.& iO?V./o^\ yAOLXVl THORACIC DISEASES: PATHOLOGY, DIAGNOSIS AND TREATMENT. IN FOUR PARTS. PART I. GENERAL PATHOLOGY AND DIAGNOSIS—SUCCUSSION, PALPATION", AUSCULTATION", PERCUSSION, ETC. PART II. PATHOLOGY, DIAGNOSIS AND TREATMENT OF DISEASES OF THE LUNGS, BRONCHI, PLEURAE AND HEART," DISEASES OF THE AORTA AND UPPER AIR PASSAGES. PART III. TREATMENT OF FEVERS, INFLAMMATION, ATROPHY, HYPERTROPHY, ERYSIPELAS, ULCERS AND CANCERS; DIATHESES, ETC. PART IV. APPENDIX OF TREATMENT TO THE DISEASES OF THE BRONCHI, LUNGS, PLKUlMi AND HEART, BY NEW AND IMPROVED METHODS AND REMEDIES. BY ■(/ MARSHALL CALKINS, A.M., M.D., LATE PROFESSOR OF ANATOMY AND PHTSIOXOGY IN THE ECLECTIC MEDICAL COLLEGE OP PENNSYLVANIA; PROFESSOR OF THE INSTITUTES AND PRACTICE OF SURGERY IN THE SAME INSTITUTION; MEMBER OF THE ECLECTIC MEDICAL ASSOCIATION OF PHILADELPHIA, ETC. ETC. WITH THE POSTHUMOUS WRITINGS OF CALVIN NEWTON, A.M., M.D., Late Member of the Massachusetts Medical Society, and late Professor of Pathology in the Worcester Medical Institution. AND A BIOGRAPHICAL SKETCH OF THE LIFE AND CHARACTER OF PROFESSOR CALVIN NEWTON. Scconti Istrititm, Bcbfacti nntj jjrrnlln EnlargcU. „ "" - * CO '•■'■■* •■- •■ ■ .. l . . ■•; PHILADELPHIA: '*4ffi ^ 1 *v\ ^ H. COWPERTHWAIT & c 0/";o^ii» ' 1858. C I 5" .ST t If5t Entered according to the Act of Congress, in the year 1858, by Marshall Calkins, M.D., in the Clerk's Office of the District Court for the Eastern District of Pennsylvania. PREFACE TO THE SECOND EDITION. Since the publication of the first edition, the enlarged - experience of observers has tested the value of many new tkerapeutic agents, and made many improvements in the preparation of concentrated remedies. In the present edi- tion, it will be observed that one important change of treatment is made in the substitution of these for the crude article, and in the recommendation of many new remedies to the notice of the profession. Several important diseases have been added in this volume, which were omitted in the first, according to Dr. Newton's original plan. Diseases of the upper air passages, several diseases of the heart, the general treatment for fevers and inflammation, for erysipe- latous and ulcerative inflammation, cancer, etc., for the va- rious diatheses, and an appendix of treatment to the diseases of the bronchia, lungs and heart, making in all over one hundred pages of new and practical matter, constitute the principal changes made from the reprint of the old edition. MARSHALL CALKINS. Philadelphia, March 25th, 1858. t PREFACE. One object which Dr. Newton had in the preparation of this work, was to sup- ply the increasing demand in the New School of Medicine, for a scientific treatise upon the Pathology, Diagnosis and Treatment of Thoracic Diseases ; and another was to make public the results of his own study and investigation into General and Special Pathology, and the means of Physical Diagnosis. Many new reme- dies, though in general use among the physicians of the New School, yet not in common use by the whole profession, are substituted for those upon which depen- dence has chiefly been placed for the removal of inflammatory diseases. That they are much more efficient, and at the same time less injurious to the constitu- tion, a thorough trial will demonstrate. During nine years, Dr. Newton had giv- en special attention to the study of thoracic diseases, and their treatment, and hence he could reasonably claim ample qualification to execute the task which he commenced. He had formed the plan for the whole work and had written all the general principles of pathology and diagnosis, and also, a particular description of several of the more important diseases of the thorax. Dr. Newton's writing ends on the two hundred and twenty-sixth page, at which place the writing of the Completing Author commences. In the completion of the work, the pathology, diagnosis and prognosis, have been chiefly derived from the best medical author- ities of the age; and yet, such alterations have been made as investigation seemed to suggest. The treatment recommended, is substantially that of New School Authors, with such modifications as have seemed necessary, and of practical utili- ty. Being a student of Dr. Newton in 1847 and 1848, and having been since that time associated with him in the practice and teaching of medicine during a limited period, good opportunities have been afforded for learning his peculiar views of the pathology and treatment of disease. From many other medical gen- tlemen of extensive experience much valuable information has been derived, to whom the Completing Author would here express his thanks for the interest which they have manifested in the work, and for their many voluntary contribu- tions to the treatment of disease. In conclusion he would simply say, that he has used every possible effort to make the work valuable for the profession, to which it is now offered, with the hope that it maybe the means of alleviating hu-. man suffering, and of the advancement of sound medical education. Worcester, July 1854. CONTENTS. Thoracic Diseases, 17 Part I. General Considerations, 18 Division I. Pathology, 18 Chap. I. Fever, discussion of its nature, 19 " II. Inflammation, theories of; its nature; author's views, 20—34 " III. Congestion, active and passive, 34—35 " IV. Serous Effusion, pathology of, 35 " V. The Reparative Process ; discussion of its nature, 37—45 " VI. The Red Corpuscles; description of, 45—50 " VH. The Formation of Pus; its kinds, chemical and microscopic char- acter, 50—55 " VIII. Ulceration, 55 " IX. Mortification ; sphacelus, gangrene, 57 " X. Lymphatic Swellings, 58 " XI. Tubercles; their pathology and microscopic character, 59—69 " XII. Carcinoma ; forms of; chemical and microscopic character, 69—77 " XIII. Melanosis ; various forms of, 77—80 " XIV. Non Malignant Tumors, encysted, hydatids, vascular, 80—82 Division II. Diagnosis: definition, 83 Chap. I. Symptoms ; divisions of, rational, constitutional, physical signs, 83-85 " II. Topographical terms ; regions of thorax and abdomen, 85—87 " III. Position of patient for physical exploration, 87 " IV. Succussion; Hippocratic, 89 " V. Palpation, 89 " VI. Inspection, 90 " VII. Mensuration, 91 " VIII. Percussion; sounds of; cracked pot sound; mediate and imme- diate, 91—92 Pleximeters ; directions for their use, 93—95 " Its range of application and utility, 96 " IX. Auscultation, 97 Sec. I. Mode of application, mediate and immediate, 97 Stethoscopes; kinds of; manner of using, 98—103 Sec. H. Healthy sounds of respiration ; (a) tubular ; (b) vesicular, 103—108 Varieties of healthy sound, 108 Sec. III. Diseased sounds of respiration ; (a) bronchial; (b) cavern- ous; (c) amphoric, 110—112 Varieties of diseased sounds, 115 Sec. rV. Rales ; the dry, 116—120 " humid, 120—124 " V. Adventitious Sounds, 124 VI. Sounds of the Voice, bronchophony, pectoriloquy eeo- phony, 126—129 l '' 8 CONTENTS. V Chap. X. Rational Symptoms, 129 Sec. I. Dyspnoea ; causes of; table of causes, 129—132 " II. Cough; varieties of, 132—135 " III. The Sputa; varieties of, 135—138 Division HI. General Treatment, 139—142 Part n. Particular Diseases, 143 Division I. Chap. I. Bronchitis, Sec. I. Pathology, 143 Diagnosis; general and special symptoms, 145 Prognosis and Treatment, 148 " II. Secondary Acute Bronchitis, 149 " HI. Chronic Bronchitis, Pathology, Diagnosis, Treatment, • 150—154 " W. Bronchitis of Children ; Treatment, 155 " V. Epidemic Bronchitis or Influenza, 156 " VI. Bronchitis of Old People; Diagnosis and Treatment, 157—158 " Vn. General Remarks on Bronchitis, 158 " H. Pertussis; Pathology, 160 Diagnosis ; general and special symptoms, 161—162 Prognosis and Treatment, 163—165 " in. Asthma; Pathology, 165 Diagnosis, 168—169 Prognosis and Treatment, 171—173 ,. " D7. Morbid Changes in the Bronchi, Pathology, 173 Diagnosis, 175 Prognosis and Treatment, 176 " V. Pneumonitis, Sec. I. Pathology, 177 Diagnosis, 183 Prognosis, 189 Treatment, 190 " H. Asthenic Pneumonitis: Treatment, 192—193 " Bilious and Typhoid, 194 •' IH. Lobular Pneumonitis, Pathology, 195 Diagnosis, 196 Prognosis, .197 Treatment, 198 " TV. Secondary Pneumonitis, 198 " VI. Pulmonary Emphysema, 199 Sec. I. Vesicular Emphysema, 200 Pathology, 200 Diagnosis, 203 Prognosis and Treatment, 205 " II. Interlobular Emphysema, Pathology, 206 Diagnosis ; Prognosis ; Treatment, 207 " VII. Pulmonary Congestion, Pathology, 208 Diagnosis; Treatment, 209 VI CONTENTS. Chap. Vni. Pulmonary Apoplexy, 211 Pathology, 212 Diagnosis, 214 Prognosis; Treatment, 215 " IX. Pulmonary Gangrene, Pathology, 216 Diagnosis, 217 Prognosis; Treatment, 219 " X. Pulmonary Oedema, Pathology, 220 Diagnosis, 221 Prognosis; Treatment, 222 " XL Pleuritis, 222 Sec. I. Primary Sthenic Pleuritis, Pathology, 223 Diagnosis, 230 Prognosis, 237 Treatment, 238 ' " II. Asthenic Pleuritis, 244 " III. Chronic Pleuritis, 244 Pathology, 245 Diagnosis, 246 Prognosis, 247 Treatment, 248 Paracentesis Thoracis, 249—252 Description of Operation, 253—257 Treatment to prevent its necessity, 257—259 " IV. Latent Pleuritis, 259—260 " V. Secondary and Complicated Pleuritis, 261—263 " VI. Pleuritis of Children, 264—265 " XH. Pneumothorax, Pathology, 265 Diagnosis, 266 _ Prognosis, 269 Treatment, 270 " XIH. Hydrothorax, Pathology, 272 Diagnosis, 273 Prognosis, 274 Treatment, 275 " XIV. Empyema, Diagnosis, 280 Prognosis; Treatment, 281 " Pulsating; Treatment, 282—283 " XV. Phthisis; definition of, 283 Sec. I. Tubercles ; History of their pathology, 284 Pathological characters ; causes of, 286—289 Location; law of their deposition. 290—292 Forms of; Progress of; Softening'of, 293—295 Effects upon the lungs ; Cavities; Adhesions, 296—299 ; II. General course of Phthisis, and General Symptoms, 300 Tuberculous Cachexia, 301 Stages of Phthisis, 301 (a) first stage; Diagnosis, General and Special Symptoms, 301—305 (b) second stage; Diagnosis, General and Spec- wal Symptoms, 305—308 CONTENTS. vn (c) third stags; Diagnosis, General and Special Symptoms, 308—311 Particular consideration of Ratienal Symptoms, 311 Cough; Expectoration; Dyspnoea; Haemoptysis: Pain, 311—318 Constitutional Symptoms; Fever; Night Sweats; Emaciation; Diarrhoea, 319—321 QSdema: Cerebral, Digestive and Sexual Symp- toms, 321—324 Duration of Phthisis, 324 Sec. III. Varieties.—Acute Phthisis, 324. Chronic Phthisis, 326 Phthisis of Children, 327. Latent Phthisis, 329 Sec. IV. Complication*, 331. With Ulceration of air-passages, 332 With Disease of Pleura, 333. With Abdominal Diseases, 333. With Disease of Liver, 334. With Fistula in Ano, 335. Differential Diagnosis, 335-338 Sec V, Causes of Phthisis-.—Hereditary Predisposition, 339 Influence of age; Occupation^ Climate, 341—345 " of Malaria: Inflammation: Contagion, 345-346 " " Intemperance- Dyspepsia, 347—348 " ■" Masturbation: Poisonous Medicine, 349 Prognosis, 350 Sec. VI. Treatment, 351. (a) Preventive and Curative, 351—363 (b) Palliative, 363—368 Chap. XVI. Pulmonary Cancer: 369. Of Mediastinum, 371 Division II. Diseases of the Heart, 373. Their History: General Dia- gnosis and Prognosis, 373—377 Chap. I. Examination of the Heart—Position: Size: Impulsion, 377—381 Physical Signs, 382—384. Normal Sounds : Rhythm, 384-386 Abnormal Sounds, 387. Pericardial Sounds, the Friction, Creaking Leather, the Churning Sound, 392. Irregularities of Rhythm, 393. Vascular Sounds, bruit de diable, 393 Chap. II. Sec. I. Pericarditis.—Pathology, 394. Diagnosis, 395. Prognosis, 398. Treatment, 401 Sec. IL Chronic Pericarditis. Diagnosis, 399. Prognosis, 400. Treatment, 401. Chap. III. Endocarditis, 405. Pathology, 406. Diagnosis, 408. Prognosis, 410. Treatment, 411 Chap. IV. Myocarditis, 413. Pathology, 413. Diagnosis, 414 Chap. V. Hypertrophy, 414. Pathology, 416. Diagnosis, 416. Prognosis: General Treatment, 418. Treatment of Hyper- trophy, 421 Chap. VI. Dilatation of the Heart, 424. Pathology, 425. Diagnosis: Prog- nosis: Treatment, 426 Chap. VII. Disease of the Valves of the Heart, 427. Pathology, 427. Diag- nosis, 428. Treatment, 430. Varieties of Organic Disease, 431. Atrophy; Softening, 431. Fatty De- generation: Tubercles, Hydatids, 432 Chap. VIII. Hydropericardium, 433 Chap. IX. Functional Disease of the Heart: Palpitation, 433. Pain: Inter- mittence, 434. Angina Pectoris, 434. Treatment, 435 Division III. Aortic Diseases, 435 Chap. I. Aortitis: Pathology, 435. Diagnosis: Treatment, 436 Chap. II. Aneurism of the Aorta. Pathology, 436. Diagnosis, 437. Prog- nosis and Treatment, 438 Vlll CONTENTS. Division' IV. Miscellaneous affections of the Heart, Asphyxia, 441 Chap. I. Asphyxia: Pathology, Diagnosis and Treatment, 442—444 Chap. II. Syncope: Pathology, Diagnosis and Treatment, 444—416. Chap. III. Tubercles; Fungus: Tumours: Hydatids: Calcareous Deposits, Treatment of, 446. Displacement of the Heart, 446 CnAP. IV. Cyanosis, Pathology, Diagnosis and Treatment, 447—449 Division V. Diseases of the Upper Air-Passages. Chap. I. Coryza, Acute; Chronic, Varieties, &c, Pathology, Diagnosis, Treat- ment, 44'J—454. Thrush ; Aphthae: Quinsey, Simple and Malignant, Pathology, Diagnosis and Treatment, 45G—459 Chap. II. Laryngitis; Varieties, 459. Pathology, Diagnosis, 460—463. Aphonia in, 463. Treatment of Pseudo-Membranous, 464. Spasmodic, 466. Syphilitic, 469. Chronic, 470 Part III. Division I. Treatment Adapted to Pathological Conditions. Chap. I. Treatment of Fevers, 473. Inflammation ; Treatment of, 475—4S7 Chap. II. Asthenic ; Inflammation ; Erysipelatous, 487—493 Chap. III. " for Suppurative and Ulcerative, 493—500 Chap. IV. " of Softening; Atrophy, 500—501. Hypertrophy, 502 Chap. Y. Diatheses; Rheumatic, 502. Arthritic, 503. Scorbutic, 503. Bilious, 504. Scrofulous, 505 Chap. VI. Carcinoma ; Treatment of, 509—515 Appendix, or Part IV. Division I. Treatment: Bronchitis; Acute; Chronic; of Children; of Aged, 516—518. Treatment of Pertussis; Asthma, 519. Treatment of Pneumonia; Typhoid and bilious, 521— 522. Treatment of Emphysema and Pulmonary Con- gestion, 522. Treatment of Pulmonary Apoplexy; Pulmonary Gangrene ; Pulmonary OSdema; Pleuritis, 523. Treatment of Pneumothorax; Ilydrothorax; Empyema; Phthisis, 524. Phthisis, Nutrition for, 525' Inhalation in, 526—532. Treatment for, 532 Division II. TTeatment for Cardiac Affections, 538. Pericarditis, 538 —540. Endocarditis and Carditis, 540. Atrophy of, 541. Hypertrophy, 541. Treatment for Dilatation' Junctional Diseases; Palpitation, &c, 542. BIOGRAPHICAL SKETCH OF THE LIFE AND CHARACTER OF CALYIN NEWTON, M.D. Biographies of medical authors are seldom found in their works. Their .» professional appropriations to the science of medicine are their only public memorial. Many circumstances, however, make a historical sketch of the life of Pofessor Calvin Newton desirable, not only by his relatives and pro- fessional friends, but by that extensive circle of acquaintance that he formed during the period of his collegiate teaching, and clerical labors. Calvin Newton was bora in Southborough, Mass., on the 26th of No- vember 1800. His father, Mr. Josiah Newton, was a respectable farmer and revolutionary soldier who held many town offices, and the deaconship of the Congregational Church in his native parish. His mother, Mrs. Eliz- abeth Haynes Newton, a lady of benevolence and piety, still lives in Ash- land. His origin was from a family remarkable for longevity and character- ized by a full mental and physical development. In early life he manifested superior powers of mind. At the age of eight years he commenced the study of English Grammar, under the instruction of his older brother, Rev. Gideon J. Newton, who says, "he easily comprehended the ideas of authors, so that he soon was prepared to enter the first class of Grammarians." In the science of numbers, he had few successful compet- itors ; in every study he was thorough, deducing the general from the partic- ular, and easily recognizing the relations of the various branches of knowl- edge. Possessing the " high purpose," " the firm resolve," and " the clear conception,"—the elements of success in literary pursuits,—he improved every opportunity for mental culture, the school vacation, the winter's eve- b X biographical sketch. ning, the summer's morning. While others sported, he studied, while oth- ers slept the sleep of the sluggard, he sought the society of those golden records written by the genius of every country and of every age. To receive instruction was his pleasure, to impart it, his delight. A youth of sixteen he commenced teaching in a village school, and soon after the study of the classics with the clergyman of his native parish. At Framingham Academy, he completed his preparation for college. In 1820, he entered Brown University, where he remained nearly two years, until the death of his father deprived him of the means with which to complete his collegiate course. The sudden removal of that dear object of filial affection made a deep and lasting impression on his mind. Reflection followed and that most desirable of all moral changes, the honest and sin- cere consecration of his talents and acquirements to the service of God. In- timately connected with these events of his life, is another, deserving a pass- ing notice. Of this I have often heard him speak with the simplicity of a child, while the tear of grateful remembrance told the deep emotions of his soul'. " I can never speak " says he, " of the benevolent act of Col. Dex- ter Fay, of Hon. Francis B. Fay, and of Hon. Sullivan Fay, in lending me the means with which to complete my collegiate course, without yielding up reason to the guidance of feeling." Freed from pecuniary embarrassment, he returned to Brown University, and there completed his junior year. Subsequently he went to Union College, where he received the degree of Bachelor of Arts in the year 1826, and afterward that of Master of Arts in the year 1829. During his senior year, he taught a high school in Worcester, and at the same time pursued his collegiate studies. The means thus acquired being sufficient in amount, were immediately used for the payment of his borrowed money. While en- gaged in teaching, he was convinced that duty called him to the work of the Christian ministry. Previously a member of a church in Providence, he then united with the Baptist Church in Southborough, from which he re- ceived a license to enter upon the duties of the clerical profession. In 1826 he commenced the study of Divinity in Newton Theological Seminary, and in 1829, received the highest honors of that Institution. During the pur- suit of his theological studies, he frequently preached in the Baptist Church at Bcllingham, and in 1828, October 22nd, he was ordained its Pastor. BIOGRAPHICAL SKETCH. XI While at Framingham Academy, he had formed an acquaintance with Miss Millisent Johnson, an intellectual and religious lady. About the time of his settlement in Bellingham, they were married. To him she ever proved a devoted and faithful companion, and although he, on account of her ill- health during the latter years of his life, expected to follow her to the tomb, yet she suddenly deprived of the object of her affection, still lingers on the verge of the grave. In 1832 he was elected to the Professorship of Rhetoric and Hebrew in Waterville College. After remaining there five years, he was elected Pres- ident and one of the Professors in the Theological Institution, first estab- lished at Charleston Me., but afterward removed to Thomaston. He was connected with this Institution four years. Subsequently he be- came the Pastor of the Baptist Church in Grafton, Mass., where he remained about three years, until declining health induced him to change his pro- fession. In early boyhood he manifested interest in the science and practice of medicine ; and although later in life, his moral sense pointed out another path of duty, yet he perceived the necessity for a radical and salutary change in the cure of disease. In the conservatism of the University, he1 saw the bias of antiquity; in the common sense suggestions of the untutored mind an occasional gleam of truth ; in the former, the ornament and sym- metry of science, in the latter the practical wisdom of unchained genius. Midway between these extremes bright and safe appeared the course of rea- son, great and enduring the improvements to which it leads. Although ed- ucated at the University at Cambridge and the Berkshire Medical Institu- tion, yet he was uninfluenced by their conservative spirit. Free from prej- udice, not biased by sect or creed, he sought to interrogate nature in "the language of science, and to rightly interpret every phenomena which she presents. After the manner of inductive philosophy he sought to deduce from facts some general principle/to guide the physician in the cure of disease. After graduating at the Berkshire Medical College, and his admission into the Massachusetts Medical Society, he commenced the practice of his pro- fession in Worcester. During the whole course of his medical study, he gave special attention to every new remedy and process of cure, which promised to become- an improvement. With interest he heard of the dis- xii BIOGRAPHICAL SKETCH. coveries of that rustic Son of New Hampshire ; how that in many cases his simple vegetable remedies were more successful when prescribed by the hand of ignorance—than the common remedies when prescribed by the hand of science. Not believing in all his crudities, he, nevertheless, saw in the simple process of applying medicine, and in the changes in the Materia Medica suggested by Thomson, a germ whose future development, by the fostering care of science would become to the world an inestimable blessing. Opportunities for the administration of the new remedies were improved, in order to test their efficacy, and ascertain the extent of their healing power. Confidence followed experiment, and a firm determination to place their util- ity in a conspicuous position before the world, succeeded the conviction of reason. Following the example of Galen, he sought to combine the practi- cal wisdom of Hippocrates and the rigid logic of Aristotle, and also, to add to their attainments the treasures of modern discovery and invention. He had no blind reverence for the authority of names. " Hereafter," he re- marks, in an address to his classmates of the Berkshire Medical Institution, " it will not be sufficient to refer to authority in support of a particular practice. In the eye of the discerning, it matters not, whether error is old, and has the sanction of distinguished names, or is new and unauthorized. The poisonous draught is none the less bitter for having been already tasted by numbers. It is now becoming fashionable, in the community to bring every thing to the test of experience. We must have the why and the wherefore to sustain any measure ; and, with the greatest reluctance, only can we ad- mit what is incapable of proof, to have science for its basis. Plain common sense comprehending in a measure the nature of disease, and proving by ob- servation and experience what medicines will do, is it not to be put aside by any reference to the history of remedies, and what has been thought in times past to be their action. Many, however, have even up to the present time, seemed to suppose that the authority of names was all the support their practice required; and with them a reference to Cullen or Brown, or other distinguished individuals, is of more importance than an overwhelming host of facts. With such persons, in truth, all investigation is proscribed; whereas we are beginning to learn, that to the test of close scrutiny everything claiming to be science must be brought." With such liberal views of medicine, he entered upon its practical duties BIOGRAPHICAL SKETCH. xiii Around him on the one hand were the representations of Allopathy, on the other a few pioneers of medical reform. To the progressive party, he mainly looked for sympathy and support, into its ranks he proposed to intro- duce the benefits of scientific study. Himself the recipient of thorough literary culture and medical education, he knew their utility, and realized the benefit that their possession confers. Than himself, in these respects, none were better qualified to lead minds, but imperfectly educated up to higher stations of medical attainment. Why was medical reform generally unap- proved by the literati, and aristocracy of New England ? Why had its ad- herents such an amount of prejudice, such bitter opposition to overcome ? One reason, doubtless was, the tendency of the human mind to condemn the. new, especially when its origin is humble ; another, the manner in which reform was advocated. With it were associated the ideas that every man can be his own physician, that one course of treatment is adapted to every form of disease, that " heat is life, and cold is death." To successfully bring to the notice of the profession a new remedy or new course of treatment, requires its presentation through a certain channel of influence. Had the simple remedies of Thomson and those of other early reformers, and their simple course of medication unconnected with other things obnoxious to the general sentiment of mankind, been used and rec- ommended, in some of those foci of influence which glow high up the hill- side of science, long since their merits would have been disclosed, and their benefits have brought joy to the afflicted in all the city streets. The truth of this, Dr. Newton fully perceived. The remedies were good, a great im- provement upon those in general use, but the fact must be told from portals of science, in order to quickly influence the world. He, therefore, resolved to free if possible, the reform part of the profession from their ignorance, to divest it of the forms of charlatanism, which to some extent it had assumed, and thus to place it on a basis fixed and immovable as the rock of scientific truth. What more useful enterprise, what nobler object could occupy the attention and kindle the zeal of a liberal and educated mind ? To effect such a result, to his mind two things seemed necessary :—A Medical Institu- tion, and Medical Journal, both conducted scientifically, yet advocating all the improvements that discovery might suggest. Accordingly on the first of January 1846, he commenced the publication XIV BIOGRAPHICAL SKETCH. of the New England Medical Eclectic and Guide to Health. Portions of his editorial address contain the best exposition of his objects and prin- ciples :— " Many pathies and isms in medicine are prevalent at the present day Besides allopathy or the old practice, we have homeopathy, hydropathy, Beachism, Thomsonism, <$*c.; and those who are solicited to be our readers, will wish to know, as we suppose, under what colors we intend to sail. In answer to the inquiry, then, we say, Our flag is our own. Our object is the extension of medical truth. We are pledged to sustain no class of physi- cians or mode of practice, except such as we are directed to by reason, sci. ence, and common sense. We belong, indeed, to the Massachusetts Medi- cal Society, and are in fellowship with our medical brethren ; but we, like them, are at liberty to use such remedies in the removal of disease as we judge to be the most efficacious. We are inflexibly opposed to every form of quackery; but we do not believe that medicine, unlike all other sciences and professions, is incapable of improvement. We believe that much yet remains to be done in developing the principles and carrying out the prac- tice of the healing art; and, if we can get at truth, we care not from what quarter it springs. We shall never hesitate to adopt any Indian remedy or old woman's prescription, when,—its nature and modus operandi being shown,—we have the evidence, that its good effects must be superior to those of any article now officinal. Time has been when some good thing came out of Nazareth; and we believe it eminently true in medicine that valuable improvements have arisen from obscure sources. In vain, there- fore, do those who have enjoyed superior professional advantages, say, "We are the people, and wisdom shall die with us." Those who stand at a dis- tance in the outer court of science, are sometimes as genuine and acceptable, if not as exalted worshipers, as others who are permitted to enter the inmost temple ; and we shall try, according to our motto, to " Seize upon truth, wherever found, On Christian or on Heathen ground." "It may be objected, that the tendency of our Periodical will be to spread out medical information too broadcast over the community. To this we reply, we have no wish for the matters of our profession to be kept, like the mysteries of Egyptian priests, secluded from all but the initiated. We do BIOGRAPHICAL SKEKJEI. XV not, indeed, accord with Samuel Thomson in the belief, that every man can, with propriety, be his own physician, any more than we believe, that every farmer can, with advantage, be his own carpenter, or blacksmith, or watch- maker. Every man, it is true, can, in a sense, be all these for himself; but he will certainly be a clumsy performer, so long as he attempts to do a little of every thing, and gains a competent acquaintance with nothing. The science on which the practice of medicine is founded,—the knowledge of the human system, the nature and operation of remedies, and the like, are mat- ters not understood, to the degree requisite for the physician, without long and arduous study. Still it is evident, that, to some extent, these matters may be brought distinctly before the minds of the common people, and made level to the capacities of all; and immeasurably better would it be for chil- dren and the various members of the family circle to employ their leisure hours in becoming acquainted with their physical systems, and with the means of promoting their health, than in dissipating their minds and cor- rupting their morals, with fictitious stories and wild romances. Our endeav- or, therefore, will be the wide dissemination of medical truth ; and, were it possible, we would gladly be professionally, what one infinitely greater than ourselves was morally and spiritually, a light to enlighten " every man that cometh into the world." " By those of our Thomsonian friends who " go the whole figure,"—as the phrase is,—we may be thought not sufficiently strenuous for Botanic principles. Some may even impugn our motives, and charge us with going between different parties for the sake of gaining favor with all. To such we put the question of Nicodemus of old. " Doth our law judge any man, be- fore it hear him, and know what he doeth V Or, again, we reply in the lancuaoe of one of Caesar's procurators, resident at Cessarea, " It is not the manner of the Romans to deliver any man to die, before that he which is accused meets the accusers face to face, and have license to answer for him- self concerning the crime laid against him." If the Eclectic is not essen- tially orthodox, even in the judgment of the most radical Botanic, then, and not till then, let us be condemned for heresy. If, indeed, any expect of us a constant warfare with diplomatized physicians, they are destined to disap- pointment; for we do not believe, that, by that medium, much medical truth is, or can be communicated. Were we, or any member of our family, dan- xvi BIOGRAPHICAL SKETCH. gerously ill, we confess, that we should prize a plain description of the dis- ease, with the means of recognizing it, and the mode of applying such rem- edies as would speedily effect a cure, far more highly than even the most el- oquent tirade or phillipic against the errors of the schools. And, besides, we must plead, in our own behalf, the peculiarity of our phrenological devel- opment. Our organ of combativeness is not large, and it is extremely dif- ficult for us to be pugnacious. We think it better to love even our enemies; and to trust to the correctness of the maxim, " Truth is great, and will pre- vail." Very few, at the present day, we believe, will sympathize much with a neighbor of ours who calls himself a doctor, and who recently avowed to a friend, that " an educated physician and an educated minister are good for nothing; and that, if we would have a good physician or a good minister, we must take a man directly from the plough." We would not conceal the truth, that we like to have physicians and ministers, as well as mechanics, merchants, and others, educated for their respective employments ; and we cannot help thinking, that (ihe fable of the fox that lost his tail, has its moral in the case of the neighbor referred to. True it is, that in medicine, as in every thing else, one may be taught error; and, under erroneous instruc- ions, he may have his mind misdirected, and his judgment perverted ; but, this affords no argument whatever against a correct education. It is the error inculcated, and not truth, which works the evil. The medical student has only to take the path marked out by reason, science, and common sense ; and then, the farther he advances, the better practitioner will he be. Ac- cording to our views, empiricism,—whether in or out of the regular profes. sion,—diplomatized or not,—has its foundation in ignorance and error. It is the lack of true professional knowledge, and not a redundancy, which makes the empiric, and sacrifices human life. Our watchword to every man who would be a good physician, will ever be, Onward, onward, in the path of truth. In this way, and in this only, will you honor your profession, and benefit your race. The time has come in which, to gain the confidence of the people, the medical practitioner must place himself on the platform of sound professional principles." Such were his ideas of medicine, liberal, philosophical, reasonable. To diffuse them in the profession, and to impress them upon the minds of stu- dents, he ever labored. BIOGRAPHICAL SKETCH. xvii In the same year the inceptive step for the establishment of a Medical College was taken. At a Convention of the friends of reform, a Board of Trustees was chosen, and Dr. Newton was elected Professor. An unsuc- cessful application to the Legislature for a charter, made it necessary for the Institution, in order to grant degrees, to act under the protecting segis of the Botanico-Medical College of Georgia. At the end of the first course of lec- tures, debts had accumulated, which he and his co-laborer in reform, Dr. J. A. Andrews, generously paid, The next course of Lectures in 1847, commenced, and progressed under circumstances somewhat more favorable ; and although efforts were yearly made, no charter was obtained until the year 1849. Before a special com- mittee appointed by the Senate, Dr. Newton presented the claims of the Wor- cester School, in opposition to the appeals made by a committee from the Massachusetts Medical Society, consisting of Dr. John Ware, Dr. Jacob Bigelow and Dr. Henry G. Clark, in order to prevent the legal existence of the Worcester Medical Institution. Dr. Newton, however, was successful in the accomplishment of his object. In 1847, the Eclectic took the name of the Journal, under which title it was published until the time of his death. For its support he yearly contrib- uted his editorial services, and even made pecuniary sacrifices to keep it in existence. In 1850, a College building was erected by the friends of the enterprise on Union Hill in the city of Worcester. For this, Dr. Newton freely con- tributed. " To the welfare of the Institution," he remarks " my heart and my life, are, and shall be unremittingly dedicated; and, when I go the way of all the earth, I hope to leave behind me, not merely a pecuniary legacy, that will supply some of the Institution's future wants, but a richer legacy of professional literature and science, embodied in medical works and in- stilled into the minds of hundreds and thousands of the profession." The Institution from this time seemed more prosperous. The sessions of 1852 and 1853, were better attended—and hope seemed more than ever be- fore to inspire the heart of its founder. The establishment of a State Society was another object whose accom- plishment seemed necessary to the success of medical reform. For this pur- pose, Dr. Newton, in 1850 was chosen chairman of a committee, by his c XVU1 BIOGRAPHICAL SKETCH. medical brethren to draft a constitution for the Massachusetts Physo-Medical Society. Rules and regulations were established, and regular meetings held, at which addresses were delivered, and topics of professional interest dis- cussed. In 1852 he attended the National Eclectic Medical Association at Roch- ester, N. Y., and was elected its President, and one of a committee to pre- pare an address for the next annual meeting at Philadelphia. At Rochester he formed, while attending the Convention, many pleasing acquaintances with his medical brethren ; he won their respect and proved to them amidst conflicting interests a nucleus of union. His election to the chair of General and Special Pathology in the Syracuse Medical College, induced him still more to labor for the production of harmonious action among the reformers of New York. By the friends and students of the Syracuse Medical College, his Lec- tures were very highly approved, and many expressions of regard and af- fection were mingled with the sadness of the parting farewell. A want of medical literature was another incentive exciting to action the mind of Dr. Newton. No works were extant written in a style purely sci- entific containing the treatment of reformers adapted to the pathology of the schools. He, therefore, retired from general practice, also resigned his chair at Syracuse and devoted his time exclusively to writing. Ailer the completion of his work on Thoracic Diseases, he had formed the determina- tion to visit Europe, in order to better qualify himself for the authorship of a work on Theory and Practice. But the room of the student was not his most healthful element. The bright sunlight of day, its toil and strife were far less injurious to his active and vigorous frame. From physical exer- cise his mental drew too much of his attention. The nervous system suf- fered. In the words of Prof. Reuben, " The insidious foe was lurking in the very springs of life, loosing the delicate affinities, and cutting off at their fountains the streams of vital force." In the private relations of life, Dr. Newton was respected and honored. By the citizens he was elected one of the Common Council, a member of the Board of Aldermen, and was Secretary of the Board of Trustees of the Worcester Academy. A full enumeration of all the places of trust which he has occupied, and the little incidents connected with the fulfilment of his BIOGRAPHICAL.SKETCH. xix official labors, would be interesting; but such is not my present purpose. A brief consideration of the more important points in his character will suliice. In doing this, I am well aware of the difficulties to be overcome, of the bias of friendly acquaintance. To love and reverence a teacher and friend, how pleasant! To analyze his character, how repugnant to the warm glow of af- fection ! And yet the public weal demands an analysis of the characters of leading men, in order that their virtues may be imitated, and their faults avoided by those who succeed them on the changing stage of life. Dr. Newton was a powerful man physically, a man of a large mould, a great body, and a great brain; his frame vigorous and well proportioned, every part alive with active, vital force. What a chest was his ! what large pulmonary and digestive organs, those two factors of physical and mental power ! From thence was derived his constant impetus to corporeal exertion, the fuel supplying the bright flame of thought. His personal appearance was not indicative of ornament, but of that physical strength and mental energy and decision which press right onward to their destined purpose. His intellect was strong and active. The forms of intellectual action may be divided into three modes :—the Reason, Understanding and the Imagination ; the Reason, dealing with uni- versal laws, the philosophic power. The Understanding, with details, the practical power. The Imagination, with beauty, the Poet's gift. Of Reason, Dr. Newton had a larger share than of the other intellectual endowments. He was a man of philosophic ideas, ever seeking to deduce from facts a law, general and universal. To generalize was his ambition, to strike out like Bacon, some new and shorter course to scientific improve- ment. His power of comprehension was uncommonly large. And hence, from his mind original ideas proceed. Originality may be divided into two kinds ; originality in applying in a novel manner the knowledge of others, and that originality which brings forth the new principle, the new idea. This latter is not so dependent upon others' thoughts; it has a creative power of its own ; within the boundaries of genius is the field of its labor. View- in"- things subjectively, it moulds into its own likeness the external world. In its ideal creations are newness, and freshness, are forms of utility unseen by common minds. Traveling in untrodden paths, pursuing its diverse way into the dark labyrinths of the unknown, there from a spark of intellec- XX BIOGRAPHICAL SKETCH. tual agency it kindles the radiant flame of science. Of this latter kind Br. Newton possessed the more, of the former the less. His ideas of disease were neither those of Allopathy, nor those of Thomsonism or Beachism; they were peculiarly " his own." He organized new associations of physicians, and moulded a system of successful medical empiricism into the form of sci- entific knowledge. His Understanding was less than his Reason. Although he acquired readily and retained well, his perception was less acute than that of many minds inferior to his own. In adapting means to the accomplishment of an end, his large hope sometimes caused him to overlook many of those minor contingencies which mould and fashion results. The secret of his success, lies mainly in his reason, in his comprehensive views of the subjects of medical study, in his indomitable perseverance, in his devotion to one object, in his spirit of self-sacrifice. To science he seems to have paid much attention, more than to general history and liter- ature. I cannot claim for him large imagination. His eloquence lacks the poetic charm, the beauty which makes luminous the page, and touches the heart of humanity. Two or three short poems are all that his poetic faculty has left. One on Superstition, has the following excellent lines :— " Hail! Sacred knowledge. Freedom's purest Friend, The richest boon which Heaven to earth could send. Kesplendent Orb, but late thy dawning ray, Hath broke the horrors of a sunless day, Soon may thy power, our languid spirits fire, And Franklin's sons to classic heights aspire, An Attic genius stamp our growing fame, And wrest the Laurels even from Grecian name, Then Superstition from the earth be cast, Not least of evils, though to die the last." His style was simple, the style of a strong, logical thinker. His theologi- cal writings, though sometimes dull, addressed to the reason, at times swell into beauty, and touch the conscience. When contending for some princi- ple or for personal interests, his opponents often felt the keenness of his re- buke, and feared again to call forth his withering, caustic words. In his writings as in his life, there were no ar.tful flourishes of rhetoric, nothino- but the language of a naturally frank and honest hearted man. BIOGRAPHICAL SKETCH. xxi All bombast in language felt the keen edge of his sarcasm, and of his judgment. No high sounding words could captivate his approval. In his lectures he was familiar, his illustrations simple, adapted to give the idea, rather than please the fancy. Dr. Newton was a conscientious man. To the guidance of the Supreme Intelligence he intrusted all his interests. In every condition of life he was trust-worthy, never deceiving with subtle tongue, nor flattering the gross prejudice of the vicious and ignorant. Rather than resort to the duplicity which every where prevails around us, he chose to be deprived of many ad- vantages which an unmanly policy often affords. Honest, open-hearted and unsuspecting himself, he sometimes gave his confidence to those not worthy of its reception. He was ambitious to excel, ambitious to occupy that station for which his education and talents best fitted him. Would he have served under the banner of those who were his inferiors in qualification ? would he submit to be transformed into an instrument whose use would elevate ignorance and quackery above himself? Dr. Newton's dignity and self-respect, could not be thus degraded. And if to exercise those qualities, is to be ambitious, then he may prove guilty to the charge. Such an ambition is worthy of all