hypertrophy coexisted in a marked degree.* The general symptoms produced by disease of the mitral valve are chiefly those of pulmonary and venous congestion, as evinced by the frequent asthmatic paroxysms and habitual dyspnoea, along with cough and an abundant expectoration occasionally tinged with blood, and by enlargement of the liver and disorder of its action, as well as of the other abdominal organs, too often mis- taken, especially when the heart is as yet but slightly deranged, for idiopathic dyspepsia. There is, at the same time, a tendency to anasarca, and other dropsical affections, along with headachs, gid- diness, and other evidence of cerebral congestion. It is from the occasional occurrence of such a group of symptoms in a very ag- gravated form, that the very name of heart-disease carries so much terror with it; but, in reality, affections of this organ often exist, in a minor degree, without any such formidable array. Disease of the pulmonary valves is so rare that Dr. Williams, though he has directed his attention so much to cardiac affections, confesses himself unable to speak of its signs from his own expe- rience, he having never diagnosticated an instance of it during life ; but he conceives that the murmurs accompanying it might be dis- tinguished from those of the aortic valves, by not being audible at the top of the sternum nor in the carotids, as also by the circum- stance of the pulse being less peculiarly affected. As to the tricuspid valve, he professes to be acquainted only with its regurgitant lesions, which are comparatively common, and * Of other causes by which irregularity and weakness of pulse may be pro- duced, independent of valvular disease, Dr. Hope enumerates,—1st, Softening of the heart. Here there will be no morbid murmur. 2d, Pericarditis, with copious effusion compressing the heart; endocarditis; and polypi within its cavities. Their peculiar symptoms and suddenness of supervention are diagnos- tic. 3d, Dyspepsia, biliousness, nervousness, gout, &c. Here the attacks are irregular, and temporary, and unattended with valvular murmur.—Author. endocarditis (Physical Signs). 505 recognisable chiefly by pulsation of the jugular veins; for the reflux here, in consequence of the natural laxity of these valves, and the inconsiderable degree of induration ordinarily present, even when diseased, is, he thinks, for the most part, unattended with any audible murmur. In a few instances, however, he has met with one of a blowing or grating character, coincident with the systolic sound, and distinctly heard from the middle to the bottom of the sternum, at the adjacent parts of the cartilages of the ribs and in the epigastrium, but not in the carotid or upper portion of the sternum.* * Very similar views to those of Dr. Williams, detailed above, have more recently been advocated by Dr. Hope, in the Med. Gazette, August 4, 1838, and March 7, 1839; as well as in the new edition of his Treatise on Diseases of the Heart, which appeared last year. Thus the distinct audibleness of the semi- lunar murmurs for about two inches above their origin is recognised by Dr. H. as their chief characteristic,—those of the aortic valves being more intense towards the second intercostal space, close to the right of the sternum; those of the pulmonary valves, at the same level, but towards the left of this bone ; whilst auricular murmurs are scarcely to be heard at this distance; and those originating in diseases of the aorta itself, besides being more acute in their pitch, are con- siderably louder in the tract of the vessel than immediately opposite to the semi- lunar valves. It is further noticed, as confirmatory evidence of the existence of semilunar murmurs, that they become gradually less distinct as we descend along the tract of the ventricles ; those originating in the aortic valves being, however, compara- tively less faint along the course of the left ventricle ; those of the pulmonic valves, along the right. The murmur of semilunar regurgitation, though loudest in the site of its origin, and in some degree carried downwards by the setting in of the current in that direction, is sufficiently distinct upwards, in the line of the great vessels respectively, and is, moreover, prolonged through the interval of repose. The murmurs of the auricular valves, it is further stated, are best explored at about an inch above the apex of the heart, on the left side of the dull portion, i. e., about the fifth left rib, and a little within the nipple, for the mitral valve, and on the right side of the dull portion, at the same level, but close to the left edge of the sternum, for the tricuspid. At these points, the obstructive murmurs of the semilunar valves sound comparatively obscure and distant, whilst their regurgi- tant ones, unlike those we are now speaking of, augment in intensity as we ascend towards the orifices of the great arteries. When both the semilunarand auricular valves are diseased, the morbid murmurs not only often differ in tone and character, but will have two distinct points of greatest intensity, up to which, respectively, we should endeavour carefully to trace them. When two murmurs have their source in the same orifice, we may recognise the fact by the circumstance of their existing in the greatest inten- sity at one and the same point; whilst the first coincides with the systole of the heart, the second with its diastole. The comparative feebleness of a refluent current through the aortic and pulmo- nary orifices, as well as of the onward current through the auricular valves, accounts for the greater weakness of the correspondent murmurs. An obstruc- tive mitral murmur is, of all those appertaining to the left side of the heart, one of the rarest, for the reason first mentioned ; being seldom heard save in cases of very considerable narrowing of the orifice. Murmurs seated in the aortic and pulmonary orifices, from* being more superficial, are in a higher key than the deeper-seated ones, connected with the mitral and tricuspid valves. The greater or less harshness of the murmurs, and their pitch, vary with the force of the circulation, the shape and size of the orifices, and the consistency of the matter forming their contour. Where they are of a very faint character, both auscultator and patient should hold their breath, and the deepest silence be pre- served. A long stethoscope should be employed, so as to render it unnecessary to 50G endocarditis (Causes). Adhesion of the auriculo-ventricular valves to the wall of the heart is usually accompanied by their thickening and induration, and gives rise to symptoms very similar to those attending con- traction of the orifices, from which therefore it is not readily distinguishable during life; viz. palpitation, bellows-murmur, purring tremor, dyspnoea, venous congestion, and serous effusion ; the reflux of blood being here equivalent to a mechanical obstruction. It is supposed by M. Bouillaud, however, that we may frequently be guided to a correct diagnosis by the bellows-sound being of a less dry and grating character in the case of simple adhesion, by the action of the heart being less irregular, by the purring tremor, if it exist, being less thrilling and more diffused, and the pulse less contracted, and, finally, by the dyspnoea, venous congestions, and serous effusions being less marked. There are no symptoms yet known by which simple thickening of the lining membrane of the heart can be recognised ; nor do the vegetations growing from it give rise to any signs by which their presence may be suspected, unless when they interfere with the action of the valves or with the caliber of the orifices ; and even then they can scarcely ever be distinguished from contraction of these apertures, or from adhesion, with thickening of the valves. Wrhen they are of a very elongated form, and consequently very movable, they may probably give rise to considerable variability in respect to the period and intensity of the murmurs, causing, in one posi- tion, an obstructive, and in another, (when inserted, it may be, be- tween the edges of the valves,) a regurgitant murmur. This, together with a varying force in the current, a spasmodic state of one or more of the columnas carneas preventing the accurate clo- sure of a valve, or, in some rare instances, the formation of fibrinous concretions within the cavities, are amongst the more probable causes of the occasional unsteadiness of the morbid sounds, even in the case of organic disease. The extreme disorganisation of a valve, it should be known, often gives rise to a much less intense murmur than a change, which, though much slighter, may be better calculated for the production of sonorous vibrations: the former, even though there may be no great induration, generally causes a sound of a graver, deeper, and more grating quality; those pro- duced by the latter being commonly in a higher key, and occasion- ally of a musical, whistling, or cooing character. (Williams.) Of the diagnosis of murmurs which are independent of organic disease, and of those connected with pericardial inflammation, from those originating in valvular lesion, we have spoken at large in former sections. Causes. Inflammation of the interior of the heart may come stoop much ; a posture which, by causing congestion of the head, interferes much with the delicacy of hearing.—Author. [A stethoscope, about two feet long, constructed of a coil of wire, the ends of block tin, the hollow cone for the reception of sound about three-fourths of an inch in diameter, has been found the best for the discrimination of valvular murmurs.] endocarditis (Duration). 507 on either as a primitive or as a consecutive affection : its causes, in the first instance, are essentially the same as those of pericarditis and of acute rheumatism, in union with which it so often occurs; more especially cold and moisture, or exposure to very sudden atmospheric changes, especially when the body is overheated or fatigued. Gout, intemperance, and long-continued and very fatigu- ing bodily exertions, hypertrophy, and nervous palpitations, pre- dispose tc*it. Complications. The disorders on which, when secondary, it most commonly ensues, are acute articular rheumatism, pericarditis, pleuropneumonia, and phlebitis. In respect to its connection with the first of these diseases, however, which is so very frequent, it is the opinion of Bouillaud, that it occurs very often as a cutaneous no less than as a metastatic affection. The transmission of inflam- mation from the pericardium to the inner lining membrane, seems to take place more frequently than from the latter to the former. Endocarditis may be excited, moreover, by sudden and prolonged embarrassment of the pulmonary circulation, such as occurs in the violent spasmodic fits of coughing of aggravated hooping-cough; by the sudden rupture of a valve in a struggle; and also, like in- flammation of the veins, by the absorption of putrescent matter, or the translation of purulent collections into the torrent of the cir- culation. Prognosis. It may manifest itself either in an acute, a sub- acute, or a chronic form. The prognosis to be formed in any given case of this affection depends not merely on the intensity and presumed extent of the inflammation within the heart, but also very materially on its complications, the age and strength of the patient, the period at which the treatment has been commenced, and the activity with which it has been pursued. Duration. In its most acute form it may terminate fatally with- in a few days; death in such cases seems most commonly to be accelerated by the formation of extensive coagula (Polypi), within its cavities. Striking irregularity, feebleness, and frequency of the pulse, partial cold sweats, with extreme anxiety and incessant dis- position «to syncope, are amongst the formidable symptoms prepar- ing us for the final catastrophe. When the disease is met by energetic measures from the commencement, it may take a favour- able turn within from three or four days to a week, even though attended by the formidable complications of pleurisy or pericarditis; and the patient, under judicious management, may speedily become convalescent. Should it pass unfortunately into the chronic form, its duration then is commonly little, comparatively, within the in- fluence of medicine ; and if the valves and orifices are very ex- tensively implicated, it terminates sooner or later, almost necessa- rily, in death ; hypertrophy and dilatation of the heart, sanguineous congestions and effusions of serum or of blood, being generally first induced, and serving to accelerate the fatal event, which sometimes takes place very suddenly and unexpectedly. When, however, the lesions which have taken place are of a slighter kind, and the morbid 503 endocarditis (Treatment). process which has given rise to them can be arrested, life may sometimes, notwithstanding their existence, be prolonged with care, even to a very advanced period. Endocarditis of children. According to Dr. Copland, inflamma- tion of the interior of the organ, even at a very early period of in- fancy, is by no means rare; presenting itself sometimes as a pri- mary disorder; but more commonly coming on in consequence of scarlatina, small-pox or measles, pneumonia or hooping-cough, or, as in adults, in the course of acute rheumatism. When connected with the exanthemata, it is generally during the convalescence that it makes its appearance, commencing for the most part insidiously; but soon revealing itself to the careful observer, by the frequent, feeble, and irregular pulse; tumultuous action of the heart, and bel- lows-murmur ; cough without pain or expectoration ; dyspnua on exertion, and subsequently orthopnoea ; a sense of weight and oppres- sion about the prascordium ; an expression of anxiety and marked delicacy, together with feverishness in the evenings ; and frequently, ere long, evidence of incipient hypertrophy and dilatation becomes quite obvious. Treatment. It is to be treated altogether on the same principles as pericarditis; or, if any difference is to be made, it is only this, that the measures employed must be even more prompt and decided, in order to prevent the formation of coagulable lymph, or of poly- pous concretions within the heart, as well on account of the imme- diate danger attending their presence, as in regard to the ultimate risk of their becoming organised and the source of permanent ob- struction. Abundant and repeated abstractions of blood, both gene- ral and local, together with the use of calomel and opium, constitute the most important part of the treatment in the most acute period. The exhibition of colchicum, or of digitalis, and the employment of counter-irritation in the shape of blisters, and in the various other forms already enumerated when speaking of the treatment of peri- carditis, find a place at a somewhat more advanced stage. When it has unfortunately become chronic, either through the neglect of treatment or its inefficiency, our chief resources consist in small venesections or leechings, and absolute rest during periods of aggra- vation of the symptoms; adherence to a low scale of diet; the occa- sional employment of digitalis; the cautious induction, from time to time, of a slight mercurial action, and steady perseverance in the use of counter-irritants where the general health is not materially deranged by their employment. Such appear to be the measures most likely to arrest the disorganising process in the interior of the heart, to moderate the action of the organ, and retard the super- vention of its enlargement. When organic lesions of the orificea and valves have, however, become once fully established, they admit at the most but of palliation. The support of the general health should here form a main object of attention ; and the benefits arising from regulation of the digestive organs, the enjoyment of a pure atmosphere, and the gentlest exercise, studiously secured. Where dropsical symptoms have supervened, recourse must be had endocarditis (Treatment). 509 to the employment of diuretics and purgatives; a part of the ma- nagement of these cases to which we shall have occasion to recur at a future page. Of the appropriate treatment of inflammation of the interior of the heart in children, it is unnecessary to speak par- ticularly, it being altogether similar to that already laid down as suitable to the pericarditis of infancy. Endocarditis is a very different disorder from the mere thickening of the valves or other portions of the lining membrane of the heart which so frequently follows it. The inflammation itself is an acute disorder, with the usual symp- toms of inflammatory reaction in addition to those of the disturbance of the circulation caused by the derangement of the heart itself. In the lesions subse- quent to inflammation the symptoms are limited to those of impeded circulation, and the physical signs furnish the best indication of their nature. In most cases those signs will point out the valve which is the seat of the lesion with very great precision, although there is still some uncertainty in a few cases. Endocarditis, properly so called, may like other inflammations occur as pri- mary or secondary. In the latter case it nearly always takes place during the course of pneumonia or of acute inflammatory rheumatism, when it is frequently connected with pericarditis. It arises as a primary affection from the ordinary causes of inflammation, which act with more power and effect if the heart be previously enlarged. Whether the disease be primary or secondary there is always present one element, which sometimes exists in other inflammations, but to a less degree, that is, a highly fibrinous state of the blood with a strong ten- dency to the formation of coagula in the heart. This condition is yet more frequently a cause than an effect of endocarditis, and may be generated by any other inflammation, and thus react upon the lining membrane of the heart. The symptoms of endocarditis are less marked than those of pericarditis with large effusion, but they are more decided than those of the slighter varieties of it; As soon as it occurs the action of the heart is more or less impeded, and the contraction of the ventricles is hurried and confused ; hence a bellows murmur is developed in the first sound of the heart. This becomes a rasping sound if the valves be much thickened. The second sound is diminished and to a certain extent suppressed from the first, not from the thickening of the valves, which occurs only at a later period, but from the congestion of the heart which neces- sarily attends endocarditis, and, as we have already seen, diminishes the second sound. Besides the bellows or rasping sounds the action of the heart is dis- turbed, and it contracts spasmodically and without that sharpness of impulsion and regularity of time which is characteristic of the healthy heart: hence I speak of the action of the heart affected with endocarditis as confused. It is not in most cases strictly irregular, although this sometimes happens, nor does it offer the strong heaving impulse of decided hypertrophy. The general symptoms are very variable : pain, or at least a feeling of stricture and uneasiness across the chest is generally felt, with more or less febrile ex- citement, sometimes rising to high fever, with an active pulse; at other times the pulse is small, full, and scarcely developed. If the disease continue for a little time, or form slowly, the cellular tissue is often infiltrated, and acute dropsy may supervene. Still the general symptoms are not decided enough to furnish grounds for diagnosis. * 65 510 carditis (Cases). The immense majority of cases terminate in, more or less, complete recovery ; but frequently the inflammation is followed by various chronic alterations of tho valves or muscular structure of the heart; hence a careful treatment becomes necessary, not only to diminish the actual irritability of the disease, but to pre- vent its after consequences. The rules for this, which are laid down in the text, require no important additions; when the disease is severe the depletory means must of course be proportionably active. CARDITIS, OR INFLAMMATION OF THE MUSCULAR SUBSTANCE OF THE Ht'ART. Infrequency of the disease.—Authenticated cases.—Anatomical characters.— Symptoms.—Causes and treatment. Carditis, or Inflammation of the Substance of the Heart, compre- hending its muscular tissue, and connecting cellular membrane, is a very rare affection, and its history as yet but imperfectly under- stood. Laennec has expressed his doubts as to whether there was on record a single well described case of indubitable inflammation of the whole heart:—he did not, however, deny its possibility much less that of partial inflammation of the organ characterised by abscess and ulceration, several authentic examples of which latter are to be met with in the works of various authors as well as in his own. But even of general inflammation of the heart unques- tionable instances have presented themselves, and to very compe- tent observers. Not to speak of Meckel's case, in the Memoirs of the Berlin Academy for the year 1756, a very remarkable one which fell under the notice of Mr. Stanley has been described in the Medico-Chirurgical Transactions for 1816, and has been more recently alluded to by Dr. Latham in his valuable lectures on Diseases of the Heart, he having also been present at the dissection. The subject of it—who, unfortunately, was not seen by either of these gentlemen during life, else the account of the symptoms would probably have been more satisfactory,—was a boy of twelve years of age, whose illness, obviously mistaken by the medical attendant for fever with predominating cerebral complication, terminated fatally on the fourth day. On the second day there had been pain in the left thigh and knee, doubtless of a rheumatic character, though apparently not recognised as such. Delirium supervened early, during which the only pain which could be detected on cross-ques- tioning him was a slight one in the head. A convulsive fit occurred on the third day and on the fourth dyspnoea and sinking. He was capable of answering questions till within a few hours of his death. It is said that the action of the pulse and of the heart was unaffected throughout; but the case, it must be remembered, occurred at a period when the examination of the state of the circulation was generally conducted in a less complete, careful, and constant man- ner than at present. On opening the body the pericardium was found to contain four or five ounces of turbid serum with flakes floating carditis (Anatomical Characters). 511 through it. Coagulable lymph was effused on the interior of the pericardial sac, as likewise on the exterior of the heart, which was of its natural size. "Upon cutting through its parietes, the fibres were exceedingly dark coloured, almost of a black appearance. This evidently depended on the nutrient vessels being loaded with venous blood. The fibres were also very soft and loose in their texture, being easily separable, and with facility compressed between the fingers. Upon looking closely to the cut surface exposed in the section of either ventricle, numerous collections of dark-coloured pus were visible in distinct situations among the muscular fasciculi. Some of these depositions were situated deeply near to the cavity of the ventricle; while others were more superficial, and had ele- vated the reflected pericardium from the heart. The muscular fibres of the auricles were also softened in their texture, and loaded with blood, but without any collections of pus between them. All the cavities of the heart were loaded with coagulated blood." No traces of inflammation were discovered within the head. Had this patient been carried off at a still earlier period of his disease it is probable that the heart would have been found merely swollen, more vascular, or of an intenser red colour than natural. The ap- pearances actually present prove at once the extent to which in- flammation may affect the heart; and also, notwithstanding the doubts of Laennec, that softening of the muscular tissue is indubi- tably one of its occasional results; and it is one which we should have been prepared to expect from what has been observed in mus- cles elsewhere, as well as in various other organs, as the brain, lungs, liver, &c. when inflamed, friability or loss of cohesion being a very common prelude to suppuration. Another instance of car- ditis, of a somewhat more chronic type, was recently brought by Mr. Salter under the notice of the Medico-Chirurgical Society. It ran a course of seven weeks, and began, whilst the patient was walking, by an acute pain in the left side of the chest. This re- curred again about a week afterwards, whilst using the same exer- cise, and became subsequently very frequent, and was now induced hy the slightest exertion, as even by the effort of raising the arm. When Mr. Salter first saw him, about a week before his death, there was orthopnoea, and an uneasy sensation or dull pain referred to the stomach and middle of the sternum. Notwithstanding the use of venesection, calomel, and opium, and counter-irritation, the disease proceeded unalleviated to its fatal termination. The peri- cardium was found inflamed, especially its diaphragmatic portion, with ecchymosed spots beneath its serous surface, and distension of its vessels. The substance of the heart was moderately firm ; but the left ventricle had almost entirely lost the colour of muscle, and pus could be scraped from its surface, and in some parts there were small cavities in the muscular substance containing pus. The heart, when in a state of softening, collapses on itself when emptied of its blood, and breaks down readily into a pulpy mass between the fingers. Its colour is various, being sometimes, as we have seen above, of a deep red, brownish or violet tinge, with occa- 513 carditis (Anatomical Characters). sionally a bloody fluid effused into the cellular membrane connecting the muscular fibres, or under the pericardium; or it may be of a pale or dirty white, which appears to indicate a more advanced or chronic state of inflammatory action, such as is occasionally ob- served in the superficial fibres of the heart in cases of chronic pericarditis with purulent effusion. It is not, however, denied that a very similar condition of the muscular substance may sometimes acknowledge other and very distinct sources. Laennec, who, as we have stated, was sceptical as to the inflammatory nature of the above-mentioned species of softening, has described another kind, characterised by its faint yellowish colour, which is very commonly confined to the deeper-seated muscular layers,and of which cachectic individuals are the chief subjects. With regard to the true nature of this variety, also, he is at issue with M. Bouillaud, who considers it, as well as the preceding, to originate in inflammation, but of a peculiarly chronic character. To Dr. Hope, who takes a middle and probably a more correct view, it has appeared to have some- times an inflammatory, and sometimes a merely cachectic origin. Ulcerations of the heart have their origin almost invariably in the internal lining membrane, though, in a few instances, perhaps, they have been produced by the bursting of a purulent collection formed within the walls of the organ, and making its way to one or other of its surfaces. They are of various depths—sometimes quite superficial, and at others penetrating so deeply as to lead to the complete perforation or sudden rupture of the organ, or else to lay the foundation of a consecutive false aneurism in its walls. The consequences of perforations will vary with their situation ; if they take place through the external walls, instant death, by the effusion of blood into the pericardium, is their natural and almost necessary result; whereas if they pass through the septum, their only immediate effect is the mixture of the venous and arterial currents. If the ulceration is seated in a valve, or in one of its tendons or fleshy columns, the perforation of the first, or the detach- ment of either of the latter, gives rise to irregular and tumultuous action of the heart, and occasionally to a rapidly fatal train of symptoms of the most distressing nature—pain in the region of the heart, extreme anxiety, uncontrollable restlessness and impending suffocation. Where a partial aneurism of the heart is determined in the man- ner above alluded to, its external surface most commonly contracts adhesions with the pericardial sac, which becomes by the irritation preternaturally thickened at the part, and this, together with the numerous layers of coagula within the tumour, tends materially to prevent its bursting, an event accordingly which rarely takes place in an early stage of the affection. Such aneurismal tumours have been met with of various sizes, from that of a nut to that of the heart itself, and often (at least of the smaller dimensions), in indi- viduals in which their existence had been quite unsuspected during life. Amongst the occasional consequences of inflammation of the carditis (Anatomical Characters). 513 heart must also be enumerated induration of the whole or a portion of the organ. That this alteration is often of a truly inflammatory nature appears in the highest degree probable, from its frequent connections with other affections of a similar origin, as endocarditis and pericarditis. Corvisart and Laennec speak of hearts in which the muscular tissue, though of its ordinary colour, had become as hard as a dice box; and Broussais compares a heart thus indurated to a cocoa nut. This morbid alteration may, according to Bouil- laud, exist in a portion of the organ, in any degree up to the actual conversion into cartilage or bone. The septum and columnas car- neas are the parts most exempt from this change; yet some of the latter have occasionally been found indurated, being converted into a yellowish-white substance, like fibro-cartilaginous tissue ; whilst, others, close to them, may have been, on the contrary, in a state of unnatural softness. Corvisart has given a very remarkable case in which the apex of the heart, in its whole thickness, and for some way upwards, was converted into cartilage, the columnas carneas of the left ventricle having nearly an equal degree of density. The disease had obviously commenced by an inflammatory attack within the chest about eighteen months before its fatal termination. M. Renauldin has related the case of a law student of thirty-three years of age, in whom the wall of the left ventricle was so penetrated with osseous particles, as were likewise the columnas carneas, as to resemble a petrifaction. In this case there had been, in addition to great pain on pressure, palpitations, dropsical swellings, and other ordinary symptoms of heart-disease. Mr. Smith has recorded an example to which we shall again have occasion to allude more at length, of very extensive ossification on the external surface of the heart, which appeared to have commenced, as is probably commonly the case, in inflammatory false membranes formed between the two serous surfaces of the pericardium ; and similar cases are to be found in Baillie, Burns, Laennec, Adams, and others. It is possible that such osseous deposition occasionallycommences also, not only in the subserous cellular tissue, when in a state of chronic inflam- mation, but, moreover, in that connecting the muscular fibres, and comes eventually, as it increases in quantity, to encroach materially on, and eventually to displace more or less of, the muscular sub- stance. Ossification of the whole heart is obviously impossible. Whether gangrene of the heart is to be admitted amongst the possible results of its inflammation has been much disputed, it appearing to many inconceivable how life could be sustained long enough tor its production in the case of an inflammation of such intensity so situated. Yet Bouillaud inclines to the affirmative ; and it appears to us, that its occurrence, in a patch of limited sur- face and depth, is not to be rejected as beyond the limits of credi- bility. Corvisart thought that, like senile gangrene of other parts, it occasionally originated in a state of general debility. We are not however, aware of any well authenticated instance of it as yet on 'record ■ most of the cases in which it has been said to exist appear obviously to have been examples of cadaveric decomposition 514 carditis (Symptoms). favoured by a depraved state of the solids and fluids—such, for instance, as is met with in putrid fevers. Inflammation of the muscular substanoe of the heart has probably never yet been met with in a perfectly simple state ; either peri- carditis or endocarditis seeming invariably to complicate it. Cor- visart was of opinion, that it for the most part assumed a very chronic character, in which, its symptoms being peculiarly ob- scure, it was commonly latent; and the substance of the organ, in nearly all the cases adduced by him, was of an unnaturally pale colour and soft texture. It is possible that some of the cases in which purulent deposits have been discovered within the walls of the heart, have had their origin, not in the local inflammation of this organ, but rather in the transfer of the matter, so found, from some other part of the body in a state of suppuration or abscess : and it is only by an accurate examination of the surrounding por- tion of its structure, and a careful consideration of previous symp- toms, that a correct conclusion can be arrived at Many recent writers are disposed to consider rapid hypertrophy of the heart, also, as one amongst the forms or consequences of subacute or chronic carditis. Symptoms of Carditis. As to the symptoms of inflammation of the substance of the heart, as distinguished from those of its lining membranes, nothing satisfactory has yet been ascertained, in con- sequence of its having hitherto been observed only in combination with the latter. Neither Corvisart, Laennec, nor Bouillaud, have attempted their diagnosis. The last-named author limits himself to stating his belief that the complication of acute carditis aggra- vates in the highest degree inflammation of the endocardium and pericardium. It has been supposed that the pain in the heart, which is augmented by pressure between the ribs and in the epigastric region, is of a peculiarly severe and lacerating or burning character, where the muscular structure is engaged: and the suffering has been said to be aggravated remarkably with each contraction of the organ. Mr. Stanley's case, however, shows that these signs are by no means universal. Greater violence of the palpitations, more marked intermissions of the pulse, which has been asserted to be generally small and weak, universal tremors, inexpressible anguish, constant jactitation, and extreme proneness to syncope, though occasionally dwelt upon as distinctive, will prove equally fallacious; being participated in, as we have seen, by very acute cases of the membranous inflammation of the organ. It has been suspected, not without some show of probability, that the extreme rapidity of pulse in the convalescences from some fevers, especially those of an adynamic character, may be occa- sionally connected with an inflammatory softening of the heart. The action of the heart in the cases in question is commonly ex- tremely feeble, both as judged of by its impulse and by its sounds, and by the great tendency to syncope; circumstances, however, which, taken alone, cannot* be considered by any means decisive, as they are equally observed in cases of very abundant pericardial HYPERTROPHY OE THE HEART. 515 effusion. Recourse to the results of percussion and to the applica- tion of the stethoscope over the track of the great vessels, may sometimes enable us to decide as to the true nature of the dis- order. There are no symptoms yet known by which abscess or ulcera- tion within the walls of the heart can be certainly recognised, and the diagnosis of aneurismal tumour of the organ is no less obscure. Indeed, any of the three may exist, without exciting even a suspi- cion of their presence. The fatal illness of the celebrated Talma, which took place about twelve years ago, when we happened to be in Paris, .and the nature of which, during his latter days, was the subject of daily conversation amongst the most distinguished of the medical professors (some of whom were in actual attendance on him), afforded a remarkable exemplification of the obscurity spoken of; for, notwithstanding the exquisite tact in diagnosis for which the French school is so justly famous, the obstruction of the bowels of which he died absorbed all attention, and the cardiac aneurism, afterwards discovered on dissection, was never, that we can recollect, even once hinted it. It is possible, however, that percussion and auscultation may eventually put us in possession of some physical signs by which this lesion may be detected ; at least, in cases where it has attained to a considerable magnitude. Unnatural extent of dulness, and perhaps, in some instances, prominence of the prascordial region, and a thrill or a peculiar sound produced by the blood passing through the aperture of communication, are the kind of evidences which have been suggested as of probable occurrence. Into the causes and treatment of carditis it is unnecessary to enter, as they are altogether identical with those of pericarditis and endocarditis, its usual associates, of which we have already spoken at considerable length in a former page. —y HYPERTROPHY OF THE HEART. Nature and Causes. — Forms. — Anatomical characters. — Physical signs.— General symptoms.—Complications and secondary affections. — Supposed causes of each form of Hypertrophy.—Duration and prognosis.—Treatment. Of all the affections to which the heart is liable, its enlargement is that which, from the obviousness of its anatomical character, the prominence of its symptoms, and the frequency of its occurrence, first attracted the attention of pathologists, and became, as it were, the type of cardiac disease. Its fatal tendency when left uncon- trolled, and the variety of complications along with which it pre- sents itself, either as a consequence, concomitant, or cause, must ever cause it to occupy a very prominent place in all treatises on hypertrophy of the heart (Nature and Causes). disorders of the heart. It may evidently have two sources,— either augmentation of the solid matter of the heart from dispro- portionately increased nutrition, or expansion of its cavities,— giving rise respectively to the two denominations of Hypertrophy and Dilatation ; the one being a disease of an active, the other comparatively of a passive nature. Their exciting cause is, indeed, often the same, viz., an increased demand on the exertions of the heart (from obstruction in the course of the circulation and other sources), the result varying with the vital properties of the mus- cular parietes of the organ, and with the general strength or debi- lity of the system. Where the constitution is naturally robust, and the structure of the heart, in particular, is strong and well supplied with rich and stimulating blood, and its ordinary action conse- quently is energetic, larger demands on the exertion of the organ will be followed, according to a well known law of muscular de- velopment, (exemplified in the brawny arm of the professor of gymnastics, the fencing master, or the blacksmith, and in the lower limbs of the porter and opera dancer,) by an augmentation of bulk and power ; a larger afflux of the nutritious fluid being the consequence of the constant and vigorous exercise of the part. This rule, indeed, holds good in an especial manner with respect to the heart, as the coronary arteries, by which it is fed, receive the first and fullest effects of the augmented force of the circu- lation. This local increase of nutrition may soon be carried to such a length as to put the affected muscle quite out of due relation to the other parts of the system. In the case of the heart, which stands in such close connexion with every portion of the body,—its con- dition determining in a great degree the quantity of blood which is to circulate through each part, its force and rapidity, and even the permanent increase in bulk and density of all the organs,—such an accession of power cannot fail to be often productive of very serious pathological results. When the habit of body is, on the contrary, naturally weakly, or deeply debilitated by disease, and when the fibre of the heart itself is relaxed and yielding, and capable of little reaction,—ob- struction or regurgitation, and consequent accumulation of blood, tend only to distend the walls and enlarge the cavities, without giving rise to the deposition of any proportional addition of solid material. It was the dilatation of the heart which seems first and chiefly to have attracted the attention of the earlier pathologists ; the aug- mentation of its substance being commonly overlooked, or only viewed in subservience to its increased capacity. Even Corvisart, to whose clear and powerful mind we owe the removal of so many prejudices in respect to this class of diseases, was biassed in the formation of his nomenclature by the prevalent error. Ilis division of enlargements of the heart into active and passive aneurism still exerts an injurious influence on practice; for the increased efficiency of an organ, and its capability of enduring debilitating measures, HYPERTROPHY OF THE HEART (Forms). 517 is often very far from being commensurate with its increased bulk or substance. In thus massing all enlargements of this viscus under the general term of aneurism, he was guided by an erroneous ana- logy. Under the influence of this false generalisation, he has not only placed in a deceptive aspect some of the morbid states which he has so vividly portrayed, but been led, moreover, to overlook other pathological conditions of equally real, though less frequent occurrence. M. Bertin was the first to insist on the necessity of considering apart the thickening of the muscular parietes and the dilatation of the cavities; these being in their nature, though so often complicated together, two totally distinct morbid conditions; and also to maintain that this thickening was not ordinarily de- pendent on the deposition of morbid matter, as Lancisi and the older pathologists, and even Portal and other comparatively recent authorities, had asserted, but merely on an increased nutrition of the part. These juster views naturally led him to a more philoso- phical and correct classification, and to the recognition of forms of disease which had previously escaped notice, as well as to a more discriminating mode of treatment. Forms. Three forms of hypertrophy of the heart are recognized by M. Bertin,—viz., the simple, the excentric, and the concentric. Dr. Hope's division of the varieties of hypertrophy, slightly modi- fied from the classification of Laennec, is into simple hypertrophy, hypertrophy with dilatation, and hypertrophy with contraction, thus coinciding exactly in principle with that just stated; whilst the terms in which it is worded are perhaps preferable, as being simpler, and less liable to misconception. Dr. Williams also treats of the varieties of this affection under nearly the same titles,—viz., simple, dilated, and contracted hypertrophy. In each there is an increase of substance in the walls of one or more of the cavities of the heart; but in the first, these cavities them- selves remain of their natural size ; in the second, they are enlarged; and in the third, on the contrary, diminished. This last variety, in which the deposition of new matter takes place chiefly towards the inner surface of the heart, though really less uncommon than the first or simple species, had previously altogether escaped observa- tion. Yet the frequent existence of an analogous condition of other hollow muscular organs should have prepared us to expect it. The bulk of the heart must, however, be as large or larger than natural, at the same time that its walls seem thickened, to warrant us in asserting the presence of this variety of hypertrophy; for great contraction of the muscular fibres, such as often takes place after death, especially when somewhat sudden, the individual having been previously in vigorous health, may give rise to an appearance of thickening, which might otherwise readily be confounded with the morbid alteration in question. M. Cruveilhier, indeed, and Dr. Budd will scarcely admit the reality of concentric hypertrophy under any limitations, save as a congenital affection ; believing that all the cases given as such in books either fall under the ex- ceptional category just spoken of, or, if cardiac symptoms existed 66 518 HYPERTROPHY OF THE HEART (Forms). during life, were examples of simple or slightly dilated hypertro- phy, with or without valvular disease ; and that the shrinking of the cavity was merely a passing condition originating at or after death. In support of this view, the latter writer adduces apparent exam- ples of this affection, in which he was able, with very slight force, to dilate the contracted cavity; and he further asserts that none of the effects usually connected with obstruction have been present, unless obstacle of some other kind, sufficient to account for them, coexisted. His arguments, at the least, prove satisfactorily, that cases have often been mistaken for concentric hypertrophy, which had no title to the appellation. Instances of simple hypertrophy of the heart had long since been recorded by Morgagni, Burserius, and even by Corvisart himself, but without suggesting to any of them the correcter general views with which the name of Bertin has become associated. It seems to be the opinion of Bouillaud, that hypertrophy of the heart rarely exists unconnected with some of the other affections of the organ already enumerated ; more especially with inflamma- tion of its outer or inner linings, disease of the valves, narrowing of the orifices, or obstruction in the great vessels. The obstacle to the circulation from these lesions are, according to him, the great source of all the symptoms usually ascribed to hypertrophy. This, however, was not the opinion of Laennec, who laid much less stress on the supposed obstruction, as a cause of the derange- ment of the functions, than either the author just named, or even than Corvisart. Ossification of the valves, in particular, he held to be a much rarer affection than hypertrophy ; and he believed, moreover, that the degree of obstruction ordinarily so produced, seldom affected the health, unless enlargement of the heart had supervened. Dr. Clendinning, too, has recently impugned the cor- rectness of Bouillaud's views, and adduced a very great number of cases to show that hypertrophy of the heart, uncombined with any of the morbid states alluded to above, is of very frequent occur- rence. Of upwards of five hundred dissections made by him of patients dying in the institution to which he is attached, where all kinds of disease, curable or incurable, are indiscriminately admitted, above one hundred and seventy—that is, about the third of the whole—proved to have had heart-disease in some form. Five- sixths of these were cases of hypertrophy, uncomplicated, he as- sures us, with other diseases of the heart, such as pericarditis, endocarditis, or valvular disease. In about thirty cases only, or one-sixth of the whole, well-marked valvular disease was detected, —combined, it is admitted, in every instance but one, with obvious hypertrophy. Dr. Hope, while he fully admits, with Bouillaud, that valvular disease is a very frequent cause of hypertrophy and dila- tation, yet agrees with Dr. Clendinning in considering the alteration in the muscular structure of the organ as the chief element in the production of the distressing symptoms; inasmuch as, commonly, it is not until this latter has been superinduced, that the embarrass- ment of the circulation and the patient's sufferings become very hypertrophy of the heart (Anatomical Characters). 519 considerable; and it is, moreover, chiefly on the prevention or treatment of these abnormal muscular conditions that our hopes of alleviation are based in the advanced stages of valvular lesion. The normal average weight of the heart, in the male subject, as we have seen, is estimated by Dr. Clendinning at about nine ounces.* In several cases, hyper trophy was proved, by recourse to the balance, to exist, though it was not obvious to the eye,—as, for instance, when the heart weighed about eleven or twelve ounces. The average weight of eighty diseased hearts of males was, how- ever, much more than this,—namely, fifteen ounces, or two-fifths more than the healthy standard. Even where diseased valves and hypertrophy coexist, Dr. Clendinning sees no proof of the ante- cedence of the former. His belief is, that the hypertrophy results exclusively from vital and not from mechanical causes, and is in its turn the source of an augmented tendency to inflammation throughout the body generally, and in the heart itself no less than in other parts; and that the valvular lesion, in conformity with this view, is often the consequence rather than the cause of hypertro- phy. " I would thus," he continues, "in a great degree, reverse the order of causation usually received, and attribute much of the valvular disease to inflammation, mainly induced (if rheumatism be excluded) by previous hypertrophy as a most potent predisposing cause." To this opinion he has been led, by observing that, in the great majority of cases of morbus cordis, no valvular disease exists ; whilst, on the other hand, he has never but once met with this last- named lesion, unless where hypertrophy was also present. Hyper- trophy and inflammation, according to the same authority, are only different stages or degrees of the same process; accordingly, a large proportion of cases of disease of the heart are hurried off by the supervention of pericarditis or endocarditis in their advanced period. Anatomical characters. In hypertrophy of the heart, the muscular tissue is commonly of a deeper red, and more richly supplied with blood than natural, its coronary arteries are enlarged, and its den- sity and firmness increased. In a very advanced stage, a state of induration in some cases, and of ramollissementin others, are occa- sionally observed. It occurs very commonly as one of the sequelas to acute rheumatism, and frequently in connection with evident traces of inflammation of the interior or exterior lining membranes. Such are the appearances which have inclined Andral, Bouillaud, Elliotson, and other recent writers, to a belief in the frequent inflammatory origin of the affection. That its source may be occa- sionally of this nature, we are not prepared to deny ; but believe that in the great majority of cases the increased bulk and firmness in the organ are the result merely of greater activity in the nutri- tive process, in consequence of a more abundant determination of blood from the greater demands made on its exertions. Whatever * The natural average weight of the heart varies with the age. Thus, in the prime of life, it falls slightly below the weight stated in the text, whilst, in old age, it may exceed it by half an ounce or so.—Author. 520 hypertrophy op the heart (Anatomical Characttrs). unduly and habitually excites the heart, or renders the performance of its ordinary task more difficult, whether the hinderance be seated in the heart itself, or extrinsic to it, must necessarily have this ten- dency, provided the vitality of the organ be unimpeached by any general or local debility. Of all the forms of hypertrophy, that with dilatation, corres- ponding with the active aneurism of the heart of Corvisart, is the most frequent; next to it is that with contraction or diminution of the cavities; whilst that in which they remain unaltered in size appears to be the rarest of all. When the cavities are enlarged, there must obviously be an increase of substance in the parietes, provided they still retain even their natural thickness. It is not very usual to find but a single compartment affected: this, however, is sometimes the case. The left ventricle, from its greater energy and power of reaction, the greater task which it has to fulfil in driving the blood through the circuit of the general circulation, and the more frequent impediments which it has to overcome, is the cavity in which this change is most apt to occur, and in which it most commonly runs to the greatest excess. In the right ventricle, hypertrophy is much rarer: when it exists in a well-marked manner, the ventricle no longer collapses, as in the natural state, on being emptied. Hypertrophy of the left ventricle often coexists with the same condition of the right, and sometimes with its simple dilatation. The size of the cavity of the ventricles is subject to a consider- able range in hypertrophy; being sometimes so distended as to be capable of containing the fist, or, if in the other extreme, so con- tracted as scarcely to hold the shell of an almond. When dilata- tion takes place, it may be either in a longitudinal direction, giving to the heart an elongated form, or, as is much more common, transversely, rendering it strikingly globular. The thickness of the parietes of the left ventricle is sometimes carried to considerably above an inch ; that of the right to four or five lines, and, in some very rare instances, even to more than double or treble that thickness, as sometimes in cases of open fora- men ovale. The instances in which the heart attains to the greatest magni- tude, are those where dilatation and hypertrophy are combined; and here it is occasionally twice, or even thrice, its natural size. It is when both ventricles are thus at once so affected, that the organ becomes most remarkably rounded, the apex being in a manner obliterated, and that it assumes a transverse position in the chest, occupying a very considerable portion of the thoracic cavity, occasionally descending as low as the eighth rib, displacing the lungs, especially that of the left side, and thrusting it up as high as the third rib. Where adhesions have taken place between the heart and the pericardium, and between the latter and the parietes of the chest, the organ as it enlarges is prevented from descending as it otherwise would do; and it is here, as has been remarked by Dr. Hope, that the cartilages of the ribs are most apt to become prominent. HYPERTROPHY OP THE HEART (Symptoms). 