honor, and respect. That ambition which never feels, moves, acts, never makes humanity rejoice. His ambition then was one of the qualities which fitted him for the performance of the duties devolving upon the station which he occupied. Its results have added to the interests of progressive medi- cine, and, therefore, let reform be thankful that a shining light has illumined its rising pathway to usefulness and honor. His affections were strong. When once entwined around their object, they were enduring and constant. He loved strongly, loved the qualities which make up the ideal of perfection, and in whomsoever these shone brightest and most constant, thither his affections were directed. Relatives and friends, neighbors and citizens loved him, for in him the good found en- during friendship. He never sought to betray for policy, nor loved to sac- rifice the interests of others for personal aggrandizement. With him the just and good found sympathy. But the vicious, base, and jealous enemy, no regard and favor. " Lofty and sour to those that loved him not, But to those that sought him, sweet as summer." XX11 BIOGRAPHICAL SKETCH. . He was a cheerful man, and loved to make company lively by the inter- change of wit. His mirthfuluess was peculiar, breaking out in that explo- sive hearty laugh, which will long be remembered by his friends and, ac- quaintance. Philanthropy was one of his qualities of mind. He heard the cry of the poor, and from his heart went forth the bright stream of sympathy and re- lief. Charity often entered his open purse, and took away that which ava- rice would hold with relentless grasp. He was a religious man, a Christian in the highest sense of that word. For its external form, its pomp and show, he had les^ regard than for its inner life. His soul had been renewed, and away in the gloom of futurity, he saw the golden gate, open for its reception. In all his actions he recog- nized an overruling Hand, and willingly submitted to Supreme dictation. In fine, his whole life shows that he had a large development of those relig- ious faculties which join the hearts of the good to the Infinite God. To principle more than to forms and ceremonies he was religiously devoted. For some benevolent purpose he labored, not for mere worldly gain, but for the purpose of gaining the approval of a smiling humanity! Having no children upon whom to bestow his care, he considered the Institution whose corner stone he laid, as worthy of his parental love and affection. That he had faults no one will deny, and yet even for these there were many palliating circumstance •. If he attempted too much, it was because he sought to rear a fabric of medical reform, and to complete the entire structure by the force of his own energy and genius. If he did not sym- pathize with all the ideas and customs of reformers, it was partly owing to his different culture, and different habits of thought. Very few are the men whose faults are so few, whose virtues so many. The day may be long ere another, so faithful to principle, integrity and to science, will descend from seats of honor, to labor in an unpopular cause for the sake of doin"; good to the world. A magnanimity of soul far transcending the little petty jealousies that divide the ranks of reform, is plainly shown by the events of his life. At first we see him an ambitious and honest youth, obtaining the prize of intellectual valor at the common school; now teaching with one hand, with the other studying the classics, and now entering the University, and at the BIOGRAPHICAL SKETCH. XX111 end of two years, returning to his home to bid an affectionate father a last farewell; now cheered by the benevolence of his neighbors, now exulting in the joy of that hope which is as an anchor to the soul; then teaching a high school in Worcester, and next returning from Academic halls laden with the honors of science; now entering the theological seminary and devoting his talents and acquirements to the service of God, and now the village pastor ; next the college professor, then the theological teacher, again a pastor, after- ward a student of medicine, a practitioner, a professor and founder of a medical institution, an author; and finally we see him, " The hale and strong, who cherished Noble longings for the strife, By the wayside fall and perish, Weary with the march of life." Born November 2Gtb, 1800, he died of typhoid fever August 9th, 1853, died in the midst of useful labors, at a time when victory over difficulties was just before him. But his life was not in vain ; it was marked with achievements in the field of utility. He wrought a work which humanity will bless, for he labored for the interests of man ; a work which heaven approves, for he sought to extend the religion of Christ. He had induced the student to press on in the path of knowledge and virtue ; he had elevated the groveling ideas of youth, and had pointed them to the benefits of thorough mental culture in order to insure success in the practice of a profession; he had taught them to exercise their own faculties of mind, to think and investigate .for them- selves, rather than to depend upon the authority of others ; he had taught the physician the importance of 'possessing an unblemished moral and relig- ious character. Of these labors he began to receive the reward. His ideas of medicine began to enter the walks of the higher circles of society, induc- ing legal protection and securing popular favor. Before his decease, he had seen these indications of the speedy and final triumph of medical truth over prejudice and conservatism. If he did not complete the entire fabric, he formed and fashioned the plan, laid the corner stone and reared thereon the central pillar. The consciousness of having done so much for the good of mankind, must have lighted with joy the last moments of his existence. Life to him was desirable for its opportunities to do good to others, and his xxiv BIOGRAPHICAL SKETCH. regret was, that a disease should take him away from a field of labor in which he was conscious of conferring a lasting benefit upon the world. Prophetic omens of the sad event had appeared. I was with him at Syr- acuse, his room-mate and colleague, and often heard him remark " My work is nearly done—adhere to me, carry out my plans." Death came though scarcely welcome. A few faithful friends and medical attendants gathered around him ; upon them he called for aid, but for the cold touch of death there was no healing balm. His strength failed, delirium stirred up his brain, and again he hopefully talked of his College, his Journal, his Book. Finally, the silver cord was loosed and his soul rising to newness of life was calm and peaceful in the bosom of God. Such was his life ; his physical, vigorous, and energetic ; his intellectual, in its onward flow constructs a more accessible pathway to scientific truth; his moral and religious, like a cone its apex at the earth, its base in the light of eternity is ever expanding, ever progressing in the bright sunbeams of the Pure Intelligence. He is no longer a citizen of earth; but There is a happier clime, A larger and a purer life, unknown to earth and time, A clime with light ineffable, unveiled by midnight gloom, Beside whose living streams the fairest flowers perennial bloom ; A clime beyond the circling stars, the floating cloud, the sky, All radiant with its glowing hues ; there all beneath it lie, There with the loved and lost of earth, undestined more to sever, In their glad presence shall he dwell, in blessedness forever. THORACIC DISEASES. Any classification of the diseases to which the human body is subject must necessarily be, to an extent, artificial and imperfect. Both advantages and disadvantages attend every arrangement which ever has been, or ever can be adopted. In what I may say in this volume, and in others which I intend {Deo volente) to succeed it, I shall employ, in the main, a topographical divis- ion. As the subject of this volume I have selected the various dis- eases BELONGING TO THE CAVITY OF THE THORAX ) but, passing down the cervix to exclude cervical diseases, where shall I begin my reckoning of thoracic ? It best suits my convenience to com- mence at the bifurcation of the trachea, that is, at the origin of the right and left primary bronchi. I pause upon that separating muscle, the diaphragm. Having, however, bounded the field of my observation, I find myself at a loss in examining the objects within. Some of the diseases here observed are of such a nature as to exist only in this locality : others imply an affection common to-the thorax and other parts of the body; while others still are only local manifes- tations of a morbid influence pervading the whole system. In my classification, I shall embrace all those affections which are quite prominently exhibited in the thoracic cavity. 3 18 THORACIC DISEASES. PART I. GENERAL CONSIDERATIONS. Before proceeding to a particular description of the several dis- eases appertaining to the thorax, various abstract principles and preliminary matters require some illustration. On such topics as are but remotely connected with these diseases, or are readily un- derstood, the medical reader must be left to inform himself from other sources; and the following pages take it for granted, that, as far as these topics have a bearing on the primary subject of this work, the labor of proper investigation has already been performed. Other topics, however, of the first importance, are of such a nature as to demand here a somewhat full discussion. DIVISION I. PATHOLOGY. Pathology treats of whatever relates to the physical system in a state of disease. In its most limited application, it implies a de- scription of altered structures or morbid conditions. In a more enlarged sense, however, it involves, besides this consideration, an explanation of the processes by which the existing condition is produced,—also, of the causes by which those processes have been established, and of the consequences of that condition or the symptoms occasioned. My present purpose does not require nor allow an extensive discussion of pathological principles. I limit myself to such mat- ters as are quite intimately connected with diseases of the thorax; but, in illustrating them, I am obliged to dwell a little on some considerations which are in themselves strictly physiological. FEVER. 19 CHAPTER I. FEVER. The term fever, in its original application, as is evident from the import of the corresponding word in Latin and in several modern languages, signifies heat. From this sense, however, a wide de- parture has long since been taken. When the nosological system of classification universally prevailed, the term was used to indi- cate a certain collection of symptoms, such as an abnornal degree of heat in the body, an accelerated pulse, a furred tongue, and a generally impaired state of the corporeal functions. Inasmuch, however, as very different pathological conditions may produce these symptoms, Cullen, at a somewhat later period, chose the the term pyrexia to mark these constitutional disturbances when arising from some local cause; and he limited the former term to the designation of similar symptoms, when the cause is some general and not well understood influence upon the physical system. It would be well now for the interests of medical science, if the pro- fession would favor this distinction. At any rate, to avoid confu- sion of ideas, it is indispeusible to remember, that the term is em- ployed to indicate symptoms which arise from very dissimilar causes. When the cause is inflammation or any local disturbance, what- ever, I call the constitutional excitement symptomatic fever, or pyrexia. On the contrary, when the cause is the existence of mor- bific matter in the current of the circulation (,whether this has been introduced from the atmosphere without, or by means of mal-assimilation within the system), I designate the disturbance as idiopathic fever, or fever more properly so called. In the former case, that of pyrexia, the term employed is nec- essarily applied to the manifestations of disease; and, when the cause is purely imflammation of some part, the constitutional man- ifestations of that cause are sometimes characterized as inflamma- tory fever,__the phrase being used in a sense somewhat more limit- ed than that of symptomatic fever. In the sense of idiopathic 20 THORACIC DISEASES. fever, the term should be understood to involve more immedi- ately certain pathological conditions as giving rise to that consti- tutional excitement which manifests those conditions. If this distinction should be rigidly observed, the term fever would distinctly characterize a class of diseases, pathologically considered; and all controversy, in regard to the recuperative ef- forts of nature as constituting fever, would be forever at an end. In this sense, however, the term embraces an extensive and im- portant subject,—one which, though concerned, to some extent, with thoracic diseases, yet more appropriately belongs elsewhere, and which I design to discuss at length in another volume. In the sense of symptomatic fever or pyrexia, as the subject only in- volves directly the manifestations of existing local disease, it does not require any separate discussion. CHAPTER II. INFLAMMATION. Inflammation is a term derived immediately from inflammatio, a Latin word, the root of which is inflammo, to burn or inflame. It is applied to a local disease, one prominent characteristic of which, is an abnormal degree of heat. That some things, connected with the nature and manifesta- tions of this disease, are complicated, and have, till of late, been involved in intricacy, I freely admit. In its most prominent fea- tures, however, it is exceedingly simple; and one cannot avoid the emotion of wonder, that numerous pages and even volumes have heretofore been written with little effect, except to make gross darkness the more visible. In the theories of medicine in- deed, as in those of theology, much talent has, on different topics, been wasted in dreamy speculations. The more acule have been the intellects employed, the more delicately, it is true, have hairs been split, but the less has been the amount of practical common sense exhibited. We need not historically come down to the days of Hahnemann, and of sugar globules, represented to possess power in proportion as they approach an infinitesimal division. INFLAMMATION. 21 Homoeopathy may be, indeed, the quintessence of professional nonsense; but that which is, at least, double-refined, has existed, from an earlier period than any portion of the present century. This lamentable truth has been made more evident on no sub- ject than on that of inflammation. More than one hundred and fifty years since, Boerhaave taught the luminous doctrine, that inflammation is caused by viscidity of the blood, and an error loci of its particles, together with a morbidly acrimonious state of the fluids. Next come the fanciful and frivolous notions of Stahl and Hoffman respecting the influence of the nervous system in pro- ducing inflammation. Passing forward to the middle of the eighteenth century, we find Cullen maintaining the theory, that, in inflammation, there is an obstruction of the blood, produced by "spasm of the extreme arteries, supporting an increased action in the course of them." Hunter, who was nearly contemporary with Cullen, supposed, that, when inflammation exists, there is "a dis- tracted state of parts, which requires another mode of action to restore them to a state of health." This other and necessary mode he considered inflammation to be. Of course, in his opin- ion, it was a recuperative and not a morbid process. Of late years, considerable controversy has been raised, by two conflicting and almost opposite opinions on this subject. One of these opinions makes inflammation depend on "increased action of the capillaries of the part;" the other, on "weakened action of the same vessels, and increased action of the trunks." In support of the one or the other of these opinions, English physicians, no less distinguished than Dr. Thomson, Sir Everard Home, Dr. Wilson Philip, and others of equal professional rank, have adduced their own experiments on living animals; but these experiments, though convincing to their authors, do not, as they are now viewed, establish either of the opposing theories. Dr. George Hay ward of Boston, late "Professor of the Princi- ples of Surgery and Clinical Surgery," in the Medical Depart- ment of Harvard University, has been accustomed, in his Medical Lectures, to define inflammation to be "a diseased action of the capillary vessels, attended by redness, swelling, pain, and heat." In this definition, the Professor has certainly manifested talent, lying in one directioa. In other words, he has shown ability to 22 THORACIC DISEASES. speak with such vagueness, that, while he seems to utter an im- portant sentiment, he really says nothing definite or of moment. Except those who embrace that absurd Hunterian notion, that inflammation is a process of recovery or increased physiological action, none, of course, can doubt, that, in it, there is an abnor- mal condition of the capillaries, and that redness, swelling, pain, and heat are phenomena attending the local disturbance; but What is the. disease of the capillaries? and What is the proximate cause of those phenomena? These, and like questions, the only ones of importance in the case, are left wholly untouched. Be- sides, the same high authority has uniformly taught the medical students of the University, that, in the healing of a wounded part, the first recuperative process established is infl immation, and that, without this, neither an adhesion nor healthy granulations can be formed. In other words, the language, if I understand it, says, that, where, from any cause, there is a solution of continuity in any of the tissues, the first part of the curative process is a par- ticular morbid action. So much for medical philosophy and con- sistency ! Having thus remarked upon the absurdities of those medical opinions which have, at different times, been entertained for nearly two centuries past, and having done this to show what inflamma- tion is not, it becomes me now to attempt an illustration of what it is. I, therefore, immediately define inflammation to be a state in which the capillaries of the part affected are interrupted in their proper function, are morbidly relaxed, and are over-distended; and, in which the blood that is passing.through them is first abnormal- ly excited and chemically changed, and then stagnates and coagu- lates. This definition supposes a pathological and not a mere symptomatic view of the disease. Its symptomatology would merely say, that it consists in redness, swelling, pain, and heat, as these are the phenomena immediately attending it. Here I would remark, that the nosological classification of dis- eases, formerly adopted by the profession, contemplated them almost exclusively, as different groups of symptoms. The symp- toms at any time existing, collectively considered, were called the disease. The causes of these symptoms were divided into proxi- mate and remote. The proximate were what we now call the INFLAMMATION. 28 disease itself,—that is, the pathological condition giving rise to the symptoms. The remote causes were sub-divided into excit- ing and predisposing. The exciting were those which, by their immediate action, developed the pathological symptoms. The predisposing were all such influences as prepared the system to be affected by the action of immediate agencies. In illustrating the disease now before me, I propose to consider its inherent nature, its causes, and its effects. In regard to the first of these particulars, I remark, that, when, for any cause, the nerves connected with the contractile fibrous tissue of the capilla- ries lose their power, the tension of the coats of the vessels is not preserved, and, as the consequence, the relaxation is immediately manifested by those vessels' becoming abnormally filled. This, I suppose, to be the usual way in which capillary congestion is ef- fected. The relaxation is primary, and the over-distention secon- dary. The process may, however, and sometimes doubtless does, commence in the opposite direction. Arterial excitement, by in- creasing abnormally the current of the blood, may mechanically force open the capillaries, and the relaxation may occur, seconda- rily, as the effect of over-distention, in destroying the innervation. The former of these modes Dr. C. J. B. Williams calls that of congestion ; the latter, that of determination of the blood. Both causes, may, indeed, exist at the same time. The vessels may morbidly relax and arterial excitement may occur simultaneously. But, in whichever manner the fulness or congestion of the capillaries takes place, it can seldom be allowed long to remain without producing the characteristics of inflammation. There may, however, for a season, be capillary congestion without in- flammation; but th^re cannot be inflammation without capillary congestion, as a primary part of the process Capillary conges- tion is not inflammation, but inflammation is capillary congestion and something more. In the commencement of inflammation, as the capillary vessels are beginning to be clogged, the onward current of blood is, of course, partially obstructed, and perturbation follows. When the part concerned is microscopically examined, the white globules and the red corpuscles are seen passing, for a time, in different directions,—onward, backward, and obliquely. Soon the white 21 THORACIC DISEASES. globules, which pass not so centrally in the current as the red corpuscles, begin to adhere to the walls of the capillaries. As the disease advances, the relaxed vessels having become distended to their utmost, by the stagnated blood, doubtless sometimes suffer a portion of it to be effused or extravasated into the circumjacent areolar tissue. When this takes place, that which has left the vessels soon coagulates and becomes foreign matter. Indeed, its coagulation is the same as that of blood drawn into a cup, in ordinary venesection. But the blood within the vessels is the only portion of special importance to be considered; and this is the subject of very pe- culiar and interesting changes, worthy of a more minute descrip- tion. The functions of secretion and nutrition, in connection with the part affected, being partially or wholly arrested, it would seem, that the nervo-vital power usually employed in those func- tions, is not supplied, or passes in another direction; and the elec- tricity, set free by the union of carbonic or proteine matter in the capillaries with the oxygen contained in the red corpuscles is ex- pended within the current itself. In this process, the fibrine is immediately increased. Probably this is due to an arrest of secretion and nutrition, not merely in the part inflamed, but, to an extent, sympathetically throughout the system. That there is such a general arrest is evident from the symptomatic fever or constitutional disturbance which takes place. The white or lymph globules, too, are soon found in an abnor- mal quantity. Chemically, these globules consist of the deutox- ide of proteine. Their organization, however, seems to involve a degree of vitality. They are spheroidal bodies of gelatinous consistency; and, indeed, have clearly the characteristics of large and crudely formed cells. At any rate, they are made up of gran- ules in such a way as, in their more perfect state, if not in every instance, to possess nuclei and cell walls. They have a strong disposition to adhere to one another and to the walls of the ca- pillaries. Hitherto physiologists have supposed these globules to be the red or blood corpuscles in a forming condition. In my judgment however, they are entirely distinct, are formed in a different way, INFLAMMATION. 25 and for very different purposes. The red corpuscles are much larger than the white globules,—are different in'form and in struc- ture. The former are discoid in shape and have no nuclei. Be- sides a proteine compound, they contain iron and the various incidental and stimulating elements of the blood; and their spec- ial office seems to be to convey oxygen from the atmosphere to the capillaries, to create animal heat, set electricity free, and, by a stimulating effect, give rise to vital action. They have their ori- gin in the blood-vessels, and, in these vessels, serve their purpo- ses, and perish. The white globules, on the contrary, are evidently formed from liquid fibrine, by the oxidizing process which makes a solid deu- toxide. Fibrinization, we know, commences at the lacteals, and increases throughout the course of the lymphatics, till the current of united lymph and chyle is passed into the venous system, at the terminus of the thoracic duct. Fibrine is polarized or partial- ly organized albumen. To my own mind, there seems good rea- son for the belief, that the elementary granules of vital being have their origin in the lymphatic glands, and pass with and as a part of the fibrine, into the current of the blood; so that fibrine, not merely is chemically organized, but has the first traces of vital organization. If a portion of chyle or any nutritious matter enters the blood, as it would seem that it does, by venous absorption, and without passing through the lymphatic system, this may aid in the chemical formation of the red corpuscles, or it may be vi- talized, by the power of the elementary granules, while in the blood vessels. Be the truth, however, in regard to these latter speculations, as it may, it is now certain, that, in inflammation, white globules exist, in abnormal amount, in the capillaries of the part affected, and they are actually formed in those capillaries. It is, also, cer- tain, that these globules adhere to one another and to the walls of the affected vessels, thereby producing partial or entire stagnation of the blood. During the process of the chemical change, the circulation of the blood is disturbed and the motion of its parti- cles is quickened. As soon, however, as the vessels are fully obstructed, the current necessarily ceases, and the blood coagu- lates. When this takes place in some of the capillaries, the sur- 4 26 THORACIC DISEASES. rounding ones receive the current by the anastomosing vessels, and, of course, are subjected, for the time, to an increased circu- lation; but, in their turn, they are liable to be obstructed, and be- come the recipients of stagnant and coagulated blood. This disposition of the white globules to adhere to the walls of the capillaries has been ascribed to the existence of vital at- traction; but, probably, it is only the result of that physical prop- erty of adhesiveness which belongs generally to soft solids com- posed of glutinous materials. At any rate, whatever may be the immediate cause of the adhesion, the effect is, at length, to arrest all vital action in the part, and produce coagulation. As for the red corpuscles, during the process of obstruction, they remain for a season free, passing tortuously in the midst of surrounding white globules. At length, however, they have no longer space to move, and are so crowded into the interstices of the white globules, that the whole vessels concerned contain a large accumulation of them. The liquid fibrine and serum pass on, or are literally filtered out. The causes of inflammation may be divided into predisposing and exciting. The predisposing are the influences which prepare the system, or some particular part of it, to take on inflammatory action. They are exceedingly various, and their specification, in this connexion, is entirely unnecessary. The exciting causes demand a hasty consideration here. They are mainly contusion, friction, heat, cold, venous compression, and the absorption, into the blood, of morbific matter. Contusion becomes a cause of inflammation by an exhaustion of nervous energy, or a destruction of nervous fibres, and an in- terference with their action; so that the vessels readily assume a morbidly relaxed and over-distended condition. In this condition there may be effusion; or the cause may even rupture a portion of the vessels, and afford unnatural outlets to the blood. This is called extravasation; and it often attends inflammation when resulting from the cause now under consideration. The operation of friction is similar to that of contusion. The nervous energy is exhausted or the nervous fibres are impaired and the capillary vessels are weakened, so as to prevent their proper action in passing the blood along to the veins. The INFLAMMATION. 27 effect, of course, is congestion; and, if long continued, inflam- mation. Excessive heat, applied to a part, produces inflammation there, much after the manner of contusion and friction, by overcoming the nervous energy aud impairing the action of the capillaries. Local inflammation, in a remote part, however, may be produced by such an application of heat as affects the constitution generally aud creates arterial excitement. The balance between the flow of blood into the capillaries aud that from them being destroyed, over-distention and morbid relaxation, with the various character- istics of inflammation, follow. Cold, philosophically considered, is a mere negation—the ab- sence of heat; but, in common language, when the temperature of the atmosphere is moderate and becoming less, we speak of an increase of cold. Using the term, thus, in the popular sense, I speak of the effect of an excessive local application of cold as im- pairing the nervous energies of the capillaries, and, as in the pre- ceeding instances, giving rise to supervening inflammation. Cold, so applied as to act constitutionally, may inflame a remote part, by destroying, as m the case of excessive heat, the balance of the circulation. The immediate effect of the compression of a vein is congestion of that vessel, in the part through which the blood is approaching the point of compression; and, if the congestion is continued for any length of time, an effusion of serum into the circumjacent areolar tissue ordinarily follows. Sometimes, however, the com- pression, and, more especially, the obliteration of a vein, extending a congested condition back to the capillaries, and disturbing vital action, gives rise to inflammation. But the most fruitful and important source of inflammation, is a depraved condition of the blood. The absorption of morbific matter, of almost any kind, so renders the circulating fluid an un- healthy stimulus to the nerves, that inflammation supervenes, as the consequence. It would seem, that, owing to some chemical or other affinity, on the part of different ingredients in the blood, for different tissues or organs, the localities of the inflammation created are varied according to the nature of the causes. In gen- eral, however, it will be found, that, when local inflammations 28 THORACIC DISEASES. take place as the effect of an abnormal condition of the blood, that blood is too rich in fibrine absolutely, or, at any rate, in pro- portion to the amount of corpuscles. Thus, while inflammation uniformly gives rise to an increase of fibrine, a quantity abnormally great, already existing in the blood, favors the local development of inflammation. The fibrine, in connexion with the primary granules which ac- company, and perhaps elaborate it, is that part of the blood which supplies the natural waste of the tissues, and repairs those tissues, when wounded. The red corpuscles, on the contrary, supply the nervous ganglia with electricity, or the material necessary for those ganglia to employ, in creating nervo-vital fluid. The fibrine evidently affords the base for the formation of that deutoxide compound called the white globules. These globules, therefore, though in part, perhaps, a chemical combination, are yet in part, at least, vitally organized,—the vital power, it would seem, being supplied by the products of the lymphatic glands. The red corpuscles, on the other hand, being too abundant, in any case, in proportion to the fibrine, we seldom have inflammation in any part, but the patient is liable to congestion of the veins, to their rupture, and to a consequent hemorrhage. This liability especial- ly exists in regard to the brain. Hence the frequency of apoplexy with plethoric persons, or those having an excess of red corpuscles in the blood. The nervo-vital fluid being increased, is adapted, in itself, per- haps, to give additional strength to the arteries. Still, in inflam- mation, there is arterial fulness; and this is evidently produced di- rectly by the capillary obstruction checking the onward current, or by the constitutional excitement increasing the arterial circula- tion. The exciting effect of the corpuscles, on the contrary, is, like the external irritation of the atmosphere, a mere chemical and not a vital influence, and is, therefore, in undue proportion, debili- tating and not strengthening. The fibrine and primary granules when not abundant, being used up, to a considerable extent at the capillaries, the red corpuscles, especially if forming too large a proportion of the blood, afford an abnormal irritation to the veins weakening their energy, and causing their over-distention. Among the effects of inflammation I rank, in the first place the INFLAMMATION. 29 various phenomena by which it has been nosologically character- ized. The redness is owing to an increased amount of blood in the congested vessels, with what is sometimes around them. The different shades of the redness result, partly, from the different proportions in the amount of arterial and venous blood in the ca- pillaries, and, partly, from the different conditions of the same kind of blood. Ordinarily the color is somewhat scarlet, because it is mainly arterial blood which fills the capillaries. This is especial- ly true in scarlatina, rubeola, and other eruptive diseases. In the active form of superficial erysipelas, we have a similar condition. Indeed, much that is ordinarily called erysipelatous inflammation, is rather erysipelatous congestion,—the blood remaining in the re- laxed capillaries, and not being coagulated, nor having undergone the chemical changes characteristic of inflammation. In this condition, the color of the part effected is a bright scarlet; but, as the congestion passes into inflammation proper, the color be- comes essentially that of ordinary inflammation. After considera- ble exposure to violent cold, the part becomes congested, and the color is then purplish. This is because the venous portion of the vascular system, lying more superficial than the arterial, the blood in the former is so stagnated as to crowd into the capil- laries and give the darkened shade. Of course, if inflammation proper becomes established, the same characteristeric measurably remains. In general, while the inflammation is in its active state and there is considerable constitutional excitement, the hue is flo- rid ; but, after the blood has been, for some time, stagnant, the color becomes deeper. The presence of the white globules,.how- ever, tends to render the tinge lighter, than is the usual tinge of simple congestion. In all cases, when the blood has been coagu- lated for a considerable time, the color becomes darker, in conse- quence of the change in the coagulated material. The swelling of inflammation is the result of the accumulation of blood in the part affected; and it is proportioned to the abnor- mal amount detained in and sometimes around the capillary vessels. Of course, the increase of the part is essentially the same before aud after the blood has coagulated. In connection with the en- largement by inflammation, there may be and often is a farther en- 30 THORACIC DISEASES. largement by other means, as by oedema, by a congestion of the lymphatic vessels, or by a collection of pus; but, in general, these different effects are easily discriminated. Different tissues, it is true, are capable of very different degrees of swelling by inflam- mation; but this is due to the difference in the vascularity of their structure and in their capacity to receive blood. Mucous tissues, for instance, are more vascular than serous, and are, con- sequently, capable of more accumulation of blood. The same is true of the cutaneous tissue. Hence the very appreciable amount of swelling shown in the skin, in different eruptive diseases, mod- ified, however by some of the other circumstances already referred to. But to the muscular, the areolar, and the glandular tissues, from the character of their structure, we are more especially to look for the greatest amount of enlargement, when the part is in- flamed. In these the swelling is, sometimes, not only considera- ble, but very great. The pain of inflammation is produced, partly, by the tension of the tissues or the pressure made on the nerves of the part affected; and, partly, perhaps, by an exaltation of the sensibility created by the temporary arterial excitement, or determination of blood. It is different in different portions of the system, being varied by the degree of innervation and other circumstances, under the influence of the same immediate cause. Let the natural sensibility of the part be acute, the arterial excitement considerable, and the pres- sure strong;—we then have the severest pain, as in inflammation of the sheath of a nerve, the pulp of a tooth, &c. Indeed, when the natural sensibility is not great, the other circumstances com- bined may give distressing pain; as, for instance, when the lining of an osseous canal is inflamed. The strong determination of blood to the part and its confinement by pressure may so exalt the sensibility, though in health it is not great, as to render the pain most excruciating. The 'inflammation may be so located and the tissues concerned may be of such a character, that but little or no pain is experi- enced, except when the part is pressed, or its tissues are somehow put upon the stretch. This condition, which is called tenderness exists commonly in enteritis, sometimes in pleuritis, and indeed in various affections. There are, under peculiar circumstances, other INFLAMMATION. 31 modifications of pain which are commonly called feelings of sore- ness, of smarting, of tingling, of heat, &c; but which need no special illustration here. They are the pain of inflammation, uni- ted with sensations produced by connected causes. The heat of inflammation presents a problem which, till of late, has not been well solved. Animal heat is maintained by a process of combustion or oxidation. In the lungs, in the act of inspiration, a portion of the blood is evidently oxidized, by the oxygen inspired, and caloric is evolved ; so that arterial blood pro- ceeding from the lungs is one or two degrees warmer than the venous which enters them. A part, too, of the inspired oxygen is taken up, " and is carried, by the agency of " the red corpuscles, or " a compound of iron, to every part of the body." In the ca- pillaries, oxidation again takes place, by a union of oxygen with either effete portions of tissue, or those portions of the circula- tion which are not in a condition to be appropriated to nutrition, properly so called. The adipose tissue of the animal body, we know, is only the non-azotized elements of the food (,or such as will not form the other tissues and nourish the system), organized (;when the oxygen present is not sufficient for their immediate combustion), and deposited, to be used for oxidation, when after- wards needed; and, " in the herbivorse, a great part of the com- bustion which yields the animal heat is carried on at the expense of those parts of the food which cannot form blood; namely, sugar, starch, or gum, fat, &c." Besides the oxygen which en- ters the circulation through the lungs, aconsiderable quantity is, also, received into the system by absorption, through the skin, and mucous tissues; aud this is, in like manner, used for the ox- idizing process. The immediate result of this process is the for- mation of carbonic acid and water, which are disposed of mainly by the lungs and by the tegumentary tissue. The effect of ac- tive exercise is to quicken the respiration, and the circulation,— thereby impelling more blood and carrying more oxygen into the capillaries of the surface, as well as elsewhere. The result of this is ii,creased oxidation, it is true; but aportion of the acid and the water, formed by the invigorated action of the perspiring fol- licles, passes upon the surface, in the form of perspired matter. 32 THORACIC DISEASES. The evaporation of this matter, in obedience to a well known chemical law, promotes coolness at the perspiring part. Now, in inflammation, the perspiring follicles are not invigora- ted by an increased power of the nervous tissue. On the con- trary, that power is weakened or destroyed, the perspiration is checked or prevented, and the cooling effect is diminished or lost. At the same time, the oxidizing process is not diminished but is increased. It does not appear, that the matter of the tissues be- comes more rapidly effete. On the contrary, it would even seem, that, to an extent, the process is, with that of nutrition, suspen- ded. But, while the nervous power is not used in the ordinary secretions and excretions by which the system is nourished and changed, that same power is evidently diverted from the nutritive to the excito-motory branch of the nervous system. Hence arises the constitutional excitement, which always, to an extent, attends inflammation. The respiration and the circulation are quickened; the materials for an increased oxidation in the capillaries of the inflamed part are supplied; and, through the local irritation, an unusual process of oxidation, within the capillaries, is set up. It is that already described, in which the white globules are abnor- mally multiplied. This process, from the nature of chemical laws, must evolve heat; and I suppose it to be the principal source of the increased heat of inflammation. The fact, that, under constitional excitement, the blood, heated at the lungs, passes more rapidly to the inflamed part, has, doubt- less, a slight influence in creating the local heat; but that the cause is principally local, is evident from the simple consideration, that, occasionally, the affected portion has a temperature of 102, 104, and even 106, or more degrees of Fahrenheit. In explaining the phenomena by which inflammation reveals itself, other effects have already been referred to. One of these is the interruption of the functions of secretion and nutrition. In health, the fibrine, with the primary granules, is constantly being applied to the regeneration of the tissues, as the matter of those tissues is constantly losing its vitality and becoming effete. But in inflammation, it has been already said, the interruption of the nervous action suspends this process, in the inflamed part • and it INFLAMMATION. 