521 When the left ventricle is much enlarged, whilst the right retains its natural dimensions, the latter has the appearance of a mere appendage let into the side of the former ; when, on the other hand, the right ventricle is solely or chiefly hypertrophied, it descends unusually low, and may form the entire apex of the organ. In simple and dilated hypertrophy, the thickness of the walls ordi- narily increases gradually from the apex to beyond the middle of the ventricle, diminishing thence somewhat abruptly towards the great arterial orifices,—being thus, as it were, a mere exaggeration of the natural state; whilst in the concentric variety, on the contrary, the deposition seems to take place more equably over the interior, inclusive of the apex, to which it gives a very blunt In some instances, the augmented deposition in the walls takes place in a very irregular or partial manner, some parts appearing thicker and others thinner than natural. The columnas carneas generally participate in the affection of the parietes; yet, where the cavity is much enlarged, they sometimes may appear, from their elongation, rather attenuated. The septum is, for the most part, much less affected than the exterior walls ; yet in some rare cases it is alone thickened, as may likewise be the case with the columnas carneas. The cavity of the right ventricle has been found almost entirely filled up from the latter cause, the enlarged fleshy columns becoming mutually adherent at their adjacent points, and thus forming a complicated muscular network, which must have considerably impeded the motion of the blood. - The parietes of the auricles, or rather their musculi pectinati, and especially those of the right, are also occasionally the seat of thickening; but this is scarcely ever observed without a coincident dilatation of their cavity; and very seldom, indeed, without the coexistence of enlargement or hypertrophy of the ventricles. The weight of the heart, when considerably enlarged, may be raised to twice or thrice what it is in the natural condition, as we have already mentioned with more detail in the introduction, (bee The symptoms of hypertrophy of the heart are either local or general; and it is only from the combined study of both, that we can determine with any certainty the existence of the affection in the earlier and, practically speaking, the most important period. Exclusive attention to the physical signs has been emphatically deprecated by Laennec and all the most judicious of his followers as tending only to bring them into disrepute, and often to lead the physician into lamentable error. Pf,riw F Of the local symptoms, or physical signs, %*™*J^*™^ gradually neavinj, i »„ PnurCrcment of the heart be extreme, ^*!S3rS?,-^."Wribi .he,hole maSS of the 522 hypertrophy op the heart (Symptoms). enlarged organ seeming to come into contact with the thoracic {>arietes at each pulsation (the apex beating generally more to the eft side, as well as at a lower level than natural), and then falling back, with a subsequent jog or shock at the end, called "the back stroke" or " diastolic impulse" by Dr. Hope, and ascribed to the refilling of the ventricles. The first sound of the heart is remark- ably diminished in intensity, of a dull prolonged character, and audible only within a narrow sphere, provided the dilatation, if any exist, bears but a slight comparison to the degree of hypertrophy present; for the thickened muscular mass is but ill adapted, as already explained, for the production or transmission of sonorous vibrations. Where, however, much dilatation coexists with] the hypertrophy, the sound is by no means thus impaired, but may be heard over a very extended surface in front, and occasionally even in the posterior portion of the chest; the impulse being strong, sharp, and hammer-like, somewhat as in nervous palpitations, in- stead of having the prolonged heaving motion characteristic of the purer form of hypertrophy. The second sound is little altered from its natural state in the simple variety when moderate in degree ; it is generally diminished in the concentric, and augmented in the dilated, species. When the natural cardiac sounds are obscured in the prascordial region by a rale or a bellows-murmur, they may occasionally still be heard distinctly towards the top of the sternum or under the clavicles. The period of repose is much encroached on by the time consumed in the systole. The pulsations of the heart, in the earlier part of the disorder, when not excited by any extraneous cause, are not ordinarily augmented in frequency ; nor yet, if there be no contraction of the orifice, nor valvular disease, nor great dyspnoea or debility, are they irregular. The sense of palpitation, or rather a consciousness of the heart's action, is more constant in this than in other forms of heart-disease; but the palpitations rarely attain to such violence as is observed in cases of valvular lesion and pericardial adhesions, except as a temporary consequence of some unusual exertion or strong mental emotion. Where palpitations have thus been excited, a bellows-sound is occasionally heard during their continuance; but where this phenomenon is permanent, it may be considered an almost infallible index of the coexistence of organic obstruction from disease of some of the valves or orifices. When the impulse and dulness of the first sound are more re- markable under the sternum, than under the cartilages of the ribs, Laennec thought the existence of hypertrophy of the right ven- tricle might be looked on as almost certain,—a reservation being made in favour of those cases of extreme enlargement of the left ventricle from the coexistence of hypertrophy and dilatation, in which this part of the heart may extend itself beneath the sternum. In order to arrive at a valid conclusion from the stethoscopic signs, they must, as we have already intimated, be investigated at such times as the heart's action is neither unusually excited nor depressed. Low diet, previous loss of blood, or evacuations of hypertrophy of the heart (Symptoms). 523 any kind, or the oppressive dyspnoea attending certain stages of pulmo- nary affections, may so enfeeble the movements of even a greatly overgrown heart, as to render such an examination quite nugatory. Hence the propriety of auscultating repeatedly, and, under every variety of circumstances, is in all dubious cases obvious. On percussion, a considerable extent of dulness is commonly recognised, commensurate with the augmented size of the organ, and consequently most considerable in those cases where the size of the cavities, as well as the substance of the organ, are greatly increased. Certain states of the lungs and cavity of the chest may, however, as already mentioned in the introductory remarks, inter- fere with the existence or value of this sign. (See p. 390.) Prominence of the prascordial region, and an increased breadth of the corresponding intercostal spaces, are sometimes observable; and this appears to be especially the case when extensive peri- cardial adhesions exist, and in children, in whom the parietes are more yielding. An uneasy sensation, a feeling of weight, or a dull pain, is occasionally felt in the situation of the heart. General symptoms. In simple hypertrophy of the left ventricle, and also in those cases where thickening predominates over co- existing dilatation, if no narrowing of the orifices nor valvular or aortic disease is present, the pulse is strong, full, and tensely pro- longed under the finger in consequence of the protracted systole of the overgrown ventricle, but at the same time regular. With these characters of the arterial pulse, a thrill is occasionally asso- ciated ; but, as it appears to Dr. Hope, only in those instances where anaemia has been superinduced, all cases of obstruction and regur- gitant lesions being for the present excluded from our consideration. In concentric or contracted hypertrophy, likewise, the pulse is tense and throbbing; but, in consequence of a smaller wave of blood being emitted at each systole of the heart, it is necessarily smaller than in the preceding instances. Hypertrophy, as distinguished from dilatation and other lesions causing impediment to the circulation, is further characterised— at least, in its earlier stages—by greater activity of the capillaries, a more highly arterialised blood, a brighter eye, and a more brilliant complexion, provided the colour was naturally florid. Thus, in the incipient period, the functions of the body, as Bertin remarks, are wot necessarily at all impaired ; on the contrary, they appear rather to be executed with increased energy, and there is, in general, a fallacious show of high health and vigour. At a somewhat more advanced period, there are frequent flushings, with marked tendency to active haemorrhages of the brain and mucous membranes. These latter, when they take place from the Schneiderian mem- brane, or from the hasmorrhoidal or other vessels of the intestines, to only a moderate extent, must be considered as exercising a salutary influence over the complaint. Hasmoptysis is likewise a frequent symptom, and perhaps more especially when the right ventricle is affected. The augmented volume of the heart may, by encroaching on the lung, in some degree interfere with its func- HYPERTROPHY OF THE HEART (Symptoms). tion; yet the respiration is, for the most part, much less early or severely compromised than in cases of simple or passive dilatation, or other lesions tending directly to impede the circulation ; and at the same time the tendency to venous congestion and serous effusion throughout the body supervenes much more tardily. If, however, these cases be not cut off in their progress, as is often the case, by a sudden arrest of the heart's action, or by apoplexy, or inflamma- tion of the lungs or some other organ (the inflammatory diathesis being strongly marked), engorgement of the capillaries both of the lungs and of the general circulation eventually takes place ; and it becomes at length evident that such patients have no special or complete immunity from cough, dyspnoea, and other pulmonary symptoms, nor yet from dropsies of the cellular membrane and great cavities. These secondary affections are here, however, of a somewhat less inveterate character, and more susceptible of alleviation by judicious treatment, than where they originate in obstruction. The oedema connected with hypertrophy, Dr. Hope remarks, usually makes its first appearance in the face, in conse- quence of the naturally very copious supply of blood to the head, and its proximity to the heart, in virtue of which it receives the full force of its morbidly vehement contractions. A slight tendency to difficulty of breathing on unusual exertion may sometimes be noticed, even from a very early period. This is especially felt at the commencement of any great muscular effort, diminishing in some degree as the body gets warm, the blood becoming determined to the surface, and the cutaneous exhalation augmented.* Though hypertrophy of the heart may almost always be recognised by a careful consideration of all the physical and general signs, it is not possible, in every instance, to say which cavity is chiefly affected. Most of the signs hitherto detailed, apply more particu- larly to hypertrophy of the left ventricle. Where it is greatly aug- ment in bulk, its enlargement is, indeed, very usually complicated with a similar affection of the other cavities. If, however, as is sometimes the case, the right ventricle is alone or chiefly affected, the increased dulness and impulse is most conspicuous under the lower part of the sternum, and the pulse has not necessarily the * This phenomenon of " the second breath," or " getting into wind," as it is called, is well known to all who practice athletic exercises, trainers of horses for the course, &c. The writer of this had himself practical experience of it in a remarkable degree, in ascending ./Etna on foot at an early period of the year, when the sides of the mountain were still covered with frozen snow to a distance of upwards of twelve miles from the summit. The ascent of this slippery inclined plane, extremely fatiguing even to one at the time accustomed to con- siderable pedestrian exertions, gave rise, during the first two or three miles, to a very painful acceleration of the respiration and pulse; the heart throbbing with such violence as if it would burst through the side, or cause instant death ; yet, under the forced continuance of the exertion (and any relaxation would have been perilous, on account of the intensity of the cold) this oppressive sensation gradu- ally declined ; and after many hours of almost incessant smart walking and running, the starting point at the foot of the mountain was regained much less with feeling of fatigue than had been experienced during the first mile of the ascent.—Author. hypertrophy of the heart (Symptoms). 525 peculiar characters above detailed ; whilst, on the other hand, there has commonly been thought to be a greater tendency to dyspnoea and hasmorrhages from the lungs (hasmoptysis, pulmonary apo- plexy,* (fcc). When the cavity is at the same time dilated, and its valves, from this or any other cause, insufficient, there will be regurgitation and jugular pulsation synchronous with the ventricular systole. From such an impulse as is occasionally transmitted to the vein by the carotid, this may be distinguished by being con- fined chiefly to the lower part of the neck, where the two vessels are far apart. Pressure on the upper part of the vessel, again, does not interfere with it. It disappears in some during inspiration, and is most conspicuous during expiration. The pulsation of the jugu- lars, as remarked by Dr. Hope, is sometimes obviously double; the first motion corresponding to the contraction of the auricle, the second to the ventricular systole. Where there is simply impedi- ment to the onward current, without actual reflux, there will be merely a dilated condition of these vessels.f As to the auricles, we are not yet in possession of any unequi- vocal signs of their increased strength or enlargement, distinct from those of similar states of their respective ventricles; but with these they so frequently coexist, as to render their separate diagnosis matter of curiosity, rather than of practical interest. Percussion may sometimes, however, lead to a very strong sus- picion, at least, of their enlargement where it exists in a marked degree; and the presence of a venous pulsation anticipating the ventricular systole might serve, in the case of the right ventricle, to confirm such suspicion. In respect to the wasting away of the eye, or its inflammatory destruction, adduced by Testa, on trie faith of a single case, amongst the occasional consequences of disease of the heart, the latter is so common, and the former so extremely rare an affection, as greatly to discredit the supposed connexion ; and the same may be said of gangrene of the limbs, which has sometimes been supposed to be a symptom of enlargement of the heart, on the authority of an old case in Fabricius de Hilden and two com- paratively recent ones by Giraud, a contemporary of Corvisart. Whenever gangrene of the extremities does coexist with disease of the heart, it has been rendered probable, by the examinations by M. Bouillaud and Dr. Carswell, that it is connected immediately, not with the cardiac affection, but with local obstruction by a * Pulmonary apoplexy occurs more frequently, according to Dr. Hope's and Dr. Wilson's experience, in connection with great contraction of the mitral valve, with or even without hypertrophy and dilatation of the right ventricle, than under any other circumstances.—Author. f A jugular pulsation synchronous with the ventricular systole, and, as is so often the case, unaccompanied by " soufflet," is not considered by Dr. Hope as satisfactory evidence of actual regurgitation through the tricuspid valve ; as he believes that an impulse fully adequate to the effect may, when the heart is enlarged and acting impetuously, be transmitted by the mere recoil of the valve Bgainst the column of the blood behind it,—and this especially when both the valve and orifice are increased in size, and the veins congested.—Author. 67 526 hypertrophy op the heart (Complications). coagulum in the artery leading to the part. Whether, however, this obstruction is the cause or the consequence of the gangrene, is not to us so evident; for where the capillaries, from any circum- stance, lose their vitality, impediment to the circulation and coagu- lation of the blood in the trunk by which they are supplied, seems an inevitable result. Mortification of a limb occurring in connection with a diseased heart, may, in some cases, moreover, depend merely on the pressure on the vessels and on the inflammation induced by the excessive effusion of serum into the cellular tissue. Complications and secondary affections. Several of the compli- cations met with in the course of hypertrophy of the heart, as, for instance, inflammation of the inner and outer linings of the organ, obstruction of the orifices, disease of the valves, aneurism of the aorta, serous and hasmorrhagic effusions, &c, have been alluded to in the preceding paragraphs. There are, however, some others which, their connection being less universally acknowledged, merit a more particular consideration ; we refer especially to general visceral enlargement and to apoplexy. Hypertrophy being characterised during the greater part of its progress by increased activity of the circulation, that there should ensue enlargement of the body generally, and more especially of the internal viscera thus profusely supplied with blood, and that too generally of a rich and highly reparative quality, is not surprising. That an increase of bulk takes place in such cases, more especially in the spongy organs, as the liver and spleen, had, indeed, long been known, and is specially mentioned by Lieutaud, Corvisart, Portal, Kreysig, Testa, and others; but was by many viewed rather as the cause than the consequence of the disease of the heart; and even where the true nature of the relation was recognised, the enlarge- ment was very commonly ascribed to mere vascular repletion, or to infiltration. Dr. Clendinning has, however, very recently demonstrated, as already noticed in our introductory remarks on disease of the heart, that even after incising the viscera, and draining off their fluid, there still remains a notable augmentation of weight as well as of bulk, indicating clearly that they have been the seat of an unusual active process of nutrition ; and this he has found to hold good, not only of the two organs just specified, but also of the stomach, intestines, pancreas, kidneys (which last are sometimes, moreover, the seat of the peculiar affection described by Dr. Bright), of the lungs, especially the bronchial ramifications, and even of the brain. And this increase of substance, it waa further stated, is not limited, as we should perhaps have expected, to cases of active enlargement of the heart, but occurs in all varieties of heart-disease, whether of an active, or passive, or obstructive nature, where the organ is enlarged, and the vascular system generally is kept in a state of abnormal repletion ; so that it would appear, as he remarks, that even a comparatively stagnant or venous blood is adequate to the production of the effect in question. Hypertrophy of the heart, as is justly remarked by the same author, does not necessarily imply an increase of efficient power; but hypertrophy op the heart (Complications). 527 rather tends, on the contrary, to induce deficient functional aptitude, as becomes evident towards the winding up of the disease,—the symptoms of dilatation at last beginning to predominate over those of hypertrophy, and the pulse often becoming soft and compressible. The influence of hypertrophy of the heart, in the aggravation of other diseases originating during its course, is very conspicuous. The prognosis in all pulmonic affections (phthisis, pneumonia, bron- chitis, &c), in cerebral diseases (apoplexy, delirium tremens, and mania), as also in abdominal inflammations and fever, is rendered much more unfavourable by its presence. To many of these dis- eases, it moreover disposes in a peculiar degree ; and more especially to chronic bronchitis, emphysema of the lungs, and to the asthmatic paroxysms generally immediately dependent on one or other of these morbid conditions; and also to softening of the brain and cerebral hasmorrhage; to brain fevers, inveterate headachs exas- perated by stooping, nervous irritability, frequent ophthalmia with sparks and flashes before the eyes, ringing in the ears, and other minor evidences of determination of blood in undue quantity to the head. The dependence of apoplexy on disease of the heart, to which attention was many years since called by Legallois and Richerand, and more recently by Adams, Lallemand, Johnson, Bricheteau, and Hope ; and of which, indeed, even Lancisi, Baglivi, and others of the older pathologists seem to have been quite aware ; may now be considered as one of the best established medical facts. In a large number of cases of hypertrophy of the heart, examined after death by Dr. Clendinning, apoplexy coexisted in three-sevenths of the whole. Dr. Hope believes that the majority of cases of cere- bral hasmorrhage have this origin, and agrees with Bertin and Richerand in ascribing to it more influence than even to the so- called apoplectic constitution.* Dr. Kellie and M. Rochoux have, as we are aware, endeavoured to discredit the connection alluded to; but the number of positive facts in its favour is too great to allow us to doubt of its reality. The ill effects on the brain appear to be, in some degree, counteracted by the occasional existence of narrowing of the aortic orifice, as has been pointed out by Briche- teau ; but less so than we might expect, unless where the contrac- tion is very considerable : and then the lungs are still more affected, and the tendency to serous effusions is more prominent. The thickening of the left ventricle is much more apt, it is supposed, to determine a cerebral hasmorrhage in those cases where ossifica- tion of the arteries within the head exists ; a morbid condition, on the importance of which the late Dr. Baillie strongly insisted, in respect to its bearing on apoplexy; but in regard to which Dr. Cheyne, in an able treatise on this disease, has, as we were sur- prised to find, expressed a different opinion. * This influence is participated in, Dr. Hope is persuaded, by various other affections of the heart, as djlatation, softening, disease of the valves, &c.; inas- much as they tend to produce congestion of the brain—Author. 528 hypertrophy of the heart (Causes). Causes of each form of hypertrophy. Concentric hypertrophy, or that with contraction of the cavity, has been supposed occasion- ally to originate in inflammation of its internal lining membrane, by means of which an increased stimulus is imparted to the nutri- ent* vessels of the adjacent muscular layers; simple hypertrophy, or that in which the dimensions of the cavity are unaltered, to a similar action transmitted from the external or pericardial cover- ing to the more superficial muscular fibres; whilst in those cases where there is great dilatation, as well as increase of substance, an inflammatory and obstructive agency would seem very often to be simultaneously concerned. The very frequent coexistence of hypertrophy with endocarditis or pericarditis, to which we have so repeatedly alluded, and the analogy of the augmented growth taking place in the walls of other hollow muscles, as the bladder, stomach, or intestines, from a long continued inflammatory condition of their lining membrane, seem to favour this view. Indeed, the analogy might be pursued still farther, by observing that, in these cases, likewise, an obstruction to the free course of the contained matters often exists, and forms an additional link in the chain of causes and effects; giving rise, in some cases, to dilatation, and in others to contraction, of the viscus. It is, however, at the same time, almost certain that the increased muscular growth is not unfrequently a primary affection, occurring from excessive exertion of the organ, from the congeni- tal preponderance of its power in relation to the rest of the system, or from some disproportion amongst its parts. Rheumatism, though it so generally makes its first attacks on its lining membranes, yet occasionally seems to act primarily, and almost exclusively, in the production of hypertrophy of the muscular tissue. All violent exercises, if disproportioned to the strength, and espe- cially during the period of growth-^-frequent and strong mental emotions—plethora—venereal excesses, or other causes giving rise to habitual palpitations—obstructions in the lungs or great vessels, and more especially aneurism of the aorta, and whatever makes unusual demands on the exertions of the heart,—necessarily tend, in the manner and under the circumstances specified in the com- mencement of this article, to produce increased nutrition of the organ, and along with this, most commonly, enlargement of its ca- vities. We may add here, that as the tendency of obstruction in a heart capable of struggling effectually therewith, is to produce hy- pertrophy, so the constant over-distension of the cavities, connected with permanent patescence of an orifice and reflux, and other causes, has appeared rather to lead to the predominance of dilata- tion.* A preternatural communication between the right and left sides of the heart is often accompanied by hypertrophy of the right ven- tricle, and this has been ascribed to the admission of the arterial blood into it; though it is more probably, for the most part, an orj- • Hope, p. 250. hypertrophy of the heart (Treatment). 529 ginal condition bearing a direct relation to its abnormal participa- tion in the general circulation, and the unusual demand on its exer- tions. Hypertrophy of the heart, whatever may be its origin, must obviously, from the constant over-action of the organ, put it in a state favourable to the development of inflammation in its lining surfaces, and more especially of that in contact with the blood, and which covers the valves and orifices; and thus Pericarditis and Endocarditis, though so often the cause, may frequently also be the effect, of enlargement of the organ. Duration and prognosis. The shortest period within which this disease can develop itself, is uncertain. Though ordinarily an affection of many years' duration, yet it has, in some very rare cases, been known to present itself almost in an acute form, having assumed a well marked character apparently within a very few months, or even weeks. But this is, indeed, very unusual. When it is moderate in degree, and uncombined with serious mechanical obstruction to the course of the blood, or other severe complica- tions, it may run a course of many years, provided the manner of life be temperate, and that every thing which might unduly excite the heart's action be carefully avoided. From a slight degree of the disease, and under the above conditions, even little inconveni- ence, beyond a slight shortness of breath, or occasional inconside- rable palpitation, may for years be experienced; nor is it even incompatible with the attainment of a very advanced age. In children, a preponderance of the size and action of the heart is in- dicated by strength of impulse; and loudness of its sound seems to be a very frequent, or even the natural condition, and continues in some degree up to the period of puberty, when the general deve- lopment of the body establishes the due balance between the organ and the parts which it supplies. As there is often much strength of body and particularly good powers of digestion in the incipient stages of this affection, the temptations to excess in exercise and diet are unfortunately strong, and too often lead not only to the rapid exacerbation of the disease of the heart, but also to the earlier supervention of apoplectic symp- toms. The formidable nature of the local disease, and the inefficiency of treatment, generally augment in proportion as dilatation tends to prevail over hypertrophy; and finally, the prognosis is still fur- ther and in a fearful degree aggravated by the existence of the various complications already so often spoken of,—viz., valvular disease, pericardial and pulmonary inflammation, aneurism of the great vessels, &c. Treatment. From what has been said of the nature of this affection, and of the circumstances by which it is exasperated, it is obvious that the chief indications of treatment consist in repose of mind and body, or rather in the restraint of their exercise within very moderate limits, together with extreme temperance in food and drinks, pushed in aggravated cases, provided the period of life 530 hypertrophy of the heart (Treatment). gives any ground for expecting to effect a radical cure, even to the length of abstinence, and aided by a systematic and persevering employment of sanguineous depletion and other evacuant remedies. It is in this form of heart-disease alone,—viz., where hypertrophy is either simple or decidedly predominant, that the intensely lower- ing method of Albertini and Valsalva could be applied with any rational hopes of permanent benefit; nor is it often that even here it would be justifiable. Where dilatation and debility of the organ form the leading features of the disorder, the mistaken employ- ment of such a proceeding could only tend to exasperate the mor- bid condition, and accelerate the fatal termination. Hence the vital importance of a correct diagnosis is evident. Few practi- tioners of the present day would venture to propose, and still fewer patients would be found willing to submit to, the treatment advo- cated by the celebrated Italian physicians just named, in its ex- treme or most rigorous form, consisting of constant confinement to bed, reiterated venassection, and a diet so low as barely to prolong existence. Laennec, however, has given his voice very warmly in favour of a modified employment of it, especially if early had re- course to. He commenced by taking away blood to a quantity just short of inducing fainting; and at brief intervals, as twice or thrice a week, for example, repeating the operation till the palpitation and the vehement impulse of the heart had been got under; and at the same time reducing the quantity of food to half that usually consumed, or even much lower, until the patient's strength was brought so low as to leave him only able to crawl about for a few minutes at a time: and this plan must be persevered in steadily for at least eight weeks after all the symptoms of the disease have entirely vanished; and even then be only gradually relinquished, and instantly recurred to as often as these threaten to reappear ; so that its whole duration may occupy many months, or even a year or years. Nor does he think it inapplicable even to the more advanced stage of the disease, where dropsical symptoms and general cachexy have supervened; and he believes that it gives an addditonal chance to the efficacy of the necessary diuretic or hydragogue remedies. Dr. Mackintosh, who countenances the same kind of treatment, and speaks of con- fining the patient to a couple of biscuits in the day, recommends, where there is difficulty in restraining his appetite, the exhibition of small nauseating doses of tartar-emetic variously disguised. Dr. Hope and Dr. Forbes are less sanguine as to the efficacy of this heroic mode of treatment, having observed that these large and fre- quently repeated abstractions of blood, though they may for a time slightly alleviate the patient's sufferings, generally lead eventually, and especially when employed in the advanced stage of the affec- tion, only to augmented debility and increased frequency of the paroxysms of palpitation and dyspnoea, and to consequent shorten- ing of life. The effect of large venesections in producing prejudicial reaction in the first instance, and attenuation of the blood subse- quently, is well known. Dr. Hope, accordingly, in such cases, rarely takes away more than from six to eight ounces of blood, at inter- hypertrophy of the heart (Treatment). 