33 would seem, that, by sympathy, it is, also, in a great degree, sus- pended throughout the system. Hence, another consequence is, that fibrine accumulates in the blood,—increasing, from less than three parts in a thousand, not unfrequently to five, and, sometimes, even to seven or eight. I ascribe to this cause the increase of fibrine characteristic of inflammation, rather than to any peculiar cause existing exclusive- ly in the part affected. That the white globules are elaborated mainly in the part affected is evident; but their elaboration is an oxidation of existing fibrine, which is a vitalized compound. The increase of fibrine is proportioned to the extent and duration of the inflammation, in the active state; but so, also, are the con- stitutional disturbance and the suspension of the secreting and nutritive processes. That the blood in the inflamed part contains more fibrine than in others, may be true; but, if so, as the ordi- nary vital processes are more interrupted there than elsewhere, this may afford an explanation of the cause. Again, the effect of the suspension of the nutritive function is, that there is no sense of want in the system,—in other words, no appetite; and the taking of food, under the circumstances, only imposes a burden upon the powers of nature. Here I may remark, in passing, that, if the process by which effete matter is thrown off, is a vital act, and governed by laws similar to those by which a new deposit is made, then it must cease, substantially, when the other process is suspended. If, on the other hand, it is a mere chemical process,—such as attends all decay of animal matter,—then it will not be effected by the con- dition of the vital functions. Some facts, it seems to me, strong- ly commend the former view; and, among these, the compara- tively slight diminution of the azotized tissues, when, by reason of constitutional disturbance, the appetite is destroyed, and little or no food is taken for a considerable length of time. In that condition, it is true, the adipose tissue is used up in creating ani- mal heat; but it is the consumption of that tissue, mainly, which produces any occurring emaciation. I have already alluded to the suspension of superficial perspira- tion as an effect of inflammation. This needs no farther illustra- tion than to say, that the matter seems to be governed by a law 5 34 THORACIC DISEASES. in common with that which controls the replenishing and the de- trition of the tissues. There are other effects of inflammation; but, being more re- mote and constitutional, they do not require discussion here. CHAPTER III. CONGESTION. I have spoken of inflammation as commencing in a congestion of the capillaries. When, however, we speak of congestion, as a disease, we mean an excessive fulness of the larger vessels, and commonly the veins. From the veins, when lying superficially, in connexion with mucous tissues, there seems sometimes to be an effusion of blood as a whole, or a hemorrhage, without any apparent lesion of the vessels. This is illustrated in ordinary cases of hematemesis, and in some cases of hemoptysis. It may, however, be reasonably questioned, whether, in these cases, there is not an actual rupture of the delicate coats of the smaller veins. Be that as it may, ordinarily at least, when blood leaks from the veins, it is because of a rupture of their coats; that is, it is hemorrhage by extravasation. This rupture, of course, is the effect of pressure and over-distention. But it is veins, and not capillaries, that are the subject of lesion; and the constitutional effects of the hemorrhage are very different from those of inflam- mation. When the hemorrhage is produced upon the brain, the result is apoplexy, and not brain fever;—when produced in the lungs, it is the disease, pulmonary hemorrhage or pulmonary apo- plexy, and not pneumonitis. In short, whatever disturbance it may produce in the system, it does not give rise to such an amount of constitutional excitement or symptomatic fever, as in- flammation. Inflammation is liable to be caused by an abnormal increase of fibrine. Hemorrhage often results from an excess of red corpuscles; or it may be produced by a weakness of the vessels, or by an obstruction; but it always has congestion as its immedi- ate antecedent. SEROUS EFFUSION. 35 Congestion is divided into active and passive, or, as some prefer, into active, passive, and mechanical. Suppose, then, that the vis a tergo (,whether consisting in the heated and expanded condition of the blood in the lungs, or in the action of the heart), or suppose, that some abnormal irritation of the arterial muscular coat, or various influences combined, are hastening the current through the arteries, while, from the capil- laries onward through the veins, it is not hastened, the invariable effect must be congestion. This is sthenic or active congestion. Again, suppose the veins to be weakened, and the circulation through them to be consequently checked,—the current from the heart coming on with its normal rapidity,—then, of course, conges-/ tion must follow as before. This is asthenic or passive congestion. I am of the opinion that a weakened condition of the muscular coat of the veins, together with a weakness in the power of the valves, is not unfrequently the principal cause of congestion. The veins not having tonicity enough to support the current, are morbidly relaxed; and, the valves not affording the proper resis- tance, the power of gravitation, when the position of the patient favors, occasions congestion. Still, again, suppose the blood to be impeded, in its return to the heart, by some obstruction in the course of the veins, so that it accumulates in a portion of the venous system. This is what Dr. Watson calls mechanical congestion; but it may, with equal propriety, be called passive congestion. It is the result, not of increased, but of obstructed and diminished action. We have an instance of it, in the case of cording the arm for venesection. The veins, lying nearer the surface than the arteries, are mechan- ically obstructed, and the blood accumulates. CHAPTER IV. SEROUS EFFUSION. There are two methods under which the serum of the blood is separated from the other portions, and is collected either in are- olar tissue or in shut sack. The one of these methods which I 36 THORACIC DISEASES. call secretion, will be considered in another connexion. The other which is effusion, requires to be illustrated here. The for- mer supposes an active condition of secreting organs. The latter implies merely a passive, or relaxed and over-distended state of the coats of the larger vessels,—ordinarily, if not always, the veins. Compress any of the veins, as when a ligature is applied to the arm preparatory to venesection, and let the compression remain for a considerable time ;—oedema of the surrounding areolar tissue will invariably take place. That is, the serum of the blood will be effused or passed through the coats of the veins. The fibrine and the red corpuscles being vitally and chemically organized, of course, their proximate elements occupy an appreciable space; whereas the serum, being without any distinct traces of organiza- tion, is made up of elements in a different condition. These elements will readily pass through interstices too small to allow the passage of the fibrine or of the red corpuscles. In all cases, in which the course of the blood in the veins is materially ob- structed, for any length of time, the consequence is a serous effusion. Hence, according to the position of the obstruction, arise different forms of dropsy. It has been supposed, that capillary obstruction, holding back the arterial current and causing over-distention in the arteries, sometimes, produces effusion through the arterial coats. In re- gard to the systemic circulation, I think this is not so. Cer- tain I am, that in general, serous effusion takes place from the venous, and not from the arterial system ; and it would seem to be owing to the fact, that venous blood contains a less proportion of fibrine than arterial, and, consequently, has a less amount of vi- tality. Two considerations favor this supposition. The first is this. The circumstances of the lungs are peculiar. The pulmonary arteries circulate the purple or venous blood; and, when in pneu- monitis, there is an obstruction of the capillaries by the inflamma- tion, besides the blood effused at the capillaries, there is also a degree of serous effusion. It would seem, that this takes place through the pulmonary arteries, from the blood which has not yet acquired the arterial character, and that it is owing to the dimin- ished amount of vitality in the purple blood. THE REPARATIVE PROCESS. 37 The other consideration is the effect of repeated acts of vene- section, or of hemorrhage from an accidental cause. As the blood loses its proportion, not merely of red corpuscles, but finally of fibrine, and becomes more serous, a dropsical effusion sets in and increases. CHAPTER V. THE REPARATIVE PROCESS- Those who embrace the notions of Hunter, that inflammation is a recuperative, and not a morbid action, seem to confound togeth- er two processes, which are almost as unlike each other, as the hardening of clay by the presence of heat, and the hardening of water by the diminution of heat. Not only, indeed, are the two processes very dissimilar, but any considerable amount of inflam- mation, in any wound, will, at any time, utterly prevent the pro- cess of reparation. It is probable, however, that the frequently close succession of the one process to the other has aided in be- traying pathologists into an important error in regard to the .nature of inflammation, and in giving rise to such language as " wounds uniting by adhesive inflammation,"—" granulations formed under the influence of a healthy inflammation,"—and the like. The truth is, the reparative process is entirely distinct from that of inflammation, and, in almost every particular, unlike it. In the former, there is nothing of the redness, swelling, pain, or heat which characterize inflammation. There is not, to any ex- tent, a morbidly relaxed and over-distended condition of the capil- lary vessels; nor is there an effusion or extravasation of blood into the circumjacent tissue, as sometimes occurs in inflammation. Indeed, the two processes have scarcely a single phenomenon in common. The reparative process, taking place after a lesion has, by any means, been produced, is but little more than an increased and slightly modified condition of that action by which the system is being constantly repaired,—i. e., by which the place of effete matter removed is supplied. The lesion may be the result of an 38 THORACIC DISEASES. incision, of contusion, of inflammation itself, or of some one of various other means; but the process of cure is substantially the same, in all cases. This process of repair is not under the control of any indepen- dent power, that is properly entitled to some distinctive name, such as vis medicatrix natures, vires vitce, or the recuperative power of nature. The process is simply one controlled by law, established in the system and at all times existing. The results, of course, differ, according to the existence of different conditions, —the law remaining the same. Under the circumstances of ordi- nary decay, the function of nutrition is performed at such a rate as just to meet the demands of the waste. When that same function needs to be executed more rapidly, the circumstances are such that more nervous stimulus is afforded; but it is all in obedi- ence to an unchanged law. The lesion, through the afferent nerves of the nutritive branch of the nervous system, impressing its condition upon the nervous centres of that branch, the increas- ed exciting influence returns through the efferent nerves of the same branch, and more rapid nutrition is the necessary effect. It is by this reparative process, that the parts of a wound, being brought together, unite, if under favorable circumstances, by what is called adhesion, or union by the first intention; if, under other circumstances, generally by the formation and appropriation of interstitial matter. Dr. Carpenter, however, considers the pro- cess to take place in three different modes; and, evidently, there is, occasionally, a modification of manner, slightly different from the two now named. I cannot, however, wholly endorse the views of Dr. C. According to him, the three modes are as follows. The first is "the adhesion of the sides of a wound by a medi- um of coagulable lymph, or of a clot of blood." The second is "reparation without any medium of lymph or granulations,—the cavity of the wound being filled by a natural process of growth from its walls." The third is "reparation by means of a new, vascular, and organized substance, termed granulations." By the first of these modes is meant to be designated what " is ordinarily termed union by the first intention." But, in this mod- ification of process, no "clot of blood" performs any vital part. Blood, when clotted, becomes dead animal matter, and can never THE REPARATIVE PROCESS. 39 be again applied to vital purposes. This is just as true, when the blood remains in the tissues and in the capillaries, as when drawn into a vessel. If, by coagulable lymph, however, is meant the hyaline fluid, then the expression contains the truth. This fluid is employed in forming cells and producing the adhesion of the sides of the wound; but the term is a bad one, as it suggests the notion of coagulated blood or a clot; and, indeed, seems t© have been used, by Dr. C, as synonymous with the phrase, "a clot of blood." The process of union by the first intention is really a simple one. In the first place, liquor sanguinis is secreted (,not effused), on the edges of the wound,—those edges being placed in juxtapo- sition. This fluid and the red corpuscles compose the blood; but the red corpuscles remain in the circulating current. That portion of this fluid which is scarcely vitalized, is composed mainly of al- bumen and water, and is called the serum. The more watery part of this is evaporated or absorbed. The other probably re- mains; and, with the fibrine (,containing the primary granules), takes on a smooth and glassy appearance. Hence, the whole is called the hyaline fluid. It is, also, termed blastema and cyio- blastema; because it is "the basis of every forming structure of the human body;"—in other words, because it contains the first buddings or cell-buddings of new growths. When this fluid is examined by the microscope, it is seen to contain regular, though minute, spheroidal cells; besides which, there are innumerable graniform bodies of still smaller size, appearing merely as specks or dots in the blastema, and these latter are elementary or primary granules,—the very beginnings of the spheroidal cells. These appearances, the fully developed cells, especially, have sometimes been called exudation corpuscles. The name, however, is an un- fortunate one, as they are entirely distinct from the red corpuscles, and must not be confounded with the latter. Though the hyaline fluid is itself vitally organized, in a de- gree, yet it is only the granules and the formations from them, which exhibit the traces of full or perfect organization. Every fully developed cell has a triple organization,—a nucleolus or nu- cleoli (,for there are sometimes two or three within one cell), a 40 THORACIC DISEASES. nucleus, and a cell-wall or investing envelope. These nucleoli are really an aggregation of the primary granules. As the reparative process advances, these nucleoli multiply, and the blastema assumes a greater opacity. Molecules aggregate around one or more of these nucleoli, and a nucleus is formed. To complete the cell, however, a transparent and most delicate membrane, composed of proteine, invests the whole, and consti- tutes the wall. The blastema, in which the cells float is albumi- nous matter, with only the faintest traces of organization, while the fluid contents of the cell—the medium interposed between the nucleus and the cell-wall—are more distinctly fibrinized— being attracted within, and, in the process, becoming changed, by the vital power of the nucleus. The nuclei, becoming the parents of other cells, are sometimes called cytoblasts or cell-germs,—the name being designed to indi- cate the peculiar function. A nucleus, with its nucleolus or nu- cleoli, being an aggregation of granules, each one of which is capable of being developed into an independent cell, new cells may be completely formed within a primitive one; or the primi- tive one may rupture and scatter its contents into the surrounding blastema, where they, in turn, may assume the characteristic triple organization,—producing and reproducing new cells, indefinitely. Again, cells may form, in the blastema, in an isolated manner from pre-existing granules, when these granules are in contact with living tissues. In this case, each granule attracts to itself, assimi- lates, and organizes a portion of the nutritious fluid, forming it into the cell-wall and the contents of the cell. Cells, as first found, are generally spheroidal in shape; but they become variously modified, in forming the several different tissues. Sometimes they become elongated, sometimes flattened, fusiform, prismatic, polyhedral, or caudate, according to the purpose to which they are devoted. In the formation of new tissue, the cells arrange themselves in longitudinal lines, the proximate surfa- ces of the cell-walls disappear, and a tubular cavity is made. In this way, according to the form which the cells assume, and the matter with which they become filled, the muscular, the nervous the osseous, and all the various tissues are formed. There are other modifications of circumstances under which THE REPARATIVE PROCESS. 41 cells appear. Some float in the blastema, independently of each other; and, hence, are called isolated cells. From their ephemer- al nature, also, they are called transition cells, in opposition to those which form an integral part of the more permanent tissues, and are, therefore, called permanent cells. The transition cells have their own purposes to serve. For instance, they are em- ployed in the formation of the epidermis, the nails, the epithelial mucous membrane, and, in general, those tissues which are rapid- ly thrown off and formed anew. Those of the epidermis and the epithelium seem to originate in molecular granules, which are diffused through the substance of the basement mem- brane. While cells are developed under such varieties of circumstances as have now been considered, it is, to my own mind, sufficiently clear, that elementary granules exist in the current which circu- lates in the lymphatic system, and which is composed of lymph and chyle united ; and these elementary granules, as well as the more organized portions of cells, are centres or poles, from which emanate nervo-vital influences, to carry on the purposes of vitali- ty and organization. To return now to the case of an incised wound, suppose new cells, as they are formed, to arrange themselves in order one upon another;—suppose this process to commence on both edges of the wound simultaneously;—and suppose, moreover, that those edges are in juxta-position, that is, are as nearly in contact as they can be conveniently arranged. No sooner does the longitudinal ar^ rangement of cells commence from each edge, than the outermost ones meet, and, by assimilating a portion of the blastema, unite, the circulation becomes established, nervous influences pass from one edge to the other, and the wound is healed. This is the sim- ple process of union by the first intention. A clot of blood, in this case, can do no more than to keep off the atmosphere and other irritating agencies from without, by filling the interstices, where the parts are not entirely in apposition. It is, from this kind of protection, that benefit is secured, by dressing a wound, in the blood, as the phrase is. The incised edges, by being im- mediately shielded from deadening influences, remain in a condi- tion to take on the healing process. Of course, as soon as the 6 42 THORACIC DISEASES. cells, accumulating upon one another, meet from the two edges, the parts unite and the wound is healed. The second mode in which Dr. Carpenter considers the repara- tive process to be effected, Dr. Macartney culls the modeling process. In this case, " the surfaces of the wound do not" im- mediately "unite by vascular connexion." The edges take on a smooth and rather red appearance, much like mucous membrane. They seem also to be slightly moistened with a thin fluid. This is usually considered as a case of natural growth from the walls of the wound, till the parts finally become united. This mode of union may, by care, be effected, where otherwise the process would be accompanied by granulations and suppuration. The means to be employed are the exclusion of air and of other irritating causes. Now, in my view, the difference between this mode and that of union by the first intention is exceedingly slight. The parts not being in juxta-position, there must be an evident accumula- tion of cells one upon another. Transition cells form an epithel- ial covering to the growth from permanent cells ; the accumulation continues; and, when the parts meet, the epithelium disappears, and union is effected. The increased accumulation of cells, and the existence of epithelium, during the growth, constitute essen- tially the whole difference between this mode and that first con- sidered. Indeed, when a wound is said to unite by the first in- tention, often interstices are first filled by coagulated blood, or are, in some way, protected; and the case is, in part, as really one of the modeling process, as any which are ordinarily regarded as such. Dr. Carpenter's third mode of reparation is one in which gran- ulations are employed. These are formed under the unfavorable circumstances of irritation or continued inflammation. The gran- ulation structure is a special one formed for a temporary purpose. It is endowed with higher vascularity, and a more rapid power of growth, than is possessed by any modification of ordinary tissue; but it is very easily destroyed, by injury or by increased inflam- mation. The formation and the effect of the granulation structure prove that parts, previously healthy, are disposed to heal, in spite of many impediments thrown in their way. Here, however there is no vis medicatrix naturcB, in the sense of an independent power THE REPARATIVE PROCESS. 43 interposing, just at this juncture, for the individual's good. An invariable law controls the process, though the nature of that law is not yet fully understood. My own conviction is, that, when granulations are formed, the capillary vessels in connexion with the part affected are always abnormally enlarged, either by irri- tating causes from without, or by the latter stage of inflammation within. The chemical influence of the atmosphere tends to weaken innervation, and thereby to relax and over-distend the coats of the capillaries. In the passive stage of inflammation, the ves- sels are yet over-distended, though the counteracting effect of the active period of the disease has essentially subsided. In this case, there is a secretion of liquor sanguinis, but it is modified by the existence of the white globules, or by a chemically changed con- dition of the blood. Either these globules actually pass through the walls of the over-distended capillaries to form crude cells with- out; or what is more probable, the primary granules, perhaps, in a modified condition, pass through the vessels, with liquor san- guinis of a modified character ; so that the hyaline fluid without differs from what is normal, and from it a different structure is consequently elaborated. In the case of granulations from exter- nal irritation, the modification of the hyaline fluid is evidently the result of a change produced either directly on the surface, or at the secreting points of the capillaries. This irritation does not, like inflammation, produce coagulation in the capillaries. Still, it may extend its effect somewhat beneath the surface, so as to form in the vessels, a proteine compound, like that of inflammation. In the hyaline fluid, as granulations are forming, there are seen extremely minute molecules, composed probably of fatty matter, and granules measuriug from one twelve thousandth to one eight thousandth of an inch in diameter, consisting essentially of the deutoxide of proteine with a central molecule of fat; also, still larger bodies, exudation corpuscles, compound granules, or cells, measuring from one six thousandth to one seven hundreth of an inch in diameter. Besides these bodies, there are extremely fine, interlaced, and decussating fibrils much like those seen in the buffy coat of the blood. The kind of action, then, in the formation of granulations is essentially the same, as that in union by the first intention, or in 44 THORACIC DISEASES. the modeling process. Liquor sanguinis, modified, is secreted ; and, the serum or its watery portion being disposed of, the blaste- ma remains pregnant with cells, which arrange themselves one upon another, presenting the appearance which has been undesira- bly called that of exudation corpuscles. Over all, an imperfect epi- thelium is formed, probably by means of transition cells. In this process, as in the more perfect one already described, a portion of the blastema is assimilated and more fully organized. New lay- ers are developed, and the void is, at length, filled. The effect of any external irritating influences and of any re- maining inflammation having passed, the usual reparative process goes forward. In the ordinary nutrition of the system, effete mat- ter is thrown off, as new matter is deposited ; and so, in this case, the granulation deposit is separated and absorbed, as the new and more permanent tissue is formed. One peculiarity of appearance, however, remains, after a wound has been permanently healed. The granulation structure, which is removed by interstitial absorp- tion, being less dense than the more permanent tissue, the portions removed, in a given time, occupy more space than those which are deposited. The consequence is, that, after the work is com- pleted, the parts are left contracted and a cicatrix shows itself. Those fungous growths which are commonly called proud flesh, are the result of an excessive granulating process. That they oc- cur in accordance with fixed law, and under modified nervous ac- tion, cannot be questioned, though we cannot trace all the work- ings of vitality in such exuberant formations. In every case of lesion, in whatever way created, the healthy condition of the part must be restored by the reparative process, in some one of the modes now considered. If the lesion has been produced by inflammation, and that under ordinary circum- stances, as in the muscular and areolar tissues lying near the sur- face,—and if, at the same time, there is no appreciable destruction of the tissues, the reparative process has comparatively little more to do than it has in serving the ordinary purposes of nutrition. When, however, the inflammation is upon a serous tissue there is frequently a too luxuriant growth, ordinarily termed false or exuda- tion membrane. In this case, the hyaline fluid is copiously depos- ited in much the same manner as in superficial fungous growths. THE RED CORPUSCLES. 45 When fungous growths and exudation membranes give place to a normal condition of the parts, the process is evidently that of ab- sorption, just as ordinary granulations are absorbed, when the more permanent structure is formed. It is proper here to remark, that the plastic power of the blood, that is, its capability of being transformed into organized tissue, is in proportion to the quantity of fibrine which it contains. Though the chyle exhibits faint traces of fibrinization, immediately on passing the lacteals, and though the current of chyle and lymph united partakes more and more of this character, till it reaches the thoracic duct; yet, in the blood, the proportion of fibrine is greater than in any part of the lymphatic current, and that notwithstand- ing the constant withdrawal of it from the blood for the purposes of nutrition. From this fact it is sufficiently evident, that fibrine is elaborated, partly, by some agency in the blood vessels. As to what that agency is I have already given my opinion. When blood is drawn from the body, and its fibrine is coagula- ted in a vessel, that coagulated fibrine has something like a rudi- mentary appearance of organization. It contains what appear much like organic germs. This particular resemblance to the change effected by the conversion of the hyaline fluid into solid tissues, has probably been principally concerned in giving rise to confused notions and uses of terms, in speaking of the reparative process. These organic germs, or corpuscles, as they have been called, which appear in a clot of fibrine, seem to be formed by means of an electric influence derived from the atmosphere. But electricity is not nervo-vital fluid, and, therefore, cannot do the full work of that fluid. It, to some extent, imitates, but it cannot become vital action. CHAPTER VI. THE RED CORPUSCLES. " The human blood corpuscles or red globules," says Dr. Mor- ton, "are flattened circular discs, with a central concavity or de- pression on each surface, which, in some respects, gives them an 46 THORACIC DISEASES. annular appearance. They vary between the 300th and the 400th of a line in diameter, and their thickness is about one fourth of that measure. Each corpuscle is a cell, of which the envelope is elastic, homogeneous, pellucid, and colorless; and the contents are of a more or less deeply red color. They are, however, destitute of distinct nuclei,—the dark spot which is seen in their centre being merely an effect of refraction, in consequence of the double con- cave form of the disc. But, since the corpuscles of the lower an- imals are distinctly nucleated, some physiologists insist, that the nucleus exists also in the blood of mammiferae, although it has hitherto eluded positive demonstration." " The vesicular envelopes of the blood discs have been sup- posed to be analogous in character to fibrine, being extremely del- icate, transparent, and highly elastic membranes." "The contents of the capsule consist of two different substan- ces, called hGemaiine" or hcematocine, "and globuline." " Heematine or hcematocine is the compound that fills and forms," with globuline, " the substance of the corpuscle, and gives it its characteristic color. When the coloring matter is separated from the other constituents, it appears as a dark brown substance, inso- luble in water, ether, acids, or alkalies, or in alcohol alone, but dissolves in alcohol with the addition of sulphuric acid or ammo- nia. This solution has also a dark color, and possesses all the properties of the coloring matter of venous blood. It contains a considerable proportion of peroxide of iron ; but Scherer has proved, contrary to the received opinion, that the coloring matter is not derived altogether from the iron, because, when the latter is wholly separated from the hasmatine, a deep-red coloring mat- ter still remains." Kirkes and Paget, however, say of it, that, as ordinarily ob- tained, " it is soluble in water, by which it may, with the globu- line, be washed out of the blood corpuscles; and from this solu- tion it is precipitated, by most metallic salts and by concentrated acids. In the living or recent state of the blood corpuscles, the hamatine is confined within their cell-walls, and appears to be in- soluble in the serum; but, when the blood begins to decompose, and the cell-walls, losing their texture, permit the outward pas- sage of their contents, both the hasmatine and the globuline are dis- THE RED CORPUSCLES. 47 solved in the serum which thus becomes blood-colored, and may impart its tinge to the surrounding parts. In the purest state in which it can be obtained, it is so far changed as to be insoluble in water, of a deep blackish-brown color, and not liable to change of color on exposure to gases. Boiling alcohol will dissolve small quantities of it, and it is freely soluble in alcohol acidula- ted with sulphuric, hydrochloric, or nitric acid, and in weak so- lutions of potash, soda, or ammonia." " The presence of so large a proportion of iron, constitutes a peculiar feature in hsematine. The mode in which the metal ex- ists in it has been much discussed. By some it is supposed to be in the form of an acid, or a salt, or in the form of peroxide in arterial blood, and carbonate of the protoxide of iron in venous blood. The greater probability is, that the iron is combined, as an element, with the four essential elements, in the same manner as, it is held, sulphur is combined with them in albumen, fibrine, cystic oxide, &c." " It is very doubtful, whether the rapid change of color, which is effected in respiration and on the contact of various gases, can be referred to any chemical changes whatever, in the hasmatine. Much more probably it is due to changes in the form of the blood corpuscles and their consequently different modes of reflecting and transmitting light. Saline solutions, if denser than the liquor sanguinis, contract and shrivel up the corpuscles, making them deeply bi-concave; and distilled water has the contrary effect, swelling out the corpuscles, and making them thickly bi-convex or spherical. Changes corresponding with these are produced, by the contact of oxygen and of carbonic acid with the corpuscles; —the former contracting them, and making their cell-membranes thick and granular,—the latter dilating them, and thinning and finally dissolving their cell-walls. Herein, then, is a sufficient ex- planation of the changes that the corpuscles undergo, without sup- posing any immediate chemical alteration in the haematine." " Globuline," says Dr. Morton, " is obtained from the capsule of the red corpuscles and is their component element. It is regarded, by the chemists as a proteine compound, closely allied to albumen, —from which it differs, however, in being soluble in serum and in coagulating in a granular form, unlike the residue from albu- 48 THORACIC DISEASES. men. Henle" suggests, that globuline is albumen, modified by combination with the substance of the disc-envelopes. The glob- uline and hasmatine combined constitute the admitted contents of the globules, and are called the cruor." Kirkes and Paget say, that " globuline appears to be a proteine compound. According to Simon, it bears some resemblance to caseine, on which account he named it caseine of blood; but Liebig and others regard it as more similar to albumen. It is so- luble in water, and its solution, when heated, forms a granular coagulum." What I have now quoted refers to the chemical character of the corpuscles. In regard to their origin, Dr. Morton says, "The human blood corpuscles are, by many physiologists, even by those who deny their nucleated character, regarded as cells, capable of reproduction in the manner of the cells of other tissues." In thus speaking of "other tissues," the doctor seems to regard the blood itself as a tissue. He continues,—" This process, accord- ing to the latest microscopists, is shown in the following manner. First, radiating lines are seen to pass from the centre to the periphery, dividing the disc into several segments, usually six in number; and these parts become gradually isolated from the par- ent corpuscle, and constitute as many new and independent cells. It is, in this manner, that the red corpuscles are rapidly generated by a power of self-production within themselves,—which is in- creased or retarded, however, by various circumstances." Thus much, in regard to the nature of the red corpuscles, being understood, the grand but hitherto unsettled question arises, What is their function? Different conjectures have been formed. One is, that they convert the albumen of the blood into fibrine. But, to this view, there are serious objections. Fibrine is exten- sively found in the lymphatic vessels, and yet these vessels con- tain no red corpuscles. Again, invertebrate animals have no red globules in their blood; but albumen, with them, is changed into fibrine as readily as with animals having red blood. Another conjecture is, that the red corpuscles are " carriers of oxygen to the various tissues, and of carbonic acid from these tis- sues to the lungs." To an extent this is, doubtless, the correct theory. Experiments, it is true, have shown very clearly that a THE RED CORPUSCLES. 49 portion of the oxygen taken into the lungs, in respiration, is, in those organs, united with carbon which is in the blood, there to form carbonic acid. So far, then, as the oxygen is there used, it cannot be carried through the circulation by the corpuscles; and, so far as carbonic acid is formed in the lungs, it cannot be brought to the lungs, by the corpuscles. Still, it is certain, that oxidation takes place in the capillaries, throughout the system ; and the oxygen employed must be trans- mitted through the arteries by the red corpuscles, while the car- bonic acid created at the capillaries must be returned through the veins, by the same vehicles. The most directly vital office of the red corpuscles, however, is the reception and transmission of electricity. Whether this is attracted from the inspired air, by the power of the iron contained in them, or is generated in connexion with the oxidizing process, is yet a matter of doubt. Be that as it may, electricity being found in connexion with the corpuscles, they then, through afferent nerves connected with the serous coat of the blood-vessels, con- vey that electricity to the nervous centres or ganglia of the sever- al nervous systems. At these ganglia, the electric fluid is con- verted into nervo-vital fluid, and is then sent, by efferent nerves, to every part of the body. Of course, a portion of this nervo- vital fluid, sent from the ganglia of the nutritive system, passes to the lymphatic glands, where the elementary granules of the cells have their origin, there to form these granules,—as well as to the lymphatic ducts generally, to elaborate fibrine from the albumen of the lymph and chyle. The shut sacs of the body, generally, are lined with serous tissue and become the repositories of nervo-vital fluid. Hence, when any portion of that tissue is inflamed, the excited nervous action, circulating an increased quantity of nervo-vital fluid, gives a full and hard pulse; whereas excited nervous action on mucous tissues, passing off this same fluid too rapidly to the atmosphere around, creates a rapid and feeble pulse. In regard to the white globules or lymph corpuscles, which are found in the blood, they are evidently allied in character to the primary cells, which repair the system as already explained. Experiments have conclusively shown, that repeated venesec- 7 50 THORACIC DISEASES. tions reduce the quantity of red corpuscles and of albumen in the blood, but do not readily affect appreciably the amount of fibrine. The explanation of this truth is as follows. As the veins are being partially emptied of their contents, they collapse upon the remaining current, for the time being; but they are soon filled again by the absorption of a watery liquid from the system. The blood abstracted diminishes proportionally the corpuscles, the al- bumen, and the fibrine; but the last being elaborated, to a con- siderable extent, in the lymphatic vessels, those vessels, almost immediately, supply a quantity nearly equivalent to what has been removed. The red corpuscles elaborated in the blood-ves- sels, and the albumen of the serum which escapes the fibrinizing power, are not subjected to influences to give them so rapid an accumulation. CHAPTER VII. THE FORMATION OF PUS. That pus is very commonly formed, in connexion with the pro- duction of granulations is admitted by all; but whether it is al- ways so formed,—what its precise nature is,—and by what means it is created, are questions which, till of late, have been quite un- settled. Pus appears under various modifications, and circumstances will rapidly change its qualities. Well-formed pus is an opaque, smooth, yellowish fluid, without scent, and having nearly the consistence of cream. By the old writers, it was spoken of as laudable pus; and it is still quite frequently called healthy pus. The latter epithets, laudable and healthy, are unfortunate ones. They were selected when the most incorrect and absurd notions prevailed in regard to the reparative process. A degree of inflam- mation was considered benign in its influence, and as constituting in itself, the process of healing. Well-formed pus always indica- ted, that, to some extent, reparation was going on. So, as it would seem, it was taken as evidence of a very laudable trait in the gov- ernment of that superintending power, the vis medicatrix nature; THE FORMATION OF PUS. 51 or as evidence, that healthy inflammation was restoring the part diseased. Well-formed pus consists of yellowish globules, diffused through a thin fluid, which somewhat resembles the serum of the blood. "If six or eight ounces of good pus be suffered to stand in a phial, it will separate into two portions. A yellowish matter will sink to the bottom, and there will be a slightly yellow, clear, su- pernatant fluid, like oil in appearance, but not greasy to the touch." The sediment consists of the globules; and, by some, they have been regarded as the blood corpuscles, deprived of their coloring matter, and modified in form. To this view, however, there are, at least, two objections. The most prevalent opinion of physiol- ogists, at present, is that the red corpuscles take no part in the for- mative process; and, to my own mind, it is pretty clear, that an entirely different office is assigned them, in the discharge of which they do not leave the vascular system, and cannot, therefore, ap- pear, with the granulations, upon any surface. The other objec- tion, alluded to, has respect to the rapidity and the kind of change which the pus globules are apt to undergo, on exposure to the air. The blood corpuscles, by a like exposure, coagulate and form a clot; whereas the change wrought on the pus globules, is clearly one of degeneracy or decay. But pus is not always well-formed. Sometimes, the globules do not bear a due proportion to the watery part; and then the pus is called ichorous. When some of the coloring matter of the blood happens to be effused or extravasated and combined with it, it is spoken of as sanious. Mucus may be mixed with it, ren- dering it viscid and slimy. In scrofulous persons, diseased lymph may blend with it, and give it flaky and curdled appearance. Oc- casionally, morbific or effete matter, in the system, may find an outlet, in connexion with pus, giving it a fetid odor. When, by a breaking down of tissues, to some extent, a cavity forms abnor- mally in the system for the reception of pus, that cavity is termed an abscess; and pus from abscesses which form in or near the al- imentary canal, is peculiarly liable to be offensive in character. This fact is probably owing to the tendency of the system to depuration through mucous surfaces, and to the existence, near those surfaces, of matter which needs to be eliminated. 