531 vals of two or three weeks, or even longer, so as just in some degree to keep down the heart's action, and to relieve dyspnoea ; removing blood by cupping from the nape of the neck, if the head be much affected : the diet is to be moderate,—only the white kinds of animal food being permitted, and the use of liquids being restricted to small quantities, whilst stimulants of all kinds are of course strictly inter- dicted. Much benefit is often derived from the occasional applica- tion of a few leeches to the region of the heart: this mode of local bleeding may be had recourse to as an auxiliary to venesection ; or it may be employed alone, when the powers of the patient render general bleeding not advisable. In regard to exercise, it should never be taken in such a manner as to hurry the circulation. Where bloodletting seems inexpedient, the daily use of saline aperients for a week or so at a time is a good substitute, or the exhibition of mild diuretics, as the supertartrate or acetate of potash, or the decoc- tion of broom; and this, even before dropsical symptoms have appeared. Subsequently, a selection of the most powerful of the same class of remedies, or, if they have failed, and the dropsical symptoms are on the advance, hydragogue purgatives must be had recourse to. From the known influence of the stomach, intestines, and liver, on the action of the heart, Dr. Forbes insists, with great justice, on the essential importance of close attention to the condition of these organs in this and other cardiac diseases. Where there is much irritability of the nervous system, consider- able benefit often results from the judicious employment of narcotics (Williams, Lombard, &c), as the extracts of hyoscyamus, conium, or belladonna, or the salts of morphia in fractional doses, or, though more rarely, from one to two drops of hydrocyanic acid. In the use of opiates, however, we must be cautious, as they produce great general derangement of system in some individuals,—locking up the secretions, and disordering the functions of the stomach and brain, and so eventually aggravating the deranged action of the heart. Camphor, assafoetida, and ether may occasionally be had recourse to with advantage, especially during the paroxysms of dyspnoea and palpitation. About the efficacy of digitalis in quieting the action of the heart in these cases, there is considerable variety of opinion. Laennec had little or no confidence in it; whilst Bouillaud, on the other hand, styles it emphatically " the true opiate of the heart." The last- named writer prefers the endermic method of exhibiting it,—a blister being applied on the skin of the prascordial region, and the raw sur- face sprinkled daily with from fifteen to sixteen grains of this sub- stance in powder. Dr. Hope recommends the tincture internally, in doses of from twenty to thirty minims twice or thrice a day ; Dr. Davis is also partial to its employment. The coexisting state of other functions seems to have a great influence in determining the effect of this remedy; when the stomach or bowels are in an irri- table or sub-inflammatory state, it is generally inapplicable. Of the danger of its accumulating in the system, and producing alarming 532 hypertrophy of the heart (Treatment). depression and slowness of the heart's action, as well as of deranging temporarily the cerebral functions,and thus giving rise to a remark- able form of delirium, every one who ventures on its employment should be well aware, and always on their guard, and ready instantly to intermit its use and counteract its ill effects. The hydrosulphuret of ammonia, in doses of four or live drops gradually increased to twenty or thirty, and largely diluted with water, was recommended some years ago by Dr. Marsh and Mr. Newton as a means of lowering the action of the heart without inducing much debility ; but on the subsequent employment of it on a larger scale, in hospital practice, it does not appear to have sustained its character. (Dub. Journal of Med. Sc, May, 1832; also a paper in same, by Dr. Thwaites, for Nov. 1832, vol. ii., p. 185 ; and another by Dr. Graves, in same volume, p. 23.) In excessive doses, or insufficiently diluted, it causes headach, nausea, and giddi- ness; and its use requires much circumspection. The preparations of iodine, from their known power of promoting absorption, more especially of the solids, and controlling some of the chronic consequences of rheumatism, have been recommended in this affection ; and very recently, the long continued and frequent employment of mercury in small doses has met with a strong advo- cate in Mr. Salter; and Dr. Colles, likewise, has dwelt with much and just emphasis on the beneficial influence of this remedy over some of the most distressing effects of morbus cordis. When the symptoms have once been reduced by some of the various measures just spoken of, the establishment of permanent counter-irritation, by means of an issue or seton, either in the region of the heart, or, what sometimes answers better, at some distance from the affected organ, as in the arm, for example, is advisable. When the disease dates its commencement from the suppression of a chronic cutaneous complaint, or from repelled gout, and when we cannot recall these affections, recourse to counter-irritation in some of its forms is peculiarly indicated. Colchicum, moreover, is a useful auxiliary. During the paroxysm of palpitation and difficulty of breathing, Morgagni was accustomed to employ, as a palliative, warm pedi- luvia, and at the same time to have the arms plunged into water as hot as could conveniently be borne,—measures which seem to owe any slight beneficial influence exerted by them, to their drawing away an additional quantity of the circulating fluid to the extremities, and so temporarily relieving the heart; and with the same view, dry cupping over the chest and back may be employed. But when there is much congestion of the lungs, severe dyspnoea, troublesome cough, or evidence of thoracic inflammation in some of its grades and varieties, the scarificators or leeches should be applied, or a moderate venesection speedily practised. In advanced cases, however, and when the constitution is greatly enfeebled, the recur- rence to general bloodletting demands much caution and discrimi- nation. Even in its earlier, uncomplicated, and most curable condition, DILATATION OF THE HEART. 533 hypertrophy of the heart requires for its permanent removal that the treatment should be steadily pursued, and for a very consider- able period, which may be stated on an average at about one or two years. A slight intermission of the symptoms soon after the treatment has been commenced, affords no warrant for its interrup- tion, but rather an inducement to proceed in the same path. In all cases the patient, if he would avoid the speedy recurrence or aggravation of the complaint, must make up his mind for a life of temperance and self control, both moral and physical. All over- loading of the stomach, whether with solids or fluids, however simple their nature, is to be studiously avoided, and a rather low scale of diet habitually adhered to. The age and habit of body, and the previous mode of living, must, however, be taken into consider- ation ; for an extreme system of abstinence will, in many cases, by deranging the digestive functions, and unduly augmenting the nervous sensibility, give rise to a state of body very unfavourable to the regular and moderate action of the heart. Though violent or prolonged exercises are obviously improper, the opposite condition of total indolence and inactivity is scarcely less to be shunned, except at very aggravated periods of the disease; the object to be kept in view, being, on the one hand, to avoid all undue excitement of the nervous, vascular, and muscular systems; and, on the other, to support an equable distribution of power throughout the several functions, a healthy action of the capillaries, and a free state of all the secretions and excretions, and so to guard against the dangeja- of plethora and of local accumulation. ^S^ DILATATION OF THE HEART. Nature and mode of production.—Anatomical characters.—Physical signs.— General symptoms.—Diagnosis.—Treatment. Of the influences under which dilatation of the heart takes place, we have already spoken in the commencement of the preceding section, and also in our " General Observations on Diseases of the Heart," p. 430. It was there seen that they are reducible to ob- struction in the course of the circulation, and weakness of fibre in the heart, often occurring simultaneously, though the latter alone seems adequate to the effect. When the power of the heart is not proportioned to the mass of the blood to which it should give motion, nor to the extent of the circulation, there is necessarily a tendency to accumulation and distension. It is in those who are advanced in life, and of a tall, slight make, and relaxed habit of body, that it is most apt to originate. On dissection, the muscular tissue of the part is very generally found to be unnatural in consistence and colour, being flabbier and easier torn than usual, and commonly of either an unnaturally pale or dark hue. It was conjectured by 68 534 dilatation of the heart (Causes). Burns, that the attenuation of the parietes might eventually be car- ried so far as to cause them to give way at some point; and Dr. Hope has since actually met with such a case, the patient having expired suddenly at stool, a fissure of an inch in length being dis- covered in the left ventricle, which was softened, and of a violet colour around the aperture; and he alludes to a somewhat similar case, on the authority of Dr. Williams. Of the local conditions said to predispose to dilatation, one of the most probable is weakness of one or more of the compartments of the heart of congenital origin ; or a similar state induced under the influence of disease, as of inflammation of the organ, for example, and especially of its internal or external linings; for to the state of over-action in a muscle, induced in the first instance by the inflam- mation of a membrane in contact with it, one of atony is very apt, as Abercrombie has remarked, eventually to succeed. Various general debilitating causes, as protracted fever, scurvy, and perhaps also scrofula (Dr. Cheyne), chlorosis, excessive losses of blood, or the relaxed state of the solids brought on in some habits by the long-continued use of mercury,—or, in fine, impairment of the nutritive and stimulant qualities of the blood, however arising, —may be placed amongst the predisponents to this affection. Chronic obstructions in the lungs, habitual paroxysms of dyspnoea or of nervous palpitation, sexual excesses, or any efforts which demand a frequent and protracted suspension of the respiration, or which at the same time accelerate the afflux of blood to the heart, and diminish its powers of reaction—violent as well as depressing passions, constant compression or deformity of the thoracic parietes, and trades in the exercise of which the trunk is ordinarily kept much bent, and the circulation on the descending and abdominal aorta interfered with,—all obviously have a tendency to aid in the development of the disease ; as must likewise, and in a still more powerful manner, aneurism or other obstruction of the aorta, obsta- cles seated in the orifice of the heart itself, and lesions admitting of regurgitation. Obstruction in an orifice or imperfection in a valve commonly manifest their influence first in the cavity immediately behind such causes. Eventually, however, the whole organ may become di- lated ; and not very seldom a more distant cavity, apparently from being peculiarly weak and yielding, suffers earlier than that in closest proximity to the obstacle. Above all other causes, the most influential, according to Laen- nec, is congenital debility or disproportion in the organ itself. Few individuals, he believed, will be found to have a perfectly propor- tioned heart, if we compare the cavities amongst themselves, or estimate the power and capacity of the organ in relation to the other parts, as the lungs, the vascular system, inclusive of the capillaries, &c. From such disproportion, if the habits be temperate and the mode of existence favourable, no marked inconvenience may result during the greater part of life ; but, on the other hand, the sudden supervention of emaciation, or irregular habits, violent exertions, or, dilatation of the heart (Anatomical Characters). 535 on the contrary, too sedentary a life, may destroy the balance ot the circulation, and lead to the development of the morbid tendency. r Anatomical characters. Dilatation may exist either with an in- creased, a natural, or a diminished thickness of the walls of the heart. The two former conditions have already been alluded to, when speaking of hypertrophy of the organ. Where, however, the enlargement of the cavities predominates greatly over the increase of substance in the parietes, the symptoms of debility and obstruc- tion preponderate, and require, even from practical considerations, that such 'cases should be arranged under the head of dilatation rather than that of hypertrophy. Dilatation with attenuation is, however, a much rarer affection than that with an opposite condi- tion of the parietes. In dilatation of the simple or passive kind, the parietes of the left ventricle are sometimes rendered as thin as those of the right in its natural condition; whilst the latter may be so attenuated as not to exceed the auricles in thickness. The simultaneous dilatation of both these cavities is much more com- mon than that of only one. The columnas carneas are necessarily elongated, and participate in the general wasting of the organ. The septum ordinarily suffers least. Dilatation does not always affect the whole extent of a cavity; thus it is occasionally almost confined to the upper portion of the ventricle, or near to where the great artery takes its rise; and in other instances it is more con- spicuous in the lower part or the neighbourhood of the apex. The auricles, from the less resisting nature of their parietes, are, according to Bouillaud, more prone to dilatation than the ventricles ;* and the right ventricle, from the same cause, is more exposed to this change than the left. The right cavities have an additional source of dilatation in the frequent obstructions which occur to the pulmonary circulation. Dilatation and hypertrophy of the auricles almost always present themselves combined. In attempting to decide upon the existence of dilatation of the auricles, it is to be remembered, that though these cavities, in their natural state, are of nearly the same capacity with the ventricles, yet the external magnitude of the former, in consequence of the thinness of their walls, should not be more than half that of the latter. Another circumstance to be kept in mind, if we would avoid error, is, that the auricles, and especially the right, are liable to a considerable degree of temporary distension from the accumu- lation of blood in them taking place just before death, especially when of a lingering kind. This must be carefully discriminated * This opinion is not, however, universally adopted. Dr. Williams's experi- ence leads him to think that the right ventricle and the left auricle are the most common seats of simple dilatation ; whilst Dr. Hope believes with Laennec, that the auricles from being protected by their valves from the direct influence of the numerous causes of pressure which operate on the ventricles, are far more exempt both from dilatation and hypertrophy,—at least, as long as the valves are perfect. But where disease of the auricular valves arises, causing impediment or regurgi- tation, it speedily leads to their dilatation.—Author. 530 dilatation of the heart (Physical Signs). from the structural change constituting permanent dilatation. As in the latter case, a certain degree of hypertrophy ordinarily co- exists, their parietes are more opaque, and, as remarked by Laennec, they do not shrink in the same manner on removing the contained blood, as when they are simply and recently distended. Disease of the mitral valve often gives rise, not only to dilatation of the left auricle, but also, from its influence being reflected through the circuit of the pulmonary circulation, to that of the right ven- tricle and auricle. Prasternatural enlargement of the orifices of communication is very commonly associated with dilatation of the adjacent cavities; and where the growth or distension of the valves does not keep pace with such enlargement, or where the valves, from extreme at- tenuation, become perforated or lace-like, regurgitation is the result, and must necessarily tend to accelerate the progress of the disorder. Physical signs. On applying the hand over the prascordial region, in the case of a greatly dilated and attenuated and feebly acting heart, a quick but very slight impulse is felt somewhat lower down, and more to the left side than natural. Even during the existence of palpitations, which are often peculiarly obstinate in these cases, the shock of the heart is still very feeble. If there be considerable difficulty in recognising it at all in the recumbent or erect posture, as is sometimes the case, by making the patient lean forward or lie on his face it becomes much more perceptible. The extent of dulness on percussion is manifestly augmented (es- pecially in the directions just indicated in respect to the impulse), provided emphysema of the lung do not interfere. Recourse being had to auscultation, the first sound is found to be of a peculiarly loud, clear, and brief character, approximating much in quality to the second sound, and being heard over a greater extent of the chest than natural; whilst the interval of silence is relatively augmented, in consequence of the shortness of the first sound. When the action of the heart is distinctly heard in the dorsal region, and the first sound is quite as clear as the second, the dilatation, according to Laennec, must be very considerable. When it is most loud under the cartilages of the left lower true ribs, the left side is chiefly affected; when under the inferior portion of the sternum, the right is principally implicated. Of the circumstances which limit the value of these deductions, especially that which regards the extent over which the sound is audible, we have already spoken at large in the introductory remarks, p. 403. Dr. Hope, we may add, trusts much more to the quality of the sound, especially its short- ness and clearness, than to its loudness ; for he thinks that it is often louder in dilatation with hypertrophy, or even with a natural thickness of the parietes, than with attenuation; which last, when extreme, must tend greatly to weaken the energy of contraction; and this is in conformity with the observation of M. Bouillaud, though opposed to the more commonly received opinion originally promulgated by Laennec. The sound often loses its intensity for several days previous to death ; and this is especially the case, dilatation of the heart (Symptoms). 537 when there is considerable softening of the muscular tissue, or an obstructed state of the lung. General symptoms. The pulse is large, soft and compressible, and slow of reaching the distant arteries, but not essentially prone to iregularity or intermission when the dilatation is uncomplicated with softening of the heart, narrowing of the cardiac orifices, or valvular disease. In the latter stages of the affection, however, when excessive debility has supervened, as well as during severe attacks of dyspnoea, the pulse often becomes both irregular and small. The lungs are early and much oppressed, their vessels being over-distended with blood, and the pulmonary tissue infiltrated,— circumstances which explain the distressing tendency to dyspnoea, hasmoptysis, and habitual cough, with abundant watery expectora- tion. The capillary circulation is languid, the extremities conse- quently inclined to be cold ; there is ordinarily little physical acti- vity, and often a constitutional tendency to depression of spirits. The necessary result of the accumulation of blood within the heart and lungs in these cases, is impediment to the venous circu- lation all over the body. Hence the early supervention of serous effusion, first in the extremities, and subsequently in the thoracic and abdominal cavities ; the purple tint of the face, if the capillary vessels there be naturally much developed, or otherwise a pallid or leaden hue; congestion of the cerebral vessels, evinced by dull pain of the head; frequent recurrence of frightful dreams, and sud- den starting from sleep in alarm ; great want of mental energy, and for some time before death a marked tendency to stupor or coma —symptoms which appear to be connected in some instances with serous effusion within the cranium, and in others with extreme vascular distension. The mucous membranes are universally congested, and passive haemorrhages from them, consequently, are frequent in the form of epistaxis, melasna, or bleeding from the in- testines, &c. The viscera generally are enlarged and gorged with blood, more especially the liver ; and the obstructed state of the portal system necessarily helps to accelerate the supervention of ascites. The general symptoms of dilatation of the right ventricle are scarcely to be distinguished from those of impediment to the circulation from other causes, and may be stated generally to con- sist in extreme dyspnoea, with a very early appearance of venous congestion, hasmoptyses, pulmonary infiltration, and universal dropsy. According to Laennec, an habitually swollen state of the external jugular veins, without pulsation, and not ceasing on the compression of the vessel in the upper part of its course, is one of the most frequent indications of this affection, and next in value to those furnished by the stethoscope. Of dilatation of the auricles, as already stated, no characteristic signs are yet known ; but the existence of such a condition may be looked upon as almost certain, when considerable obstruction or regurgitation is recognised in the adjacent orifices, or great en- largement of the ventricles has been detected together with a remark- able increase of dulness on percussion about the base of the heart. 538 dilatation of the heart (Treatment). Most of the general symptoms usually ascribed to dilatation, as, for instance, the overloaded state of the capillaries, serous effusions, and passive hemorrhages, arc by Bertin referred directly and solely to some mechanical obstacle to the circulation, the common cause, according to him, both of the symptoms in question and of such enlargement. But this is too narrow a view, according to Dr. Hope, who very justly remarks that debility of the heart is in itself a sufficient cause of accumulation of blood and consequent obstruction, and of the whole train of morbid effects just alluded to. Mechanical obstacles seated in a valve did not appear to Laen- nec, unless very considerable, necessarily to derange the circulation in any material degree, prior to the occurrence of enlargement of the heart. This latter state alone, on the contrary, and in the ab- sence of all impediment at the orifices or in the great vessels, is quite adequate to produce great embarrassment, the distended and weakened muscular fibres being incompetent to deliver the organ duly of its contents, or to make way for the returning blood. The prognosis in dilatation of the heart, when simple and mode- rate in degree, is much less formidable than where there is hypertrophy. It may often, by a tranquil mode of life, the prompt and appropriate treatment of any febrile or inflammatory disorders by which the patient may be casually attacked and which tend so injuriously to excite and derange the circulation, be prevented for many years from increasing, or causing any considerable incon- venience beyond the weakness of habit and tendency to dyspnoea on exertion which accompany it. When however dropsical effu- sions make their appearance, and in spite of regimen and medical treatment recur at short intervals, the fatal termination of tho case, at no very distant date, is to be apprehended. The rapidity of its progress and the severity of the symptoms will however depend in a great degree on coexisting lesions, and more especially on disease, or inadequacy of the valves, obstruction of the orifices, and a chronic morbid condition of the bronchial membrane. Treatment. When dilatation exists alone, or decidedly predomi- nates over hypertrophy, and the action of the heart is consequently greatly weakened, a plan of treatment, in many respects the very opposite of that noticed in the last section, is obviously demanded. The object in the present case is, if possible, to improve the nutri- tive process in the heart, to augment the energy of its contractions, and so enable it more effectually to cope with the obstacles under the influence of which it is suffering. To fulfil these indications we are unfortunately in possession of no very direct means, and are obliged to trust to the influence of such agencies, therapeutical and dietetic, as tend gradually to improve the general health. Where the tendency to dilatation can be traced to any obstruction of inflammatory or other origin in the heart or lungs, or in the course of the general circulation, the necessity of obviating its effects, or if possible entirely getting rid of it, is apparent. Inflam- matory affections, especially of the organs contained within the dilatation of the heart (Treatment). 539 chest, are to be promptly combated, and the absorption of effusions, whether of air or liquid, into the tissue of the lungs, or into the thoracic cavity, studiously promoted ; the indulgence of all violent as well as depressing passions, and of every species of intem- perance, restrained; unsuitable exertions of the respiratory organs and body generally, constrained postures and too sedentary habits avoided. Where permanent obstruction in one or more of the orifices of the heart is in fault, or a congenital or deeply-rooted and long- established debility of the organ exists, it only remains for us in general to palliate existing symptoms, and to prevent if possible the supervention of new ones, especially of an inflammatory nature. Thus every precaution should be taken to avoid, or appropriate means exerted speedily to subdue catarrhal affections, as they tend so materially to aggravate the dyspnoea and to favour the develop- ment of the morbid condition of which we are treating. The body should be warmly clothed, and the cutaneous circulation strength- ened by the use of the tepid shower-bath, diligent friction of the surface, and easy exercise. The diet should be nutritious without being stimulating, and the quantity taken at any one time ought to be very moderate, and liquids in particular sparingly indulged in, lest distension of the stomach and flatulence ensue, or relaxation of the muscular tissue generally, and that of the heart in particular, together with vascular repletion, be induced or augmented. Gentle but regular exercise, either walking, riding, or driving, according to previous habits and present strength, should be enjoined. The system should be braced by the occasional use of tonics, more especially some of the preparations of iron, and all dyspeptic ailments immediately attended to. In the choice of a residence, the dryness and purity of the air and freedom from the necessity of perpetually ascending flights of stairs within doors, and hills without, should chiefly be considered. In the more advanced stage of the affection, when pulmonary con- gestion and copious expectoration set in, a warm and humid atmo- sphere, as is judiciously remarked by Dr. Hope, is often more suitable, inasmuch as it favours both the cutaneous and the bron- chial secretion. Where the susceptibility to cold is very marked, and the period of life advanced, it may be advisable during the colder months in this variable climate to confine the patient to the house, his apartments being well ventilated, but kept at the same time of an equable and rather elevated temperature. During the paroxysms of dyspnoea, the occasional exhibition of an antispasmodic draught, and the free admission of fresh air to the lungs, whilst the surface of the body is protected by warm coverings, perspiration promoted, and the extremities plunged into warm water rendered somewhat stimulant by the addition of mustard, are amongst our chief resources. Opiates, though not altogether to be rejected, require caution in their use, as by check- ing the secretion or expectoration of mucus, they may often do more harm than good. Tea or coffee taken very hot, by their 540 the heart (Partial Dilatation of). action on the nerves, and exhalants, sometimes afford considerable relief when the attacks assume the form of spasmodic asthma. Bloodletting to any extent is, generally speaking, inapplicable to this form of heart disease, and should scarcely ever be had recourse to, save with a view to cutting short the intercurrent inflammatory attacks, which occasionally complicate it; and even here the local abstraction of blood is generally preferable: and, along with the use of calomel and Dover's powder, or antimony and aperients, together with blisters and other counter-irritants, is commonly quite sufficient to this end. In extreme cases of dyspnoea, however, when all other means have failed, the removal of a few ounces of blood in the remissions of the paroxysm may sometimes be warrantable; but it is always a perilous remedy, too often only increasing the general debility, and rapidly accelerating the progress of the case. It has even been known, when carried to any considerable length, to produce an almost immediately fatal result, the enfeebled organ being paralysed by the sudden reduction of its ordinary stimulus. For the treat- ment of Dropsy connected with disease of the heart, see Cardiac Dropsy. / -------------------------- PARTIAL DILATATION, OR REAL ANEURISM, OF THE HEART. Aneurism peculiar to the left side of the heart.—Aneurism of the left ventricle, its causes, symptoms, physical diagnosis, prognosis, and treatment.—Aneurism of the left auricle.—Aneurism of the valves. Dilatation of the Heart is, in some rare instances, partial, being confined to one spot, which, being particularly yielding, gives rise to an aneurismal sac. Such aneurism may originate, as we have seen, in ulceration or in rupture of the interior of the heart, and the subsequent gradual distension of the muscular substance which forms the bottom of such ulcer or laceration. That it has not however always this source, but results occasionally from actual dilatation of all the coats of the organ, is deducible from the cir- cumstance of its being sometimes possible to trace, in the earlier stage, the lining membrane of the heart in an unbroken form into the interior of these pouches. In some instances, again, the disease seems to begin by dilatation, and to end in rupture of the endocar- dium and inner muscular fibres: and here the case in its com- mencement will fall under the denomination of true aneurism ; and at another part of its progress, of that of false consecutive aneurism of the heart. So many as three or four of these pouches have, in at least one the heart (Partial Dilatation of). 541 instance, been found in the sides of the ventricle. Hitherto it has been invariably in the wails of the left cavities, and most com- monly of the left ventricle, that this disease has been met with. Aneurism in the heart, then, as in the vessels, would seem to be confined to that portion of the circulatory apparatus which trans- mits the arterial or red blood. The exemption of the right ven- tricle is ascribed by Mr. Thurnam, in a recent elaborate monograph on the affection which we are now considering, to the yielding or imperfect nature of the tricuspid valve already alluded to, which necessarily tends to diminish the stress on the walls of this cavity. M. Breschet and M. Cruveilhier, it is further remarked, were in error in ascribing such exemption to the greater relative thickness of its apex as compared with that of the left ventricle; for the vicinity of the apex, as has now been fully ascertained from the examination of a larger number of cases, is by no means the only portion of the ventricle liable to partial dilatation. It is true it still appears to be somewhat more frequently its seat than other parts of the cavity, but it also occurs, and not a great deal seldomer, near the base of the heart, and in some rare instances, likewise, in the middle or thickest portion of the walls, and even in the septum and valves. The aneurismal sac is found sometimes imbedded in the sub- stance of the ventricle, and sometimes prominent on its exterior wall, and is met with of various sizes, from that of a nut up to that of an orange, and in extreme cases even equalling the heart itself. In old cases in which it has attained to a considerable magnitude, the mouth of the sac is generally narrower than the rest of it, and often opens into the ventricle by projecting lips, and has its interior filled in a great degree with laminated coagula. In a few instances steatomatous or cartilaginous degeneration has been noticed in its walls ; and most commonly strong adhesions exist between its outer surface, even though as yet but very slightly prominent, and the bag of the pericardium, the result of a process of nature which has the effect of strengthening the parts and preventing early hasmor- rhage. The heart is very rarely free from other concomitant dis- ease. The coexisting morbid alterations are, as Mr. Thurnam remarks, generally of an inflammatory origin, such as opacity and roughness of the endocardium, ossification of the valves, &c. Either dilatation or hypertrophy of the heart, or at least of the left ventricle, existed in above a third of all the cases, fifty-eight in number, which have been collected and carefully analysed by him. The frequency of the affection in males, as compared with females, is as three to one,—a disproportion which, though considerable, is far inferior to that known to obtain in respect to aneurism of the arteries: the latter, moreover, has been ascertained to be chiefly confined to the period of life comprised between the thirtieth and fiftieth year; whilst the analogous affection of the heart does not manifest a decided preference for any particular age from puberty upwards. Of its causes nothing very precise can be stated, save that, like 09 542 the heart (Partial Dilatation of) as in regard to many other diseases of the heart, fatiguing exercises, intemperance, vehement passions and rheumatism, have appeared in some instances to predispose to it; and that its first symptoms in a few cases have coincided with the reception of a severe blow on the chest, a bad fall, or violent mental emotion. In the great majority of cases Mr. Thurnam, contrary to most other observers, believes it to be of the nature of true aneurism, commencing by a gradual dilatation of all the tissues in consequence of a local weak- ness in the wall of the heart, probably for the most part of an inflammatory origin. He supposes further that it may have its source in the gradual distension of some one of the sulci or pits which exist in the natural state in such number amongst the adherent and variously crossing columnas carneas, through the agency of a coagulum spontaneously forming within it and enlarging it. A variety of this affection, involving the whole circumference of the ventricle in a part of its length, is noticed under the title of Diffused True Aneurism, analogous to the cylindrical or fusiform aneurism of the arteries. A remarkable case of this kind has been met with by Dr. Macreight, in which the apex and adjacent portion of the heart were distended into a bag capable of containing a small orange, the walls of which were of a cellulo-fibrous texture, and ossified in parts, whilst the base of the organ was in a state of hypertrophy: ossification of the aorta and its valves was likewise present. Another species, originally observed by Dr. Hope, is spoken of under the name of " dissecting aneurism of the heart," in which the blood burrows under the internal lining membrane, and makes its way out again into the cavity at some distance. Instances of " hernial aneurism" have likewise been met with in the heart, where the internal coat, itself intact, protrudes through a hole in the middle or muscular tissue, the sac being then formed jointly by the endocardium and pericardium. In aneurism of the septum opening quite through into the adjacent cavity, we have a parallel to varicose aneurism of the vessels. There being thus, continues Mr. Thurnam, for every species of arterial aneurism, an analogous variety discoverable amongst the partial dilatations of the heart (if we except " the external mixed aneurism," for the impossibility of the occurrence of which in this organ there exists an obvious anatomical cause,—the absence of an external cellular coat), it is obvious how erroneous are the views of those who imagine an affinity to exist between general dilatation, or that a^ffecting the interior of one or more of the cavities of the heart, and the aneurismal enlargement of an artery. Such general enlargement, by which the heart adapts its dimensions to coexisting circumstances in the circulation, is more allied to the physiological process by which the arteries become dilated, when there is an additional demand made on them, as in the case of the arteries supplying the gravid uterus or a tumour, or the collateral branches, which re-establish the circulation where a main arterial trunk has been obstructed. the heart (Partial Dilatation of). 543 The symptoms of this affection are very obscure. Its commence- ment is for the most part insidious, and not marked by any dis- tinct functional derangement. In the more advanced period, dys- pnoea, prascordial pain, or rather a sense of weight and uneasiness, dropsy, palpitation, and tendency to syncope, and other symptoms indicative of a disease of the heart, are occasionally present; but from the very common coexistence of other lesions of this organ, it is impossible to say how much of all these functional derange- ments can be fairly laid to the charge of the affection in question. The physical diagnosis is as yet no less dubious. Negative evidence, as Dr. Hope remarks, might occasionally at least excite a suspicion of the true nature of some of these lesions,—as, for example, the absence of the appropriate signs of valvular disease, and of any of the varieties of pulse characteristic of better-known forms of cardiac disease. Dr. Williams apprehends that there may sometimes exist a bellows murmur or whizzing sound accompanying the systole, if the opening of communication be somewhat con- tracted, as also either a diminished, increased, or tumultuous action of the heart: if of unusually great size, there might possibly be a pulsating tumour felt opposite to the cartilages of the ribs, with increased extent of dulness on percussion, and perhaps some dis- placement of the organ. It might be practicable to distinguish it from aneurism of the descending aorta by the absence of any un- usual pulsation or grating sound along the left side of the dorsal vertebras. As to aneurism of the commencement of the aorta, which as it enlarges presses upon and occasionally bursts into the heart, it seems improbable that we shall ever be able to discriminate it by any characteristic physical signs from the affection here spoken of. Where the septum is perforated from the bursting of an aneurism seated in it, cyanosis might, by its sudden supervention, lead to'a suspicion of the nature of the case. The prognosis of this disease, supposing its existence to be recog- nised, is evidently of the gloomiest description. Its duration would seem to vary from a few days to several months or years. Death has occasionally taken place by syncope, but more generally by internal hasmorrhage into the pericardium. It has been known to end in apoplexy, and also sometimes, like other cardiac affections, by obstruction of the lungs, and the gradual supervention of asphyxia. The treatment most applicable to this disease, if discoverable, would partake equally of that proper in aortic aneurism and of that of dilatation of the heart; the objects being to induce organisation of the coagula, and obliteration of the sac, without at the same time too much sinking the powers of the organ. Hence a moderate use of the antiphlogistic system, together with the scrupulous avoidance of all stimuli, moral or physical, which could produce injurious excitement. A single case only of sacculated aneurism of the auricle has been seen by Mr. Thurnam amongst all the pathological museums exa- 544 ATROPHY OF THE HEART. mined by him; and in this the pouch, about the size of a nut, was filled with coagula, and communicated with the cavity by a nar- row neck. The aneurismal affection of the auricle is almost always of the diffused kind, involving the entire sinus or the appen- dix ; the dilated walls being generally thickened and opaque, rough, and occasionally ossified, and the cavity occupied by fibrinous con- cretions. Narrowing of the mitral orifice exists in almost every instance. Aneurism of the valves of the heart. The mitral valves have sometimes been observed to form an elongated pouch-like projec- tion into the left auricle, of which an example has been recorded by Morand, another by Laennec, and a third by Mr. South. The aortic valves were found simultaneously extensively ossified, so that the development of the disease was probably intimately connected with impediment to the escape of the blood from the ventricle, and consequently greater reaction against the yielding, and, in most instances, diseased structure, of the dilated valve. A similar ap- pearance has been met with in the aortic valves themselves, and even in the tricuspid. Coagula have not been observed in the pouches so formed ; and for their absence the incessant agitation to which these parts are exposed, sufficiently accounts. Such aneu- rismal tumours must materially obstruct the passage of the blood by their bulk, and where the sac becomes eventually perforated by ulceration or rupture, regurgitation will necessarily take place. Their stethoscopic signs, we apprehend, will be merely those of ob- struction or regurgitation. ATROPHY OF THE HEART. The heart, like other muscles, is liable to a remarkable diminution in size, more especially in certain kinds of chronic disease, as the tubercular, cancerous, and gastro-enteritic cachexies, which are attended with much general exhaustion and emaciation. It may likewise be induced by excessive and long-continued depletions, the pressure of pericardial effusions, obstruction of the coronary arte- ries, and perhaps also by a long-continued state of mental depres- sion. In regard to this last, however, there will often be room for doubting whether it should be ranked as a cause, or as an effect. In extreme cases the heart of an adult has been found to be no larger than that of a child, or even of an infant, having lost a third or half or more of its natural magnitude. For more precise infor- mation as to the extent to which such wasting may be carried, we must refer to what has been said in the introductory remarks. (See pp. 394-397.) The cavities of the heart in these cases are often remarkably di- minished in size, and the walls, in thus contracting on themselves, occasionally appear, notwithstanding their real loss of substance, the heart (Induration). 545 even thicker than natural (but they are then commonly wrinkled on their surface), or the opposite state may present itself, that of extreme attenuation of the parietes with dilatation. The muscular substance is, moreover, very generally altered also in colour and consistence from its natural state. Of the difference of opinion existing amongst pathologists as to the occasional connection of this condition of the heart with phthi- sis, we have already spoken, p. 395. Laennec, who seems to have considered it as a distinct well defined disease, remarks that it con- fers a certain degree of immunity from inflammatory affections, and is, on the other hand, often accompanied by hypochondriasis and a tendency to faint from very slight causes. The general symptoms are those of depressed vital energy mani- fested throughout all the functions of the economy,—emaciation and proneness to dropsical effusion; whilst the physical signs consist in peculiar feebleness of the sounds and impulse; the latter being unusually circumscribed as to the extent in which it can be felt, and occasionally even altogether imperceptible, save in the prone posi- tion of the trunk; whilst at the same time the natural dulness on percussion in the prascordial region is either not at all perceptible, or is limited within unusually narrow bounds. The pulse is not only weak, but uncommonly small and thread-like. As to the treatment of wasting of the heart, most of what has been already laid down in respect to the management of dilatation of the organ is equally applicable here. CHANGES IN THE CONSISTENCE AND COLOUR OF THE HEART, MORBID EFFUSIONS INTO ITS SUBSTANCE, AND NEW FORMATIONS. Induration.—Softening.—(Edema.—Hemorrhagic effusion.—Purulent deposits. —Ossification of its vessels.—Surcharge of fat.—Tubercle, fungus haemato- des, or cneephaloid cancer.—Scirrhus.—Tumours.—Serous cysts.—Hyda- tids.—Cartilaginous and bony deposits. Induration of the substance of the heart has already been alluded to in connection with hypertrophy and with carditis; and it was stated that its density was sometimes so remarkably increased, that when struck it resounded like a leather dice-box, or the coriaceous hull of the cocoa-nut; and yet occasionally, even in these extreme cases, its colour has not deviated strikingly from that which is na- tural to it. Nor was its contractile power in these instances considered by Laennec, as it was by Corvisart, to be impaired, but, on the contrary, he thought it was even augmented,—an opinion which later observations by no means confirm—nor yet did he coin- cide with Bertin and Bouillaud, in looking upon it as a preparatory step to ossification, such a transition never having been observed 546 the heart (Softening). by him. The one affection, moreover, he remarks, occupies very generally the whole heart, and has its chief seat apparently in the muscular fibre; whilst the other morbid process is commonly very partial, and manifests a decided preference for the serous, cellular, or fibrous portion of its structure. Softening of the heart, with various alterations of its colour, has likewise been already treated of in the section on Carditis, inasmuch as it appears to be sometimes at least of inflammatory origin. The sounds of the heart in well marked cases are much impaired, and when this change exists in an extreme degree, the first sound may be almost or altogether inaudible, the impulse likewise being notably diminished, except during the presence of palpitations. The beat of the pulse is brief and feeble, and for the most part unequal and irregular, or intermittent. Softening of the heart appears to pre- dispose in a remarkable degree to dilatation of its cavities, as well as greatly to aggravate the nature of this lesion : where the two alterations coexist, the former tends in some degree to prevent the clearness and loudness of sound characteristic of the latter; and the disproportion between the extent of dulness on percus- sion, and the intensity of the natural sounds of the organ, may lead to a suspicion of the nature of the complication. A softened condition of the heart is often met with on dissection in cases of hypertrophy with dilatation, where "death has been pre- ceded by long and frequent attacks of dyspnoea, and where the patient having survived for some weeks in a state of impending suffocation, a high degree of venous congestion has taken place in consequence of the obstructed state of the circulation. The diagnosis between softening and disease of the mitral valve— affections in both of which the pulse is small and irregular—may be made, as Dr. Hope remarks, by the absence of the murmur cha- racteristic of valvular disease. The two lesions often, however, it must be remembered, coexist—and also that a very similar irregu- larity of the pulse may depend merely on temporary nervousness, violent dyspnoea, or excessive debility, as in the moribund state. When hypertrophy and softening coexist, we may generally, ac- cording to the same authority, recognise the first by the impulse of the heart being either constantly, or with occasional beats, de- cidedly stronger than natural—and the latter alteration, by the first sound being not only diminished, as in simple hypertrophy, but having moreover a short flapping character approximating to that of the second sound, as if it were now almost entirely dependent on the sound of valvular extension. The softened and somewhat glutinous state of the heart, ob- served in the advanced stage of putrid fevers, was supposed by Laennec to be but a part of the general affection of the muscular system in these cases, owing to a diminution of their solid, in pro- portion to their liquid constituents. Dr. Stokes, who has recently paid much attention to this subject, takes rather a different view of it, considering the softening of the heart to be a peculiar local secondary effect of typhus, and often to exist where the muscles of the heart (Haimorrhagic Effusion). 547 locomotion are little, if at all, altered from their natural colour and consistence (Dub. Med. Journ., March, 1839). Where it exists in a marked degree, the first sound of the heart becomes quite inau- dible and the impulse deficient. From the great feebleness or ab- sence of the systolic sound, he has satisfied himself that a valuable practical indication may be deduced in respect to the propriety of resorting to stimulants, and one which he holds to be much more trustworthy than the state of the pulse, which is not always, by any means, in accurate relation with it. Accordingly, where there is absence or extreme diminution of the first sound in typhoid fevers, he administers wine boldly, no matter what other secondary affec- tions of the gastro-intestinal mucous membrane, pulmonary organs or brain, may coexist, and believes that where the stimulant plan is, under such circumstances, neglected, and the strength not ade- quately supported until this and other concomitant secondary affec- tions, as well as the fever itself, have run their course, syncope is very apt to occur and prove fatal. Where, on the contrary, wine and other stimulants having been diligently exhibited during a day or two, the pulse begins to lose its frequency, and the first sound of the heart becomes again audible, the prognosis becomes decidedly favourable, and the propriety of the line of treatment adopted con- firmed. There remains still another species of softening of the heart to be adverted to,—viz., that where an unusual quantity of fat enve- lopes the organ, and is intermixed with its muscular fibres, its sub- stance in such cases loses altogether its natural firmness, and becomes of a peculiarly light colour, and seems prone to rupture. It is probable that many obscure cases of sudden and unexpected death have their origin in syncope connected with ramollissement of the heart. The treatment of softening of the heart when inde- pendent of inflammation, or where this, if its original cause, has been subdued, is similar to that of dilatation, a morbid condition with which, as we have seen, it very frequently coexists. An cedematous state of the cellular membrane enveloping the heart, and connecting its fibres, has been noticed by M. Bouillaud both in connection with a general dropsical condition of the system and also with a varicose appearance of the cardiac veins, indica- tive of the difficulty with which they discharge themselves into the right auricle in consequence generally of some concomitant ob- struction within the heart. A similar dropsical state of the organ may also originate in obliteration of some of these same vessels. The heart is occasionally the subject of hcemorrhagic effusion, either in the form of patches or petechias, on one or both of its surfaces, as has sometimes been observed both in land and sea- scurvy and in putrid fevers; or blood may be poured out in larger quantities, and either infiltrated into the very substance of the organ, or collected into a factitious cavity formed by the separation and laceration of its fibres, constituting the disease spoken of by some authors under the title of apoplexy of the heart. Cruveilhier, who has seen many instances of it, believes it to be much more 548 the heart (Surcharge of-Fat). often than inflammation and ulceration the cause of rupture of the heart. Hitherto it has only been observed in the left ventricle, and generally in connection with hypertrophy. The muscular fibres are found quite broken down and displaced, and a coagulum occupies the cavity so formed, and with it, at a later period, purulent matter appears to be mixed. Perforation towards the inner or outer surface of the organ seems to be a fre- quent result, as is likewise the false consecutive aneurism described by Breschet. Purulent deposits within the parietes of the heart have already been alluded to in our account of carditis. When of inflammatory origin, the muscular substance surrounding them is generally in a softened condition. They have their source probably, in some in- stances, in the translation of pus in the blood from some distant organ in a state of suppuration. The vessels which supply the heart are not exempt from disease. In addition to the varicose state of its veins just alluded to, ossifica- tion of the nutrient arteries is by no means very unfrequent in the aged: it is not, however, necessarily productive of the formidable consequences ascribed to it by Parry and some other authors, who have endeavoured to connect it inseparably, as already mentioned, with the group of intensely distressing symptoms described under the head of Angina Pectoris. Enlargement of the arterial and venous coronaries is, as Bizot has pointed out, the ordinary conse- quence of advancing years; and this is only in conformity with what we should expect from knowing that the heart, which is de- pendent on them for support, gradually increases in size and weight as old age approaches. The derangement of the nerves which supply the organ has already been spoken of. The heart is often found overloaded with fat, especially about its base, and along the course of the coronaries, in the furrow of se- paration between the adjacent cavities, and likewise occasionally on its flat surface. In such cases, there is often an excess of the same substance in the neighbouring mediastinum, especially in front of the pericardium. The muscular structure of the heart is ordi- narily much reduced in thickness and firmness, where in contact with the accumulated fatty deposit, either in consequence of its pressure, or from the new appropriation of the nutritive fluid. The heart in one or more of its cavities is in these cases fre- quently at the same time greatly enlarged. Though the adipose matter may occasionally penetrate for someway between the mus- cular fibres, yet the two structures do not here run insensibly into each other, but are, on the contrary, perfectly distinct, so as to be capable of being separated cleanly by the dissecting knife. Corvi- sart, Laennec, and Hope, all agree in considering this as a mere augmentation of a natural deposit, and unattended, as far as their experience reaches, with any definite morbid symptoms: still if in very great excess, it could scarcely fail, we apprehend, in some de- gree, to enfeeble or embarrass the heart's action. M. Chomel be- lieves that it may, in such extreme cases, give rise to dyspnoea, the heart (Surcharge of Fat). 