52 THORACIC DISEASES. According to Lebert, a French writer, as translated by Dr. John A. Swett of New York, pus globules "are always found floating free in serum. Their mean diameter is from .01 to .0125 of a millimetre. Their shape is spherical. Their surface is slightly rough, and is sometimes covered by molecular granules. Their investing membrane is more or less transparent. Their contents are liqnid; and you can notice in them, when they have attained their full size, one, two, three, rarely four or five true nuclei, whose diameters are from .0033 to .005 of a millimetre, and in the interior of which a nucleolus can often be detected. " With a high magnifying power, it is easy to discover these nuclei without the aid of any chemical reagent. The acetic acid, however, renders them more distinct." Bearing in mind that the pathological and surgical writers, gen- erally, have not distinguished the reparative process from inflam- mation, we shall see, by their writings, that they considered sup- puration to be a process necessarily succeeding the formation of new tissue. Dr. John Hunter says, " The new-formed matter peculiar to suppuration is a remove farther from the nature of the blood than the matter formed by adhesive inflammation." Dr. Thomas Watson says, " Pus appears to be poured forth or secre- ted by coagulable lymph, after it has become organized. Its for- mation seems to characterize a more advanced stage of inflamma- tion—to denote that the inflammation has been pressed a little be- yond the adhesive stage." Dr. S. G. Morton, speaking of exu- dation corpuscles and false membranes, says, " By tracing the metamorphosis a single step further, we come to the pus-globule." Dr. Watson does, indeed, say, that, " in the natural cavities of the body, pus seems, sometimes, to mingle gradually with the se- rous effusion, which grows turbid and whitish, and at length dis- tinctly assumes a puriform character." But, whether he intended this remark to involve an exception to the usual manner in which pus is formed, or not, it is clear to my own mind, that, in fact, he only describes a case in which the reparative process goes on slowly, and is, at the same time, attended with but a slight elab- oration of pus. Just that condition of things must be induced when the vital or recuperative power is not strong, and yet, as in THE FORMATION OF PUS. 53 a shut sac, there is not great irritating or destructive influence at work to counteract the granulating process. Let us suppose, then, that suppuration is, ordinarily, an inter- ruption of action in the formation of granulations, and that it is never a direct secretion from the blopd, irrespective of tissue form- ing or formed. Still, another question arises whether false mem- branes and other granulation structures, which gradually disap- pear during the existence of suppuration, are not converted into pus; and whether even old tissues, which are broken down in the case of ulceration, do not undergo the same connection. On this question, I remark,—we know, that often granulations are removed by interstitial absorption, when there is no suppuration; and we know, that, in ulceration, matter often loses its vitality and breaks away from the living tissue, just as in a simple case of mortifica- tion. Antecedently, therefore, to a consideration of the true na- ture of suppuration, the probabilities are, that existing tissues, whether temporary or permanent, are always removed by other means. But what is the true nature of pus ? or what is the kind of ac- tion which elaborates it ? I regard suppuration as simply a degen- eration and disintegration of the organized hyaline fluid, or exu- dation corpuscles just as they are being deposited, in the granula- ting process. The change always supposes a reduced state of vi- tality in these corpuscles, by which they, in a measure, lose their power of organization, and become a kind of loose aplastic ma- terial. With the loss of vitality, there is, also, in the material involved a chemical change, which consists, mainly, in an increased oxid- ation of that material. Well-formed, pus " is composed chem- ically of water, deutoxide of proteine forming the cell-walls, tri- toxide of proteine and albumen in solution, fat, osmazome, and other extractive matters, and the same salts as those in the blood." In a more general description of these, however, it is sufficient to say, that the more solid parts are deutoxide of proteine, and the more dissolved or liquid parts, the tritoxide. " Microscopically, pus consists of a limpid serum, and very nu- merous globules of pretty regular size and form," or of such glob- 54 THORACIC DISEASES. ules containing such serum. "These globules have much resem- blance to granular cells or exudation corpuscles; but they are larger, and are more distinctly and constantly provided with a cell-wall and nucleus, in addition to granules and molecules." In form, they are generally " spherical," though " sometimes irregu- larly rounded or oval. Their cell-wall is commonly opaque and somewhat uneven, from being studded with minute granules." "Pus globules are," in general, "larger than exudation corpuscles, even exceeding in size the blood-discs. According to Mr. Addi- son, they measure from 1-2000 to 1-1500 of an inch." They are evidently a modification of exudation corpuscles. Physically, pus globules are without great power of cohesion. In this respect, they are in contrast, with the primordial cells and the red corpuscles. This physical effect, however, is, doubtless, the result of a chemical change. The circumstances which give rise to suppuration are mainly three; an increase of inflammation, an irritating influence of air, and a certain depraved condition of the blood. It is easy to il- lustrate, at least in part, the manner in which these circumstances produce their effect, and increase the oxidation of the material concerned. It is, however, only necessary for me here to say, that it belongs to the nature of inflammation to expose the affected part to the reception of more oxygen ; the pressure of the air does the same directly, and likewise increases the inflammation; and a certain depraved condition of the blood irritates and tends to the same result. All these influences, where the vital powers are at work, feebly and under embarrassments, are sufficient to give chemical laws the ascendency over vital, and thus to produce the effect, of degener- ating and destroying the imperfectly organized material which is about to form a temporary tissue. But, when once that tissue is formed,—especially, when the more perfect organization of per- manent tissue is produced, it is not to be expected, that the kind of chemical influence referred to can be made to overcome vital in- fluences. In this view of the subject, we perceive, that to speak of pus as a secretion, is not philosophically correct. Liquor san- guinis is secreted, and subsequently undergoes vital changes upon the surface. Indeed, if a surface which is suppurating be fre- ULCERATION. 55 quently sponged, a thin fluid only will, from time to time, be dis- covered, and no pus, as such, will be seen. The simple reason is, it has not time to form. What has thus been said of the nature of suppuration throws important light on the question how the absorption of pus pro- duces hectic fever. In the first place, the loss of vitality in what is absorbed renders it foreign matter; and that, when absorbed, always produces more or less constitutional disturbance. In the next place, the increased size of the pus globules must render them exceedingly irritating in their forced passage through the capillaries. And, finally, the soluble tritoxide of proteine, which is a prominent part of pus, acts, chemically, as an irritant. It will even dissolve dead animal matter; and it, doubtless, has an inju- rious effect, wherever it travels in the human system. CHAPTER VIII. ULCERATION. In ulceration there is a breaking-down and removal of tissue, essentially in the same manner as in mortification. The loss of vitality, in the part, however, is gradual; and, at the same time, there is, in immediate proximity to the decaying part, a struggling and partially successful effort of vitality. By this effort, granula- tions are being formed, though they are also being disintegrated, in part, and converted into pus. In the case of an abscess, the hyaline fluid forms an organized or exudation membrane, around a limited part, and thereby de- fends the exterior structure from the noxious influence of the gathering pus. This membrane has been called pyogenic, on ac- count of its supposed office of secreting pus. We have seen, how- ever, that pus is not a secretion. Still, the name, for distinction's sake, may well enough be retained. This pyogenic membrane varies somewhat, in its strength and influence, according to cir- cumstances. Very commonly, it affords the least resistance in the direction of some cutaneous or mucous surface, and the abscess is said to point in that direction. The parts there are put more upon 56 THORACIC DISEASES. the stretch, the vessels are more obstructed, the vitality is dimin- ished, and the liquor sanguinis is less secreted. Fibrous and other hard textures generally resist pretty fully the progress of ab- scesses and the escape of pus. " Serous membranes, by their ready plastic process, first adhere together, and then often give passage to the contents of an abscess through them," thereby for- bidding the escape of any pus into the sacs which they form. After an abscess has opened and discharged its contents, the gran- ulation process, to an extent, gets the ascendancy of the morbid chemical influences; and, though the superficial layer of exuda- tion corpuscles degenerates, more or less, into pus, the healing process is, in time, effected, and the cavity is obliterated. Sometimes ulcers form superficially. Inflammation gives ori- gin to the destruction of the tegumentary, and portions of deeper- seated tissues. They lose their vitality, and are either absorbed or carried away with the pus discharged. The excavation being greater, in some portions than in others, often gives a ragged form to the ulcer. Sometimes, especially when the impurity of the blood enfeebles the vital power, the reparative process will go on but imperfectly, and the pus discharged, or a portion of it, will not be well-formed. It may be ichorous or sanious, or may, by other characteristics, show the weakness of the vital action; but, as soon as the vital energies, working by fixed laws, begin to get the ascendancy, well-formed pus takes the place of that of other traits, and granulations, to a greater or less extent, restore the part. In general, ulceration has its origin in a suspension of the nor- mal nutrition of the part, by means of inflammation. Frequently, however, it is immediately preceded by an induration which is produced by some abnormal deposit, either from the blood vessels, or from the lymphatic system, or from both. In this case, " the ulceration commences in the centre of the induration, because the nutrient influence of the vessels is most reduced, by the pressure at that spot." Sometimes, it would seem, that the impoverished and impure condition of the blood gives rise to ulceration with- out its being preceded by induration or inflammation. This es- pecially happens in parts, the blood vessels of which become con- gested by posture; and in the non-vascular textures, which are not nourished the most directly by the blood. MORTIFICATION. 57 CHAPTER IX. MORTIFICATION. Mortification consists in the decay of animal tissue, in conse- quence of a suspension of circulation in the part, or of the blood's having, in a great degree, lost its vital properties. The part dies; and, if the vital energies in the parts immediately around are suf- ficiently energetic, the reparative process is immediately set up, and, by means of it, the dead portion is separated or sloughed from the living. If, however, the vital power in the surrounding parts is but feeble, and the separating process takes place but slowly, decomposition will, to an extent, ensue, while the dead portion remains attached to the living. For convenience's sake, degrees of mortification have been ex- pressed by different terms. When the death of the part seems en- tire, when the color is a dark bronze or almost black, and when sensible decay is going forward, the mortification is called sphace- lus. On the other hand, when vitality seems gradually to depart, when the color is only livid or a greenish yellow, and when decay is not yet sensible, the mortification is called gangrene. These terms, however, are not always used with precision. When the vital energies have been sufficient to cause a slough- ing of the mortified part, immediately the granulating process will appear, attended with suppuration. Sometimes, when a part is gangrenous, and even when its mortification seems almost entire, it will be, in a measure, supplied with warmth and moisture from the healthy adjoining tissue, it will exhale an offensive odor, and, if it be upon the surface of the body, the cuticle will run in blis- ters. At other times, the mortified portion becomes dark-colored, dry, and horny, but does not rapidly putrify. It is then called dry mortification or dry gangrene. When the mortification is internal, as the matter becomes putrid, it is liable, by being pent up, to affect the living body and produce constitutional symptoms. If, however, the constitution be vigor- ous, and the reparative process be well established, the living parts will be more or less protected from the infectious influence of the. 8 5S THORACIC DISEASES. dead matter; but, in persons of feeble constitution, whose blood is deficient in plastic power, the infection will be felt, and typhoid or putrid symptoms will appear. And, in general, it may be said, that no living parts, however great their activity, can long resist the pernicious influence of dead matter in connexion with them, without experiencing a poisoning or injurious effect. CHAPTER X. LYMPHATIC SWELLINGS. Besides the enlargements produced by inflammation and serous effusion, there are forms of swelling which arise from an accumu- lation of lymph in the part. The lymph is detained in the lym- phatic vessels, and over-distends them. Of course, the part is enlarged. Such an enlargement, when it exists simply, may be called lymphatic congestion. In some cases of ague, nervous swelling, &c, the enlargement is little more than congestion of the lym- phatic vessels. When, for instance, the face suddenly swells, in consequence of diseased teeth and a disordered condition of the nerves connected with those teeth, the effect is evidently lym- phatic congestion. So, too, when the abdomen suddenly puffs up, by means of disordered uterine action, the puffiness is imme- diately caused by lymph detained in the lymphatic vessels. The nerves connected with this set of vessels, become weakened in their power, and the lymph does not pass with its normal rapidity; —it accumulates in the part affected. Such, at least, is my view of this matter. There are, however, modifications of this condition. Not un- frequently, lymph is detained in the glands, until it becomes hard- ened and assumes a pasty appearance. Inflammation is set up in and around the glands, and so the enlargement is compound in its character. It arises partly from lymphatic congestion, and partly from inflammation. Scrofulous enlargements of glands about the neck, in the axilla, in the groin, and in other localities, are instances of this compound character of disease. So also' TUBERCLES. 59 are those scrofulous swellings which, at length, take on the char- acter of abscesses. Here, too, I confidently rank the case of phlegmasia dolens. The swelling is mainly owing to the lym- phatic congestion, while phlebitis and perhaps inflammation of different tissues, to some extent, attend the lymphatic disturbance. CHAPTER XI. TUBERCLES. t According to Dr. Wm. B. Carpenter, tubercle is a degenerated form of the exudation corpuscle. It is unpossessed of organiza- tion, and exists, like a foreign body, in the tissues in which it is deposited. It consists of albumen, with a greater or less admix- ture of fibrine. It generally exhibits no other trace of structure, than a congeries of minute albuminous granules, mingled with shapeless flakes or filaments; but cytoblasts and cells may be oc- casionally detected in it, especially when it is recently formed. Dr. Carpenter, also, supposes, that tuberculous matter is deposi- ted in persons of a scrofulous habit, in the same manner as what he calls organizable lymph is deposited in persons of sounder con- stitutions ; or, as I should say, in the same manner as granula- tions or exudation membranes are formed. He, also, further says, that " the difference between a deposit of tubercle and the effusion (I should say secretion) of plastic lymph consists in this,—that the former is composed of the albuminous constituent of the blood, a mere chemical compound, which is not prepared to un- dergo organization until it has passed through the condition of fibrine, whilst the latter is a portion of the vitalized fibrine, which possesses within itself the tendency to organization and only re- quires the contact of a living membrane to enable it to pass into a regular structure." He, however, admits "that tubercular mat- ter may be deposited by a perversion of the ordinary process of nutrition, without anything like an inflammatory state." "Unor- ganizable albumen" takes the place "of organized fibrine." That these views of Dr. Carpenter are not very remote from the truth, is sufficiently clear, in the present light of pathological tin THORACIC DISEASES. science; and yet, to my own mind, it is equally clear, that a crude and peculiar organization characterizes tubercle. It is something more than a mere chemical compound. It is a somewhat vital- ized, though a cacoplastic deposit. It is " the result," says Dr. C. J. B. Williams, "of modified textual nutrition. The cell-germs, by which the material of textures is renewed, are imperfect at par- ticular points; a granular or amorphous matter is deposited from the plasma, and concretes without fibres or regular cells' being de- veloped. At this point a granulation appears, and gradually hard- ens. When a granule has once been formed, it becomes a nucleus for the concretion of more; a new habit or mode of nourishment is established at the spot; or, to speak less figuratively, cacoplas- tic matter (if present in the blood plasma) concretes around it by a process similar to that by which fat attracts fat, or bone osseous matter. Perhaps the process is not wholly unlike that of crystal- ization. But, however it happens, the result is, that the granular tubercle grows, and may attain the size of a millet-seed, hemp seed, or even a small cherry stone; or, being subjected to press- ure, may slightly spread or flatten into various shapes. "The microscopic character of these miliary or granular tuber- cles is the complete predominence of minute and often irregular granules, and the comparative absence of fibres and cells, of which mere traces are seen, at least in the older specimens. The gran- ules are aggregated together by an amorphous material, the solidi- ty of which gives hardness and some transparency to the mass. The chemical nature of granular tubercle is albuminous, with some gelatine, and a little fat, the latter in very minute proportion, and occupying the centre of some granules, and the gelatine being, probably, the amorphous cement just noticed. In all these characters, we find a close analogy to the granular defeneration of textures, of which, doubtless, these deposits are a kind of exaggeration. "Tubercles rarely grow much or last long, without exhibiting another change in their appearance. They lose their semi-trans- parency, and become of an opaque or dead pale yellow hue like the color of raw potato or parsnip. This is the transformation to crude yellow tubercle, first described by Laennec. This change is the result of a further degradation or degeneration of the de- TUBERCLES. 61 posit. The few fibres and cells which are to be detected in gray tubercle become indistinct, the interstitial hyaline or amorphous solid diminishes, and oil globules appear in its stead, and the mass becomes less coherent and more granular, and therefore quite aplastic. Generally, the change begins in the centre of the mass ; apparently because, being devoid of vessels, the centre is further removed from the vivifying influence of the blood. " But tubercle is frequently deposited at first in this yellow opaque state,—this circumstance being a mark of the still more degraded condition of the nutritive function; and the more ex- tensive forms of tuberculous disease commonly abound in this aplastic matter. Thus, in rapid phthisis, yellow tubercle com- monly forms a large portion of the deposit. Yellow tubercle is rarely so hard or so tough as the gray or semi-transparent kind; and, in the cases of rapid deposit, just mentioned, it is often much softer and more friable. Now, this is the commencement of a change to which the lowest forms of tubercle tend,—that of ma- turation and softening into a cheesy substance." In the softening of tubercle, " the deposit becomes less dense, and loses the little trace of structure which it possessed. It degenerates into an amorphous granular mass; and, being lifeless, it is no longer nour- ished. Its granules lose their cohesion and become disintegrated by the chemical action of the adjoining fluids. Mr. Gulliver and others have observed a remarkable increase of fat globules in soft- ened tubercle. In fact, from the time that tubercle assumes the opaque form, these oil globules appear to increase, until it either is softened and eliminated, or undergoes a kind of "petrifactive change,"—a chemical and mineral transformation. But the microscopic character of tuberculous deposits is that by which they are specially discriminated. This character is admira- bly described by Lebert who, at present, "is the highest authority in France on this subject, and is, perhaps unsurpassed, by any microscopist now in existence, in microscopic pathology." I add a portion of what he says on this subject, in the translation of Dr. John A. Swett of New York. " The constant elements of tubercle are: " 1st. A great number of molecular granules, perfectly round, of a grayish-white color, or with a slight yellow tint, sometimes 62 THORACIC DISEASES. compact, sometimes transparent in their centres, with a diameter of -0012 to -0025 of a millimetre. These granules completely sur- round the tubercle globule, so that it is often difficult to recognize it in the crude yellow tubercle. They are seen in much greater numbers, and quite disaggregated, in the softened tubercle. "2d. These granules, as also the tubercle globule, are united with each other by an intergranular, interglobular, hyaline sub- stance, of considerable consistence, which serves as a cement to the elements of tubercle, and which becomes liquefied by soft- ening. "3d. If the two elements which I have just described possess no peculiarities which belong to tubercle, and which do not dis- tinguish it from other morbid products, there is a third element which is much more important, which, in fact, is entirely charac- teristic of, and peculiar to tubercle—the tubercle globule, or cell. " The form of the tubercle globules is seldom perfectly round, although it is probable, that, at the time of their excretion by the capillaries, they do assume a form more or less spherical, and that they afterwards assume a less regular shape, often becoming an- gular, on account of their close juxtaposition. Thus, as they commonly appear under the microscope, especially in the crude tubercle, their outline is irregular, approaching sometimes to the sphere, sometimes to an oval; but generally they are irregularly angular and many-sided, with the angles and the edges rounded, as is very evident when they are suspended in water or in serum. Their color is a clear yellow, assuming a blackish tint when a high magnifying power is employed. Their interior is irregular and of unequal consistence, which gives them a spotted appear- ance, independently of the granules which they may contain. But I have never been able to detect a true nucleus in these glob- ules, although they sometimes present in their interior the appear- ance of an irregular vacuum, which resembles a nucleus. I have always examined this point with great attention, using the highest and the best defining magnifying powers, as well as different chemi- cal re-agents. We cannot consider the granules, which are irregu- larly distributed in the substance of the tubercle globule as nuclei. These are only molecular granules, whose diameters seldom reach and never exceed, -0025 of a millimetre; often, indeed, they are TUBERCLES. 63 not more than -0012 to -0015 of a millimetre. These granules, variable in number from 3, 5, to 10, or more, are not regularly distributed, and are not all visible in the same focus. The inter- granular substance of the globules surrounds them, so that they are not ordinarily encompassed by a transparent areola. The in- terior of these granules appears opaque. " The diameter of the tubercle globule varies. In the rounded globules, it ranges between -005 and -0075 of a millimetre, rare- ly extending to -01 of a millimetre. The oval globules, as a mean, are -0075 of a millimetre in length, and -005 to -006 of a millimetre in breadth. The diameter of the tubercle globule in- creases at the commencement of the period of softening. "The diameter of the tubercle globule varies within certain limits; but this variation is independent of age and of the tissue or organ in which the deposit has formed. It is more easily rec- ognized in the yellow crude tubercle, than in the gray miliary granulation. In the recent tubercle, the tubercle globule is de- tected with difficulty, because it is concealed by the interglobular hyaline membrane which unites the globules, and by a large number of molecular granules which surround them. "It is important, therefore, in commencing the study of the tubercle globule, to select for examination a yellow cheesy tuber- cle, not too hard nor too soft, to disaggregate it with needles, in a drop of water, which can, however, never be done completely; and this difficulty is one of the most striking characteristics of the tuberculous deposit. It is well, after this has been done, to let the preparation dry a little between the plates of glass, in order that as many globules as possible may be seen at the same focus. The distinctness of the view may be increased by a fine dia- phragm and by a good light. A lamp is, however, not as favora- ble for the examination of tubercle as the daylight; and, if the lamp is employed, care must be taken that the light is not too strong. We having thus become familiar with all the details of the tubercle globule, it will be easily recognized whenever it is pres- ent. By this method, then, the tuberculous deposit can be readi- ly distinguished from all other morbid products, a result which, in doubtful cases, no other mode of examination is capable of producing. 64 THORACIC DISEASES. Water does not change the tubercle globule. Acetic acid ren- ders it more transparent without changing it much, and establishes the absence of nuclei in its interior. It is a very valuable mode of distinguishing the tubercle globule from other globules resem- bling it, except that they contain one or more nuclei. Acetic acid is especially useful in distinguishing the tubercle globule from the pus globule. Ether and alcohol react very slightly upon the tu- bercle globule. Strong ammonia renders it, at first, more trans- parent; it then dissolves the intergranular substance, and allows the molecular granules contained in it to become separated. A concentrated solution of caustic potassa completely dissolves the tubercle globule. The concentiated acids, especially the hydro- chloric and the sulphuric acids, also dissolve it, but more slowly. "What is the position which the tubercle globule is entitled to occupy among the pathological cells ? If it be true, that a perfect cell is composed of an investing membrane, and of one or two nuclei, and of nucleoli in the interior of these nuclei; yet I am convinced, from many observations of pathological cells, as well as of those found in healthy organs, that this mode of cell-forma- tion is by no means universal, and only peculiar to a certain num- ber of elementary globules. The tubercle globule appears to me to be one of the most simple forms of pathological cells, being composed of an enveloping membrane, containing a semi-liquid substance and a certain number of molecular granules irregularly scattered through it, as in the pyoid globule. This pyoid globule, however (,which is a variety of the development of the pus glob- ule), differs from the tubercle globule in being more regularly spherical, more pale, more transparent, and by containing granules which are transparent in their centres, and seated in the periphery of the pyoid globule. "I will now pass to the study of the softened tubercle, limiting myself, for the present, to indicating the physical changes in the softened tubercle as revealed by the microscope, and reserving the physiological explanation for another place. In order to appreci- ate properly the changes which take place during the softening of the tuberculous matter, the use of the microscope is indispen- sable, for the reason, that the parts surrounding the tubercles often inflame and secrete pus, and then the elements of suppuration are TUBERCLES. 65 mixed with those of tubercle. As the naked eye cannot discover all these details, much confusion would exist without the aid of the microscope. " I may say, in general terms, that the principal change that occurs in the tubercle, while softening, consists in the liquefaction of the interglobular hyaline substance, which is sufficiently solid and consistent in the crude tubercle to hold the tubercle globules in close union. But, in the softened tubercle, they become disag- gregated, separated, although clustered groups may still be discov- ered. As the globules become free, they become more rounded, almost spherical; they become, at the same time, more transpa- rent and more thin, and the blastema which surrounds them be- comes more granular. " Both by the naked eye and by the microscope, pus is fre- quently found united with softened tubercle. It would appear that the presence of pus hastens the decomposition of the tuber- cle globule, and this is one reason why the matter contained in tuberculous ulcers is so often without tubercle globules. "Finally, it may be stated, that the tubercle globule disappears in a nearly perfect dissolution, after having been disaggregated into granules. These globules, then, undergo three phases of development. They are at first closely packed together, and compact in their interior. Then they separate from each other and increase in size, which, instead of being owing to a more perfect development, is, in fact, the commencement of decompo- sition, and is owing to an endosmosis of the surrounding blastema, which becomes more and more liquid. At last, these little glob- ules, whose internal and molecular cohesion has already been dis- turbed, finally, by running together, form a yellow and a more or less liquid mass. " There is some analogy in the mode in which the pus globule and the tubercle globule disappear. The former is disintegrated into granules before it can be absorbed. "If the crude tubercle and the softened tubercle constitute the first two stages of this deposit, and the diffluence of the elements of tubercle the third stage of its evolution,, there is still a fourth stage,—its passage into a cretaceous state. I can confirm the opinion that this cretacequs transformation of tubercle is, one of 9 66 THORACIC DISEASES. the most powerful means which nature employs to cure the tu- berculous disease. Ps microscopic composition is altogether in favor of this view of the question. At the commencement of this change, we can still recognize a considerable number of tu- bercle globules, and with them a kind of mineral dust formed of very fine granules, whose diameters are from -001 to -0015 of a millimetre, transparent in the centre, looking black under a high magnifying power, but under low power, as well as by the naked eye, having a yellowish-white "tint, and being more resis- tant to compression than the soft elements of ordinary tubercle. These latter elements diminish in proportion as the granular, amorphous, mineral elements increase. They become more solid and dry, as the portions capable of dissolution are absorbed. The cretaceous tubercle often contains much black pigment, and many times I have met with a considerable number of crystals of chol- esterine. "Having described the elements which are essential to tubercle, I will next examine other elements which are not essential, but yet are of frequent occurrence. " The pigment infiltration, or melanosis, which is also met with in many other morbid products, appears in three different forms. 1st. As a granular infiltration. 2d. As the contents of certain globules, having a diameter from -016 to -024 of a millimetre, and sometimes reaching -033 of a millimetre. 3d. As fine granules contained in certain normal, or pathological cells. Thus it is fre- quently contained in epithelial cells, and expectorated in abundance. " This pigment is also found surrounding pulmonary tubercles, as the gray granulation, the cretaceous tubercle, and tuberculous excavations. It is also often found in abundance in the bronchial glands. It is sometimes noticed in the mucous membrane of the intestine, and especially around tubercles of the peritoneum. It is a carbonaceous substance. " Fat, in the form of fat vesicles, is frequently found in tubercles. " It is not uncommon to find fibres in tubercle, but they very rarely belong to the tuberculous secretion. Generally, thev are fibres of the tissue of the organ in which tubercle is'secreted. Thus, the gray, semi-transparent tubercle in the lungs, often con- tains the elastic fibres of the cellular tissue of the lungs TUBERCLES. 67 " In certain rare cases, crystals exist in tubercle. Once I met with three-sided prisms in tuberculous matter from the lungs; another time, in the bronchial glands; and, in a third case, rhom- boidal plates of cholesterine in softened tubercle in the neck, which was not cretaceous. " Another element not unfrequently met with, and which might easily lead to mistakes, are young epithelial cells, derived from the capillary bronchi when the lung is cut, having a diameter of •0125 to -015 of a millimetre. These are of an irregularly round- ed shape, containing a nucleus with a diameter of -005 of a millimetre, which sometimes contains a nucleolus, or a finely granulated matter. These cells are found in considerable number around agglomerated masses of tubercle globules, but never in the midst of them, so long as they are united by the intercellular hy- aline substance. By the side of these round or oval young epith- elial cells, are found the cylindric epithelial scales, with or with- out vibratile cilia, which could not easily be mistaken for tu- bercle globules. " In conclusion, we find, as the constant and essential elements of tubercle, granules, and an interglobular hyaline substance, and globules peculiar to tubercle. After its excretion, the tubercle first assumes a compact form, then it softens, and at a still later period it dissolves; or it withers and becomes cretaceous. The elements which are not constant, but which are found more or less frequently in tubercle, are melanosis or black pigment, which is the most common, fat, fibres, globules of a decided color, and finally crystals, commonly those of cholesterine. "As elements accidentally mixed with tubercles, we often find under the microscope different products of inflammation, of exu- dation, of suppuration, and of the epithelial secretion, globules of different kinds, which come from the tissues surrounding the tu- bercle, but which are never met with in the midst of its elements. "In the gray semi-transparent granulation of the lungs, we al- ways find a mixture of areolar fibres with a grayish hyaline sub- stance and with tubercle globules. The fibres are composed of the elastic fibres of the pulmonary cellular tissue. The gray tint of the granulation is sometimes heightened by the admixture of the black pigment. 68 THORACIC DISEASES. " The yellow opaque tubercle is identically the same as the gray semi-transparent tubercle, only, in the latter, the tubercle globules are smaller, and more closely packed in the substance which surrounds them. The yellowish aspeot is produced by the confluence and increased size and abundance of the tubercle globules after the destruction of the surrounding fibres which tended to separate them, and at the same time the hyaline mem- brane becomes more opaque and granular. " The gray, semi-transparent granulation is not the constant or the necessary commencement of the tuberculous deposit. It may occur originally as the yellow opaque granulation. Very small yellowish points make their appearance, in which the microscope discovers a few fibres, much less numerous than in the gray gran- ulation. Their principal element is the tubercle globule, and the interglobular hyaline membrane is granular, and with very little transparency. "The liquid which covers the internal aspect of tuberculous excavations contains, sometimes, tubercle globules in their perfect form; but generally they are more or less distended by the soften- ing that has taken place, and most of them are in a state of dif- fluence. It also contains pus globules, the large granular globules of inflammation, a viscid mucous fluid, blood globules, pulmonary fibres, black pigment, epithelial scales, three-sided prisms, and fat vesicles. " Under this liquid layer, composed of so many elements, are false membranes, composed of a fibrous stratified substance, and containing numerous pus globules. "Beneath this layer of fibrine is the true lining membrane of the excavation—it is organized and vascular. Its structure is ir- regularly fibrous, and among the fibresare numerous small globules. Sometimes it contains but very few blood-vessels, and then the fibrous tissue is dense; white, and very abundant, appearing like cartilage. But I have never found in it the slightest traces of the elements of cartilage. " The microscopic examination of the expectoration in tuber- culous phthisis discloses the following facts: The matter contains in the first place, substances which are not at all specific as sali- va mixed with mucus and epithelial scales from the mouth which CARCINOMA. 69 latter are sometimes quite abundant; epithelial scales from the bronchi, mucus, vibriones, blood globules, crystals, black pigment, globules of fat, granular globules, and pus globules. " Besides these, are noticed small masses or little pellicles, which at first sight might be mistaken for tuberculous matter. The mi- croscope, however, only discloses globules of pus and a granular coagulation. These are probably false membranes coming from tuberculous cavities. Again, we notice masses like the preceding in appearance, in which the microscope only discloses numerous molecular granules, which are probably produced by diffluent tu- berculous matter. Again, there are noticed amorphous mineral granules, which, perhaps, come from cretaceous tubercles. And, finally, we may meet with the true tubercle globule. But this is very rare. I am not sure, that I have ever met with it so dis- tinctly that its existence was not doubtful. Sometimes pulmonary fibres are found in the expectoration. There is, then, nothing spe- cific in the tuberculous expectoration." CHAPTER XII. CARCINOMA. Carcinoma, from the Greek mpxivog, a crab, and synonymous with cancer, indicates a disease which has generally been consid- ered to exist in three distinct forms. These forms are originally such, and not merely different stages of the disease; and they arise mainly from the different proportions and arrangements of the elements entering into the composition of the deposit. " These elements," Dr. Swett has well remarked, "are a fibrous tissue, and a viscid fluid, contained in cells and called the cancerous juice. " If the fibrous tissue predominates, you will find the mass hard and creaking, when divided by the knife. Yon will notiqe that its cut surface is intersected by white lines, or by larger mas- ses of a dense white structure. In the midst of these lines you will discover a finely granulated substance, contained in cells, which is the cancerous juice, and which may be pressed out by the. finger or scraped-<# by the scalpel, when it often very much 70 THORACIC DISEASES. resembles apple-juice, in appearance. This form of cancer is known as scirrhus. " When the fibrous element is less distinct, and the cancerous juice more abundant, the cancerous mass is much softer in texture. It is often more distinctly granular:; and, from its resemblance, in many cases, to the substance of the brain, it has been called en- cephaloid. " Finally, the fibrous tissue may be still more deficient, or even entirely absent, and a jelly-like mass, sometimes semi-fluid or even fluid, and collected in cells, often of considerable size and united with cancer cells, may exist, constituting what has been called the colloid or gelatinous cancer." But, in addition to this three-fold division of cancerous depos- its, there are minor differences, which arise from accidental causes. —One of these respects the color. Commonly, the cancerous juice is semi-transparent and of a yellowish-white color. Its ap- pearance has well been compared to that of apple-juice. Some- times, however, the mixture of fatty matter gives it a greater yel- lowness ; and then a mass, of the proper consistence, bears the re- semblance of a tuberculous deposit; or, if it be more fluid in form, it very much resembles pus. Sometimes, too, the juice is of a milky-white color, and gives to the fibrous deposit an aspect al- most white. Often the fibrous deposit is of a rosy-red appearance; or portions of it may take on a dark, and almost black or melan- otic appearance. The cancerous mass, also, varies much in form and general character. Sometimes, it is exceedingly vascular, and the vessels are easily ruptured. Often, it is loose and spongy in texture like the lungs. Again, its fibrous structure is close and unyielding. Sometimes, there is a large undivided mass; sometimes, minute particles are deposited in clusters; and, sometimes, there is an un- defined infiltration into the tissues involved. Generally, the deposit is at first of pretty firm consistence. In process of time, it softens and discharges a fluid. It is then called a cancerous ulcer. The terms fungus hasmatodes, rose cancer, &c, are very commonly employed to designate some of the ap- pearances now described. Chemically considered,-the most abundant element in the com- CARCINOMA. 71 position of cancer is albumen. "It, also, contains," says Dr. Swett, "some fatty matter, and some fibrine, with inorganic salts, —as the sub-phosphate of lime, the carbonates of lime, soda, and magnesia, the hydrochlorates of soda and of potassa, the tartrate of soda, and the oxide of iron." It is only microscopically, however, that cancer, as such, can be recognized with certainty. The elementary cancer cells or glob- ules differ from all other cells, whether concerned with healthy or with diseased structures. The cancer cells are not, indeed, found alone, but they are mixed with other forms of matter; and these accidental ingredients assist in varying the visual appearance of the mass, as a whole. It is now admitted, that inflammatory indurations, non-malignant fibrous tumors, &c, when the eye is the only test employed, are liable to be mistaken for true carcino- ma. Hence the importance of a means of diagnosis on which re- liance may be unerringly placed. This means is found in micro- scopy. In illustration of the microscopical character of cancer, I quote from Lebert's work on Pathological Anatomy, as translated by Dr. Swett. " Authors of much merit have denied that the microscopic ele- ments of cancer were characteristic. I have arrived at an oppo- site conclusion, and I maintain that the cancer globule has strik- ing characteristics which distinguish it from every other form of morbid product. It must not be forgotten, that there are certain general forms of cells and of nuclei, the types of which are met with in very different products. But this I maintain, that the different pathological products which are composed of elementary globules, individually present certain characteristics by which they can be distinguished by those somewhat accustomed to the use of the microscope. I will go even further, and state that the cancer globule is one of the cells which possess the most striking char- acteristic features to distinguish it from every other kind of cell. It is important, however, to add, that the cancer globule is sub- ject to very many variations; but I hope, by pointing out these varieties carefully, and at the same time by explaining the sources of mistake, and the difficulties in the diagnosis, to place before the reader their peculiar characteristics. 72 THORACIC DISEASES. " Not only the globules of cancer, but even their nuclei, are larger than the entire tubercle globule. The globules of scirrhus have a diameter of -0175 to -02 of a millimetre, and sometimes of -025 of a millimetre. Their outline is regular, their appear- ance pale, and their surface is finely dotted with minute granules, which are situated between the investing membrane and the nu- cleus. This nucleus is commonly single, but sometimes double, and with a strongly marked outline, round or oval, and with a diameter of from 0125 to -015 of a millimetre. These nuclei are often found freed from their investing membrane. When this is the case, and a large number of these free nuclei are clustered together, they resemble somewhat tubercle globules; but the dif- ferences in the diameters, in the outline, in the central substance, and in the existence of a certain number of perfect cancerous globules, will remove any doubt that may exist. "The globules of encephaloid, which are very much like those of scirrhus; or rather the nucleus of the true encephaloid glob- ule—for authors have generally mistaken the nucleus for the per- fect globule—has a diameter from -01 to -015 of a millimetre. Its shape is a very regular sphere, or oval, with a marked outline finely shaded all around its internal circumference, containing, be- sides a fine granular matter, one, two, rarely three round nucleoli, with diameters of from -0025 to -0033 of a millimetre, and trans- parent at the centre. A fact which establishes the diagnosis still more clearly is, that, when the globules are perfectly formed, they are surrounded by an investing membrane, which is often irregu- lar in shape. The whole globule thus represented has a diameter of -015 to -02 of a millimetre, and sometimes even of -035 of a millimetre, and possesses characteristics peculiar to itself. "The cancer globule is composed of an enveloping membrane, and a nucleus which contains nucleoli. The diameter of the external cell varies in different cases. Its mean diameter is -02 of a millimetre. Sometimes it is only -015 of a millimetre. Very often it is much greater, extending to -03 of a millimetre, or even beyond that point. Its shape is round or ovoid—round more frequently in the globule of encephaloid, a little elongat- ed in the globule of scirrhus. In many cases it is easy to trace the progress of one of these forms, as it passes into the other CARCINOMA. 73 form. Very frequently this external enveloping membrane as- sumes many different forms. It is generally more flattened than the nucleus. Sometimes it is pale, and perfectly transparent. At other times it is covered by fine dots ; and quite frequently it is so filled with granules that it exactly resembles the large granular globules of inflammation. It is also not uncommon to meet with both regular and irregular globules, which contain a certain number of nuclei; and we may discover large parent cells, with a diameter reaching even to -05 of a millimetre, of a rounded or oval shape, which contain four, five, six, or even a greater num- ber of nuclei. At other times we meet with large membranous expansions, in which we can distinguish a considerable number of nuclei, surrounded by a granular and dotted mass. " The nuclei vary in their diameters from -0075 to -02 of a mil- limetre. The smaller are found chiefly in the perfect globules of scirrhus. The large round or elliptical nuclei, with diameters ex- tending from -015 to -02 of a millimetre, are principally found in the encephaloid cancer. In some forms of cancer these nuclei constitute so decidedly the predominating element under the mi- croscope, that we might be tempted to assume that they were the type of the cancer globule, did we not observe these same glob- ules in their more perfect form, that is, with their enveloping mem- brane, in other cases of cancer. These nuclei are sometimes very pale. At other times, and this is especially the case in scirrhus, their outline is very distinct. In many cases of encephaloid they present a characteristic shading at their whole circumference. In a certain number of cases the enveloping membrane of the cancer globule is elongated, pointed at each* end, and even at several points of its circumference. It then bears some resemblance to the fusiform fibro-plastic bodies. It can always, however, be readily distinguished from these bodies by its much greater size, by being much less elongated, and by its characteristic nuclei and nucleoli. "If the nuclei and nucleoli of the cancer globule always pos- sessed the distinct form which I have just described, nothing could be more easy than to detect them by a microscopic examination. But, as it generally happens that cancer is mixed with much fatty matter, the nuclei are found to undergo different changes on this 10 74 THORACIC DISEASES. account. Thus we often find them filled with grauules and small grumous masses. Sometimes, indeed, they are infiltrated with a homogeneous and confluent fatty matter. " The nucleoli have a diameter which varies from -0025 to ■0033 of a millimetre, and even to -01 of a millimetre. Their number is from one to five. But, as the nuclei which contain them are somewhat thick and spherical, we cannot recognize them all under the microscope at the same focal distance. These nu- cleoli have a peculiar character. Their outline is distinct, but their interior is seldom transparent—ordinarily it is dull and hom- ogeneous. I was for a long time in doubt what these nucleoli were; but I have recently discovered that they are imperfectly developed nuclei. In examining some large nucleoli under a mag- nifying power of 1000 diameters, I saw that they contained two or three secondary nucleoli. " It is not uncommon to meet, in cancer, with large concentric cells with a diameter from -04 to -05 of a millimetre, and with thick walls inclosing many concentric globules. " The cancer globule appears to me to be formed in this way: The capillaries excrete the cancerous matter in a liquid state. In this liquid, nuclei form, and soon after nucleoli. Possibly the nu- cleoli may form first. Around the nucleus, molecules of the liquid blastema first excreted arrange themselves, so as to form irregular enveloping shreds, or regular rounded or oval globules. It may possibly be the case that these concentric globules are only ordina- ry cancer globules, all the portions of which are remarkably devel- oped. I have also seen the cancer globules assume the appearance of clustering when they were filled with granules of fat, and when the nuclei also were deformed by the infiltration of fatty matter. "It is not reasonable to suppose that the cancer globules, which are first secreted, continue to exist for a long time. After a time they become deformed, they lose their distinct outline, and are fi- nally dissolved into granules. At the same time, the excreted blastema which is constantly being poured out by the vessels forms new cells. Thus, a certain number of the cancer globules appear incompletely developed, others are well developed and a certain number are undergoing decomposition. " The cancer globule of scirrhus is ordinarily furnished with an CARCINOMA. 75 enveloping membrane, which is round, ovoid, or irregular in shape. Its mean diameter varies from -015 to -02 of a millimetre. It is finely dotted all around the nucleus. This nucleus is small, its diameter varying from -0075 to -01 of a millimetre. Its outline is very sharp, and it exhibits, in its interior, granules and little masses (grumeaux), and sometimes nucleoli. " The cancer globule of encephaloid is surrounded by an en- velope, regular or irregular in shape, having a diameter between ■02 and -03 of a millimetre. The nucleus is spherical, or very often elliptical, pale, shaded at its circumference, and containing from one to three very distinct nucleoli. Generally, as already stated, the nuclei are seen under the microscope in greater num- ber than the perfect cells. Frequently every form intermediate to these two types of the cancer globule will be noticed. "Next to the cancer globule, which is the characteristic element, is the fibrous element, which is sometimes the predominating ele- ment. It presents very different appearances in different cases. In scirrhus, it is formed by a network of fibres arranged in bun- dles, which cross each other in every direction, and communicate with each other by fibres, which pass from one bundle to another. The primitive fibres, in this case, are well defined. They are del- icate, and do not exceed in breadth the -0025 of a millimetre. They are generally less tortuous than the fibres of ordinary cellu- lar tissue. In some cases these fibres interlace with each other without being arranged in bundles. In certain organs, especially in cancer of the mamma, there are numerous elastic fibres. In some exceptional cases, I have met with a fibroid network, in- closing in its meshes cancer globules and resembling exactly co- agulated fibrine. In the soft encephaloid cancer, the fibres are pale and delicate, and much less numerous than in scirrhus. Nev- ertheless, I have met with cases of medullary cancer, in which the encephaloid matter was inclosed in a dense and fasciculated fibrous stroma. " Fusiform bodies, such as are met with in other morbid prod- ucts, are very frequently seen in cancer. They are distinguished from the fusiform cancer globule by the difference in their nuclei, that of the cancer globules being much larger. " These fibres, these fusiform fibro-plastic globules are formed 76 THORACIC DISEASES. from the exuded blastema, as is also fat, pigment, and other sub- stances. "After the cancer globules, the fibres, and the fusiform bodies, the substance which is met with most frequently and abundantly in cancer, is fat. It is seldom absent, and it is sometimes so abun- dant and so mixed with the cancer globules, that they can hardly be distinguished. The fatty element occurs under the forms of granules, of free fat vesicles, fatty spots, and cholesterine. The granules are commonly found in abundance outside the cancer globules; but very often, also, they exist in their interior, and then we can distinctly trace the change from a simple cancer globule to that which resembles exactly the large granular globules of inflam- mation. Frequently, these granules are deposited in the nuclei of encephaloid globules. But that which renders these globules not easily recognizable, is the fact that fat is frequently depos- ited in them which is confluent and homogeneous in its character. Their outline is thus altered, and it requires great attention to distinguish them. It is these globules which constitute the fatty matter which looks like tubercle, an appearance noticed especially in sarcocele. "Large granular globules analogous to those noticed as the prod- uct of inflammation, with a diameter of from -02 to -03 of a mil- limetre, are commonly noticed in cancer. I have already stated that the cancer globule when infiltrated with fat, may assume the appearance of these inflammatory globules. But I think that the true inflammatory globule is also often found in cancer. When it is examined by a low power and by direct light, it appears in groups of a dull white or yellowish aspect. With a high power, and by reflected light, it appears of a blackish-brown color. It is usually so spherical, that it can be burst by compression, and made to discharge numerous granules. These globules are found in all kinds of cancer. I have sometimes seen them existing as a general infiltration into the cancerous mass, and sometimes form- ing a network of a dull-white color, constituting the reticulated figures so well described by Muller. They can sometimes be enucleated and studied separately. " The black pigment or melanosis, both in the form of granules and of globules, is found in both scirrhus and encephaloid cancers. MELANOSIS. / i " I have also noticed a peculiar coloring matter, of a yellowish tint, which I have named Xanthosis. It varies from a saffron to an orange tint. It appears to be a kind of fatty matter. " Crystals of cholesterine are one of the most common elements of cancer. I have also seen prismatic needles in cancerous depos- its; also, mineral concretions, amorphous or bone-like, yet with- out the structure of bone. "All the forms of cancer present the evidences of vascularity. " The colloid or jelly-like cancer is as well recognized a form of the disease as scirrhus or encephaloid. The cancerous tissue, especially the encephaloid, sometimes constitutes the base of the tumor, and then the cancer globules are only found in the deeper portions. In this case the gelatinous matter does not contain the true elements of cancer. We find a network of fibres forming large areolae, and filled by a transparent matter, containing pale granular globules. This colloid matter does not appear to be dif- ferent from that noticed as the product of inflammation, or as the contents of various kinds of benignant tumors. It only differs from it by being combined with encephaloid. But, in other cases, these areolae are filled by large cells or semi-transparent lobules, which contain numerous cancer globules and nuclei. CHAPTER XIII. MELANOSIS. The term melanosis, is derived from the Greek word ps\ag, sig- nifying black. It is a disease in which there is the deposit of a dark unorganized substance in some portion or portions of the sys- tem. As exhibited in the solid tissues, the deposit commonly has a viscous appearance, strikingly resembling the vitreous humor of the eye, and is, in color, very much like the pigmentum nigrum. It has no smell nor taste. It is soluble in water; and, when dis- solved, will stain like Indian ink. There are, however, different shades of color,—it sometimes exhibiting a brown and sometimes even a yellowish hue. Hard melanotic deposits, unlike tubercle and scirrhus, do not 78 THORACIC DISEASES. soften down at any stage of their existence. Sometimes, from the part where the deposit exists, a dark-colored fungus will arise, resembling fungus haematodes, and probably being of essentially the same nature. On the other hand, where carcinoma previously exists,—especially the encephaloid variety,—a melanotic deposit not unfrequently takes place. Sometimes absorbent glands,—en- larged as in scrofulous disease,—become blackened by a deposition of melanotic matter. In such cases, of course, the substance of the tumor is mainly organized structure,—the melanosis doing lit- tle more than give the coloring. Sometimes, as is the case with scirrhus, we have melanotic tu- bera, occurring as a secondary form of the disease, and appearing simultaneously in various parts of the system. Indeed, scarcely any organ or tissue is exempt from liability to be affected by it. The lungs, the pleura, the heart, the pericardium, the liver, the spleen, the uterus, the ovaria, the bladder, the peritoneum, the ali- mentary canal, the areolar and mucous tissues generally, the muscles, the skin, and even the bones are subject to the affection. So, also, are false membranes, or the depositions of organized lymph, which take place upon previously inflamed serous membranes. Occasionally, melanotic matter appears in a fluid form. In this case, a cyst is filled with a dark liquid, which, in its general fea- tures, precisely resembles the solid deposits. It seems, however, to be originally fluid, and not the result of a converted solid. That, in this disease, the blood itself is impregnated with par- ticles of melanotic matter, which really give rise to the formations in the solid tissues, is evident; and, not unfrequently, it is easy to detect these particles, by a chemical analysis. The discovery of melanosis, as a disease, is claimed by Dupuy- tren. It was, however, first described by Laennec. He repre- sented it as existing under the following four forms. 1st, Masses enclosed in cysts. 2d, Masses without cysts. 3d, Infiltration of the tissue of organs. 4th, Deposition on the surface of organs. This division, it is clear, presents the leading distinctive features of the disease. Dr. Carswell, however, has suggested another ar- rangement more comprehensive and various, as follows. MELANOSIS. 79 Origin,—A modification of secretion. Locality.—1st, Tissues, systems, and organs ; a, In the substance and on the surface of organs, b, In the cavities of hollow organs. 2d, New formations. Form,—1st, Punctiform, 2d, Tuberiform, 3d, Stratiform, 4th, Liquiform. Seat,—1st, Molecular structure of organs, 2d, The blood. As there are other morbid states of the system and products presenting distinctive characters, similar to those of melanosis, Dr. Carswell has also given us a tabular view of what he calls spuri- ous melanosis, in distinction from the true. The following is his arrangement. Origin,—A, Introduction of carbonaceous matter, B, Action of chemical agents, C, Stagnation of the blood. Locality,—Of the first kind, the lungs. Of the second kind, the digestive organs, the surface of serous and mucous membranes, the cavities of hollow organs, new formations. Form,—Of the first kind, uniform. Of the second kind, 1st, punctiform, 2d, ramiform, 3d, stratiform, 4th, liquiform. Of the third kind, 1st, punctiform, 2d, ramiform. Seat,—1st, The blood, contained in its proper vessels, or effused, 2d, Pulmonary tissue, cellular, and membranous.* Persons, suffering this affection, sometimes discharge a dark and almost black secretion from the intestines, the stomach, and even the cystis. Under these circumstances, the old authors termed the disease meloena—the black disease. The morbid secretions, in all these cases, are evidently melanotic; and, aside from the natural secretions with which they are mixed, are scentless and tasteless. °See Cyclopedia of Practical Medicine, Volume 2d, Page 86th. 80 THORACIC DISEASES. The pathology of this disease is not yet, it is true, fully under- stood. The melanotic discharge, however, so far as it has been analyzed, is found to contain the important elements of the blood, —fibrine, albumen, &c; but, in addition, nearly one third of the quantity is a highly carbonized and abnormal substance. That the disease is one producing general and decided debility will readily be inferred from the few hints given above, respect- ing its pathology. The depraved condition of the blood, of course, renders it, at best, an inadequate stimulant to the nervous system; but, especially, when the alvine and other discharges are melanotic, the nutrient and stimulating portions of the blood are abnormally removed, in such quantities, as greatly to exhaust the vital powers. In conclusion, I will only add, that various new formations, such as tubercle, carcinoma, and melanosis, may exist simultane- ously in the body and in the same organ; yet each is as distinct in its nature, as are the influences by which one organ is atrophied another hypertrophied, one indurated another softened, at the same time. CHAPTER XIV. NON-MALIGNANT TUMORS. Tumors in general differ from hypertrophy and euplastic de- posits in the peculiarity of their structure, or their kind of vitali- ty. They differ from cacoplastic and aplastic deposits in their possessing a higher degree of organization, that is, their degree of vitality. They are new structures; though some of them, in general characters, and most of them, in elementary composition, have a resemblance to healthy textures. Tumors may be divided into malignant and non-malignant The various forms of carcinoma, already generally considered, constitute essentially the class of malignant tumors. The non- malignant may be sub-divided into different classes, though it is difficult or impossible to draw a clear line of demarcation between some of these classes. NON-MALIGNANT TUMORS. 81 Non-malignant Tumors are, in general, those growths which occur in any part of the body without tending to infect other parts,—which, though arising among, yet do brane, according to the circumstances in which it is placed." This quotation from Dr. Gerhard, contains substantially the views of pathologists generally on this subject; and to my own mind, it seems strange, that they could have mistaken the truth for'so long a time, and yet not have fallen upon it, in all its sim- plicity. In the deposit of the hyaline fluid, and the formation of new tissue, it will be remembered, that the liquor sanguinis is at first secreted. This is composed of a little less than three parts of fibrin, and more than eight hundred and fifty of serum in one thousand parts of blood. The fibrin is essentially the only portion used in forming the hyaline deposit, while the serum, not entering into the vital economy, has to be otherwise disposed of. When a surface exposed to the external world heals, the serum is mainly evaporated ; but in a shut sac, like that of the pleura, it must either be absorbed or fall to the bottom. In persons possess- ing a good deal of vital energy, the absorption may go on nearly or quite as fast as the serum is separated from the fibrin ; and hence the pleuritis is called dry. In persons of a lymphatic tem- perament or those whose general health has become much im- paired, the power of absorption will be diminished, while the blood itself, from which the hyaline fluid is taken, is liable to have too small a proportion of fibrin, and too large a proportion of serum. Of course, under these circumstances, there must nec- essarily be a collection of serum in the pleural sac. In the formation of false membrane, as it is called, I have else- where explained, that the process is only the granulating process, or union of the parts by granulations. This, too, I have said, is mainly a vital, though in part a chemical process. It shows the disposition of tissues to heal, not by means of inflammation, but in spite of the existing inflammation. In the case of the pleura, the exudation corpuscles appear on the surface, at first in distinct points; but they accumulate near together, and finally form a 29 226 THORACIC DISEASES. membrane. The rubbing of the two parts of the pleura together, fritters away a portion of these exudations, and they mingle with the serum collected in the sac. The fact that the pulmonary and the costal portions of the pleura often unite, is strictly an accident. They being in contact, while the reparative process is going on, cannot escape the accident, except the rubbing of the parts to- gether in respiration, prevents; but this is not likely to obviate that result. While there is a collection of water in a portion of the cavity, that prevents the accident; but, after the water is absorbed, it generally occurs. As the serum is absorbed in the progress of recovery, the pres- sure of the atmosphere without, forces the parietes of the thorax towards the lung, and adhesion takes place between the two sur- faces of the pleura. The lung is compressed against the spine, and, in that position is covered with exudations or false membrane, so that it cannot afterwards rise to meet the ribs. When the pleuritis is slight and the effusion small, there is little or no con- traction of the chest. If there is some, at the time, it does not remain permanent, but, after a while, the lung expands in a good degree.* But when the pleuritis is severe, and the effusion great, the size of the lung by the pressure of the effused fluid, is greatly dimin- ished. To its normal dimensions after a very great compression, it seldom returns. And yet, by this, its structure is often unaf- fected. In appearance, it is wrinkled and flaccid, not crepitating, and containing but little blood. By surrounding inflammation, it is but little affected. For the tendency of serous inflammations to implicate subjacent tissues, is but slight. Air forcibly blown into its branches, readily distends it nearly to its original size. Some- times, however, its vesicles adhere, and thus the ingress of air is prevented. Then it looks like a piece of flesh, and is said to be carnified. The small size to which the lung in the chronic form of the disease, is sometimes reduced by the effusion, and its con- cealment beneath thick layers of false membrane, led the ancient pathologists to conclude, that the lung itself was entirely destroyed by suppuration. 0 Here ends the writing of Dr. Newton. PLEURITIS. 227 Such a degree of atrophy remaining permanent, after the ab- sorption of effusion, would, of course, cause a vacant space in the chest, and this gives rise to contraction of its walls, and to an el- evation of the subjacent viscera, the degree of which will depend upon the size of the space, left vacant by the removal of effused fluids. The quantity of effused fluid varies from a few ounces to sev- eral pints. When very copious, it fills the cavity of the pleura, and, in some cases, has been known in the course of a few days, largely to distend the chest, to cause the intercostal spaces to be- come more prominent than usual, and by its pressure to displace the adjacent viscera, whether of the thorax or abdomen. But these results more frequently take place in the more protracted cases which more properly may be described under the head of chronic pleurisy. In the sthenic form of the disease, the distension is rarely very great. In character the liquid is usually yellowish, limpid, or slightly clouded with flocculi of concrete albumen floating in it. Often it is turbid, like whey, sometimes bloody with or without coagula. In short, its color generally varies according to the va- riable quantity of its contained blood or of its red globules. In the progress of the disease, there are, moreover, mingled in the effusion, more or less of coagulable lymph and pus. In ordinary cases it has but little odor. This, however, is not always the case. Gangrene of a portion of the lung, or the admission of air into the pleural sac, constituting pneumothorax, often makes its odor most offensive from the generation as some suppose, of sulphure- ted hydrogen gas by decomposition. During the progress of the disease, the proper serous membrane, or the epithelium upon the areolo-fibrous layer, is not thickened or materially softened. In fact, the inflammation of serous mem- branes generally is located in the areolo-fibrous layer, because this is vesicular, and, therefore, more subject to inflammation. Whether or not the pleura pulmonalis is more liable to take on inflammatory action than the pleura costalis, authors, generally, to my knowledge, do not express an opinion. That pneumonitis often extends inflammatory action to the pleura, and that tubercu- lar deposits, adjacent to the surface of the lung, often cause a sim- 228 THORACIC DISEASES. ilar effect, are facts well known to medical men. And hence, it seems reasonable to conclude, that inflammation at first more often affects the pleura pulmonalis, and that the affection of the costal membrane is secondary. The adhesions of some parts,of the lung are more strong, and more often occur than those of Others. Whether or not adhesion shall take place at all, will depend on the quantity of serous effu- sion, and the character of its coagulable lymph poured out on the pleural surfaces. Of course, the fluid would ponderate to the low- est part of the chest, and pressing apart the two surfaces of the pleura, would prevent adhesion. If the upper portion is inflamed, and the fluid is not so copious as to fill the entire pleural sac, the part of the lung above the surface of the fluid, will adhere, while the parts below will remain free. But if the pleurae be inflamed in their lower portions only, a moderate quantity of liquid will be enough to keep their surfaces separate ; and, if the lymph then be- comes organized, it forms, not an adhesion, but a false membrane coating the lung, which may have effects in modifying the remains, / or the products of previous inflammation. A second condition modifying the liability to adhesion, is the composition of the coagulable lymph. If this contains a large proportion of what Mr. Paget calls the fibrinous lymph, or, in other words,, if the lymph partakes more of the fibrinous, than of the corpuscular character, the liability to early adhesion will be increased. When little or no liquid exists to prevent contact of sur- faces, the union, when the fibrinous lymph is exuded, takes place in a short time. As absorption removes the fluid, the lymph becomes organized, adhesion is the result, and in this man- ner, many times nearly the whole pleural sac is obliterated. When this is the case, that side so affected is not liable afterward to take on pleuritic inflammation. In some cases, the adhesion is only partial. Sometimes filiaments of cellular membrane are seen ex- tending from one surface to the other, having been formed, prob- ably, during the plastic state of the effused lymph, by the move- ment of the lung upon the side of the chest in respiration, draw- ing out the lymph into slender connecting bands. There are cases in which, contrary to common experience, the lower parts of the lung are firmly bound down to the parietes of PLEURITIS. 229 the chest, while the upper parts are free. A new attack of pleuri- sy on the same side, under these circumstances will, of course, cause effusion from the upper and free surface of the lung, and in this way give rise to abnormal sounds on percussion, in a locality, where by the inexperienced physician, they would not be suspected. Another effect of pleuritis is the formation of pus. This, how- ever, in cases of sthenic pleurisy, is gradual. In the advanced stages only, it assumes the character of pure pus. In fatal cases terminating after a few weeks, the effusion is thin, and is evident- ly composed in part of serum. And hence it has received the very appropriate name, sero-purulent effusion. It is probable, also that in the earlier stage of the disease, a certain number of pus globules exist in the effused serum. " Sometimes, in persons of feeble constitution," says Dr. Swett, " there are cases which, if measured by the time the disease had existed, would be called cases of chronic pleurisy, but, in which after death an abundant serous effusion, and but very little lymph or pus exist." Such cases seem to be developed by the existence of a low de- gree of inflammatory action which does not advance much beyond the effusion of serum, but which, occurring in feeble constitutions, and developed insidiously, is protracted to a fatal termination. On the contrary, the formation of pus is not always so protracted as before described. When the inflammation is violent, in its char- acter, pus may be secreted in the acute stage of the disease, and a fatal termination is quickly the result. The existence of pus alone in the cavity of the chest, cannot, therefore, be justly con- sidered as a sure indication of the stage of the disease. For the time of its formation depends very much upon the constitution and temperament of the patient. Caeteris paribus early adhesions, instead of copious effusion of serum, or the formation of pus, take place in mild cases, and in the young, strong and healthy. On the contrary, in the feeble, old, and scrofulous, the effusion of serum of a puriform character more frequently occurs early in the disease. ' The cause of this is found in the varied character of the effused lymph. In the young and plethoric, in those whose blood is rich in fibrin, the fibrinous lymph—using the division of lymph as made by Mr. Paget—is most commonly effused. While 230 THORACIC DISEASES. in persons having blood of an opposite character, the effused lymph partakes more of the corpuscular or less vitalized form which, very readily, and with but little change, degenerates into pus. Diagnosis.— General and rational symptoms. Acute sthenic pleuritis usually commences with a chill, soon succeeded by an acute lancinating pain in the side, cough, short and quick breath- ing, and fever. Each of these will receive a particular notice. The pain may come on either before, at the same time, or a short time after the chill. In character, it is severe as if resulting from the thrust of an instrument, and hence, it is often called a stitch in the side. Usually it is felt somewhere in the mammary region. But sometimes, elsewhere; sometimes near the lower margin of the chest, in which case it is, probably, the result of inflammation of that part of the pleura which covers the dia- phragm. In most cases it is confined to one place, but it may be diffused over the surface of the chest, when it is sudden, very sharp and severe. It is so nearly simulated by the nervous pains of hysteria, that it may lead to error in diagnosis. By inspiration, cough and motion, it is increased. Generally, lying on the af- fected side, and pressure over the-intercostal spaces, aggravate it. There is, a day or two after the occurrence of the most severe pain, a greater degree of soreness externally, than when early in the disease, the pain is most acute. As the effusion increases, the pain decreases in consequence of the separation of the inflamed membranes by the fluid, and the prevention of friction. It is, in some cases, almost entirely wanting, being perceptible only as soreness on pressure. The cough is usually short and dry, attended with but little expectoration of mucus or frothy matter. Sometimes a more co- pious expectoration is present. When the pleuritis is complicated with a degree of bronchitis, it is occasionally, somewhat bloody. Severe pain often attends it, to avoid which, the patient tries to suppress the cough, and to a certain extent he succeeds by the effort. This, however, in some cases is wanting. When such is the fact, and there is at the same time no pain, the disease by some au- thors is called latent pleurisy. PLEURITIS. 231 The breathing, in most cases, is more or less difficult. The pain prevents a full, deep inspiration. The patient is said to have a catch in his breath. In consequence of this, less air is taken into the lung when the pleura is affected, and the frequency of res- piration is therefore increased inversely as the quantity of inspired air at each inspiration decreases. The dyspnoea, unlike the pain, increases as tjie disease advances. The effused fluid filling up the space, usually occupied by the lung, causes this symptom. The function of one lung is more or less suspended, and the ac- tion of the other is increased beyond its normal degree ; so that the breathing of the patient becomes painful, and difficult. This is more particularly the case, when the effusion is both sudden and copious. When gradual, the system accustoms itself to the abnormal conditions of the respiratory organs. In the latter stag- es it is most severe, The decubitus has been considered as a pathognomonic sign of the disease. Yet there is much variance among the opinions of observers in respect to this symptom. This results from the va- riation of the decubitus in the different stages of pleuritis. At first, the patient cannot lay upon the affected side, on account of the increase of pain which that position produces. At a later pe- riod, when the effusion separates the inflamed surfaces, the pain, resulting from the position of the two portions of the pleurae, be- comes less, and sometimes is entirely wanting. , When the decu- bitus is on the sound lung, the weight of the effused fluid, press- ing upon the mediastinum, and forcing this beyond the median line, preventing the ingress of air into the sound lung, causes pain from dyspnoea. And, consequently, at this period of the dis- ease, the decubitus is most free from unpleasant sensations on the affected side. The fever is usually considerable, and attended with the most common phenomena of febrile affections. The pulse is quick, sometimes rising to over a hundred beats in a minute, hard, full and tense. The skin is dry and hot, particularly over the chest, or the seat of the disease. The tongue is parched; the urine is scanty and high colored; and occasionally there are cerebral symptoms. Of the fever there are often daily remissions and exacerbations, the former coming 232 THORACIC DISEASES. on in the morning, the latter in the afternoon or evening. In four or five days it moderates considerably. " The physical signs, at the commencement of the attack, are nearly normal. Before effusion has taken place, percussion is quite clear, and no auscultatory sign is given, except a slight di- minution of the respiratory murmur, consequent upon the defi- cient expansion of the lung, which is rendered more evident by a comparison of the two sides. As this depends nearly upon the pain of inspiration, it is obvious that the same result must take place in all other cases in which the pain is equally acute, and es- pecially in pleurodynia; so that the sign is of no great value. But very soon after the onset of the disease, when the concrete exudation has had time to cover in some degree, the surface of the membrane, a peculiar and characteristic sound may often be heard, in the middle portion of the chest. Sometimes it is ac- companied by a tremor when the hand is applied to the affected side. This is the friction sound, produced by the rubbing of the opposite roughened surfaces against each other. It is thought that the sound may be developed even before the commencement of exudation by the rubbing together of the pleuritic surfaces, rendered dry by the commencing inflammation, or unequal by the enlarged vessels. The grating movement which gives rise to the sound, may be felt by the hand applied to the side. As the con- ditions upon which the sound depends, are of short duration, the sign must be evanescent. It must vanish whenever a union of the opposite surfaces takes place, or as soon as they are separated by the liquid effusion. Although, from its uncertain occurrence, and its fugitive character, it cannot always be depended on, yet, when observed, it is a valuable sign, especially, in cases unattended with liquid effusion, such as have sometimes been called dry pleurisy. " The most decisive signs are those afforded after liquid effusion has commenced. A diminution of the healthy resonance on percussion may very soon be perceived by a comparison of the opposite sides, and the dullness goes on increasing with the in- crease of the effusion, until at length it often amounts to perfect flatness. At first, it is observed in the most dependant parts of the chest, and rises higher and higher with the advance of the disease. It usually varies with the position of the patient, fol- PLEURITIS. 233 lowing, of course, the position of the liquid which necessarily gravitates to the most dependent part, while the lung, which is lighter, has a tendency to float above it. The only exceptions to this rule, are cases in which the lung, and, consequently, the liquid, are confined by adhesions, and those in which the whole cavity is filled with the effusion. In the latter case flatness is universal over the affected side of the «chest. Sometimes, when a small portion of the lung is in contact with the walls of the chest, while all the rest is separated from them by effusion, a tympanitic sound is yielded on percussion, which might be mis- taken as the sign of pneumothorax or of a pulmonary cavity. " The respiratory murmur, somewhat enfeebled by the defective movement of the lung from pain, is still more so when liquid ef- fusion takes place, and goes on diminishing with the increase of effusion, and of the consequent compression of the lung, until it entirely ceases in those cases in which the liquid is abundant. In parts in which the lung is still in contact with the chest, the healthy murmur is often superseded by bronchial respiration, de- pendent upon the compression of the air-cells, which thus more readily convey the vibrations of the bronchi to the surface. This sound is usually greatest near the root of the lung, and diminish- es as we recede from that part, though it often extends more or less over the whole side of the chest. But, when the effusion is very abundant, this sound alone is quite lost, except in the region between the scapulae, and sometimes even there. On the opposite side of the chest, the respiration is louder than is usual in health, and often becomes puerile. " The vocal resonance, increased at first while the exudation is plastic, becomes, at a somewhat more advanced stage of the dis- ease, quite peculiar. When a moderate effusion has taken place, and a thin stratum of liquid intervenes between the lung and side of the chest, the tremulous, quivering, or bleating sound of the voice denominated egophony is heard. The bronchial sound, con- veyed outward by the compressed parenchyma, is modified as it passes through the trembling liquid, and acquires the striking character alluded to, before it reaches the ear. This modified sound is heard, especially between the third and sixth ribs, in the 30 234 THORACIC DISEASES. interscapular regions, and between the scapulae and mammae. It is most obvious in women and children, in consequence of the higher tone of their voice. Over the larger bronchi, near the spine, for example, it is often mingled with the bronchial reson- ance, and the sound acquires a peculiar complex character. As the effusion increases, egophony diminishes, and at length ceases altogether. Dr. Williams is of opinion, that little sound of the voice is transmitted when the stratum of intervening liquid ex- ceeds an inch in thickness, except over the larger tubes. When ' the quantity of liquid is very great, no vocal resonance is heard, except in a narrow space upon the side of the spine. " These results are of course modified, when the lung adheres more or less extensively to the sides of the chest. In such cases, * the bronchial resonance is usually loud and distinct at the adher- ing parts in consequence of the compression, of the aiivcells. When the extent of adhesion is small, the compressed lung forms a column, or kind of internal stethoscope, for conveying the sound to the ear. The vibratory movements of the walls of the chest are affected similarly with the sound of the voice, being somewhat increased so long as the effusion is plastic, gradually diminished with the increase of liquid, and entirely suppressed where the intervening effusion is copious, but still distinctly ob- servable where the lung adheres. Hence, when one hand is placed upon the sound side, and the other upon the diseased one, and the patient is told to speak, little or no movement is felt in the latter, with the exception just mentioned, while in the former the thrill is distinct. " Besides the above signs, there are others derived from the movements and shape of the chest, and the relative positions of neighboring organs. Thus, the affected side may be observed to be quiescent, while the other moves in respiration. When effu- sion is great, the chest may be visibly distended, and, if meas- ured by a tape, in the direction of a line around the body at the scrobiculus cordis, it will be found to be larger on the diseased than on the sound side. This, however, is not common, to any great extent, in acute pleurisy. Any difference that may exist will be most readily detected by making the measurement at the moment of full expiration, as it is then greatest in consequence PLEURITIS. 235 of the non-contraction of the distended side. But the fact must always be taken into account, that the right side in health ordin- arily measures from a quarter to a half an inch more than the left. The displacement of the heart, liver, etc., is much more frequently to be observed in the chronic than in the acute form of the disease. " The course of acute or sthenic pleuritis is very variable and uncertain. There is reason to believe that, if the disease is vig- orously treated at the beginning, it may often be arrested almost at the threshold, before it has exhibited any other signs of its existence than pain, decubitus on the sound side, a little cough, and a chill followed by fever. Exudation not having jet taken place, the physical signs are wanting. Should a catarrhal cough have preceded the attack, or should no cough exist, as sometimes happens, there are no means by which the disease could be cer- tainly distinguished from febrile pleurodynia, which has the general symptoms above mentioned, and the same diminution of the respiratory murmur, arising from the restrained movements of the chest. Hence, the doubt, in these cases, whether it was pleurisy or rheumatism of the intercostals, that was cured. " In other cases, along with the general symptoms mentioned, there is the friction sound upon auscultation, which is sufficiently decisive as to the nature of the complaint. The effusion of coagulable lymph has probably taken place, and a longer period is necessary for the cure. Sometimes, however, the morbid phe- nomena wholly disappear in from three to five days, leaving no unhealthy sound in the chest. In such cases, the opposite sur- faces of the pleura have uuited, and the friction sound ceases, because the surfaces do not move on each other. " In a third class of cases, the signs of liquid effusion are per- ceived sometimes on the first day; sometimes not until the second, third, or even fourth day, when the severe pain abates. In these cases, the friction sound, if observed at all, is soon fol- lowed by feebleness and gradual cessation of the respiratory mur- mur, by bronchial respiration, egophony, and dullness or percus- sion. Should the progress of the disease be now arrested, the general symptoms abate, and the morbid sounds gradually give way to the healthy, as the fluid producing them is absorbed. 236 THORACIC DISEASES. The friction sound is sometimes heard for a brief'period after absorption has taken place, and before union between the opposite surfaces has been effected. The disease is usually cured in five or seven days. " But, instead of the favorable turn at the period above alluded to, there is often a continued advance of the disease ; the effusion goes on increasing ; egophony Ceases; the bronchial respiration becomes more and more distant, until this also ceases, or is but faintly heard; flatness upon percussion prevails to a greater or less extent over the chest, generally varying with the position of the patient; the dimensions of the affected side of the chest are sometimes even visibly enlarged; and the healthy vibratory movement of its walls in speaking is much lessened or quite want- ing, as may be ascertained by applying the hand to the surface. The pain has nearly ceased, and the fever moderated, but the dyspnoea is often great, and the patient is unable to lie upon the sound side. The disease, in this form, continues for a variable period. Sometimes recovery takes place in two or three weeks, sometimes not for months; and the complaint not unfrequently assumes the chronic form. Should it terminate favorably, the fever, cough, and dyspnoea gradually disappear, the dullness on percussion diminishes, egophony occasionally returns in the pro- gress of the absorption, the respiratory murmur is again heard, the friction sound may be noticed for two or three days or more, and health is at length re-established. The clearness on percussion, and the healthy respiratory sound, return usually first in the upper part of the chest and afterward in the lower. " As the lung has not been sufficiently long compressed to have lost its expansibility, it is generally dilated as the fluid is absorbed ; but sometimes, either from its own altered state, or because bound down by false membrane, it does not completely resume its orig- inal dimensions, and a degree of contraction in the diseased side of the chest ensues, which, however, generally diminishes, or dis- appears with time. The favorable termination is often attended or preceded by certain critical affections, as urinary sediment, co- pious perspiration, diarrhoea, eruptive affections of the lips and skin, plegmonous tumors, and rheumatic pains. After convalesc- ence, the patient not unfrequently complains of a stitch in the PLEURITIS. 