549 palpitations, and a sense of sinking, together with feebleness of pulse and dropsical tendency; and others, as we have already seen, ascribe to it, though on less plausible grounds, the production of all the symptoms of angina pectoris. Dr. Hope considers its signs to consist in " diminution of the sounds, especially the first; irregular pulse without valvular disease ; and oppression or even pain in the prascordial region ; with general signs of a retarded circulation, producing cerebral, hepatic, and other congestions." It is much more common in females than in men, and is met with frequently where there is no tendency to obesity in other parts of the body. The habitual use of fermented liquors to excess seems in some constitutions to favour the morbid deposition of fat in this as well as in other situations. But besides the condition above described, the heart is liable, like the Solasi and some other muscles, to a species of true fatty degen- eration, in which a portion of the muscular tissue of the organ be- comes actually transmuted into adipose matter. This change seems generally to commence towards the apex of the organ, and thence spreads upwards; and has appeared in some instances to be ush- ered in by inflammatory symptoms. Unlike the former species of fatty deposit, the transition here from the one to the other tissue is gradual and insensible. The affected parts are of a pale yellowish hue, softened and greasy to the touch. The external muscular layers suffer first; and from these it spreads gradually inwards till a mere shell of muscular substance has been left, consisting, in ex- treme cases, such as that recorded by Mr. Adams, of little more than the reticulated interior of the ventricle ; and even those fibres which are but little altered in appearance will impart to paper a greasy stain, as Laennec has pointed out. The latter had never, within his own experience, known it to determine a rupture of the heart, and confessed himself unable to ascribe to it any characteristic symptoms. It seems obviously, however, from the cases recorded by Mr. Adams and Dr. Cheyne to predispose to serous effusions and to apoplexy, as the impediment to the circulation, necessarily connected with such a weakened state of the heart, would lead us to expect. In two remarkable examples of greasy degeneration of the heart described by Mr. Smith of Dublin, globules of a limpid oily matter were found floating on the blood in such quantity that half an ounce of pure oil was with ease collected,—its presence affording, as Mr. Smith remarks, an additional evidence of imperfect assimilation. In one of these cases, too, rupture of the left ventricle had taken place. In similar cases the texture of the heart, which breaks down readily between the fingers, has been compared to liver by M. Bizot. , , . , r . If this affection were recognisable during life, the appropriate treatment would consist in such measures, dietetic and medicinal, as are calculated to give additional activity to the processes of digestion and assimilation, to render the circulation less languid, and to cause the absorption of redundant adipose deposits;—such 550 the heart (New Formations). as suitable exercise in a bracing atmosphere, temperance in diet, due regulation of the functions of the stomach and intestines, to- gether with the exhibition of such remedies as are known to increase the tone of the nervous, muscular, and vascular systems. The pre- parations of iodine, moreover, on account of their marked influence over the absorbents, especially those of the cellular tissue, would seem here to be deserving of trial. New formations. The heart, as compared with most other or- gans, appears to enjoy a remarkable degree of exemption from the formation of adventitious growths, if the products of ossification only be excluded, together with the warty and cauliflower excres- cences on the valves, the nature of which has been already dis- cussed in connection with the inflammation of the internal lining membrane. The presence of tubercle in the muscular structure of the heart is rare, no instance of it being given either in Louis or Lombard's tables exemplifying the comparative frequency of the occurrence of tubercular matter in the different parts of the body, and com- prising together above five hundred examples of the presence of this morbid product. Laennec, however, had met with it three or four times in this situation. M. Sauzier speaks of having detected it in the substance of the auricles of a strumous subject, and Dr. Hope once, in that of the right ventricle of a child. Andral states that it is never found in the heart without existing simultaneously in several other organs ; but neither he nor Bouillaud appear them- selves to have seen it so situated. Fungus hcematodes, the encephaloid cancer of the French, is likewise very uncommon here, though it has been met with, both infiltrated and in the form of separate tumours, but almost exclu- sively in cases where it was extensively diffused through other organs at the same time. An example of what appeared to be true scirrhus was met with by Recamier; and Rullier and Billard seem to have seen each another. A fourth instance in an advanced state of carcinomatous ulceration, occupying the whole posterior surface of the left ven- tricle, is quoted by Andral from the description by Carcassonne in the Transactions of the Royal Society of Medicine for the year 1776; which had been characterised by pungent pain, palpitations, small intermitting pulse, syncope, and orthopnoea. In a few instances on record, cancerous disease implicating the heart has appeared to have had its origin in the anterior mediasti- num, or in the fibrous layer of the pericardium. In a case of very marked cancerous diathesis, in which even the bones were exten- sively affected, we have seen a minute tumour apparently of a scirrhus nature under the pericardium lining the heart. Melicerouss, teatomatous, and various encysted tumours have also, though rarely, been discovered within the parietes of the heart. Serous cysts, varying in size from a pea to a hen's egg, have like- wise been observed by Dupuytren and others in the same situation. the heart (Cartilaginous Deposits). 551 but more commonly between the walls and the external serous membrane; and Andral once met with one, about as large as a small nut, attached to the internal lining of the right ventricle. Hydatids have also been found in the substance of this organ: Morgagm mentions an instance of this kind, which appears from his description to have been an example of the genus Cyslicercus ; and Andral has recorded a similar one. They are, as observed by the last-named author, by no means rare in the heart of measled pigs. The symptoms of these foreign growths are commonly very ob- scure. By their number, bulk, or interference with the freedom of , the valves or orifices, they are obviously capable of occasionally producing both physical and general signs; but we are not yet in possession of definite knowledge of any symptoms which can be considered truly characteristic. The encephaloid cancer or medullary sarcoma has sometimes been attended by fits of excruciating pain of a lancinating charac- ter, and by that peculiar sallow or straw-coloured complexion indicative of malignant disease; in addition to habitual dyspnoea, frequent palpitations, and finally dropsical symptoms. Cartilaginous and bony deposits. Of morbid depositions of a cartilaginous or bony nature taking place in the valves, the ten- dinous zones of the orifices, or internal lining membrane of the heart (and especially in the left side of the organ), and also in its pericardial covering, or in the false membranes interposed between its two serous surfaces after violent attacks of inflammation, we have already given an account in the sections devoted to endocar- ditis and to pericarditis. But the muscular tissue itself is liable to a similar species of degeneration or encroachment, though such an occurrence here is infinitely more rare. Corvisart has detailed a case of hypertrophy of the left ventricle, where the heart at its point, and for some way upwards, was converted throughout its whole surface into cartilage, the columnas carneas likewise patici- pating in the affection, and the mitral valve being diseased. The disease had obviously commenced by an inflammatory attack within the chest, about eighteen months before its fatal termination. The pulse was small and irregular, and quite disproportioned to the apparent energy of the heart's contraction. A similar case has more recently been met with by Mr. Smith of Dublin, in an epileptic lunatic of forty-five years of age, who died in a convulsion. '; The cavity of the left ventricle of the heart was slightly enlarged, and its parietes diminished in thickness. The muscular substance had completely lost its natural colour and consistence, particularly towards the apex of the ventricle; it was converted into a dense, white, firm cartilaginous structure, the division of which with scissors required the employment of considerable force: the altera- tion of structure had extended to some of the carneas columnas, and the auricles were hypertrophied." The cerebral vessels were found distended with dark blood, the retardation of the circulation in them being probably, as Mr. Smith observes, a consequence of the ira- 552 RUTTURE OF THE HEART (Causes). paired contractile power of the heart. M. llenauldin's singular case, in which the left ventricle was converted, as it were, into a petrifaction, the columnas resembling stalactites within its cavity, has been already alluded to. In Burns' celebrated case of ossifi- cation of the heart, the pericardial sac which adhered to the ven- tricles, and the entire ventricles themselves, with the exception of about a cubic inch at the apex and part of the columnas carneas, were " ossified and firm as the skull." The patient, a woman of sixty, had never been known to complain either of palpitation or pain in the heart. Andral has seen an ossific tumour isolated in the middle of the muscular substance of the left ventricle. It is proba- ble that, in all such cases, the deposit of phosphate of lime takes place into the intermuscular cellular tissue, and that the true mus- cular fibre in its proximity becomes atrophied and supplanted rather than absolutely transformed. A bony girdle of varying width, its average breadth being about one inch, was found by Mr. Smith surrounding nearly the entire of the base of the heart, in a man of thirty-nine years of age who had laboured under all the ordinary symptoms of diseased heart. The external surface of the ossific deposit was quite rough ; its inner portion penetrated into the muscular substance of the ventricles, coming almost in contact with their internal lining membrane. The auricles were remarkably hypertrophied, a great portion of the duty of the ventricles having devolved on them. The opposed sur- faces of the pericardium were universally adherent, and the bony matter appeared to have been originally deposited in the adventi- tious membranes of inflammatory origin ; and such is probably the true explanation of most of the superficial ossifications of the heart related by authors. Yet withal, ossification within the pericardial sac is much more rarely observed than in the case of most of the other serous membranes. y--- RUPTURE OF THE HEART. Causes.—Frequency in respect of the different cavities of the heart.—Seats of this lesion.—Symptoms and treatment.—Rupture of the valves of the heart.__ Wounds of the heart, and their treatment. Rupture of the Heart may be caused either by external violence, or by its own efforts ; but, in the latter case, previous disease of the organ seems almost a necessary condition. Amongst the external injuries capable of rupturing the heart may be enumerated falls from a considerable height, even though the person lights on his feet; heavy carriages passing over the chest; the kick of a horse, or other severe blow. By such violence, the ventricles, generally the right, as being the most exposed, the auricles, the valves, and septum, and the great vessels at their origin, have RUPTURE OF THE HEART (Causes). 553 been known to be torn across or burst, even in cases when the parietes of the chest have escaped without any fracture or other obvious injury. Of the morbid conditions which predispose to rupture, ulceration of the inner membrane, as already mentioned under the head of Endocarditis, is one, and, according to Laennec, by much the most usual one. We are not, on the other hand, aware of any well authenticated instance where it had its origin in ulceration com- mencing on the pericardial surface of the heart, though such an occurrence is obviously possible. Abscesses or tumours within the cardiac parietes discharging their contents through either or both surfaces of the organ, ramollissement, partial or general, also the condition described at a former page, under the name of Apoplexy of the Heart, fatty degeneration, or the thinning and weakening of its muscular tissue from any other cause,—and, finally, partial aneurism of the organ itself, or the continued pressure of an aneu- rism of the aorta, or other thoracic tumour, may all of them con- duce to the same formidable result; and most effectively in those cases where impediment in the orifices or hypertrophy coexists. The immediate determining cause of rupture may be either some external injury, or the momentarily augmented action of the organ itself; such as takes place from strong mental emotion, or during violent muscular exertions, as in struggling, coughing, vomiting, or straining at stool, &c. It has likewise been known to occur during an apoplectic attack, as also in the convulsions of an epileptic fit; and the Hun Attila's is not the only instance on record where the heart has given way in the act of coition. When, however, the predisposing conditions have already greatly weakened its walls, even the ordinary motions of the organ may suffice to rupture it. This lesion, when occurring spontaneously, has been observed, in a great majority of cases, in the left ventricle; the right ventricle comes next in point of frequency, then the right auricle, and lastly the left auricle. When, however, it results solely from great exter- nal violence, the proportionate frequency of its occurrence, to judge from M. Ollivier's investigations, is in favour of the right cavities as compared with the left, and of the auricles as compared with^ the ventricles,—a circumstance for which position and relative weakness of walls appear sufficiently to account. It seems from Dr. Townsend's tables to be twice as frequent in men as in women, and very rarely to occur spontaneously before the sixtieth year. In some instances more than one rupture has been detected in a single cavity. In a remarkable case related by Andral there were found no less than five lacerations in the back part of the left ventricle, unaccompanied by any obvious softening around their margins. As to the point where this lesion most commonly occurs, there is great discrepancy of opinion. Thus, according to the distinguished pathologist just named, the middle of the ventricle, notwithstanding its great comparative thickness, is the most frequent seat of rupture: and Laennec too remarks that it is rare towards the apex, though one of the thinnest parts. Dr. 554 rupture of the heart (Symptoms). Townsend, with some other writers who have attended much to the subject, stands opposed to these authorities, and asserts, on the apparently satisfactory grounds of numerical investigation, that the apex of the left ventricle, or rather a point half an inch above it, and at the same distance from the septum, is the most frequent situ- ation of this lesion, having been observed in nineteen out of the twenty-five cases analysed by him ; and hence he thought wc might deduce that Laennec was in error, in considering ulceration, which manifests no peculiar preference for this point, to be the chief source of rupture. Dr. Townsend thinks it is, on the other hand, most commonly the consequence of a form of hypertrophy described by M. Rostan as not uncommon in advanced life, in which, whilst an increase of thickness takes place towards the basis of the heart, the apex becomes thinner than natural, and a general softening of the parietes often coexists. The above evidence, in favour of the greater frequency of rupture near the point of the heart, though apparently so strong, is yet not altogether conclusive; for M. Ollivier from the examination of nearly double the above number of recorded cases of its sponta- neous occurrence, in thirty-four of which it occupied the left ven- tricle, has ascertained that the apex was its seat only in nine; thus affording a fresh proof, that, to give solidity to deductions arrived at through the numerical method, a very extended basis of observa- tion is indispensable: nor do we feel certain that the question is even yet settled. In some rare instances the external fibres of the heart have alone been found lacerated, the fissure not extending into any of its cavi- ties. When however the rupture is of some size, and penetrates quite through the parietes of the organ, death is for the most part its almost instantaneous result, in consequence of the sudden effusion of blood into the pericardium, the derangement of the functions of the heart by the pressure so caused, and the arrest of the cerebral circulation thence ensuing. Where the aperture however has been very small, and its track through the walls oblique, a coagulum has, in some very rare instances, been formed within it, and, with jhe aid of the great mass of coagulated blood in the pericardium pressing against the mouth of the wound, delayed the fatal event for a few hours, or even days. Theoretically speaking, even cicatrisation is not impossible ; and Rostan adduces a case in which this appeared to him to have actually occurred. The immediate symptoms of rupture of the heart are, faintness, absence of pulse, sudden syncope with cold extremities, and col- lapsed features—a state of things very different indeed from that occurring in apoplexy with which the ignorant so often in the first instance confound these cases. In the effusion of blood within the head, death rarely, if ever, ensues so instantaneously. In some instances of rupture of the heart, the fatal stroke has been preceded for some time by pain in the prascordium, extending occasionally to the left shoulder, with or without other symptoms of heart disease; whilst in others no premonitory ailments have existed. THE HEART (Wounds). 555 Of the treatment of so suddenly fatal an affection it is almost unnecessary to speak. In the very unusual cases, however, where life is not instantaneously cut short, the obvious indications would be to support the nervous system in the first place under the shock which has been inflicted, and subsequently to keep down the action of the heart by absolute repose of mind and body, all even the slightest exertion of the voluntary muscles being scrupulously avoided ; by complete abstinence from solid food, and making use even of liquids only in the smallest quantities, and by the employ- ment of every means likely to promote the formation of a clot within the ruptured orifice, and to prevent its dislodgement. The heart is subject, moreover, to another species of partial rupture, implicating its valves, their tendons or muscular columnas, the occurrence of which commonly gives rise to sudden and extreme sense of suffocation, with excruciating pain, violent dis- turbance of its action, and indescribably tumultuous sounds within the chest. On applying the hand to the prascordium in a case of this kind, a singularly confused tremulous pulsation has been felt over the whole cardiac region. Various species of bellows-murmur will be audible where, the attachments of a valve having been extensively destroyed, the lacerated fragments flap to and fro in the corresponding orifice, and give rise to regurgitation, and pro- bably also to more or less obstruction of the sanguineous current. This formidable accident has in some instances appeared to result from violent efforts, as in coughing; but has most probably in such cases been preceded by ulceration of the yielding part. Dr. Townsend has met with it in no less than three patients who were carried off by phthisis, and Bouillaud in a fourth case of the same kind, when the fits of coughing had been peculiarly violent: others have noticed it in connection with hypertrophy and dilatation of the heart. When life has been prolonged for some time after its occurrence, all the usual symptoms of heart-disease have gene- rally soon set in, and on dissection the ruptured tendons have occasionally exhibited granulations on the seat of the laceration. Wounds of the heart, although in a great proportion of instances immediately fatal, have yet in some and not very rare cases been survived for some days or even longer. M. Ferrus tells of a madman who forced a short iron instrument between the fifth and sixth ribs into the heart, which it traversed obliquely from below upwards, passing through the left ventricle and septum, and who yet lived for twenty days afterwards. A soldier, who fell on his bayonet, so as to penetrate the left ventricle, not only survived for two days, but was able during part of the time to walkabout almost as if no very serious injury had been inflicted; but at length went off suddenly in the effort of evacuating the bowels. There is a case on record, apparently well authenticated, of an individual who survived a gunshot wound in the chest for six years, a ball being found upon dissection in the right ventricle; and similar instances have presented themselves in the animals of chace, the ball being occasionally discovered embedded and incysted in the walls of the 556 the heart (Polypous Concretions). heart. In Dupuytren's Lecons Orales several examples of wounds of the heart which did not prove fatal for a considerable time after their infliction, are to be met with. The heart has occasionally been penetrated by the end of a fractured rib when the accident has occurred under the influence of great external compression, even when no laceration of the parietes had been caused; as, for example, in the case of a man who was jammed between the wheels of two carts, and who became immediately insensible, and speedily breathed his last. According to M. Ollivier d'Angers, the chances of surviving for some time or even recovering completely, are considerably greater in the case of wounds of the auricles or right ventricle than those of the left ventricle; so likewise when the wound is very narrow and oblique. The circumstance of the weapon having remained fast in the wound has been known, as in the celebrated case of Epaminondas, to retard for a brief space the fatal hasmorrhage. Some of the examples of wounds of the heart alluded to above show that we should not absolutely and invariably despair of their recovery as of a thing utterly impossible. The treatment, where the sufferer survives for a few hours after the closure of the external wound (which, to promote the for- mation of a coagulum, should be instantly effected) consists in free venesection, the application of cold to the exterior of the chest, and in keeping the individual, moreover, in a very cool atmosphere, exhibiting digitalis largely, and enjoining absolute quietude and abstinence. When the sufferer appears in imminent danger of suffocation from the internal effusion of blood, it might sometimes perhaps be proper to reopen the external wound, or if it be cicatrised, even to make a new aperture for the removal of the contained fluid, but obviously only in such cases where, from the return of the heat and colour of the surface, there is reason to suppose the hasmor- rhage has at length ceased. The subject of wounds of the heart, though strictly surgical, has been introduced here chiefly on account of the light which some acquaintance with it is calculated to throw on rupture of tlje organ, a condition with which it is so closely allied. y POLYPOUS CONCRETIONS OF THE HEART. Origin and mode of formation.—Anatomical characters.—Symptoms.__Prog- nosis.—Prophylactic treatment. During a considerable part of the last century, polypi, or firm and adherent coagula of blood within the cavities of the heart and great vessels, were looked upon commonly as a fertile source of cardiac symptoms, many of the results now ascertained to have their origin in organic affections being at that time erroneously ascribed to them. Morgagni, and a few others of the more en- the heart (Polypous Concretion*). 