237 side upon taking a long breath; and sometimes a degree of cough, dyspnoea, and frequency of pulse remains for a considerable time. " When acute pleurisy is about to terminate fatally, which very seldom happens in the uncomplicated disease if well treated, the effusion increases, the breathing becomes very greatly oppressed, the countenance assumes a pale hue and anxious expression, the pulse increases in frequency, and at length becomes small and feeble, and the heart ceases to beat, in consequence of the imper- fect performance of the respiratory function. In the advanced stages, death sometimes results from a gradual failure of the pow- ers of the system, caused by the irritation of the diseased struc- ture. In double pleurisy, according to Andral, a fatal issue may take place from the mere influence of the inflamed membrane, without any discoverable amount of fluid secretions." [Wood's Practice of Medicine.] The most common terminations of this form of pleurisy are, 1st by resolution; 2nd, by passing into a chronic state ; and 3d, by" fatal asphyxia. Resolution may be complete, the effused fluid and false membranes being absorbed,' cellular adhesions being the only traces left of the disease, or it may be incomplete. In the latter case, the fluid is absorbed, but the false membranes remain, and are subject to various pathological changes. The second of these terminations will be considered under the head of Chronic Pleurisy. Death by asphyxia occurs only in the most severe cases, and is the result of great and sudden effusion. This termination is more frequent in pleurisy than in pneumonia. It is very rare, in the acute stage, and in those cases not compli- cated with other diseases. It more often occurs in the chronic form of the disease. Prognosis.—In primary sthenic pleuritis, affecting only one lung, there is seldom much danger, if treated in the early stages with proper remedies. After copiouseffusion the cure, of course, is liable to become protracted, but is generally effected, in uncom- plicated cases, without much difficulty. In short, the mortality from this disease, when not associated with others, is comparative- ly small. According to the report of the City Inspector of New York, the whole number of deaths from pleuritis during three sue- 238 THORACIC DISEASES. cessive years, was only one hundred and six, while during the same period of time, the deaths from pneumonitis, were two thousand five hundred and fifty-eight. Treatment.—In laying down the treatment of particular dis- eases, I will endeavor to recommend the pursuit of that course, which to me and to my medical brethren, seems most necessary and effectual. My object will be to adapt the treatment to the different stages of disease and to its various forms whether sthenic or asthenic, changing the remedies according to the pathological changes of the organs affected. In the inflammatory stage of sthenic pleuritis, when the pain in the side is severe, the skin dry and hot, the pulse full and tense, a decided impression should speedily be made upon the circula- tion of the blood. To accomplish this, and to relax the muscu- lar system and to favor cutaneous secretion, the vapor bath, is an efficient means of cure. It should be continued until a degree of prostration bordering on syncope is produced. When the bath cannot be used, sinapisms, stimulating lini- ments, warm fomentations should be substituted. And, in cases where the bath is applied, the latter means should also be used as valuable accessory treatment. The contact of air,—a thing always to be avoided in pleurisy, —is prevented by these external applications. For the same pur- pose, and to supersede entirely the use of other external means, there is used in Bellevue Hospital, New York, a jacket or waist- coat of oiled silk. This, when it can be applied, has many ad- vantages, over other applications. It is less troublesome to the patient, more neat, and permits a change of position, without be- smearing or wetting the bed clothes. The internal remedy upon which the most reliance should be placed, is lobelia. I prefer the extract. Ordinarily this should at first be given in small and increasing doses, in order that the re- laxing and sedative effect may precede the production of free emesis. Cases may occur in the treatment of which the remedy should be administered in common emetic doses. My manner of giving it, is to administer an extract pill, containing from gr. ii, to gr. v, once in half an hour, and to continue so to do, PLEURITIS. 239 until perspiration, relaxation and free emesis are the result. The degree to which the remedy should be carried in its application, must depend upon the violence of the disease, and the difficulty of obtaining relief. The pain may be removed, in part, at least, by applying tight around the thorax, a bandage. The object of this is to stop the friction of the lung on the parietes of the chest, and to throw the labor of respiration mostly upon the abdominal muscles. After the stomach has been thoroughly evacuated, the patient should have an interval of rest, and should take freely of gum acacia water in order to sustain the system. After the stomach has become quiet, in case a cathartic is indi- cated, one should be administered. The following in most cases is as serviceable as any. The proportions of the articles in the formula should be varied according to the exigencies of the case :— M Leptandriae* gr. v., Or leptandriae virginicae 5 i-j Podophylliae gr. i. ad gr. ii. Misce. To be taken in sirup or molasses. 0 In using the termination as of the genitive singular of Latin nouns in the first declension, I pursue what seems to me the most reasonable course. - Nearly all the names of concentrated remedies terminate in ine or in. If they be considered as Latin nouns of the third declension, terminating in the nominative singular in ine, then, like sedile, their genitive must end in is. For example podophylline (nomina- tive), podophyllinis (genitive). Against this method of termination, though, so far as I can see perfectly proper, these objections may be brought:—In the first place it makes the words longer:—In the second place, it does not conform to the termination of other names of medicines. Thus, from quinine, we have quinia in the nominative, and consequently quinice in the genitive, the termination of which case is the proper one to be used in writing Latin recipes. The same may be said of morphine and strychnine. In these examples the last n, with the last vowel, is eli- ded, and the letter a forming the correct termination of Latin nouns of the first declension, is substituted for the last n in these words. What objection, then, can there be to the adoption of the same rule in forming terminations to the concentra- ted remedies ? I can see none, except it be this;—that in three words, leptandria, sanguinaria, lobelia, meaning, these articles in a crude state, these are the same terminations, as would be found appended to the names of those articles in a con- centrated state, in case the above rule were adopted. Thus, leptandrine, dropping the termination ne, and adding a becomes leptandria, the name of the crude article- This, I believe, is the only reason which at first might seem to militate, against the 240 THORACIC DISEASES. After the operation of the cathartic, in order to produce diapho- resis, and lessen the inflammation, administer once in four hours, a pill containing of the extract of lobelia, from gr. i. to gr. iv. al- ternately with the following powder:— Asclepiae gr. xv. Or asclepiadis tuberosae 9ii-i Pulveris camphorae gr. xii.. Pulveris opii gr. iii., Pulveris ipecacuanhae gr. vi., Potassae sulphatis 9j- Misce. Dose—from gr. v. to gr. x. once in four hours alternately with the pills. If the above treatment, after twenty-four or forty-eight hours, fails to give relief—which it will seldom fail to do—inflammatory symptoms still continuing, the whole chest should be fomented with flannels, wet in water so hot as to almost blister the surface. This is usually very effectual in removing the pain. The ex- tremities may with a good effect, be bathed in some cooling li- quids, either water alone, or weak ley water, or alcohol and water. Some prefer cold water applied directly to the affected side. Whether or not this is better than warm water, or fomentations, is not as yet fully decided. To me it seems too dangerqus an application to be left to the discretion of a nurse. In the purely sthenic variety of the disease, its effect is probably best—But in asthenic cases, it would be liable to produce a permanent chill, and thus become a source of new difficulty in the cure of the patient, adoption of the above rule. A little consideration, however, will remove this ob- jection. Whenever the crude article is meant, in writing the Latin formulae, by append- ing to the generic terms, the specific names of those three articles, a clear distinc- tion can be made between the crude and concentrated remedies. No such difiiculty, in the great majority of cases, occurs. Out of twenty-six articles, there are only three in which there is any need, in order to perspicuity, of using the specific name. I shall, therefore, in all formulae, in this work, adopt the above rule; and, in order that there may be symmetry and uniformity in the nomenclature of concen- trated remedies, I would recommend others, in case the above suggestions shall seem proper and useful, " To go and do likewise." PLEURITIS. 241 In case these means do not have the desired effect, as a " der- nier resort " an enema of lobelia retained until emesis is produced, and relaxation is complete, will, in persons of strong constitutions, and of plethoric habit, be the most effectual means of subduing the inflammation. " The application to the side," says Dr. J. A. Andrews, "of a poultice composed of equal parts of podophyllum and ictodes foetida will in most cases produce sufficient counter irritation to effect the desired object." When copious effusion is evinced by the physical signs, and the object is to excite the action of the absorbents, a blister pro- duced by an adhesive plaster, sprinkled over with podophyllin, will be useful. By high authority, which to be sure is not always to be obeyed, unless that authority be clad in the garb of reason and science, the common mode of vesicating in the stage when effusion is Copious, is highly recommended. Concerning the pro- priety of this, the scientific practitioner should exercise his judg- ment, rather than yield to the bias of preconceived opinions. The above course of treatment is the one most frequently adopted in the inflammatory stages by eclectic practitioners. Dif- ferent physicians have different methods of applying remedies. Dr. J. A. Andrews—who, during nearly twenty years of practice has had almost universal success in the cure of this disease—pur- sues the following course of medication. At first he adminis- ters an emetic compounded after this formula :— R Asclepiadis 3 ii., Lobeliae inflatae 5vi-3 Capsici 9 i. Misce. Dose,—gr. xxx., once in fifteen minutes, until free emesis en- sues. After the effect of the emetic has subsided, he then adminis- ters, once in three hours, a powder of the following compound :— R Asclepiadis 5 v., Lobeliae inflatae 5 h\j Ictodis foetidae 5 i-j Capsici 9 *■ 31 242 THORACIC DISEASES. To be administered in infusion, and in doses sufficiently large to produce diaphoresis and relaxation. In case an expectorant is needed, he uses the following:— Senegae pulveris gr. x., Lobeliae inflatae pulveris gr. v., Corallorhizae odontorhizae pulveris gr. v. Misce. This should be administered as often as its effects are desirable. On the third day he usually prescribes a mild cathartic, moving the bowels, if necessary, before that day by enemas. Whenever the common nervines, such as cypripedium, Scutell- aria, fail to produce the necessary repose of the patient, he prescribes as a " dernier resort " an opiate :— R- Asclepiae 5i-j Potasses bitartratis 3i-j Opii 3 ss., Ari triphylli 3 i. Misce. Dose,—from gr. v. to gr. vii., as occasion requires. All of these anti-inflammatory means should be repeated as the case demands. In the second stage of simple sthenic pleuritis, or that of effu- sion, diuretics are often of great value. In case the quantity of effused fluid is great and the patient sufficiently strong, hydra- gogue cathartics, are also effectual means of exciting absorption. The articles most useful for this purpose are podophyllin, jalap, and cream of tartar. When catarrhal symptoms coexist with those of pleurisy, sene- ga is useful. Diuretics are also valuable to fulfil similar indica- tions. Among the best are galium aperine, eupatorium purpureum, aralia hispida, the seed of arctium lappa. These latter remedies are much more safe than others. Of the aralia hispida, Dr. H. Jacobs, an experienced and successful practitioner, makes frequent use for the purpose of producing the absorption of serous effusion. In the treatment of pleuritis, reference must always be had to the state of the system, and when this is asthenic the relaxing PLEURITIS. 243 and sedative means must be employed with more caution. In bilious pleuritis, cholagogues should be administered early in the disease. If there are typhoid symptoms, or if the disease assumes an intermittent form, quinine should be freely given. When pleu- ritis is complicated with tubercular disease, care should be taken that the relaxing remedies are not carried too far, lest their effects by producing debility, tend to excite the further deposition of tu- bercles. The diet in acute pleuritis should be very low, consisting in the early stages chiefly of mucilaginous or farinaceous liquids. Gum acacia water is almost the only food allowed in the Hospitals in Paris. This, by French physicians, is considered perfectly safe, for diet, and a very useful medicament, even when given in large quantities. Refreshing acidulated drinks may be freely allowed. Lemon juice, added to acacia water, or to an infusion of flax-seed, makes an excellent compound. Sometimes, the addition to the above drink of licorice is useful. The patient should avoid mo- tion and speaking, or coughing as much as possible. The shoul- ders and chest should be somewhat elevated with pillows. The i temperature of the room should be uniform, both day and night. In making any physical exploration, the chest should not be un^ necessarily exposed to the contact of air. " When we find the pleuritis nearly well," says Dr. Gerhard, " but the patient still complaining of some dyspnoea, or a little feverishness, and we discover on examination that a portion of the liquid remains unabsorbed, nothing is so efficacious as a jour- ney, with its necessary consequence, change of air. Although the sea-air is not always adapted to pectoral diseases, it is often of decided advantage in chronic pleuritis, especially if combined with a voyage. This is generally the surest means of dissipating the remains of the disease, and insuring a restoration to entire health. Of course, the usual hygienic precautions as to dress should be attended to." 244 THORACIC DISEASES. Section II. ASTHENIC PLEURITIS. Pathology.—This form of pleuritis is usually met with in per- sons who have been debilitated by previous acute or chronic dis- eases. Most frequently it occurs in the intemperate, or during con- valescence from febrile diseases of a typhoid type, from exanthe- matous and puerperal fevers, from erysipelas ; or it arises from or- ganic changes in the kidneys, from phlebitis and diffusive inflam- mation resulting in the formation of abcesses. With acute or painful local symptoms, this form of the disease is seldom attended. The disease is, for the most part, latent, ef- fusion often existing long before the disease is detected. Rarely a primary affection, it is most often associated with some other disease, or with some structural change. Its presence is indicated at first, by shortness of respiration, the position of the patient, and the sinking of the powers of life, more than by any severe local distress. The diagnosis, prognosis and treatment of this variety of pleuritis, are so similar to those of the chronic form of the dis- ease, that no separate description is necessary. Section III. CHRONIC PLEURITIS. Pleurisy varies greatly both in severity and in duration. It may be acute, in respect to the degree of suffering, and the rap- idity of its progress; it may be latent in its character and slow in the progress of the successive changes attending and consequent upon it. Between these extremes, the intermediate grades of morbid action are almost innumerable. The term chronic, then, in respect to pleuritis, seems to be more of a conventional term, than when applied to most other diseases. In pleuritis the tran- sition of the acuti to the chronic state is so indefinite, and the symptoms of the recent disease sometimes have so little of an acute character, while that of a long duration occasionally mani- PLEURITIS. 245 fests so much greater an intensity of irritation, that the terms acute and chronic would seem to be less applicable to pleuritis than to other diseases. This difficulty arises from the anatomical relations of the pleura. Being a shut sac, its acute inflammation is liable to be made chronic by the retention of inflammatory products. And the chronic is liable to be changed into the acute by the irritation of effused fluids. But, notwithstanding these difficulties, there seems to be no impropriety in ascribing to the disease, when highly inflammatory and until the inflammatory symptoms seem to arrive at an acme, the term acute. If after that period, lingering fever continues, evidently excited by the products of previous inflammatory ac- tion, then the term chronic may, with as much propriety, be ap- plied to the disease after, as the acute to the disease before the acme. In some cases, however, such an acme never seems to exist; and, to these the name sub acute may with propriety be applied. Pathology.—The anatomical appearances caused by chronic pleuritis are very similar to those of the acute form of the disease. Of course, the influence of time would tend to produce certain modifications. In general we find the membranes thicker, often composed of several adherent layers, the earliest deposits being harder than those subsequently formed. The character of the liquid, too, is subject to various changes in the onward progress of the disease. It is less limpid, more prone to become turbid with flocculi of a fibrinous character. In some cases it even ap- pears in consistence like jelly. The quantity is greater, and con- sequently the displacement of adjacent viscera is much more ap- parent. The lung by continued compression is altered in its ap- pearance, and often becomes wholly destitute of its normal crepi- tation on pressure. Here and there adhesions are often formed, between which in some cases, little sacs of fluid are enclosed. Under the best treatment, the disease, when uncomplicated, will generally advance to a favorable termination. But it often is the case, that the morbid products cannot be absorbed, and, con- sequently, they remain and pass through a series of pathological changes, sometimes ending in gangrene. Cartilaginous laminae, 246 THORACIC DISEASES. bony plates, abscesses, tubercles and hemorrhagic effusions, are among the successive steps in the progress of chronic pleuritis. "Sometimes," says Dr. Wood, "the walls of the chest are forced inward contrary to their elasticity, so that, when a puncture is made from without, the air rushes in to supply the vacuity pro- duced by their resilience. In some instances secretion goes on as rapidly as absorption, and the liquid accumulation remains for a great length of time. This is especially the case in empyema, or collection of pus in the cavity of the pleura; sometimes the pus makes its way into the substance of the lung, and a fistulous communication is formed between the bronchi and the pleural cavity, through which pus is discharged and air admitted. " In other instances the liquid takes an external direction, and by means of ulceration escapes into the cellular tissue without the chest, and, traveling occasionally for a considerable distance, produces subcutaneous abscesses in various parts of the chest, which ultimately open, unless life is previously worn out. In thus traveling, the pus has been known to occasion caries of the ribs and vertebrae, sometimes the purulent collection is found to be connected with a tuberculCus vomica." It is sometimes difficult to determine the causes which change ordinary acute pleuritis into the chronic form. Evidently in many cases, too much depletion, the too free use of mercury and other articles making up the antiphlogistic regimen, tend to the production of chronic pleuritis. Often, when a case seems to be cured by such means, the impoverished state of the blood, caused by the use of the lancet, thus rendering the system more liable to be affected by low grades of inflammation, develops a new and unwelcome train of symptoms admonishing the physician that the supposed cure, was after all, delusive. Dr. Gallup, defining chronic rheumatism, says that it is acute rheumatism half cured. So it may with equal propriety be said, that chronic pleuritis is the acute variety half cured. Diagnosis.—The general inflammatory symptoms of acute pleu- ritis may gradually disappear, but, unless the morbid products of the diseased action are removed from the pleural sac, the fever will recur and change its type, now very closely resembling PLEURITIS. 247 hectic, now becoming identical with it. This recurring fever is one of the most troublesome and alarming symptoms of chronic pleuritis; for in other respects the patient does not suffer in a manner proportionate to the extent or the duration of the effusion. Dr. Gerhard observes, " I once saw a patient who had performed the full duties of a sailor, going aloft, with an enormous pleuritic effusion. When he returned from sea, it amounted to two or three gallons. This is an exceptional case ; but it is very com- mon to find patients who can perform many laborious occupations without much inconvenience. This is generally the case if the dyspnoea is not severe; and we find that some patients complain of little difficulty of breathing with an extent of pectoral disease which will give rise to great distress in other individuals. The symptoms which so frequently characterize chronic organic dis- eases, are extremely variable in this variety of pleurisy. These are emaciation, loss of the firmness of the muscles, harshness and dryness of the skin, and slight oedema of the legs. Sometimes they are nearly as well marked as in tuberculous disease of the lungs ;—in other cases they are very slight; hence, they consti- tute a diagnostic sign of the disease; and, if we find them well characterized, we will do right to regard the case as one, probably, complicated with tubercles. If our impression be erroneous, we will soon rectify it, as the symptoms will gradually become more decided in the latter case, and slowly disappear if the pleurisy be followed "by recovery." The diagnosis of chronic pleuritis without the aid of the phys- ical signs, is often very difficult. Its general symptoms simulate those of phthisis. • But the physical signs are far more reliable. When these are present there is no difficulty in ascertaining the true character of the disease. If it is complicated with tubercu- lous deposition, the case should be regarded with much anxiety; for the diagnosis then becomes much more obscure, and the prog- nosis more unfavorable. Prognosis.—In this variety of pleuritis, when attended with copious effusion, the prognosis is doubtful. The liquid consisting mainly of pus, causes irritation, sometimes so severe as to produce marasmus, and to deprive the system of all that recuperative THORACIC DISEASES. power ever necessary in the progress of recovery. Sometimes it proves fatal in consequence of the obstruction to respiration; sometimes by the occurrence of metastatic abscesses in parenchy- matous organs. This latter result, however, is not very common. Treatment.—The treatment of chronic pleuritis differs from that of the sthenic character, less in the kind of remedies used, than in the manner of their application. Whatever means are applied should be such as tend to prevent effusion and promote absorption. For these purposes gentle emetics, followed by the use of vegetable tonics, are very serviceable. Of the utility of occasional emetics of lobelia in chronic pleuritis, there is much evidence. Their operation, in my opinion, is more sure than any other means, to prevent effusion and promote absorption, and to prepare the digestive organs, for the successful administration of tonics. Those who are anaemic seldom bear well the effects of emetics, especially of thorough ones. But those whose digestive organs are inactive, accompanied with febrile excitement, with dry and hot skin, and headache, with derangement in the circula- tion of the blood, will receive benefit from their occasional use. In connection with them, the vapor bath, or in cases where proper reaction is sure to result, the pack sheet, may often successfully be applied. Counter irritation is useful in this variety of the disease. For this purpose podophyllum or podophyllin sprinkled upon the sur- face of an adhesive plaster and applied to the side, will, in a short time, produce free suppuration. The same and perhaps a better effect may be derived from the use of Dr. Hill's irritating plaster, Senega and squill may be employed with benefit. To promote absorption, the iodide of potassium has been highly praised. When hectic symptoms appear, they should be combatted with tonics. The infusion or the sirup of wild cherry, I have found more efficacious than many other tonics. I prescribe this, in connection with the sirup of the iodide of iron. One ounce of the latter, added to one pint of the sirup of the former article, makes a good compound. If there is great debility sulphate of quinine, salicine and hy- drastine should, either separately or in combination, be adminis- PLEURITIS. 249 tered. To allay cough and produce sleep in those cases attended with much fever, I am accustomed to use, in connection with other nervines, the following preparation :— R Extracti lobeliae gr. ij ad gr. iv., Morphiae acetatis gr. 1-8 ad gr. 1-4. Misce. Administer at bed time. This usually produces diaphoresis, allays febrile symptoms, and, by promoting expectoration and quieting nervous excitability, relieves the cough. If there is a tendency to tubercular disease with considerable debility, not attended with much fever, I direct the patient to use for diet, eggs, oysters, beef, with other nutritious and easily diges- tible articles, and to take as a beverage some pure wine, in quantities not large enough to excite febrile action, and for medi- cine to take some tonic sirup containing iodine' in some of its forms. In very old pleurisy, tonics are sometimes necessary, especially when the suppuration is abundant. In such cases the chalybeate preparations are recommended by Dr. Gerhard. With these and vegetable tonics, acutaneous tonic and alterative may with benefit be combined; such as a stimulating bath, especially the sulpur and salt water bath. These are usually taken at their natural sources, by resorting to sulphur springs or to sea bathing. When the artificial baths are used they should be warm. Of cold sea bathing, and the cold sulphur bath for mere debility, after the sub- sidence of inflammation, Dr. Gerhard says, "that they are seldom appropriate, and that if used at all some caution should be ob- served in their management." " In chronic pleurisy " he continues,- " it sometimes becomes a question whether the operation of paracentesis should be per- formed. This is, as is well known, one of the most simple oper- ations in surgery, and no one can meet with the least difficulty in performing it,—but at the same time, it is often very serious in its consequences. There is a rule in surgery which is here strictly applicable ; that is, that the exposure of a large suppurating cavi- ty to the air, necessarily excites hectic fever, and sometimes fa- vors the development of secondary abscesses. The chances of 32 250 THORACIC DISEASES. recovery are not, therefore, on the whole increased by the opera- tion, and it is one which we should not perform, unless it be to relieve excessive dyspnoea, which may in itself be severe enough to threaten life." Concerning the safety and utility of this operation, authors ad- vance different opinions. To prove that many lives have been saved by the spontaneous, or by the artificial discharge of the purulent collection, much evidence can be advanced. "In my own mind," says Dr. Swett, "there is no doubt that in many cases in which the discharge of pus occurred at a late period, and in which death finally ensued, recovery would have taken place, had the discharge of the purulent secretion- taken place at an earlier period in the disease. " My decided impression is, that in all cases, after proper reme- dies have been tried in vain, the operation for empyema should be resorted to, and, if possible, before the vital powers are much exhausted. Because, notwithstanding the great and immediate relief experienced from the discharge of the pus, still, a great deal of it remains to tax the powers of life. A more or less copious purulent secretion continues often for a long time. " There are three classes of cases, in which the question as to the propriety of performing the operation may be discussed, First, there are the cases in which the side is much dilated, the intercostal spaces bulging and fluctuating, and in which pointing even has occurred. These are the cases in which the operation has most generally been performed. Before the discovery of aus- cultation, these were the only cases in which it could be performed with propriety, for in such cases only could the existence of mat- ter in the pleural sac be ascertained with any degree of certainty. Many cases in which the operation is performed under such cir- cumstances, recover, but death is by no means of rare occurrence. The patient is relieved, often very much relieved at first, but he soon dies of exhaustion. "Again, there is a class of cases in which the disease, having resisted all treatment, presents a different condition of things. The affected side is not at all dilated, or but slightly so; the in- tercostal spaces may be a little dilated or not, but there is no fluc- tuation, and especially no pointing. Shall an operation be ad- PLEURITIS. 251 vised in this case ? I think so, and that the chances of success will be greater than in the first class of cases. There is one thing that you must endeavor to be certain about—that is, the ac- tual existence of pus in the chest. The history of the case, the progress of the physical signs must be your guide, and your judg- ment must guard you against a hasty decision. " Finally, there is another class of cases, in which the effused pus has been absorbed partially, and in which the dilatation of the affected side, if it had existed, has given place to even a par- tial contraction. Yet the existence of great dullness, and the ab- sence of a respiratory murmur over the lower portion of the lung, the existence of hectic fever, and of other symptoms, must lead to the belief that the pus is still there, and that it refuses to be absorbed. The cause of this cessation of the absorption is prob- ably the compressed state of the lung, which refuses to expand. What shall be done in this case ? Open the chest ? I confess I have never seen the operation performed under these circumstan- ces, but I have examined fatal cases in which I wished it had been performed. " Another question presents itself in these cases. What is the condition of the lungs ? What is the condition of other organs ? It is certainly desirable to know that the lungs were probably healthy before the attack, and that no evidence exists of any sub- sequent disease. Suppose, after examining the chest, we suspect that an abscess is forming in the lung. Shall this make you hes- itate ? Shall you wait and see if nature will not open a commu- nication with a bronchus, and thus discharge the pus ? We may wait in vain for this result, and even if it should, in time occur, it is a far less agreeable and thorough mode of evacuating the chest than the operation of paracentesis. Suppose we have rea- son to fear that the patient may be tuberculous, should that deter us ? I think not. Would we not open an abscess anywhere else in a tuberculous patient ? Would the discharge of pus exhaust him ? I think not. It would relieve him, and thus prolong his existence. "Even in cases in which a softened tubercle has ruptured into the pleural cavity, and a bronchial communication has been, at the same time established, constituting what is called hydrp-pneu- 252 THORACIC DISEASES. mothorax, should this operation even then be performed ? I have never seen the operation performed under these circumstances but once, and then a fatal termination soon ensued. But I have re- cently met with two cases in this hospital,—the New York Hos- pital—in both of which the post-mortem examination made me hesitate as to the propriety of the course pursued. In one case, all the signs of hydro-pneumothorax continued until death, yet after death the lungs were found so nearly healthy, the tubercu- lous deposit was so small, that I could not help thinking, had the operation been performed—this was decided against in consulta- tion—the life of the patient might have been prolonged, and his condition rendered more comfortable. "Another case occurred, in which the signs of hydro-pneumo- thorax existed, but after a time the evidences of communication with a bronchus ceased, and this condition continued until death. In this case, also, the lungs were very little diseased, and the open- ing into the bronchus could not be detected by inflating the lung. It had no doubt been closed, perhaps by being covered by a coat- ing of lymph. In this case, and for a still stronger reason, the bronchial communication having ceased, the operation might have aided materially in prolonging life. _" It is difficult to say what the precise condition of the lung is in such cases. But this we do know, that hydro-pneumothorax occurs most frequently when there are but few tubercles in the lung. A copious deposit of tubercles leads to a secondary pleuri- sy with effusion of lymph only, by which the cavity of the pleura tends to become obliterated, and the form of the disease I am now considering, is no longer likely to occur." [Swett's Lectures.] The operation for empyema, or for the evacuation of other liquids besides pus, from the cavity of the chest, is very ancient, being referred to by Hippocrates, B. C. 460, as well as by many others at different subsequent periods of time. Although a full description of this operation belongs more properly to works on surgery, yet following the example of several standard authors, I deem it best to insert its*description, as given in Smith's Opera- tive Surgery. The diagnostic physical signs, indicating such a condition as would justify the operation, are enlargement of the side, dullness PLEURITIS. 253 on percussion, absence of free respiration, vocal resonance and a projection or fluctuation in the intercostal spaces. " The operation of paracentesis thoracis " says Dr. Smith, " has been variously performed, but the object of all the plans is to ( evacuate the liquid contents of the part, without admitting air into the pulmonary cavity. To accomplish this, it has been sug- gested to puncture the parietes of the chest with a trocar and can- ula, or with a trocar and syringe, or to make a direct dissection, layer by layer, from the skin to the pleura. In all the plans that have been recommended for the accomplishment of this object, surgeons have differed mainly in regard to the best point for the puncture; but, as the patient is usually compelled to sit up, and as the general anatomical relations of the region especially favor a certain point, it is sufficient to state that, when circumstances admit of it, the space between the fourth and fifth, or fifth and sixth ribs, and a little posterior to their middle should be selected. In order to avoid Wounding the diaphragm, which is presumed to be pushed up by the liver, it is generally advised to puncture the right pleura one rib higher than that advised for the left. Such a position is, however, far from being established as correct, the idea being based rather on the descriptions of the normal con- dition of the part than on the diseased state, and it is most prob- able that the weight of the fluid collected within the right pleura will more than counteract any elevation of the liver when the patient is in the erect position. In counting the ribs in a person of moderate flesh, but little difficulty will be found in tracing them from below, upward; but in those who are fat, or in those who have the side oedematous and swollen, it may be impossible to distinguish these spaces, and under such circumstances the rule has been given to select a spot which is about six finger-breadths below the inferior angle of the scapula.*" " Ordinary Operations of Paracentesis Thoracis.—The pa- tient being propped up in bed, and a little inclined to the sound side, so as to separate the ribs as much as possible on the diseased side, the skin is to be divided to the extent of one and a half 0 Malgaigne. 254 THORACIC DISEASES. inches in a direction parallel with the superior edge of the low- est rib on the intercostal space, that is selected for the puncture. After dividing the superficial fascia, and any portion of a muscle of the chest that may intervene, as well as the external and in- ternal intercostal muscles, the pleura will be found generally to < bulge into the Avound. After being distinctly felt by the fore- finger, so as to establish the fact that only fluid is behind it, the puncture should be made with the point of a bistoury, and the opening gradually enlarged as the liquid escapes* " If the pleura is very much thickened, care will be requisite to avoid the error of pushing it before the instrument. Velpeau en- tertains the opinion that in cases which require the operation, the effused liquid, or even an abscess, will remove the lung from the point of puncture. He, therefore, objects to the details just given, and advises that the side of the chest be at once opened by a deep puncture with the bistoury in the same manner as an ordinary abscess. " After Treatment.—If circumstances render it desirable to keep the wound open, a tent may be introduced, and removed from day to day ; but if the whole of the liquid be evacuated, the opening may be at once closed with adhesive strips, a com- press, and bandage. " If the subsequent discharge continues copious, or becomes very fetid, advantage may be derived from washing out the cavi- ty with warm water, or warm barley water; weak astringent washes, or those of an anti-septic character, being subsequently employed. In order to evacuate the liquid, and yet prevent the entrance of air, various contrivances have been employed. Pelle- tan employed a syringe for this purpose, and Reybard placed a piece of gold-beater's skin, or the intestine of the cat, over a canula introduced into the pulmonary cavity, by means of a per- ' foration in the rib, so that the matter might flow out and yet the air not enter. " Dr. Wyman, of Cambridge, Mass., has invented a brass suc- tion-pump with an exploring canula, in order to permit the evac- "Velpeau's Op. Surg., by Mott, p. 515, v. iii. PLEURITIS. 255 nation of the fluid without allowing the air to enter the pleura, and has reported numerous instances of the success of this mode of operating, which he thinks is preferable to the ordinary mode of incising the soft parts. " Remarks.—The value of the operation of paracentesis tho- racis has been differently estimated at various periods; most of the surgeons, up to the time of Laennec, having regarded it as a doubtful or dangerous operation, especially from the difficulties attendant on the diagnosis. Since the more general resort to aus- cultation, many of these difficulties have been removed. " But, though the cases can now be better selected than they were formerly, a successful result is not always obtained. The true results of the operation may, it is thought, be correctly stated thus :—Paracentesis always affords temporary relief, and almost one- half of the cases recover ; but whether these patients would have died without it, it is difficult to tell. " The idea is certainly erroneous that paracentesis thoracis is an eminently successful operation, and though its results have been such as to justify its performance, the prognosis should be guarded. From statistics collected from various sources, it appears that the mortality is considerable, and the objections that have been raised against the operation in former days should be regard- ed. They are thus stated by Yelpeau:— " If the lung has been forcibly compressed by the liquid, and yet is permeable, the evacuation of the liquid without the en- trance of air into the pulmonary cavity may distend it so rapidly as to excite violent inflammation. If, on the contrary, the lung has shrunk so much as to yield but slowly to the entrance of air, the void which is immediately left about the parts, is very liable to derange the respiration and pectoral circulation. The intro- duction of air into the cavity of the pleura, though obviating this, yet exposes the patient to danger by exciting the inflammation, and creating unhealthy pus, thus giving rise to adynamic symp- toms, under which many have died. " Estimate of the Operation.—In estimating the value of any of these modes of operating, the difficulties or objections 256 THORACIC diseases. applicable to each should not be overlooked. When the inter* costal spaces are prominent, and the presence of liquid certain, the direct puncture of Yelpeau is best. " When there is any doubt of the position of the liquid, then the ordinary operation by dissection of layers would be prefera- ble. Where, however, the diagnosis is positive, and the chances of failure from the accident of pushing forward the thickened membrane, instead of perforating it, is guarded against, the in- strument of Dr. Wyman of Massachusetts may prove advan- tageous. In Boston, the experience of the profession is said to be favorable to it. " Under all circumstances, the surgeon may anticipate an anx- ious and long-continued convalescence of the patient, and one which will exact all his skill as a practitioner, to conduct the case to a favorable result. " The employment of a trocar is the most objectionable of the various instruments employed, as it is not so shaped as to obtain a keen edge, whilst the point of the cannula, even when closely fitted to the shoulder of the instrument, is very liable to tear or push the pleura before it, as is occasionally seen in cases of hydro- cele, accompanied with thickening of the tunica vaginalis. " When the surgeon recalls the constitutional effects liable to result from opening closed cavities, and especially those contain- ing pus, and covered by a pyogenic membrane, he can readily foresee the consequences of opening the pleura in cases of em- pyema. The natural tendency of such collections is either to be absorbed or discharged by the efforts of nature. If discharged by nature the inflammation of the surrounding parts, and the character of the opening made by ulceration, are well known to be more favorable to a cure than is the case when the surgeon punctures it. I would, therefore, express the opinion that this operation should not be resorted to until the latest possible mo- ment ; that, when done, air should be prevented from entering the cavity of the chest; that the pus should be slowly and only partially discharged, the wound closed, and the operation repeated, if necessary. If, however, the entrance of air cannot be pre- vented, it. will be better to evacuate the whole of the liquid, and treat the case subsequently like one of abscess." PLEURITIS. 