557 lightened pathologists of his day, stood in opposition to the popular opinion on the subject, and denied their influence altogether, believ- ing them to be merely & post mortem appearance, or, at the most, that the coagulation did not take place till the vital energies were on the very point of extinction. Both of these opinions were however, too exclusive. The more accurate investigations of later pathologists have proved satisfactorily, that such formations do occasionally originate during life, and that it is possible for them to be the source of very formidable symptoms; whilst, at the same time, they have rendered it evident! that in the vast majority of instances they occur either in the very last moments of existence, or after death. Hence the division of polypous concretions into true and false. That the blood is capable of coagulating, and even becoming organised within its natural recipients in the living body, we have ocular proof, in what takes place in inflamed and obstructed ar- teries and veins; and analogy would lead us to expect a similar change in a portion of the contents of the heart under similar circumstances. Accordingly, it is in those cases, where the pas- sage of the blood through the orifices of this organ are impeded, either by disease of the valves, aneurism of the aorta, or obstruc- tion in the lungs, or where the lining membrane in contact with this fluid is inflamed, that this formidable change is most prone to occur; and this result seems often to be facilitated by a coexisting inflammatory condition of the blood itself, in which the fibrinous portion is in excess, as well as by anything which enfeebles the organ and retards or temporarily arrests its action, as in the instance of protracted syncope. Hence the two free abstraction of blood, or the injudicious employment of digitalis, tartar-emetic, hydrocyanic acid, and other agents which greatly reduce the powers of life, are fraught with peculiar danger in the latter stages of heart-disease; in which the machinery of the circulation, already working imperfectly, is, by comparatively slight causes, readily brought to a final stop. Polypi, when there is reason to suppose that they have been formed for some time previous to death, are peculiarly firm, tena- cious and fibrous in their structure, and adhere so strongly by a filamentous union to the parietes and columnas carneas, with which they are interlaced, that they break across in attempting to detach them, and leave the surface of the organ rough with their frag- ments; whilst on scraping these away, the membrane underneath is often observed to be covered with bloody specks, indicative of incipient vascularity, induced apparently by the irritative contact of the newly-formed substance, and constituting a preparatory step to its organisation. In addition to these appearances it has been pointed out by Laennec, that in place of being uniformly white or yellowish like recent concretions, or the buffy coat of the blood, they are in parts of a pale flesh colour, or have a slight violet tinge, or finally are speckled over with bloody points, the rudiments of vessels • if of a still older date, they are perfectly consolidated with 71 558 the heart (Polypous Concretions). the endocardium, and are obviously as completely organised as polypi of the mucous surfaces. Polypous concretions are more frequent in the right side of the heart than in the left; probably both in consequence of the frequent obstruction to the blood in its passage through the lungs, and of the extension of inflammation from the veins to its lining membrane, and the subsequent influence of this on the contained blood ; as well as also from the introduction of purulent matter from distant parts, which comes into earliest contact with this portion of the organ, and forms there a nucleus, around which the fibrinous matter is deposited. When, however, extensive and firm coagula do present themselves in the left cavities, they ought always to be examined with peculiar care, as from the ordinary recession of the blood from this part of the organ immediately after death, there is the greater probability, d, priori, that any such adherent masses have been formed during life. Within the auricles, the concreted fibrinous matter ordinarily presents itself in the form of a thick lining over their internal sur- face, diminishing the capacity of their cavity, and sometimes by prolongation into the corresponding ventricles, embarrassing the action of the auriculo-ventricular valves, and compressing and flat- tening the muscular columns. When there is reason to suppose them of long standing, they are sometimes of a friable texture, re- sembling, to use the words of Laennec, an old rich cheese, or the decomposed fibrin in an old arterial aneurism. The globular vegetations of Laennec, already spoken of, adhere occasionally by a pedicle of obviously more recent formation than themselves, and here, probably, have originated in the organisation of a small coagulum of blood. They are of various sizes, from that of a pea to that of a pigeon's egg, are hollow, and contain within their cavity a sanguineous fluid, if recent, or a sanious or puriform one occasionally, if of longer standing. The wart-like vegetations of the valves, likewise, have been supposed by Laennec to have their source in minute polypous concretions, rather than in the effu- sion of coagulable lymph, as asserted by Kreysig and Bouillaud,— for their consistence and colour is very similar to these substances, and they display, moreover, frequently a violet tinge towards their centre, apparently the trace of the colouring matter of the blood. It would perhaps, however, be nearer the truth to say, that they originate sometimes in the one way, and sometimes in the other, or that both, when the excrescences are considerable, may be con- cerned in their formation. The very fact of their more frequent occurrence on the left side, where coagulation is a much rarer, and inflammation a more frequent event than on the right, must prevent us ascribing them solely or even chiefly to the source advocated by Laennec. The blood, when once it is coagulated, and organised within the heart, as in other situations, exercises the power of a living substance, and occasionally secretes within its new-formed tissue purulent, tubercular, or even osseous matter. The ossific concretion met with by Burns within the heart, which was about the heart (Polypous Concretions). 559 equal to a hen's egg in size, had probably originated in this manner. Kreysig has attributed to the inflamed parietes of the heart and bloodvessels a power of determining the coagulation of their con- tents. That inflammation of the endocardium promotes in some degree the formation of polypous concretions is indeed highly probable, the effused lymph or pus forming a centre, around which the morbid solidification commences ; but the existence of such a condition cannot be admitted as essential thereto. The low degree of inflammatory action requisite, in order that they shall become eventually solidly adherent to the interior of the organ, may as well be considered the result, as the cause, of their presence, and probably often ensues merely upon the pressure and irritation pro- duced by them. It is not in the young and sanguineous most com- monly, but rather in the aged and debilitated, that this morbid appearance is met with; and the stagnation of the blood, however induced, seems alone, in any case, quite sufficient to cause its sepa- ration into its elements. The symptoms of polypous concretions of the heart are nearly all referrible to the impediment to the circulation which they cause; as, for instance, the extreme dyspnoea, violent palpitation, and ten- dency to faint, sudden venous congestion, coldness of the skin and sense of sickishness, extreme distress and restlessness,—all of which are particularly characterised by the suddenness of their superven- tion. They are in some cases intermittent, making their appear- ance at uncertain intervals, and ceasing as instantaneously as they commenced. In such instances it seems probable that a portion of the newly formed mass floats loose by at least one of its extremi- ties, so as to permit of its being carried temporarily by the current of the circulation into the auriculo-ventricular opening, or into the orifice of one of the great vessels. When the effects are more per- manent, this circumstance may with great probability be ascribed to the greater magnitude and fixity of the fibrinous substance, and its constant interference with the play of the valves and with the freedom of the orifices of the heart. The existence of polypus, says Laennec, is almost certain, when the motions of a heart, which had previously been beating regu- larly, become all of a sudden irregular, obscure, and confused to such a degree that we can no longer analyse them. The group of symptoms specified by Bouillaud as diagnostic, if they come on all at once, is as follows:—tumultuous pulsations of the heart, with dulness or obscurity of its natural sounds, together with a blowing, hissing, or musical murmur, orthopnoea, or a degree of difficulty of respiration bordering on asphyxia, in consequence of the obstructed state of the pulmonary circulation, extreme anxiety, congestion of the venous capillaries, and even loss of consciousness, coma, stertor, and occasionally convulsions resulting from the gorged state of the cerebral vessels, together with a remarkably small pulse and cold extremities. If in the course of an acute inflammation of the heart, very great 560 HYDROPERICARDIUM (Causes). difficulty of breathing and extreme disturbance of the circulation set in suddenly, the rapid formation of the concretions in question may be suspected, with a high degree of probability, as their source; so likewise when there is sudden and very violent aggra- vation of an habitual dyspnoea. The prognosis in this affection is, generally speaking, of the worst possible kind. As, however, coagula within veins have been known to undergo absorption, it is just within bounds of possibility, that those of the heart also when small may, in some very rare cases, be susceptible of spontaneous removal. The best prophylactic treatment, according to Bouillaud, consists in the repeated abstraction of blood and free use of diluents in those cases of organic and inflammatory disease, in which their occur- rence is most to be apprehended ; but Dr. Hope very justly cautions us against the empirical or indiscriminate use of bloodletting in organic diseases of the heart, and especially in cases of dilatation and softening, or even in the advanced stage of valvular lesions when there is already great debility, as here it will not only fail to prevent the formation of polypi, but, like the imprudent employ- ment of digitalis and nauseants under the same circumstances, will, by augmenting the languor of the circulation, directly favour their occurrence ; whilst at the same time it tends unnecessarily to reduce the strength, accelerate the advance of dropsy, and the fatal termina- tion of the complaint. M. Legroux puts some faith in the exhibition of potass or soda, or their subcarbonates,from their power of diminishing the tendency of the blood to coagulate,—a property of the alkalies well known to Huxham, who deprecates their continued use, lest a dissolved state of this fluid should be induced. Dr. Copland thinks the sub- borate of soda the most influential agent for preventing the concre- tion of fibrin, and dissolving coagulable lymph. The efficacy of mercury in effecting the latter object is also well known ; but un- fortunately in the vast majority of cases there is little time for the trial of this or any other remedy. HYDROPERICARDIUM. Causes.—Symptoms.—Treatment. Dropsy of the pericardium may, like that of the other serous sacs, be either of an active or passive nature. The active species, or that depending on increased energy of the exhalants, is scarcely ever ob- served save as a consequence, or one of the latest stages, of inflammation of the pericardium, in which, when the original turbid, albuminous, or sero-purulent effusion has been absorbed, a transparent watery secretion gradually takes its place, which is either colourless, or with a slight greenish or pale yellowish tinge. HYDROPERICARDIUM (Causes). 561 Its occurrence in an active form, as an idiopathic and insulated atlection, is so extremely uncommon, that it is difficult to point to an unequivocal example of it even in the writings of authors who have had the largest experience in diseases of the heart. The passive form, or that resulting from impediment to the cir- culation, in consequence of obstruction in the heart or lungs, or from debility of the heart's action, is, on the contrary, by no means unfrequent; and its existence maybe anticipated in most cases when there is a general dropsical tendency throughout the system, as well as in the final stage of many typhoid and malignant dis- eases, in which the fluids are deeply contaminated, and the capil- laries relaxed ; as in cases of cancer, for example, the worst forms of puerperal fever, the exanthemata, when accompanied by symp- toms of pulrescency, &c. As to the quantity of effusion requisite to constitute hydroperi- cardium, authors are not agreed. After death, whatever may have been its source, there is usually found a small portion of a serous fluid, amounting generally to a few drachms, within the pericar- dial sac, poured out either during the mortal struggle or after its termination. An effusion in such minute quantity, and taking place under such circumstances, does not fall within the scope of the term hydropericardium ; nor does Corvisart recognise any thing under six or seven ounces as being entitled to the appellation. Laennec has not. ventured to fix on any precise quantity as a mini- mum, contenting himself with saying, "a few ounces or a quantity exceeding that commonly found after lingering deaths." Bouillaud thinks that any thing above a couple of ounces may be considered as an example of dropsy of the pericardium, even though the mode of death may have been tedious. In many cases, however, there is no room for doubt as to the amount of fluid being sufficiently. great to constitute a morbid state, as so much as one, two, or three pints are sometimes found; and Coryisart mentions an instance where there was no less than eight pounds. The serous membrane in some of these cases has been observed to have an opaque whitish or macerated appearance.* Amongst the symptoms occasionally present, are a sense of weight about the heart and inferior part of the chest, and oppres- sion in the breathing depending probably on the pressure of the distended sac on the lungs, diaphragm, and neighbouring parts. The pulse is generally small, frequent and irregular, the integu- ments of the prascordial region being occasionally cedematous, whilst orthopnoea and tendency to syncope frequently coexist. But all these symptoms taken together are very far from being conclu- * Under the title of hernia pericardii, a curious case has recently been described by Mr. Hart, in which, along with hypertrophy of the heart, and dropsical effu- sion into the'pericardium, there existed a pyriform sac, likewise containing water, occupying the anterior mediastinum, and connected by an aperture at its narrower end with°the pericardial sac, close to its reflection on the aorta. If not congenital, it was probably formed by gradual pressure of the effused fluid against a weak and yielding portion of the pericardium.—Author. 562 hydropericardium (Treatment). sive as to the existence of an unnatural effusion ; nor even, though it should be present, do they necessarily depend on it, but much more frequently on coexisting organic lesion within the heart. Senac declares he had seen a motion of fluctuation in the left side of the chest in cases of pericardial effusion ; and Corvisart believed he had himself felt a similar motion in the same situation; but as nearly all subsequent observers have sought in vain to confirm these observations, it seems probable that the tremulous feeble im- pulse of the heart may have led to deception. In cases of considerable effusion there is a striking prominence of the prascordial region with bulging of the corresponding inter- costal spaces, together with a very extensive dulness, sometimes reaching even from nipple to nipple, and all along the sternum from near the second rib to the ensiform cartilage, in a pyramidal form with the base towards the diaphragm. The pulsations are fre- quently quite imperceptible, at least in the supine position, and when felt in the erect or prone posture often present themselves at suc- cessive moments, as Corvisart remarks, in different points of the prascordium, sometimes more to the right, sometimes more to the left than natural, giving the idea of the organ floating free, and altogether unrestrained by its enveloping sac ; and they are usually moreover, preceded, with an appreciable interval, by the com- mencement of the systolic sound. The sounds of the heart are feeble and distant, as heard immediately opposite the organ, but are much more audible at the top of the sternum opposite the arch of the aorta, and over the great vessels at the root of the neck; which latter circumstance aids us in distinguishing the case from one in which the heart is really acting very feebly. Withal, the diagnosis of hydrops pericardii is extremely difficult unless the effusion be considerable : if it were less than a pint, La- ennec thought the recognition of its presence impossible; and not by any means certain though of double or even triple this amount: but from its rarity as an idiopathic or leading affection he consi- dered the discovery of it of the less importance. The greater tact which many now possess in regard to the practice of percussion, has however recently, in a considerable degree, diminished the difficulty of ascertaining the presence of pericardial effusion. Thus where it is only of a moderate quantity, M. Piorry speaks confidently of being able to detect it by making the patient whilst lying down turn alternately on the right and left side, and finding, by practising percussion successively in these two postures, that'there is an obvious dulness which changes its place correspondently from the right edge and the upper part of the sternum to its left and up- per part, and cartilages of the upper ribs. Treatment. The active idiopathic form of hydropericardium, if recognised in its earlier stage, would of course require to be treated on the same principles as other active dropsies—by blood- letting, mercurials, purgatives, and counter-irritants, and subse- quently by diaphoretics, digitalis, and other diuretics. And similar means in a modified form, may afford useful aid in the passive or hydropericardium (Treatment). 563 secondary variety ; though here the proper management of the primary atlection or organic cause forms, in cases which are not as yet altogether hopeless, the chief object. As a forlorn hope the removal of the fluid by a surgical opera- tion has been recommended by high authority, but the practice has as yet but little support from actual experience. The operation proposed by Senac was paracentesis of the pericardium, by the introduction of the trocar between the ribs. Corvisart thought that if an operation were justifiable at all, the best method of pro- ceeding would be to lay open the parietes first, and then the peri- cardial sac cautiously with the knife; whilst Laennec expresses a preference for trepannation of the sternum just above the ensiform cartilage, as in this way we avoid laying open the pleuras, and escape the error of Desault, who, attempting to perform the opera- tion previously described, and having made his incision between the sixth and seventh rib of the left side opposite to the apex of the heart, mistook a circumscribed pleuritic effusion for a distended pericardium, as was subsequently obvious on dissection. It has been proposed, somewhat too boldly we think, by Laennec, to inject the serous bag when emptied of its contents with some slighly irrita- ting fluid with a view to inducing adhesion of its opposed surfaces, as in the ordinary operation for hydrocele. Bouillaud, without advocating either the operation or this addition to it, of which he has had no experience, yet thinks that what we know of the history of pericarditis and of its frequent termination in comparatively salutary adhesions, proves that the danger from such a proceeding is at least much less formidable than was once thought. Romero, who has thrice made an opening into the pericardium, in order to evacuate prasternatural accumulations of fluid, and twice successfully, makes his incision between the fifth and sixth rib, first into the pleural sac; and then having satisfied himself of the existence of a fluid in the pericardium, he next lays this open with a pair of curved scissors, and lets its contents run off into the pleuras, from whence they are subsequently drained away by placing the patient in such a posture as favours their escape by gravitation. During the whole proceeding every care must be taken to pre- vent the entrance of air. This operation has the advantage over that of Laennec of evacuating any fluid which may happen, as is so frequently the case, to coexist in the pleural sac ; whilst at the same time if an error in diagnosis, similar to that recently alluded to, have been committed, it may be detected in the first stage, the actually existing effusion evacuated, and the additional risk of opening the pericardium avoided. But this or any other operation can scarcely ever be warrantable, except where the affection sought to be relieved is idiopathic, or depending on local inflammation or increased action of the serous membrane. Where there is organic disease of the heart or lungs, or constitutional diseases of the kinds already specified, no judicious practitioner would ever for a moment think of having recourse to it. 564 /the pericardium (Secondary Efu&ions). (/ SECONDARY EFFUSIONS INTO THE PERICARDIUM. Fluids of various kinds have been known to make their way into the pericardium from neighbouring organs in which they were originally poured out. Thus those of a purulent or semipurulent description may get into the pericardial sac in consequence of the bursting of abscesses in that direction which had been formed in the cellular membrane of the mediastinum or in the lung, or from the irruption of a circumscribed pleuritic effusion through the medium of a gradual process of interstitial absorption. An instance has been recorded by M. Alibert of the rupture into the pericardium of a very large hydatid or serous cyst, said to equal the foetal head in magnitude, and which had been developed between the lung, diaphragm, and exterior of the pericardial sac. It had previously considerably displaced the heart to the left side. Its bursting in the manner indicated gave rise to sudden precordial pain, orthopnoea, tumultuous action of the heart, and a membranous crackling sound, synchronous with the respiration; and was fol- lowed by death within a few hours. A very interesting case has been recently described by Dr. Graves, of abscess of the left lobe of the liver making its way through the diaphragm into the pericardium, and also by three several per- forations into the stomach. The abdominal tumour which had previously been very obvious, began, soon after the formation of these preternatural communications apparently, to diminish in size, and no longer imparted a sense of fluctuation, but became tym- panitic, doubtless from the entrance of air into it from the stomach. The secondary pericarditis thus induced manifested itself in the first instance by the sudden supervention of acute pain, by palpitation, and a sense of burning heat under the left breast; a rough bellows murmur and a species of creaking accompanied both sounds of the heart ; and this was converted into a loud frottement when con- siderable pressure was employed. On the following day a metallic click indicative of the dropping of a fluid, and an emphysematous crackling were present. The patient being eventually run down by diarrhoea, caused by the escape of the purulent matter into the bowels, on dissection the pericardium, which was of four times its natural thickness, was found sprinkled internally with red dots, and arborizations, and coated over with lymph and minute semitrans- parent granulations. A remarkable case has been recorded by Mr. Thurnam where the pericardium of a man who had been knocked down by a carriage, and thus almost immediately killed, was found filled with blood, though there was no rupture of the heart or great vessels within the sac. The effusion appeared to have its source in rupture of the veins in front of the trachea by the ends of the fractured clavicles, and to have forced its way through the intervening cellular membrane till it reached the apex of the pericardial sac, which it lacerated at length by its accumula- tion and pressure. the HEA.RTJ;&isplacement). 