257 From statistics, it appears that nearly two-thirds of the cases operated on have been cured. [Smith's Operative Surgery.] The result of the operation, though more favorable than some authors represent, should teach the importance of using all posst ble preventive means, in order to avoid the necessity of its per- formance. The question, then, very naturally arises, can any means more efficient than those in common use among allopathic physicians, be used to prevent the recurrence of its necessity? I think so. The object, as has been before stated, is to promote ab- sorption, and to sustain the strength of the system while the cur- ative process is going on. Ordinarily physicians depend, for the most part, upon diuretics and tonics; seldom using as curative agents emetics. But notwithstanding this, these when properly used, and composed of such articles as produce temporary debil- ity only, are in rny opinion of great service. In acute pleurisy they have had the sanction of Riverius, Ruland, Blegny, Mur- sinna, Morgagni, Wright, Stoll, Tissot, Ackermann, and Schel- hammer. And Dr. Copeland adds that, when discreetly pre- scribed, they are important aids in the treatment of most of the forms of the disease. Dr. Gallup observes " that the character of the chronic morbid habit leads us to infer, that certain operations which may bring into exercise the minute circulations, may be useful to restore their integrity of function. One adjuvant has been found in the exercise of vomiting; and we make it a substitute for corporeal exercise for those not in a condition for this. Not only so, but it exercises every minute tissue more effectually than any mere mus- cular exercise. It is necessary that this, with other processes, should precede, and prepare the system to endure muscular mo- tion with benefit by removing the morbid derangements. " The lungs as well as all the internal organs, are exercised by emesis, and their functions promoted by it. The exhalents and mucous follicles discharge more freely, and the internal infarc- tions of the blood vessels are agitated, and absorptions promoted. The centrifugal and exhaling surfaces are excited, not by direct stimulants, which would add to the diseased state, but by a train of associate motions restoring or exciting their lost functions. Even the exercise of nausea is extended very considerably to all 33 258 THORACIC DISEASES. the tissues, and in many conditions may, where there is much lowness, be used as an occasional substitute for emesis. These processes may be so conducted as not to exhaust overmuch. Like corporeal exercise, they may be extended to the point of fa- tigue but not of exhaustion. " It is not a single emesis that will be of much use, to remove a fixed state of disease of slow access; but it must be reiterated, and in connection with other auxiliaries. The patient should always be in a warm condition during the process, so as to pro- mote dermoid action, and sometimes moderate sweats." Emetics, it seems to me, are for another reason, useful in chron- ic pleuritis. One object is to produce expansion of the com- pressed lung. While the emesis promotes absorption of the ef- fused fluids, it also, by producing deep inspirations, expands the lung, which, in consequence of its sudden increase in size, excites still more 'the function of absorption. They, also, when eom- posed of proper articles, and properly administered, prepare the system for the effectual application of tonic remedies. To pre- scribe this latter class of curative agents, when the mucous mem- branes are coated with morbid secretions, is worse than useless. I have seen patients laboring under some chronic disease of the pleura, who had been treated with tonics with no benefit, rapidly recover after the administration of an emetic, followed by the use of those very remedies, which they had before been using with no salutary effect. They should be repeated once a day, or once in two or three days, according to the degree of benefit received from them. A very good time is in the evening about an hour after coming from a warm bath. Some who suffer much in the morning from col- lections of muco-purulent matter, receive the most benefit by using the emetic at this time. The intervals between their administration should be sufficient- ly long to afford rest and refreshment to the patient. Nor should he, in the interval be continually harrassed by other medicines of doubtful utility. A nutritious diet should be used, and all food containing but little nutriment in a large bulk should be avoided. My manner of administering the emetic in very feeble patients is this:—I give, after the patient is warm in bed, and his stom- PLEURITIS. 259 ach is somewhat distended with warm water, at suitable inter- vals, a pill containing from gr. ii to gr. iv. of extract of lobelia, until considerable nausea is produced. Then I direct the copious drinking of warm water which in a few moments,is usually fol- lowed by an easy and free evacuation of the contents of the stomach. In ofher cases, when the patient can bear more heroic treatment, the pursuit of the above course is not necessary, but the emetic may be given in the ordinary way. In case much distress results from the effects of the emetic, administer, in cold water, and repeat the same, acetic, or citric acid. The means chiefly to be relied upon, in warding off the neces- sity for an operation, are the vapor bath followed by brisk fric- tion, gentle and repeated emetics, followed by the strongest ton- ics, and nourishing food, and vegetable diuretics. Inhaling tubes for the purpose of expanding the compressed lung, are by some highly recommended. When the effusion has a purulent charac- ter, the hydriodate of potassa in the dose of two or three grains, three times a day is often useful; in more asthenic cases, the iodide of iron, in rather small doses may be given. For a diu- retic, when the vegetable diuretics before mentioned, fail to give relief, the tartrate of iron is serviceable, especially where a dropsi- cal diathesis prevails. Section IV. LATENT PLEURITIS. This variety differs from others mainly in the absence of the more common rational symptoms, such as dyspnoea, cough and pain. These are either entirely wanting or are so imperfectly de- veloped as to make it impossible to found upon them an accurate diagnosis. The disease passes so insidiously through its different stages, that the patient is seldom aware of the nature of the mal- ady with which he is affected. After recovery he often forgets the trifling indisposition which he felt during its progress. In this form of pleuritis adhesions of the lungs to the costal pleura often become extensive. In rare cases the general symptoms are more marked, attended with a gradual wasting of the vital forces. In general such cases are complicated with phthisis. 260 THORACIC DISEASES. Pathology.—The anatomical lesions in latent pleuritis differ so little from those already described, that their consideration in this place would be but a useless repetition. Diagnosis.—The absence of the rational symptoms, makes the diagnosis dependent almost wholly upon the physical signs. In case there is considerable effusion, we have dullness on percussion, feeble respiration and egophony. Additional evidence of the pleuritic character of the disease is afforded by the existence of the friction sound. In case this is absent and the other signs above referred to are but imperfectly developed, there is danger of confounding the disease with enlarge- ment of the liver, or with consolidation of the lung. In the ma- jority of cases, however, the physical signs are so well marked that a correct diagnosis may be made. With tuberculous disease it is often so intimately connected that it is difficult to determine how many of the morbid phenomena proceed from the tubercular deposits, and how many from the pleuritic inflammation. Almost always in those of a scrofulous diathesis, these two diseases are more or less mingled together; and hence, in such persons, the slightest symptoms of phthisis occurring in pleuritis should be closely observed. Prognosis.—The prognosis is favorable or unfavorable accord- ing to the nature of its complicating diseases, and the condition of the constitution. When associated with phthisis there is but little reason to hope for recovery; when isolated and occurring in a healthy constitution, it generally, under proper treatment, ter- minates favorably. Treatment.—The treatment does not materially differ from that of other chronic forms of the disease. There is, therefore, no need of any repetitiori in this place, of that which, under the head of Chronic Pleurisy, is fully described. The remedies should, of course, be continued until all physical signs of the disease dis- appear, and the general healthy appearance of the patient is indi- cative of complete recovery. PLEURITIS. 261 Section V. SECONDARY AND COMPLICATED PLEURITIS. Pathology.—Pleuritis is often associated with inflammation of an adjoining tissue or organ, or with'some other lesion or malady. It may be either: primary or secondary. With inflammation of the pargnchyma of the lung it is frequently complicated ; the dis- ease sometimes beginning in the pleura and extending to the sub- stance of the lung; at other times, on the contrary, beginning in the lung and extending to the pleura. This complication is usu- ally termed pleuro-pneumonia, and by older writers was known by the name peripneumonia. In such cases the inflammation usu- ally assumes a sthenic character. The pleuritic and the pulmonic inflammation may be coetaneous. More often, however, the pul- monic, is antecedent to the pleuritic than the reverse. Some writers assert that the complication of pneumonitis with pleuritis lessens instead of increasing the danger. The reason given is derived from the idea that the pneumonia is lessened by the pressure of the effused fluids of pleuritis. The lung also by its increased size, in consequence of the engorgement of its ves- sels, presses upon the fluids, and this excites a degree of activity in the absorbents, which under other circumstances would not exist. There is, then, according to this theory, a reciprocity of action, whose tendency is to the cure of the disease. Pleurisy is sometimes complicated with exanthematous and con- tinued fevers. Unless it occurs in the period of convalescence from these maladies, it is prone to assume the sthenic form, but when during recovery the fluids of the body are contaminated, and the vitality of the system depressed, the asthenic form is most common. Whenever, in fevers, the breathing becomes very short and frequent, whether dr not accompanied with pain in the side and cough, then pleuritic inflammation may be suspected, and an examination should be immediately made in order to arrive at a correct diagnosis, and predict with certainty the nature of the termination. 262 THORACIC DISEASES. Another very frequent complication of pleurisy is with phthisis and chronic tubercular pneumonitis. Tubercles existing near the surface of the lung, often excite inflammation in the circumjacent tissues, which is readily extended to the pleura pulmonalis. On its free surface lymph is effused, which, coming in contact with the pleura costal is, excites on it inflammation. Adhesion usually is the result. Sometimes, however, a different state of things takes place. A cavity, by the softening of tubercular deposits, is formed near the surface of the lung before adhesion is effected. This, in some cases, producing a perforation of the pleura pul- monalis, and at the same time communicating with the bronchial tubes, admits into the cavity of the pleural sac, the atmosphere. This kind of lesion is called pneumothorax, which, in another place, will be more fully considered. Tuberculous pleurisy may be consecutive to tubercular depos- its in the parenchyma of the lungs, and then it is strictly secon- dary. Again, in the second place, it may arise from the deposit of tubercles in the pleura itself; and, lastly, the inflammation of the pleura is antecedent to the tubercular deposit, the pleuritis thus becoming an exciting cause of phthisis. The latter effect of pleuritic inflammation should then be considered in this con- nection. Why is pleuritis more prone to produce tubercular dis- ease, than pneumonitis ? To answer this may be difficult; and yet such is the fact. May not the absorption of pus into the blood be one prominent cause ? This, like all other impure mat- ter in the blood, must tend to produce more or less debility, must excite an irritative fever simulating the hectic of phthisis. That febrile action which most nearly resembles the hectic of phthisis, should caeteris paribus be most likely to afford conditions most favorable to the development of tubercles. This may be one cause of the tendency of pleuritis to generate phthisis. Pleuritis is also complicated with many other diseases, with pericarditis, hepatitis, peritonitis, and rheumatism. These com- plications, however, are not sufficiently common to be made sub- jects of separate consideration. Diagnosis.—The diagnosis in complicated pleuritis, must de- pend upon that accurate discrimination in the balance of symp- PLEURITIS. 263 toms, which is the possession of every close observer of disease. Each symptom is often a complex phenomenon, divisible into a number of separate signs. If in the course of pneumonitis, the friction sound occurs, if there is great dullness on percussion, the limits of which change on every change of posture, if there is egophony, if either one or all of these physical signs, are com- bined with those of pneumonitis, the diagnosis will be evident. Complications with phthisis will of course, give the signs of both diseases; with pericarditis, will give the friction sound of pleu- ritis heard only during respiration ; while the friction sound of pericarditis is heard during the suspension of respiration. The effusion, and consequent dullness of pericarditis is confined to a small space—the praecordia; that of pleuritis extends over the base and sides of the lung and is in general changed by any change of posture. When both these trains of symptoms are coetaneous, the nature of the complication will be evident. The diagnosis of other complications must depend upon principles similar to those already suggested. The Prognosis will depend upon three conditions, the nature of the complicating disease, the extent of the pleuritis and the constitutional state of the patient. Pleuro-pneumonitis, has al- ready been referred to. Pleuritis complicated with phthisis is always very dangerous; with pericarditis it is unfavorable. Treatment.—The complications of pleuritis necessarily involve the same principles of treatment as the more distinct forms of the disease. Regard must be had to the nature of the malady with which the pleuritis is associated. If its complication be with some other sthenic inflammatory disease, the anti-inflammatory means must be used in the process of cure. If associated with pneumonitis, all narcotics should be used with more caution than in its simple form. When arising from the retrocession of eruptions from the surface, warm bathing with stimulants and diaphoretics should be used. When complicated with phthisis, the treatment for the latter disease is most appropriate. 264 THORACIC DISEASES. Section VI. PLEURITIS OF CHILDREN. Pleurisy is common in children of all ages ; but is most fre- quent in its uncomplicated forms after the age of five years. Anterior to that period it is, in general, associated with pneumon- itis and bronchitis. Sometimes it is a sequela of eruptive fevers. During the whole period of convalescence from them, while the functions of the skin are but partially restored, this disease in children is prone to occur. Pathology.—Primitive pleurisy in young children does not present any striking anatomical characteristics which distinguish it from the disease in adults, as in the case of pneumonitis. There is, however, one fact in those cases, which points out the affection. It is a want of compressibility in the lung from the liquid effusion. The effect of this is seen in the modification of the physical signs which it produces. Diagnosis.—Dullness on percussion presents its usual charac- teristics. But the respiratory murmur, on the contrary, instead of being feeble or absent, assumes a bronchial character, equally as distinct as that of pneumonitis, but far more extensive, accom- panying the dullness on percussion, and being often heard all over the affected side, and without crepitation or rhonchus. "This bronchial respiration," says Dr. Swett, "as connected with pleuritis, is the rule, in the pleurisy of young children, not the exception, as in that of adults." Prognosis.—Pleuritis in children is far more dangerous than in adults; more especially when it occurs as the sequela of eruptive fevers, of pneumonitis, or pertussis. In infants this disease, whether simple or complicated with pneumonitis, bronchitis or whooping-cough, is often fatal. In twenty-four hours, by caus- ing suffocation, it may end in death. In very young children it seldom assumes a chronic form ; for in them the later stages of the disease are less liable to occur. pneumothorax. 265 Treatment.—Pleurisy in children requires the same measures which are recommended for adults, modified according to age and to the susceptibility of infancy to the influence of reme* dies. Relaxing enema should be more frequently directed, and the use of the more harsh and debilitating means, more cautiously prescribed. Warm demulcent poultices, instead of irritants or ves- icants, should be employed. In the chronic form, the frequent sponging of the surface with warm salt water, as an external ap- plication, is excellent. For an internal remedy, the sirup of the iodide of iron, administered in simple sirup of sugar, is sometimes serviceable as a tonic. Other varieties and modifications of .pleurisy are described by some authors. But they are for the most part, unimportant, and their consideration is of no practical utility. CHAPTER XII. PNEUMOTHORAX. The term pneumothorax from the Greek rfvsu/xa air and dwpaf chest, which would, according to its etymology, mean any collec- tion of air in the chest, is at present, used to designate more es- pecially the effusion of aeriform fluids in the cavity of the pleura, whether the air exists alone, or whether there is sometimes a cer- tain quantity of liquid mingled with it. In the first instance the collection receives the name of pneumothorax, in the latter that of hydro-pneumothorax. Notwithstanding the distinctive use of these terms, the name pneumothorax is in general applied to both of these phenomena. Before the commencement of the present century, it had not been made a subject of thorough investigation. To Laennec be- longs the honor of first making it an object of scientific study. Pathology.—Pneumothorax is a consequence of lesions of both the lungs and pleura. In most cases it is the result of tubercular disease perforating the pleura pulmonalis, before it adheres to the pleura costalis. The cavity formed by tubercles communicating 34 266 THORACIC DISEASES. with the pleural sac, and at the same time with the bronchial tubes, gives rise to this affection. Sometimes pneumothorax oc- curs in gangrene of the lungs. A gangrenous eschar may break into the pleural sac, and a communication be formed with the bronchi. It is possible for an emphysematous vesicle in the lung to rupture the pleura covering it, and thus produce a pneu- mothorax. Another way by which this has been supposed to be produced, is the secretion of air by the absorbing surfaces of the pleura, or by the decomposition of inflammatory products. A fistulous opening or wounds produced by accident or by the hand of the surgeon sometimes are its immediate cause. When the air enters the cavity, it compresses the lung and gives rise to the physical signs of this organic lesion. Perforations of the pleura, as we should expect from the more frequent location of tubercles in the left lung, oftener are found on the left than on the right side. Reynaud found in forty cases of perforation, twenty- seven on the left lung, and thirteen on the right. Diagnosis.—General symptoms. These are very equivocal, and altogether insufficient to serve as the basis of a confident di- agnosis. Dyspnoea caused by the compression of the lung is a very constant symptom. Its degree depends upon the amount of air and liquid in the cavity of the pleura, upon the rapidity and permanence of the accumulation, and upon the condition of the opposite lung. Caeteris paribus the dyspnoea will be less, when the admission of air or the collection of other fluids, is gradual; because the organs of respiration and circulation, to a certain ex- tent, accommodate themselves to the new condition. Most frequently it happens that the entrance of the air is sud- den, and as a consequence, dyspnoea quickly becomes severe at- tended with acute pain, and sometimes with a sensation as if something had given way in the chest. In case the pleural sac is distended with pus, a copious expectoration of a puriform charac- ter suddenly supervenes as a result of the opening into the pleura. Sometimes it so happens that the pleural opening is so large as to permit a ready egress of the air admitted into the pleura, in which case the dyspnoea will be less violent. On the contrary, if PNEUMOTHORAX. 267 the opening be such as to permit the passage of air only one way, like the valve of a pump, then at every inspiration more air is ad- mitted than is expired, until the accumulation is so great as to cause suffocation. Very soon, under such circumstances, death may occur, preceded by the most painful and laborious breathing, intense anxiety and general prostration. When one lung from the effects of the disease is unfitted alone to arterialize sufficient blood to sustain life, and the pneumothorax occurs on the other side, sudden death is almost inevitable. When communication first takes place between the lung and pleural cavity, there is not only dyspnoea, but also sharp pain and cough, in consequence of the irritation of the pleura. , This is sometimes very severe; so much so as to cause a great depres- sion of the vital powers. This, however, is usually followed by reaction, giving rise to the ordinary symptoms of fever. The cause of this irritation, by many, has been supposed to arise di- rectly from the contact of air' with the serous membrane, the pleura. Concerning this, there is, however, some doubt. A prob- ability exists, that the acid matter from vomicae, drawn into the pleural sac with the air, produces much of the effect usually as- cribed to another cause. In case liquid exists in the pleura, ante- rior to the ingress of air, its admission would be very apt to pro- duce chemical changes in the effused substances, and thus secon- darily cause irritation. In general, the sitting posture is most agreeable to the patient, or if he lies down, the decubitus, after the pleuritic pain has subsided, is on the affected side. Special symptoms. Without some more sure means of detects ing the existence of pneumothorax than the general symptoms, a correct diagnosis could not without great difficulty, if at all, be determined. Of all the diseases affecting the chest, this, though once so obscure, has now become by the aid of the physical signs, the most easily detected. As soon as the air enters the pleural sac, the lung collapses, and consequently less air is inspired. The effect of this, is to lessen the respiratory murmur on the affected side. Under such circumstances, what does percussion reveal ? The pleura distended with gas, and the lung collapsed, afford condi_ tions which, from reason we should expect to favor the production 268 THORACIC diseases. of great resonance. And thus we find it to be. On the diseased side, we get the drum-like sound on striking the chest, while on the opposite side we have more flatness on percussion, but a louder respiratory murmur. So that the physical signs on the two lungs, are opposite. On the diseased side there is great res- onance, but very feeble if any respiratory murmur. On the healthy lung, the resonance is less than on the other, but the res- piratory murmur is more distinct than natural. As the disease ad- vances, and pus collects, or if there is at first water in the pleura with the air, the percussion detects the exact extent of the liquid collection, it draws the line of demarkation between the water and the air. Whenever the patient changes his position, the loca- tion of the flatness is likewise changed, and the metallic tinkling is heard when the patient, after lying in one position, suddenly changes it; so that the liquid adherent to the sides of the pleura falls in drops upon the surface of the liquid below. The produc- tion of this sound, however, is a matter concerning which There is not among physicians a full agreement. There are according to some two methods by which it is produced; the first by the fall- ing of the liquid drops as above described, the second, by the passage of air, which, entering the liquid in the pleural sac beneath its surface, causes, as it perforates the surface of the liquid, little bubbles to rise, that burst and produce the sound. This bursting of bubbles, makes a sound, which, on being reflected from one side of the cavity to the other, comes to the ear so modified, as to produce that peculiar tinkle, which authors describe. Sometimes this occurs when there is no liquid in the pleural sac. In this case how can it be produced? Mr. Castelnau's views will explain the phenomenon. The metallic tinkling, according to his theory, may be caused by the bursting of air-bubbles in the tuberculous abscess itself, just at or near the point of perforation, and the sound thus generated resounding in the large air-chamber formed in the pleural sac, changes a rattle which would otherwise be a mucous rale, into metallic tinkling. The metallic tinkling is by no means a constant sign, therefore it should be considered as of less1 importance than amphoric respiration, and resonance of the voice. To detect the presence of liquid in the pleural sac, the Hippo- PNEUMOTHORAX. 269 cratic method of succussion is useful. The mode of procedure is simple. The patient is placed in a sitting posture, and while the body is .quickly though moderately shaken by applying the hands upon his shoulders, the agitation of the fluid thus produced, is very clearly heard. Another morbid sound heard in this disease, is the amphoric respiration, that buzzing sound caused on blowing into a bottle. The cavity of the pleura may be compared to the bottle, and the perforation of the pleura, to the opening into it. As soon as the pleural sac becomes somewhat distended with pus, the amphoric respiration ceases, or if the opening is covered with false mem- brane, so as to prevent the exit of air from the cavity, after hav- ing entered it in inspiration, the amphoric sound is not heard, and there is either no morbid sound, or a slight bronchial respiration. Attendant upon the amphoric respiration is a corresponding res- onance of the voice, which follows the same course and ceases at the same time. As pneumothorax passes into empyema, the physical signs de- < cline, and there is then dullness on percussion, with almost entire absence of the respiratory murmur. The accumulation of pus is then much greater than in ordinary cases of pleurisy, sometimes amounting to several gallons, causing extreme difficulty of breathing. By the general symptoms of pneumothorax, certainty cannot be obtained in diagnosis. With.the physical signs, however, there is no difficulty in detecting the nature of the lesion. These are not only pathognomonic of the existence of the disease under consideration, but they go farther, and enable us to point out its different stages, its degrees of severity, and its .gradual passage into empyema. Prognosis.—The prognosis is generally unfavorable. In gen- ' eral, it is speedily fatal. But this result depends as much upon the disease which causes the pneumothorax, as upon the degree of the existing lesion. In case one lung is affected by tubercular disease, or in any way prevented from performing its functions, and the healthy lung is so perforated as to produce on that side, pneumothorax, the effect is necessarily fatal. In such a case the 270 THORACIC DISEASES. patient dies in a few hours or days, from exhaustion and or- thopnoea. In forming the prognosis, therefore, the condition of the lung, not the seat of perforation, should be made an object of special study. If one lung is healthy it niay carry on the functions of both. Whenever, then, we have one healthy lung and the other is not the location of tuberculous disease, the prognosis is more favorable. But if the diseased lung is tuberculous, although the other is comparatively healthy, the probability of recovery is small,- for the phthisical disease soon extends to the healthy lung, and de- stroys it. If the pleura is completely filled with pus, the effect is to develop hectic fever, and therefore the physical condition is worse than when the pleural sac is filled with air alone. Under the most favorable circumstances, we should consider the progno- sis uncertain, and in those cases complicated with phthisis, there is no hope of a cure. Pneumothorax has no fixed period of duration. In a short time it may prove fatal. Dr. Gerhard relates one case in which death took place in less than an hour, and two other cases in which life was prolonged until the lapse of fifteen or eighteen months. In one of these latter cases, the patient made two long voyages, and, according to his own statement, did full duty as a seaman while his pleura was enormously distended with pus. Treatment.—The means which art is able to employ in the cure of this disease, are limited. There are, however, certain general indications to fulfill, a knowledge of which is serviceable to the practitioner. If the pain is severe and if dependent upon a perforation of the pleura with inflammation of that membrane, local means, such as warm fomentations, or sinapisms applied over the painful region may be employed with advantage. The de- ' gree to which general relaxants should be carried must be propor- tionate to the intensity of the symptoms. Some preparation of lobelia, or the employment of some other diaphoretic and seda- tive agent administered according to the necessities of the case, will be useful to allay inflammation. Cough preparations sometimes are useful. In cases in which there is but little hope of permanent relief from medicine, and in GARLICK, FRED'K S. An Essay on Vaccination. 16mo., paper $ 50 GUT, WM. Principles of Forensic Medicine. Third edition. Revised enlarged, and illustrated. 16mo.................... ' q c,- HJLLIER, THOMAS. Diseases of Children Treated (Vinicaliy' ijjmo ' 4 <>5 HOLMES, T. 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To sustain the strength, the most efficient tonics and nutritive diet, should also be used, In case these do not have any good effect in consequence of the disease of the digestive functions, gentle emetics should be occa- sionally prescribed. If remedies fail to prove at all salutary, and the disease should threaten immediate suffocation from the quantity of air and liquids in the pleural sac, the gas and liquid should be evacuated by the operation for empyema. Experience proves, that, under certain circumstances, the opening of the chest may be made with a good effect. Successful cases are reported by Laennec, by Riolan and Ponteau. In case the opening is made without the admission of air, the disease under favorable circumstances admits of cure. [The operation, according to Dr. Gerhard, is allowable when the object is to favor the escape of gas, or the pus which is after- wards secreted. Immediately after the perforation of the pleura, the dyspncea may suddenly become so great that immediate death is to be feared. The side may be punctured in the usual man- ner, and the gas be allowed to escape; but, as in this case, the subsequent dangers of the disease are certainly increased by ex- posing the cavity of the pleura so freely to the air, the operation cannot be justified except it be a measure of absolute necessity j at best, it relieves the patient only for a short" time. In the cases of advanced empyema which follow pneumothorax, paracentesis may be performed when the oppression is extreme, and the inter- costal spaces are much bulged out. The operation is, however, very far from being devoid of danger; for the free entrance of the air into the cavity, tends to increse the inflammation, and to aggravate the hectic fever. The usual precautions should be carefully attended to after the operation. 272 THORACIC DISEASES. If it be thought advisable to perforate the chest, the best mode is perhaps the one performed by Dr. Bowditch of Boston, who states that he has several times performed the operation without difficulty, or subsequent suffering to the patient. He uses a very small trocar, and allows the fluid to flow through it; the instru- ment is too small to allow of the entrance of any notable quan- tity of air, and in that manner all mischievous results from the operation are prevented.] CHAPTER XIII. HYDROTHORAX. Although generally applied at present exclusively to dropsical collections in the pleura, the term hydrothorax, may from its ori- gin-1-—u5up, water, and dwpag, chest,—be applied to any case of serous effusion within the cavity of the chest. In this cavity three kinds of dropsy may exist. In the first place, there may be dropsy of the parenchyma of the lungs, called pulmonary oedema; secondly, dropsy in the pleural sac, and thirdly, dropsy of the per- icardium. The former of these varieties is already treated of; the latter will be considered when I treat of diseases of the heart. Only of that serous effusion, therefore, which distends the pleural cavity, I shall speak in this place. Pathology.—The pathology of the pleural variety of hydro- thorax, is, in some respects, similar to that of chronic pleurisy. The liquid effusion, however, is serous and not purulent. In color it is more frequently yellowish or brownish, and sometimes is tinged with blood. The pleura is not, in many cases diseased and in this respect, it differs from chronic pleurisy. It is apt to be associated with tubercles in their earlier stages of develop- ment. Like other forms of dropsy the effusion often depends upon inflammation of the secreting membrane. Some authors consider the effusion arising from this cause as distinct from dropsy ; but they fail to assign a good reason for the distinction. Whatever is its origin, when the effusion is serous in its character, HYDROrHORAX. 273 it must be considered dropsical. A very reasonable explanation of the phenomenon is, that the pleural membrane is irritated, and that the congestion of the blood-vessels, is relieved by the serous effusion, before the inflammatory process is far advanced. In the pleural sac more or less serous fluid after death is fre- quently found, which, during life had caused but little disturb- ance. This may be the result of effusion in the dying state, or of chemical changes occurring after death. To constitute dropsy the effusion must be sufficient tq derange in some degree the functions of life. Whenever existing in-this manner, it causes extreme difficulty of breathing, always increased by exertion, by walking, running or ascending heights, or by the horizontal posture. Diagnosis.-—General symptoms. When the effusion is small, the dyspnoea is not great, but as fluid collects, the difficulty of breathing increases. In general, the patient lies on the side af- fected, and is most comfortable when the shoulders and chest are elevated. In t*he advanced stage the horizontal position causes great suf- focation, from the tendency of the fluid when the patient lies down, to impede the pulmonary functions. Sometimes placing the patient, during a few moments on his back, may cause sudden death. Preceding such a result, there are a livid or purplish hue of the face, and an almost black appearance of the lips, caused by a deficient oxydation of the blood. In many cases, it is associated with other forms of dropsy. Anasarca, dropsical swelling of the eye lids, especially in the morning, and in the evening oedematous swelling of the feet, frequently accompany it through most.of its progressive changes. Special symptoms. The affected side is dilated so much in some cases, as to be apparent to the eye, and easily known by measurement of the corresponding parts of the chest on oppo- site sides. The heart, mediastinum, diaphragm, in fine, all adja- cent organs, are more or less displaced when the effusion is very copious. The intercostal spaces are bulging, and the ribs farther separated than natural. By succussion, a splashing sound may sometimes be produced. The vibrations of the chest caused by 35 274 THORACIC DISEASES. the voice, over the side in which the effusion exists, are less easi- ly felt by the application of the hand. Fluctuation is sometimes perceptible on placing the left hand on the chest, and with the other percussing near to the position of the former, and over an intercostal space. Bichat considers increased dyspnoea caused by pressure upon the abdomen, a useful diagnostic sign. From chronic pleuritis it may be, in general, distinguished by the absence of acute pain, and of the general and local signs of inflammation; and by the extreme difficulty of breathing, which at times, comes on in paroxysms. It is attended by dropsy of some other part of the system, much more frequently than pleuritis. The physical signs of hydrothorax resemble very much those of effusion from pleuritis. " There will be less dullness on per- cussion, and diminution of the respiratory murmur in the depend- ent parts of the chest; and afterwards we have egophony in the middle regions; but as the effusion is seldom so extensive in hy- drothorax as in pleuritis, or so much confined to one side, we do not get that abolition of the sound on percussion, and of the res- piration and voice, or the displacements of organs, or the'peurile respiration on the opposite side, which occur in the latter disease." Prognosis.—The prognosis depends to a great extent, upon the nature of the exciting cause of the effusion. If this can be re- moved, or if a recurrence of the same causes can be prevented, hope of recovery may be entertained. Spontaneous cures are re- corded. Some critical evacuation may be the means of effecting a radical cure. Dr. Watson relates a case in which hydrothorax was greatly relieved by the copions expectoration of a limpid fluid. Instances are recorded in which dropsical effusions have been cured by profuse vomiting of serous matter. When not dependent upon tubercular disease, the hope of a cure should be much greater. If the pleural sac be simply distended by an infusion caused by a congested state of the pleura, appro- priate treatment will generally produce recovery. Under more adverse circumstances remedial agents will for some time give re- lief, so great and durable, as to lead the patient to hope for com- plete restoration. But after the temporary removal of the liquid, HYDROTHORAX. 275 it continues to return again and again, until the ordinary evacuents are not admissible in the treatment on account of the increase of debility which they induce. Under such circumstances, of course, the prognosis must be almost hopeless. Treatment.—In this disease the remedies should be adapted to the particular exigencies of each case. There are, however, cer- tain general considerations to which the practitioner should have reference in the application of curative agents. In the first place, the object should be to correct, as far as practicable, the patholog- ical condition on which the effusion depends. * Secondly, to re- move by absorption or otherwise, the effusion, by means which, while they attain the desired object, debilitate but little the pa- tient. And thirdly, to support the strength of the system, under the exhausting influence of the disease, or of remedial agents. The same remedy sometimes fulfills more than one of these indications. When the effusion is the result of an irritation of the pleura,—and strong inflammatory symptoms arise, the relax- ing remedies should be immediately prescribed. Diaphoretics and sudorifics, and, if there is very much febrile excitement, emetics, and the use of the vapor bath or warm bath,—all these means are to be applied as necessity requires. This kind of medication fulfills two indications. It tends to remove from the irritated membrane, by restoring an equilibrium in the circulation, the congestion, and by exciting to activity those vessels which remove from the system detrita, it also tends on the well established principle, that " the fulness of the blood-vessels and the activity of absorption are in an inverse ratio to each other," to remove from the pleural sac, the serous accumulation. These means may be employed with much more efficiency, than the ordinary anti-phlogistic treatment which, while it is the cause of present relief, produces such an anaemic, state, as to ren- der the patient more susceptible to another attack than before. Another advantage arising from the course of treatment above di- rected, is the fact, that it prepares the system for the application of other remedies, and for the reception of strength from the ready and good digestion of food. To the side affected a large irritating plaster should be applied, 276 THORACIC DISEASES. and kept on until a free discharge of sero-purulent matter is pro- duced. The kind recommended in the chapter on pleuritis may be used. Cathartics, if rightly administered, proper care being taken during their operation, to keep up a free diaphoresis, are use- ful. The following is perhaps as good as any :— R Podophylliae gr. i. ad gr. ii., Jalapge pulveris gr. x., Capsici gr. ii., Pottassse bitartratis gr. x. Misce. * Give in sirup or molasses. When, instead of irritation of the serous tissues, we have re- laxation or debility with an anaemic state of the blood, or when tubercular disease is the exciting cause of the pleural irritation, the treatment must be modified according to the indications. If the former condition exists, then tonics are the most useful means. These should consist of preparations of iron, or of peruvian bark. Five grains of the pill of carbonate of iron of the U. S. Pharma- copoea, conjoined with sulphate of quinia, may be given three or four times per day; and it will be found convenient to unite in the same mass some diuretic which the case may require; such as squills, or some other of which the dose is sufficiently small to admit of easy combination. To these means, the vegetable diu- retics should be added as very important adjuncts. Juniper, eu- patorium purpureum, aralia hispida, galium aperine, apocynum androsemifolium, and asparagus. The erigeron canadense, a diu- retic and tonic, is considered by some, as preferable to the above mentioned articles. "Among the remedies employed," says Dr. Wood, "is the decoction of pipsisewa which is, at the same time mildly tonic, astringent, and diuretic, and is admirably adapted to mild cases of this kind requiring a gentle impression very long continued." Hydrastin salicin, apocynin or apocynum androsemifolium are among the best tonics. The latter article is both tonic diuretic and laxative, and is, therefore, better adapted to these cases than almost any other remedy. In case tonics cause difficulty of breathing, and are not well borne, on account of the inactive state of the digestive organs, tha most effectual HYDROTHORAX. 