565 PNEUMOPERICARDIUM ANI> HYDROPNEUMO-PERICARDIUM. When bodies have been kept for several hours after death before being opened, especially when the atmospheric temperature is somewhat high, air is very frequently found within the pericardium, as well as in other shut sacs, and escapes on an incision being made, with a hissing noise. But besides these instances in which the air has obviously its source in post mortem decomposition, examples are occasionally met with where there is every reason to believe that it had existed during life, being evolved generally either during the final struggle or at the most but a few days before dissolution. It is in such cases almost invariably accompanied by a liquid effusion, from the decomposition of which, if of a foetid character, it has for the most part its origin, though at the same time we are by no means prepared to deny the possibility of its being occasionally a product of direct secretion from the vessels. Its presence during life is indicated by a preternatural degree of resonance, of a tympa- nitic character, elicited on percussion in the prascordial region, as also by a sound of fluctuation produced by the motions of the heart through the elastic and inelastic fluids, as well as by forcible inspira- tions—a sound compared by Brichetau to the plashing of the wheel of a watermill. On dissection, if we would ascertain accurately the quantity and quality of the gaseous fluid present, the body should be opened under water, in order to facilitate its collection. Laennec has expressed his belief that those cases in which the sounds of the heart are audible at some distance from the chest, depend for this peculiarity on the existence of air within the peri- cardium ; but in support of this very improbable opinion he adduces no proof. DISPLACEMENT OF THE HEART. We have already seen that the heart when greatly increased in size is felt to extend its pulsations to unusual situations, generally more to the left side or lower down than natural; but besides this enlargement of the limits within which it is perceptible, it may be thrust out of its place by various extraneous causes, such as tumours in its vicinity, augmented dimensions of neighbouring organs, and morbid effusions. Such unusual position then, when 72 566 the heart (Displacement). ascertained not to have been congenital, is to be considered an evidence of some serious organic change having taken place within the thoracic or abdominal cavity. The most frequent cause of this phenomenon is, unquestionably, a large pleuritic effusion, which, according to its situation and quantity may push the heart over either into the centre of the chest or to the right side, or, on the contrary, further than natural to the left. Hasmorrhage into the pleural sac from injury will have similar results. Sudden and even permanent displacement has been known to result from external violence, as in the remarkable instance recorded by Dr. Stokes when it originated in the compression of the chest by a millwheel by which the heart was forced into the right side of the thorax. The individual, notwithstanding the severe symptoms which immediately supervened, survived the accident many years, and was occasionally even capable of taking very violent exercise, his heart ever after continuing to beat on the right side. Aneurisms of the aorta, pneumothorax, or an emphysematous state of the lung, thoracic and abdominal tumours, ascites, and enlarged liver, are amongst the occasional causes by which respec- tively the heart may be displaced, either downwards, laterally, or upwards. Instances are alluded to by Dr. Stokes where this organ has been felt beating as low as the ninth intercostal space, in con- sequence of very extensive pulmonary emphysema, a morbid affec- tion which, as has been remarked by an able anonymous writer in the British and Foreign Medical Review, must, by the pressure caused by it on the great vessels, tend greatly to the development not only of asthmatic symptoms but of actual organic disease of the heart. It has further been supposed, with great probability, by Dr. Stokes, that the heart may sometimes be drawn over in a very remarkable degree to the right side, by the absorption of a large pleuritic effusion in that part of the chest; especially when it takes place rapidly, and when in consequence of the lungs being closely and extensively adherent, the parietes of the thorax cannot fully accommodate themselves to the diminished contents of the cavity: and a case by Dr. Abercrombie, in the Edinburgh Medical Irons- actions, shows that a similar effect may sometimes be produced by atrophy of one lung, accompanied by an hypertrophic condition of the other. In a case which occurred to Dr. Hope, in which the heart was just so far displaced towards the right, by a pleuritic effusion of the opposite side, as to be impacted between the sternum and unyielding spine, the augmented impulse was such as to have conveyed to a less experienced auscultator an erroneous idea of the existence of hypertrophy; and Dr. Stokes has known a similar effect produced by tubercular consolidation of the lung behind the heart. In cases of diaphragmatic hernia, generally of congenital origin, the introduction of the intestines into one side of the chest necessa- rily displaces the heart more or less to the opposite side. Prolapsus the heart (Hernia) 567 of the heart, or that condition in which, from its unusual weight, andlfie relaxation of the parts by which it is suspended, it pushes the diaphragm before it, and encroaches on the abdominal cavity, is a very uncommon state, if indeed it is at all to be recognised as a distinct affection. Corvisart, who speaks of it, supposes it capable of causing severe pain in the oesophagus and cardiac orifice of the stomach, difficulty of deglutition, and imperfection of the digestive process, with frequent tendency to nausea and vomiting. The diagnosis of displacement of the heart is based on the results of percussion and auscultation, and the examination of the prascor- dial region by the eye and by the touch, taken together with the history of the case, from which last we learn whether the phenomena are of comparatively recent origin, or at least not coeval with birth, and so independent of congenital transposition of the organ here- after to be spoken of. When the displacement is very considerable, the functions of the heart maybe much embarrassed, as is manifest from the severe palpitations occasionally complained of in these cases. In the instances described by Dr. Graves and Dr. Stokes, where the heart was thrust upwards and to the right side, as high as the third intercostal space, by an aneurism of the abdominal aorta, the aneurismal tumour itself presented a double pulsation (the first stroke coinciding with the arterial pulse), imparted to it obviously by the contact of the heart; whilst at the same time two sounds were audible corresponding to the natural double sounds of the latter organ. A similar double pulsation was observed by the same authors in a case of aneurism of the ascending aorta, and in two others of a like nature by Dr. Townsend. HERNIA OF THE HEART. Hernia of the Heart (Ectopia cordis), though of congenital origin, may as well be briefly alluded to here. From original deficiency of a portion of the sternum, cartilages of the ribs, diaphragm, or abdominal muscles, the heart of the foetus, or new born infant, may be found protruding either on the exterior of the neck or chest, covered only with the common integuments ; or into the abdominal cavity; or finally forming a portion of the contents of an umbilical hernia. Such examples of displacement as are here spoken of, generally occur in connection with other congenital malformations, often from their very nature incompatible with the continuation of existence for any length of time after birth, and are hence obviously rather matter of curiosity than of practical interest. In some very rare instances, however, life has been prolonged even to a very advanced period, notwithstanding the existence of such singular 568 the heart {Malformations). malposition of the heart, as in the very remarkable case recorded by Deschamps, in which this organ was found on dissection occu- pying the place of the left kidney. An interesting case of partial" ectopia cordis," in an infant which survived its birth for three months, has been lately published by Dr. O'Bryen of Bristol in the sixth volume of the Transactions of the Provincial Medical and Surgical Association. In consequence of absence of the ensiform cartilage and of the part of the recti muscles and diaphragm usually attached thereto, a portion of the pericardium containing the apex of the left ventricle preternaturally elongated, protruded through the opening, and lay immediately underneath the common integuments, along with a portion of the transverse arch of the colon. In this tumour the following motions were observed :—1 st, a lessening in size and contraction of its whole body, which was obviously the systole, as being synchronous with the first sound of the heart, and with the pulsation of the carotid ; whilst at the same time its whole mass was carried forcibly downwards: 2d, a movement of dilatation during which the tumour became tense. and appeared shortened ; while at the same time it was much enlarged by as active a force as that of contraction, powerfully separating the fingers when an attempt was made to compress it; and immediately after which a sensation was imparted as if of a wave of fluid rushing into it and communicating a thrill to its walls. This movement of dilatation was synchronous with the second sound of the heart, but appeared to continue for some time after it. No distinct period of rest was perceptible after the dilatation. The heart in this as in Harvey's case appeared insensible to the touch. If the phenomenon accompanying the second sound be admitted to have been accurately observed, they afford stronger evidence in favour of an active power of dilatation in the ventricles, than any we have yet met with. MALFORMATIONS OF THE HEART. Congenital Malformations. Transposition of the heart.—Acardia.—Bicardia. Congenital irregularities in the structure and relations of the heart, as may be deduced from the works of Winslow, Beclard, the St. Hilaires, &c, are referrible either to diseases occurring during the progress of the evolution of the foetus, inclusive of inter- rupted development, or else to primitive anomalies in the germ the heart (Malformations). 569 (excess or malposition of parts), or to both these sources together. Of the reality of the second of these causes, we have incontestable evidence in cases of Transposition of the Heart, in which the organ is not only placed in the right side of the thorax, but has, moreover, its aortic ventricle turned to the right, and the pulmo- nary ventricle to the left, and where a similar transposition of all the other thoracic and abdominal organs coexists, the aorta running down along the right side of the spinal column, the vena azygos along the left; the lung on the right side having but two lobes, that on the left three; the liver, duodenum, head of the pancreas, and the cascum being in the left side of the abdomen ; the great curva- ture of the stomach, the spleen, and descending colon, lying to the right side. Such anomalies of position are by no means incompatible with the due exercise of the functions, or with attainment of advanced age. Though very rare, the practical physician should be aware of the possibility of their occurrence, to prevent the mistaking the physical signs of such irregular congenital conditions for evidence of acquired disease. Aeardia. The heart has been discovered to be altogether wanting in some foetuses; and this is said by Beclard to be universally the case in acephalous monsters, atrophy or absence of the upper part of the spinal marrow also ordinarily coexisting. Bicardia. Two hearts have, on the other hand, been found within the chest of the foetus in some extremely rare instances; but the accompanying plurality of other organs naturally single, has indi- cated the source of this phenomenon to be the intermixture of two germs. A case in which three ventricles were supposed to exist, has been recorded by Chemineau, but M. Is. G. St. Hilaire thinks it was probably only an example of a supernumerary septum. A second appendix has been noticed, in connection with the left ventricle by De Haen; and we have the authority of Breschet for believing that the pericardium has been observed to be entirely absent. ^s^ Preternatural Communication between the two Sides of the Heart. Forms of preternatural communication between the two sides of the heart.— Cyanosis.—Symptoms of this lesion.—Progress.—Treatment. Of this, the chief forms are permanence of the foramen ovale, abnormal apertures in other parts of the septum of the auricles, or in that of the ventricles, or in the common point of junction of both septa, throwing the four cavities into one; origin of the aorta or pulmonary artery from both ventricles simultaneously; and con- tinued patescence of the ductus arteriosus. 570 the heart (Malformatio'is). Many of these irregularities have, in several instances, been known to coexist in the same individual, and frequently along with additional anomalies in the origin of several of the great vessels.* When only one of these preternatural communications exists, by much the most common is the first of those mentioned above. A mere oblique opening between the over-lapping and imperfectly adhering edges of the foramen ovale does not, however, constitute an example of the malformation or lesion here spoken of; for a valvular aperture of this kind, in consequence of the counter-balanc- ing pressure made on each of its sides simultaneously, will obvi- ously not allow of the mixture of the contents of the adjacent cavi- ties, and accordingly, though it is a condition so often found on dissection (in one out of every four subjects according to Bizot), it is known not to give rise to any morbid symptoms. To have an injurious influence, it is necessary that the opening should be nearly at right angles to the septum, direct and patulous; and even here, many months of early infancy may elapse, ere any very obvious functional disturbance ensues; its first manifestations taking place occasionally during the irritation of dentition, or when the child begins to walk. The diameter of the open foramen ovale, in these cases, varies from two or three lines to upwards of an inch ; whilst, in other instances, in place of one large opening, there are several smaller ones. M. Louis, after investigating the matter very scrupu- lously, has come to the conclusion that the perforated condition, not only of the auricular septum but also of the ventricular, is con- genital in almost every instance, as the edges of the aperture are rounded off, smooth, and polished, and occasionally membranous, or even somewhat tendinous, and without any traces of softening or * In a "Treatise on Cyanosis," by Dr. Gintrac of Bourdeaux, published in 1824, the following results have been deduced from 53 cases analysed by him :— In 33 instances the foramen ovale was open ; in 22, aorta arose from both ventri- cles ; in 22, the pulmonary artery was contracted ; in 14, the ductus arteriosus was open ; in 5, ventricular septum imperfect; in 5, pulmonary artery obliterated; in 4, a single heart, i. e., only one auricle and ventricle; in 4, the aorta arose from the right, and the pulmonary artery from the left ventricle (foramen ovale open, and occasionally also the ductus arteriosus) ; in 1, the aorta obliterated. The following additional deviations from the natural state have been noticed by other authors :—The existence of two auricles with only one ventricle; or, in other words, total absence of the ventricular septum (Wolff, Breschet, Farre) ; the four cavities thrown into one, from a deficiency of the septa at their common point of junction (Thibert, cited by Laennec) ; the pulmonary artery arising from both ventricles, and sending off the descending aorta,—the ascending originating naturally (Sir A. Cooper) ; the right auricle opening into the left ventricle, the ventricles communicating by a preternatural opening, and the auricles by the open foramen ovale (Holmes) ; the right ventricle bifid (Kerkringius) ; the arch of the aorta double (Bertin, sen.) ; the coronary veins opening into the left ven- tricle ; the inferior or the superior cava opening into the left auricle; the foramen ovale closed in the foetus ,- the valves of the heart, adherent along their edges, and consolidated into one substance, leaving only a small central aperture, or else perforated by numerous holes, or altogether absent (Morgagni, Bertin, Laennec, Desires). —Author. the heart (Malformations). 571 other recent morbid process; whilst further, the coexistent lesions are frequently of an obviously congenital nature, such, for instance, as the permanence of the ductus arteriosus, the origin of the aorta from the right ventricle, &c. The greater frequency of morbid altera- tions in the right side than in the left, contrary to what is observed in ordinary or acquired disease of the heart, is likewise adduced in proof of a primordial source ; as is also the commonly existing con- traction or obstruction in the orifice of the pulmonary artery. M. Louis does not, however, altogether deny that such openings might in some very rare cases originate in ulceration. The frequency of these exceptional cases appears to M. Bouillaud, on the other hand, much more considerable, in consequence of his having frequently noticed the coexistence of traces of inflammatory action in the lining membranes of the heart along with the unnatural communications alluded to, as well as from the occurrence of the symptoms taking place often suddenly, and for the first time in advanced childhood, or even in adult age. The valves, in particular, according to the same authority, very often present changes of an inflammatory nature, more especially those of the right side, and particularly of the pulmonary artery, the orifice of which is at the same time, and, as he thinks, from the same cause, very commonly contracted. We are bound, however, to confess that M. Louis's view of the case seems much the most consonant with the facts, and that the more frequent occurrence of the concomitant lesions or malforma- tions on the right side appears altogether decisive against their inflammatory origin. The heart in these cases is usually much enlarged, and trans- versely placed within the chest, the right cavities, and more espe- cially the auricle, being almost invariably the subject either of dila- tation, or hypertrophy, or both. When hypertrophy exists, it is not unfrequently, as Bouillaud remarks, of the concentric kind,—a circumstance which has been attributed by Bertin with more inge- nuity than probability to the contact of the arterial blood unnaturally admitted into the right cavities. The additional work thrown on the right side of the heart, as well from the opposition encountered in the delivery of its contents through the contracted pulmonary artery, as from its unnatural participation in the labours of the general circulation, would seem sufficiently to account for its being the principal seatof enlargement. Besides, as Dr. Hope has remarked, this hypertrophy is often most considerable in those cases where in consequence of the contraction of the pulmonary orifice, the current through the opening in the septum must decidedly have been from right to left, so that no arterialised blood could possibly have entered the right side. There are a few cases on record which would seem to show that the foramen ovale may be violently reopened even in adult age by severe falls or blows, prolonged fits of coughing, or other fatiguing muscular efforts. The sudden supervention of the symptoms is not, however, sufficient to prove indubitably that such is the fact; 572 the heart (Malformations). it may, perhaps, be nearer the truth, even here, to suppose that the malformation alluded to had all along existed, but that it required some unusual derangement of the circulation in order to its reveal- ing itself by external signs. With regard to the septum of the ventricles, a preternatural opening maybe met with in any part of it; but it is certainly found most frequently in that portion which adjoins the auricular septum, near to the insertions of the aorta and pulmonary artery. It is from this cause that the former of these vessels in particular has in these cases often an equal connection with both ventricles. From the almost invariable coexistence of some of the compli- cations just alluded to (hypertrophy, dilatation, disease of the valves, narrowing of one or more of the orifices, &c), it is nearly impos- sible to fix on any set of symptoms as strictly characteristic of the preternatural communications in question. The bluish colour of the skin of the whole body, and of the face, extremities, and parts covered with a thinner cuticle particularly, which had commonly been looked upon as its pathognomonic sign, and which led to the use of the terms cyanosis, morbus caruleus, the blue disease, blue jaundice, <$*c, has been clearly shown by M. Bertin and by M. Louis to be often entirely absent; and even when present to depend with much greater probability on coexistent lesions capable of obstructing the course of the circulation, and so causing accumulation of venous blood in the capillaries. So like- wise with regard to the frequent coexisting disorder of the heart's action, indicated by palpitations, purring tremor, bellows murmur, fits of excessive dyspnoea, occasionally amounting almost to asphyxia, with proneness to syncope on the slightest exertions or unusual mental excitement, irregularity and feebleness of pulse, and extreme suffering from defective power of generating heat,—these, together with an occasional tendency to serous effusions, being, as we have already seen, morbid phenomena of ordinary occurrence in cases of enlargement of the heart and obstruction of its orifices, whether from contraction or valvular disease. The narrowing of the pulmonary artery, which so commonly exists in cases of cyanosis, appears to be a very important element in the production of the peculiar appearance of the skin, as it must needs cause, as Morgagni has pointed out, an embarrassment of the circulation through the right side of the heart, and consequent stagnation throughout the whole venous system ; and especially at such mo- ments when paroxysms of dyspnoea have been induced, and the circulation is peculiarly obstructed. That the deep colour of the skin, interior of the mouth, &c, occasionally observed, is not a necessary consequence of the mere communication between the two sides of the heart, we have proof, as M. Fouquier remarks, in the fact of its not being observed in the foetus when such commu- nication naturally exists, and when dark blood is necessarily circulated. When the communicating cavities are of equal strength, it has the heart (Malformations). 573 been ingeniously suggested by M. Jules Cloquet, that no admixture of their contents in all probability takes place ; whereas if the left cavity exceeds the right in power, which in the natural state at least is always the case, the arterialised blood should make its way into the venous receptacles; so that if this view be correct, it may be only in a smaller number of cases that the contents of the right cavities are propelled immediately into the greater circulation ; and even here it will not be in such quantity as to account for the deep blue tinge without taking the coexisting sources of obstruction into consideration. M. Louis, on the contrary, believes that, whether the two ventricles be equal in strength or not, no mixture will take place during their contraction, provided all their orifices be free; but as the pulmonary artery is very commonly contracted, a por- tion of the blood of the right side of the heart will usually make its way through the preternatural opening at the moment of systole, or if not then yet in every case during the diastole, or entry of blood into the cavity; so that a certain degree of admixture will occur in every instance: but this he believes to be quite inadquate to the production of the deep blue or violet colour of the skin, unless the coexistent sources of obstruction in the heart, and con- sequent stasis in the venous and capillary circulation be taken into account; for the fluids circulating in the cutaneous vessels in most parts of the body are in the natural state colourless ; whilst, more- over, in M. Ribes' remarkable case, though the aorta sprung from the right ventricle, and the circulation of venous blood in the arte- ries must have always existed, yet no such peculiarity in the colour of the surface manifested itself till the third year, when it made its appearance in company with other symptoms of heart disease. M. Breschet, again, mentions an instance where the left subclavian artery^ arose directly from the pulmonary artery, and yet the colour of the corresponding limb was altogether free from any blue tinge. Of all the symptoms usually attributed to the lesion under con- sideration, the one in which M. Louis is most disposed to confide is the recurrence of suffocating paroxysms at periodical or at least at very short intervals; these paroxysms being often accompanied or followed by fainting, and induced by very inconsiderable causes; whilst, as for the blue colour, it may be either present or absent. The existence of a bellows murmur and thrilling tremor, if perma- nent and unattended with a marked disposition to dropsy, is con- sidered by Bouillaud as strongly confirmatory of the above symp- toms. The blueness of the surface, we repeat, may or may not exist; and even when present, Laennec thought it was often rivalled in intensity by the dark colour of the skin in certain diseases of the lungs, and more especially emphysema; but this Dr. Hope doubts. As active enlargement of the heart is an almost invariable accom- paniment of these preternatural communications, there is commonly a very considerable extent of dulness in the prascordial region, along with increased impulse, and at the same time often a super- ficial hissing murmur, with the first sound, about the middle of the 73 574 the heart (Malformations). sternum, in consequence either of the contraction of the pulmonary orifice or of the unnatural aperture through the septum, or both.* In infants with this malformation, even the effort of sucking is often sufficient greatly to embarrass the respiration and circulation ; and the suffocative paroxysms so induced are occasionally accom- panied by convulsive movements. In childhood there is an inability to participate in the sports of that age; the sufferer is disposed to crouch over the fire even in summer, and is very easily benumbed in cold weather. The ends of the fingers and toes are often bulbous as well as discoloured; there is a tendency to cough on making use of any muscular ex- ertion, and pulmonary congestions very frequently manifest them- selves under the influence of slight exciting causes. The disco- loration of the skin and interior of the mouth is sometimes, as Dr. Hope expresses it, as deep as the stain of the small black cherry. The contractions of the pulmonary artery, which so commonly exists, is looked upon by M. Louis not only as of indubitably con- genital origin, as already stated, but also as a chief cause of the prevention of the closure of the aperture in the septum, by means of the over-distension of the right cavities kept up by it. The progress of the disease is very variable. In most cases the sufferers are cut off early, in infancy or childhood, in the midst of one of the suffocative paroxysms: in some instances a precarious existence has been prolonged to middle life, or even to advanced age. One of the cases alluded to by M. Louis reached to the for- * The murmurs indicative of a communication beween the two sides of the heart, though not yet fully ascertained, Dr. Hope conceives would be nearly as fol- lows:—"An unusually loud and superficial or near sounding murmur with the first sound, immediately over the semilunar valves (i. e., about opposite to the in- ferior margin of the third rib) is generally seated in the mouth of the right ven- tricle, and may proceed either from a contraction of the pulmonic valves or orifice, or from an opening out of the right into the left ventricle, or from both these lesions conjoined. If it proceed from contraction of the pulmonic valves or orifice alone, it will be audible along the course of the pulmonary artery, up to the second intercostal space, much more distinctly than along the course of the aorta, and will be attended with a thrill. If it proceed solely from an opening out of the mouth of the right into the left ventricle (the pulmonic orifice being either healthy or totally obliterated), it will be more audible along the course of the aorta than along that of the pulmonary artery. If it proceed from the double lesion, viz., a contracted pulmonic orifice, and an opening into the left ventricle, it will be loudly audible along the course of both vessels, and a thrill will be felt over the pulmonary artery. When these signs of a lesion in the mouth of the rightiven- tricle coincide with cyanosis, the evidence of a communication between the two sides of the heart is almost positive ; and as hypertrophy of the right ventricle is usually a concomitant, its presence is a corroborative circumstance. When the signs in question do not coincide with cyanosis, an appeal must be made to the history of the case. If it appear that the patient has exhibited the symptoms of organic disease of the heart from early infancy, yet has never been affected with endocarditis, to which the valvular disease could be ascribed, there are strong probabilities of a congenital malformation, and presumptions of a communication between the two sides, though without so considerable an intermixture of blood, or so great an obstacle to its ingress into the lungs, as suffices to occasion cyanosis."—Author. the heart (Malformations). 575 tieth year, and another to the fifty-seventh, and then terminated by the supervention of a new disease. The treatment of this affection is simply palliative, as its organic cause is irremediable. The judicious management of coexisting diseases in the heart and other organs, together with exemption from mental and corporeal excitement or over-exertion, and from every thing which might hurry the breathing or the pulse, the early reduction of all inflammatory attacks, the enjoyment of a pure mild air, the avoidance of cold and damp, together with great temper- ance, and a due regulation of the digestive functions, and the pro- motion of all the natural excretions, are the points towards which attention should chiefly be directed. THE END. IEDICINE NATIONAL LIBRARY OF MEDICI*-; p—- s • IVNOIIVN JNDIOIW JO AH V IB 11 IVNOIIVN 1NI3IQIW JO A I V II I 1 IVNOIIVN 1 N I 3 Id 1 W JO fr-i I /V? 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