277 means of removing the difficulty, is to give two or three times a day, alternately with the tonic remedies, the compound lobelia pills. To the above treatment, the use of the vapor bath should be added. This should be continued until the extremities become warm, and the pulse full, and strong at the wrist, and then, before its full relaxing power is felt, which might cause too much debil- ity, the patient should be thoroughly rubbed by assistants, in order to produce capillary circulation. In case there is a deficiency of biliary secretion attended with constipation and feeble circulation of the blood, I have found the following preparation very useful:— R Capsici Hydrastis a a 5 i. Fellis inspissati bovum q. s. Make a mass, and divide into four grain pills. Dose,—-from three to five three times a day. In some cases podophyllin may be added. When there is no evidence of excitement and none of debility or anasmia, the remedies should be directed to the removal of the effused fluid. [For this purpose no remedies according to Dr. Wood, are more effectual than diuretics. From this class he se- lects as the most efficient, the bitartrate of potassa. Even when the disease is the effect of tubercular deposits, he, when the strength of the patient will permit, prescribes this in small, but frequent doses, in order by its manner of administration to secure a more potent effect upon the kidneys. His method of giving the remedy is to direct a certain quantity of the salt to be added to a pint of water, or other vehicle in a bottle, and the whole to be taken in wine-glass doses, at certain intervals in twenty-four hours; the caution always being observed to shake well the bot- tle before using, and then to take the sediment with the superna- tant liquid. Half an ounce during the day is usually sufficient; but sometimes it will be necessary to increase to an ounce, an ounce and a half, or even two ounces, in the same period of time. In case it acts too much upon the bowels, it may be proper to check its action by astringents. If there be dyspeptic symptoms, to the bitartrate of potassa there should be added an infusion of 278 THORACIC DISEASES. juniper berries of wild carrot seed or some aromatic, as cardamom, fennel or ginger. By Blackwell, squill is considered as peculiarly useful in dropsy of the chest. Beginning with two or three grains three times a day, the dose should be quickly increased, either in quantity or frequency of repetition, until it produces nausea. After this effect is obtained, the remedy should be less- ened in quantity and subsequently kept within the nauseating point. Dandelion is useful when the dropsy of the chest is complicated with disease of the liver. Various stimulating diuretics have been used; such as horse-radish, mustard, garlic, buchu, and copaiba. The following formula for a stimulating diuretic infusion was much employed by the late Dr. Parrish:—Take of juniper ber- ries, mustard seeds, ginger roots,; each bruised § i; horse-radish, parsely-root, each bruised, % ii; hard cider, Oiv; A wineglassful to be taken four times a day.] Emetico-cathartic remedies, possessing diuretic properties, have been much used in dropsy. The different articles recommended for this purpose, are the bark of the different species of sambucus, the root of black elder, the broom(scoparus) and hedge-hyssop (gratiola officinalis.) The cathartic should be repeated according to the strength of the patient. In general its administration two or three times a week is sufficiently often to secure all the bene- fit derivable from its use. Diaphoresis, at present, is not so much depended upon in the cure of dropsy as cathartics and diuretics. But, in hydrothorax caused by disease of the lungs, or pleura, it is of greater ser- vice than has been supposed. One reason why its use has been so much abandoned, is the fact, that too much dependence has been placed upon the common means of exciting capillary action, and when these means to a great extent had failed of accomplishing the desired effect, the conclusion was hastily drawn, that no rem- edies tending to produce copious and long continued diaphoresis, were of much utility. The means upon which the practitioner can, with the most confidence rely in the fulfilment of this de- sign, are the warm or vapor bath, the hot-air bath, followed by the administration of nauseating doses of lobelia, gradually increased HYDROTHORAX. 279 in frequency and quantity, until emesis is produced. The gel- seminum, also, promises to be a useful auxiliary remedy in bring- ing about the same result. In several cases I have succeeded in effecting diaphoresis by the use of minute doses of aconitum fre- quently repeated. The wet sheet, is also in many cases an easy and most effectual means of producing diaphoresis. The time and manner of its application must of course be left to the dis- cretion of the physician. Immediately after the use of evacuents, strong tonics should be given to prevent a return of the effusion. Diet and drinks. The diet should be nutritious. That which is at the same time easily digested, and which contains a large amount of nutriment, is in general best for the patient. All un- necessary interference with the habits of the patient should be avoided. Drinks may be given to patients in this disease in small quantities often repeated, according to the intensity of the thirst. No general rule can be laid down in regard to the quantity allow- able. In some cases, copious drinking of water or other liquids, tends to produce diaphoresis, and thus acts as a curative agent. But it is in general best to be governed somewhat by the desires of the patient; directing him to use such drinks as tend to act either upon the skin or kidneys. Cold infusions of diuretic arti- cles, old cider, the potus imperialis,* cream of tartar whey, and in some cases of debility, gin,—all these drinks may be used to quench thirst. For the same purpose, I have directed patients to drink freely of Congress water. After the evacuation of the flu- ids, if the patient is debilitated, a residence near the sea, and fre- quent bathing in salt water, are very excellent to tone up the sys- tem and fortify it against the aggression of new attacks. In one case which came under my care, and in which the use of di- uretics was not followed with very salutary effects, the frequent use of the vapor bath and mild emetics of lobelia, together with hydragogue cathartics soon removed the dropsical effusion. De- bility, remaining a long time, although the most active tonics were prescribed, I recommended a residence near the sea, and fre- quent bathing in its water. Improvement immediately com- menced, and a radical cure was soon effected. - Vide mode of preparation, TJ. S. Dispensatory, p. 562, 280 THORACIC DISEASES. In case the remedies above described fail, paracentesis may be resorted to with some benefit, when there is reason to believe, that the disease has originated in mere vascular irritation, or inflam- mation of the pleura. In other cases it would be a desperate re- sort, calculated to afford only temporary relief, and yet endanger- ing the life of the patient by exciting fatal inflammation. But when sudden death threatens from suffocation, the practi- tioner might perhaps be justified in resorting to a temporary ex- pedient. In all cases it should be employed as a last resort. Di- rections for the operation are found in the chapter on Chronic Pleurisy. CHAPTER XIV. EMPYEMA. This word from its etymology sv in,*uov pus, signifies a collection of pus in any part of the body. Among the ancients, however, it had a signification more extensive than it now has among the moderns. The former applied it to those purulent collections which form in the cavities of the viscera, or in the interior of the principal organs. The latter apply the term empyema to effusions of blood, of pus, or of serum into the cavities of the pleurae, as well as to that operation by means of which those liquids are re- moved from the interior of the chest. The effusions in the chest, whether serous, bloody or purulent, are the results of diverse dis- eases, of which the pathology, symptoms, causes and general prin- ciples of treatment have, in the chapter on pleuritis, been consid- ered. I shall, therefore, consider its diagnosis, prognosis, and some of the more specific points of treatment. Diagnosis.—The diagnosis of this disease, by the ancients, and the moderns, until after th'e discovery of the physical signs has been considered very uncertain. With pneumonitis, the ancients confounded it. Its sputum they described as "bilious, bloody, yel- lowish, viscous, greenish or blackish." The deficiency of the common signs of this disease, was ac- knowledged by Cullen in his work on pneumonia. " Under this EMPYEMA. 281 head, I mean to comprehend the , whole of the inflammations affecting cither the viscera of the thorax, or the membrane lining the interior surface of that cavity; for neither do our diagnostics serve to ascertain exactly the seat of the disease, nor does the dif- ference in the seat of the disease exhibit any considerable varia- tion in the state of the symptoms." Physical Signs.—The diagnosis must depend upon the physi- cal signs; the dullness on percussion, the absence of respiratory murmur over the affected side ; while on the opposite lung, the respiration is more loud, and somewhat peurile ; the metallic tink- ling and amphoric respiration are sometimes heard. Fluctuation caused by succussion and the other general and special symptoms described in the chapter on Chronic Pleuritis, are often present. Prognosis.—-In the majority of cases, this is unfavorable. The character of the effused fluid, the constitutional disturbance, the degree of strength, and condition of the lung opposite the dis- eased one, should be considered informing the prognosis. Some- times, the pus spontaneously perforates the parietes of the chest, and is discharged during a long time. The cases of recovery are rare. But sometimes they occur, and therefore, some hope may be entertained of relief and cure either spontaneously or from an operation. Treatment.—In case the spontaneous discharge of pus is great, and the system shows signs of depression, means should be used to keep up the strength. For this purpose nourishing diet and the strongest tonics should be used. If there is a purulent expectora- tion, this should be promoted by expectorants, and if there is evi- dence that the digestive organs suffer from any collection of mor- bid matter, an emetic adapted in thoroughness or mildness to the exigencies of the case should be administered. In all cases in which purulent or sero-purulent matter,is absorbed in large quan- tities into the blood, the emunctories should be stimulated to ac- tion. This effect is produced by the use of the vapor bath. In case there is not much febrile excitement, alcoholic drinks when combined with tonics, expectorants, and nourishing food, are not 36 282 thoracic diseases. inadmissible. Pure wine, porter, or ale, and if the kidneys are inactive, gin may be given to keep up the strength of the system, while the suppurative process is going on. These last means are most serviceable, when the empyema is the result of tuberculosis. In such cases, even when the hectic fever is considerable, their use may be persevered in. If, however, there be fear of produc- ing over-excitement, alternately with the administration of alco- holic stimulants, a pill of extract of lobelia, or some other relax- ing and sedative agent should be given. Mr. MacDonnell has written an interesting article on empyema, in which he relates several cases wherein tumors appeared on the surface of the chest. These were red, tense, pulsating, and shin- ing. At length they burst, giving exit to a large quantity of pus. The empyema attended with these pulsating tumors, he calls the Pulsating Empyema of Necessity. Mr. MacDonnell relates several cases of much interest. In one of them, two tumors appeared on the left side, one near the spot occupied by the apex of the heart, the other between the tenth and eleventh ribs near the spine. The opening of the tumors gave relief, but the patient subsequently died of phthisis. In another case, two tumors, each about the size of a hen's egg were observed, one just below the nipple, the other between the tenth and eleventh ribs, about two inches from the spinal column. These tumors were rather tender to the touch, a few turgid veins surrounded their bases, the integument covering them was discol- ored, and reddish, and they both possessed a well-marked fluctua- tion, and a distinct, perceptible, and diastolic pulsation. Other cases of a similar nature are related by Mr. MacDonnell. In one case of empyema, the pus made its way into the bronchial tubes, and was removed by expectoration. These tumors arising from the " Pulsating Empyema of Nec- essity," may be distinguished from Thoracic aneurism, by (a), The history of the case, (b), The dullness extending over the whole side, the pulsation being felt only in the external tumor, (c), The absence of thrill, (d), The absence of bruit of souffet. (e), The extent and nature of the fluctuation. From encephaloid dis- ease of the lungs and mediastinum, by (a), The absence of ex- pectoration resembling black currant jelly, (b), The absence of phthisis. 283 persistent bronchitis. Such cases as above described are not often found. Occasionally they may supervene in consequence of badly treated acute pleuritis. I have seen one case similar to those de- scribed by Mr. MacDonnell. The fistulous opening was upon the left side of the spine, about an inch exterior, and between the tenth and eleventh ribs. From a gill to a pint of pus was dis- charged daily for about a month, gradually diminishing in quan- tity, until at the-end of three months it ceased. By the use of mild emetics and tonies, of which the wild cherry, and sirup of the iodide of iron were the most important, a comfortable degree of health was obtained. The affected side was left permanently contracted. Empyema has a peculiar effect upon the functions of the liver. This organ is enlarged from an engorgement with blood. This enlargement is evidently identical with that which takes place in other affections of the lungs and heart, where, in consequence of the partial suspension of their functions, an addi- tional amount of labor is thrown upon the liver. The removal of this enlargement is one of the first signs which indicate the subsidence of the effusion, and the return of the compressed lung *o the performance of its normal functions. CHAPTER XV. PHTHISIS. The word phthisis, from the Greek pd.s.v to waste away, signi- fies a gradual decay of the body. By this term is meant a state of continued and slow consumption, not exclusively of any one part, but of the general system. It is a generic term, applying equally well to organic changes in the various organs of the body, Such specific terms to the generic, are appended as most definite- ly indicate the location of the disease. Accordingly we have laryngeal, pulmonary, intestinal or mesenteric, hepatic and gastric consumption, described by authors. These distinctions are some- what arbitrary; all kinds of consumption being a constitutional rather than a purely local affection. The term pulmonary is used to denote a decay of the lungs; 284 thoracic diseases. but since other diseases produce this effect, it is necessary to re- strict its application to those cases in which tubercles are the ex- citing cause of the disease. This definition being adopted a decay of the lungs arising from bronchitis or pleuritis, uncompli- cated with tuberculous deposition, cannot properly be considered consumption. ' Tuberculous phthisis as thus defined is by far the most formid- able disease of the thorax. No other is so sure to terminate the lives'of its victims, and so little under the control of medication. Section I. TUBERCLES. Pathology.—The pathology of phthisis was but imperfectly understood by the ancients. Of its nature the Grecian Father of Medicine, Hippocrates, had no accurate knowledge. He recog- nized the existence of tubercles, and attributed their cause to pet- rified phlegm. With this error of Hippocrates, Galen associated the idea that they were caused by the descent of humors from the head, or by the putrefaction of effused blood. To Sylvius, whose works were published in 1679, belongs the honor of first giving a scientific explanation of their nature and origin. With scrofula he showed their connection, of phthisis he considered them the cause. To the degeneration of certain invisible glands in the lungs, he attributed their rise. By his successors, by Mor- ton and Broussais his opinions were adopted. In 1733 Desault revealed to the world the result of thirty-six years of investiga- tion into the nature and causes of consumption. His view, that it was dependent upon the formation of tubercles, was enter- tained by Russel Halles, Gilchirst and Mudge. By the more re- cent researches and investigations of Stark, Bayle, Laennec, Louis, Andral and Carswell, the anatomy of tubercles and their course of development, is now rendered more accurate and complete than that of any other morbid product. And yet diverse opinions re- specting their nature and development still prevail; and doubtless that diversity will still exist until chemistry shall have attained PHTHISIS. 285 an ultimatum, until optics shall have reached that limit beyond which art and science can never pass. At present, the more general opinion is, that consumption is a constitutional disease, most often producing its greatest lesions in the chest. The essential character of pulmonary consumption, consists in the deposit of tubercles in the tissues of the lungs. This deposit may begin with local mischief, or may evidently be a sequel of constitutional disorder. In both varieties the general disease is present; although it may exist in a latent form. Of this, the formation of tuberculous matter is a proof. It is evi- dent, however, that the presence of tubercles does not alone con- stitute the disease. One step back, along the chain of causation is a morbid condition, of which tubercles are but the effect. This morbid condition, whatever is its nature, may exist a long time, before the deposit of tubercle begins. That a change takes place in the blood, which causes or pre- cedes the deposit and development of tubercles, is well established. The corpuscles are diminished and the albumen increased in quan- tity. The fibrin is below rather than above the normal amount, and, it may be inferred, that it is also defective in its nature. Eisner, and some other analysts, have found the fatty principles diminished. Dr. Tricke's analyses indicate an increase, above the standard of health, in the lime and a decrease in the phosphates; while l'Heritier states, that in scrofula, the earthy salts are di- minished. Hence, the blood may be stated generally to be de- graded in quality, and endowed with a low degree of vitality. Whether these be the real changes in the blood is not certainly determined. Physiologists and pathologists are not fully agreed as to the nature of all the changes through which the blood passes, in the scrofulous diathesis. Andral showed that in phthisis pul- monalis, the fibrin was augmented. The probability is, that this increase of fibrin is most frequent when intercflrrent pneumonitis is associated with the tubercular disease. To attain to accuracy in this matter is very difficult, on account of the variable state of the blood arising from diet, exercise, time of the day, and other changing circumstances. Some general results of agreement, however, are established. These prove without doubt, that the blood corpuscles and fatty 286 THORACIC DISEASES. principles are diminished in quantity, whilst the albumen is com- paratively augmented,—a change which seems well proved by all the chemical, physiological and pathological researches with which we are acquainted. Such a condition of the blood of course, causes a deviation from the perfect physiological standard of the corporeal functions. The symptoms, indicating the existence of such a state, are constitutional debility, from a deficiency of nutri- tion. Hence the waste which takes place in the colored corpus- cles, and in the muscles and other tissues. [The conclusions to which we may logically come are the fol- lowing :—1, That from the earliest invasion, the sum of the vital force is either below the standard of health, or it is relatively low as respects the structure and organization of the individual;—2, That this diminution in the sum of vital force, is dependent on the imperfect blastema of the diseased blood causing perversion of the tissues;—3, That as tuberculosis advances, the sum of the vital force for the whole system continues to diminish;—4, That the nutritive powers of the blood, as respects the nervous tissue, frequently remains undiminished, this tissue not requiring for its nutrition, compound principles identical with it to be introduced into the blood with the food, and having a nutrition peculiar to itself, differing from that of the cellular and muscular structures. The fatal disease, tuberculosis may be traced to a primary error or defect in the blood-making process. Vitiated air, or air stag- nating or insufficiently renewed within the chest, and probably other anti-hygienic influences, as a vitiated or defective diet, act- ing singly, coetaneously, or as respects each other ancillary, pro- duces, slowly under ordinary circumstances, but occasionally with great rapidity, some unknown change in a portion of the protein- iform principle of recently formed liquor sanguinis; this change may consist in hyper-oxydation, but whether so or not, it deterior- ates its properties, rendering it more or less or altogether unsuita- ble as a material for organization. At the same time, the oily principle of nutrition, circulating with a diminished number of red corpuscles, is, in part, converted into a fatty substance of a lower degree of oxydation. These modified proteiniforrn and oleaginous principles are exuded in the blastema, and are either employed in the assimilating processes, PHTHISIS. 287 deranging the nutrition of many of the organic structures, and giving the tuberculous or scrofulous character to various patholog- ical processes; or, in the more advanced stage of the morbid process, they are deposited in particular tissues, and accumulate, generally in the form of tubercle, but sometimes both as tubercle and morbid fat; substances, for the most part, incapable of organ- ization. In the present state of pathological science, confining ourselves to its legitimate object, the study of phenomena, apart from any metaphysical views of final causes relating to the powers of nature, this appears to be the most accurate definition that can be given of the most essential nature of tuberculosis. [Dr. Ancell.] Though we no longer believe in the elements of Thales, we may, without a great stretch of the laws of the natural sciences, admit that air is the chief element of health or disease, according as it is supplied to the lungs in its unadulterated condition of four- fifths nitrogen, and one-fifth oxygen, or as it carries, diffused through it, carbonic acid gas, carbonated hydrogen, sulphureted hydrogen, the effluvia of cess-pools and drains, the poison of in- fluenza or cholera, the eminations of the variolous or typhus patient. But in what manner does the deposit take place ? We possess sufficient evidence to show that it is derived from the blood ; that it transudes from the capillary vessels of the part in which we find it; and that, after having been deposited, it is liable to un- dergo certain further changes. On a close examination of incipi- ent tubercular ^deposit, we may always note that there is conges- tion in the tissues immediately surrounding it. In the pia-mater of the sylvian fissure, we see an increased redness in which a few vessels are more prominent than usual*; in the pulmonary paren- chyma we may, especially, by the use of the microscope, discover the engorgement of the interlobular capillaries investing the air vesicle into which the tubercle is being secreted; in the mucous membrane of the intestines, we see the exquisite arborescent ar- rangement of the congested vessels, tending from the mesenteric attachment to the point where we observe the deposit, shining through the mucous surface from the sub-mucous tissue in which it has collected. The first elimination of the morbid products 288 thoracic diseases. acts like a magnetic point of attraction, and generally serves as a centre around which the deposit progressively enlarges by eccen- tric deposition. The amount of vesicular action accompanying the elimination, varies in different individuals; in some there is scarcely a percep- tible increase in the sanguinous current, in othersr we cannot deny the presence of acute inflammation, shown both by the congested state of the blood-vessels, and by the presence of plastic exuda- tion, and exudation corpuscles. In ordinary inflammatory condi- tions, we may actually observe the part taken by the capillary vessels in the process of transudation. We see the inflammatory product immediately after its passage through the vesicular mem- brane, coating the vessels; and, we may see the same matter within the vessels adhering to the coats previous to its discharge. Whether it be so or not, whether we may be enabled to observe the transition of the contents of the vessels into the surrounding parts or not, it is evident that we ought not to be satisfied with ascertaining the fact of the exudation as the primary change. We are driven to take one step more, before we gain the fountain- head of the malady; we therefore look to the constitution of the blood itself in tubercular disease, in order to ascertain whether any deficiency in the normal components, any variation in their relative amount, any new products are to be met with, which may explain the source of the extravascular deposit. All observ- ers, who have brought either the microscope or chemical analysis to bear on this subject, are agreed, that there is an alteration in the blood, indicating a want of vigor and tone. [Dr. Sieveking.] This abnormal condition of the blood, to a limited extent, is doubtless, the predisposition to phthisis of which authors speak. Consonant with this opinion Mr. Ancell, in his work on " Tuber- culosis," remarks :—" The predisposition differs from the general disease only in degree, and the'condition of the blood in the pre- disposition is the same, differing only in degree." But one thing more is wanting in order to the attainment of any practical result. We want a positive and conclusive sign by which the predisposition may be recognised. Such an indication of this incipient condition of tuberculosis would be of extreme value ; for, as the diagnosis of diseases of the thorax has improved, PHTHISIS. 289 out treatment of these diseases has commensurately acquired greater simplicity and certainty. Although, in the opinion of some, the organs of oxygenation have a greater share in its 'devel- opment, than other organs, yet the stomach is no doubt a promin- ent agent in the production of phthisis. Whenever this organ, in consequence of debility or any abnormal change, does not prop- erly furnish nutriment to the blood through the digestive process, a reduction of vitality must be the consequence. Baudelocque, however, shows a very intimate connection,—as cause and effect,—between the results of vitiated air and scrofulous disease. But notwithstanding this, we must from rea- son as well as from experience, conclude, that the effect of vitia- ted air upon the respiratory organs and through them on the blood, acting coetaneously with the effect of dyspeptic disease of the stomach upon the blood, is much more sure to produce tuber- culosis than when the stomach is in a healthy condition. The illustrations used by Baudelocque, to show the tendency of impure air to develop tubercles, are forcible and convincing. ' Speaking of the shepherds of his country, who, for the most part. lead an open-air life, he says, that in them the cause of the dis- ease is their habit of sleeping six or eight hours in confined huts which they transport with them, having only a small door, that they close when they enter, and keep closed during the day. A similar injurious effect is produced by the habit of sleeping with the head under the clothes, and the insalubrity of school rooms in which a number of children are assembled together. These causes frequently repeated, are prolific in the development of any latent germs of phthisis which may be existing in the blood. , Close rooms, Dr. Arnott has pithily remarked, " act like extin- guishers to the vital flame ; and the extinction literally takes place at the point at which the fuel accumulates for want of being burnt off." Since the blood is the true source of the tubercular deposit, it is not surprising that all the organs of the body are more or less liable to become the seat of the morbid product. Some tissues present a greater proclivity to the deposition than others; and some, as the fibrous and tegumentary tissues, appear to enjoy al- most an immunity from tubercle. At the two ends of the scale, 37 290 THORACIC DISEASES. we may place the mucous membranes and fibrous tissues; the former are the native soil for this tree of death; the latter are rarely, if ever affected. There can be little doubt, that this de- pends, in a measure, upon certain physical laws, influencing the current in the vascular system, and determining the greater or less facility of transudation in the first instance. To show that the deposit of tubercle is in the mucous mem- brane of the lungs, is more difficult than to show its location in the mucous membrane of the fallopian tubes and uterus, because these latter organs, on their internal surface, are lined with mucous membrane, so abundant as to be easily recognised. The more slow and the more free from complication, the tubercular disease of the lungs is, in its nature, so much the more readily may be detected the disease of the mucous membrane, and the tubercu- lous deposit in it. Dilatation of the air-cells in emphysema has enabled Dr. Alison to distinctly perceive the tuberculous matter contained in these cells. [Edin. Medi-Chro. Trans, vol. i. p. 427.] [Dr. Sieveking observes,—-" that we may lay it down as a law, regulating the deposit of tubercle, that it is effected at that point of an organ or of a tissue where the smallest amount of pressure is exerted upon the capillary system. This does not exclude the operation of other laws which determine the attraction to any one organ. It does not offer any reason why in one case we find tu- bercle in the spleen, in another in the mesenteric or bronchial glands, in a third exclusively in the pulmonary tissues; but it seems to embrace the various circumstances modifying the exact site of the deposit in these different parts of the system. The vis a tergo varies but little in the different parts of the capillary system; but the relation to surrounding tissues differs very much. Thus, while the force with which the blood is driven into the in- terlobular plexuses of the lungs is identical, the pressure which the respective capillary systems meet with in a case of congestion, which implies a tendency to exudation, is necessarily greater in the bone than in the soft parenchymatous structure. No.organ is more frequently the seat of tuberculous deposit than the lung, and in none do we find the capillary ramifications of the vessels with so little covering. They almost lie naked on the surface. PHTHISIS. 291 Beyond the basement membrane forming air vesicles, and possi- bly a delicate epithelial layer, there is nothing between the capil- lary net-work and the atmosphere. We need not, therefore, won- der that the ultimate vesicle, in which the bronchi terminate, is above all other points, that of tuberculous election. The re- cepticle is ready, the product being in the blood, a slight increase of pressure will overbalance the natural and healthy equilibrium between the external and the internal fluids, and the discharge takes place. [f this view is correct, nothing but a previous change in the ul- timate vesicles, or bronchules could give rise to a deposit of tuber- culous matter in the intervesicular tissue, in the parenchyma of the lung itself, as contradistinguished from the respiratory cavi- ties. We can suppose that obliteration of a portion of the breath- ing apparatus might leave the intervesicular texture less resistent than the air vesicles; and, in that case, we should expect to find an interstitial deposit. Whether this does actually occur, I am not prepared to say. I have not seen any appearances that would justify the assumption of a primary interstitial deposit, but I have seen a distinct deposit of tuberculous matter within the air-vesi- cles, and I have traced its primary deposit in the semi-liquid form, in the solitary vesicle, to the deposit in numerous adjoining vessels, causing destruction of' their breathing power and obliteration of the bronchule terminating in them. The ultimate bronchule is free and patulous, and the tuberculous matter fills the vesicle as a bullet fills its mould. The law, that the tendency to the deposit in an organ, is in- versely as the pressure the vessels sustain, or that it is in the ratio of the laxity of the tissues, is supported by the views which are commonly held with regard to the chemical constitution of tuber- cle. This law, also assists us in explaining, why certain parts of different organs possess so marked liability to become the seat of tuberculous exudation. This feature constitutes an essential dif- ference between tubercle as a mere effusion of a certain constitu- ent of the blood, and those other new formations in which we cannot but see a tendency to independent development, or organ- ization. The most familiar instances of pathological processes with which it may be compared, are the serous effusions, that 2'92 THORACIC DISEASES. take place into the peritoneal cavity, from obstruction to the vena cava or portal system, inducing congestion and consequent liquid discharge at the most yielding points. If we adopt this view of the subject, it appears to offer an ex- planation of the circumstances that the apices of both lungs are the chief seats of tubercle, while it tends to show the importance of encouraging the use of all the physical means at our com- mand to promote a free and active circulation of the entire vascu- lar current, and to obviate and anticipate anything approaching to local congestion in the organs and parts of organs which we know to be most liable, at different periods of life, and under different circumstances, to become affected with the disease in question. The manner in which the law may be applied to the explana- tion of the predominant proclivity of the pulmonary apices, is simply this :—The upper portions of both lungs are surrounded by more unyielding parietes than the inferior, they have less room for expansion; consequently, if there is any increase in the vas- cular current supplying these parts, the difference between the pressure of the parietes and of the atmosphere within the vesicles will increase unduly, and effusion will take place into the latter. In acute, tuberculosis, we do not observe this peculiar election, because the process is of a more active character; the strain upon the capillaries of the entire organ is greater than they can bear, and we consequently find the deposit takes place with much uni- formity throughout the lung. In chronic forms in which tuberculous deposit generally occurs, the balance of the forces in different parts of the vascular system, is in a measure preserved, and only the very weak points are as- sailed. There may be other forces which come into play; there may be elective affinities between different tissues, and morbid products with which we are as yet not even acquainted. The circumstance above alluded to, is one of some importance. In scrofulous deposit in the kidneys where does the tuberculous mat- ter invariably present itself? In the loose texture of the cortical substance. The dense basement membrane and firmer epithelial coat, wards off the encroachment; but the feebler texture of the convoluted tubes is unable to repel the enemy.] Another cause of the more frequent location of tubercles in the superior lobes of PHTHISIS. 293 the lungs, has been suggested, which seems somewhat plausible, and is a useful hint to the treatment required in tuberculosis. The increased motion of the lower lobes of the lungs, would cause a more ready expulsion from the vesicles of tuberculous de- posits, than would take place in the apices. In the vesicles of the apices, on account of their want of expansion, there would evi- dently be a tendency to accumulation, while in other parts of the pulmonary tissue the reverse would be true. So that, on this hypothesis, there might be an equal amount of tuberculous mat- ter exuded into the vesicles in all parts of the lungs, and yet, on account of its more ready expulsion from one part of the lung than from another, the development of tubercles, as experience verifies, be most active in the apices. " Tubercles exist in various forms ; in fine points, gray and yel- low granulations, miliary tubercles; and gray or yellow tubercu- lar masses, softened and cretaceous. Each of these modifications requires a more particular notice. "1. Pulmonary Granulations.— Gray Granulations.—Miliary Tubercles.-—These various names, have been used by authors to describe round, small, translucent, shining, homogenous bodies, often not larger than a millet seed, but varying from this size to that of a pea, which appear to be the primitive state of tubercles. Usually they are of a grayish, but often of a reddish, or of a brown- ish color; and in some cases they are nearly colorless. Some- times they are isolated, sometimes clustered in small bunches, or in aggregate masses. In the latter state they are most often found in the upper portions of the lung. But in an isolated form they are sometimes scattered thickly throughout the whole or greater portion of the pulmonary tissue ; not unfrequently they are found situated beneath the pleura, producing an irregularity perceptible to the touch. This is more often the case in children than in adults. "2. Gray Tubercular Infiltration.—Laennec defines this as the same kind of matter which forms the granules above described, deposited in the cellular tissue of the lungs in irregular masses, sometimes one, two, or even three inches in cubic dimensions, without definite boundaries, or limited only by the extent of the lobules. It is hard, homogeneous, translucent, and of a grayish 294 THORACIC DISEASES. color, sometimes darkened by the black matter of the lungs, por- tions of which become enveloped in the masses as they are formed. In some instances, no traces of pulmonary tissue can be detected in the masses; in others, they present remains of blood- vessels, bronchial tubes, and cellular membrane ; and occasionally they are partially penetrated by the air in respiration. " 3. Gelatinous Infiltration.—Under this name Laennec de- scribed a colorless or rose-colored substance, more transparent than the gray matter noticed in the last paragraph, and of a jelly-like consistence, which he had observed to be deposited in small quan- tities in the tissue of the lungs, in the intervals of the tubercular granules, and which he believed to be gradually converted into proper tuberculous matter. Louis states, that he has met with this species of infiltration, but has not noticed in it the yellow tu- berculous points spoken of as not uncommon by Laennec. Dr. Morton in his Illustrations of Pulmonary Consumption, gives two cases in which the tuberculous transformation appeared to have commenced in this gelatinous matter. "4. Crude Tubercle and Yellow Tuberculous Infiltration.— The gray translucent matter constituting the first two deposits above noticed, appears to undergo a gradual conversion into what has usually been considered the proper tuberculous substance. In the miliary granulations, the transformation commences in a small yellowish-white spot, which most commonly appears at or near the centre, and gradually enlarges until the whole granule assumes that character. In this altered state, the little bodies are now generally denominated crude tubercles. In the aggregated gran- ules, the change commences at several points, each probably an- swering to a distinct granule; and considerable masses of yellow opaque matter result from the extension and ultimate coalescence of these central spots. The same transformation takes place in the infiltrated translucent matter, beginning in like manner with isolated opaque spots, and spreading until it involves the whole deposit, which, when thus altered, receives the name appropriated to it by Laennec of yellow tuberculous infiltration. This may be distinguished from the crude tubercle by an irregular and an- gular, instead of roundish form, and by a less definite line of division between it and the pulmonary tissue. There is no doubt, Phthisis. 295 that both the crude tubercle and yellow infiltration are often orig-^ inally deposited in this state, without the preliminary formation of the translucent matter. " Progress of Tubercles.-^-The yellow tubercle, whether orig- inal, or the result of a transformation of the gray granulation, gradually increases by new accretions. As observed upon dissec- tion, it varies in size from the magnitude of a pea to that of a hen's egg, is irregularly roundish, and consists of a yellowish- white, opaque, friable substance which easily breaks up between the fingers. In relation to its chemical composition, microscopic characters, and peculiar constitution, the reader is referred to Dr. Wood's article on tuberculosis." [Wood's Practice of Medj icine.] The next change in tubercle is that of softening. This, by many authors, is said to begin in the centre, and to gradually ad- vance to the circumference. Concerning the truth of this, there is however, some doubt. The reasons as given by Mr. Carswell upon which such a doubt is based, are the following:—Tuber- cular matter according to his theory is contained in the air-cells and bronchi. If, therefore, this morbid product is confined to the surface of either, or has accumulated to such a degree, as to leave only a limited central portion of their cavities unoccupied, it is obvious that when they are divided transversely, the following ap- pearances will be observed :—1st. A bronchial tube will resemble a tubercle having a central depression or soft central point in con- sequence of the centre of the bronchus not being, or never hav- ing been occupied by the tuberculous matter, and of its contain- ing at the same time a small quantity of mucus or other secret^ ed fluids :—2nd. The air cells will exhibit a number of similar appearances, or rings of tuberculous matter joined together, and containing in their centres a quantity of the same kind of fluids, When the bronchi or air-cells are completely filled with tubercu- lous matter, no such appearances as those we have just described are observed, and hence the reason why tubercle, in such circling stances, has been said to be still in the state of crudity, or in that state which is believed to precede the softening process. The term encysted has been applied to tubercles. But this term is liable to deceive. The walls of the cyst are nothing 296 THORACIC DISEASES. more than the parietes of the vesicles distended with tuberculous matter. A biliary duct distended by a morbid deposit, has, like- wise, been called through the same mistake, an encysted tubercle. As the softening process advances, the whole tubercle becomes converted into a " soft, pultaceous, yellowish mass," in appearance resembling pus. The infiltrated mass, likewise, undergoes a sim- ilar change. Sometimes the entire tuberculous deposit seems throughout its whole mass, to become, suddenly softened ; and, in this manner, large portions of the lung are quickly destroyed. The pressure of the growing tubercles upon the circumjacent lung at first, makes it less vascular. But reaction at length takes place, and inflammation succeeds ; and congestion, ulceration and suppuration follow. In some cases the tubercular disease passes through its various stages without giving rise to marked inflam- mation. In the majority of cases, however, the bronchi, air-cells, and cellular tissue, are more or less affected by the inflammatory process. The succeeding ulceration gives rise to the formation of cavities. Frequently one large vomica is made up of several smaller ones, which in the parietes of the large cavity, make ex- cavations of irregular shape, now winding, and now crossed by bands of tissue. The size of the cavity varies from that of a pea to that of an orange. Its contents consist of a mixture of pus and bloody matter, and portions of pulmonary tissue. Some- times they are inodorous, sometimes fetid. In children the vom- icae are less common, than in adults. As the disease advances, a false membrane begins to form around the decaying tubercle, at first thin and delicate, but subsequently becoming more dense and fibrous. In some cases it is composed of layers, resembling fibro- cartilage, in others remaining delicate, and in appearance, resemb- ling mucous membrane. Large abscesses are sometimes seen, be- tween which and the bronchi there is no communication. Cicatrization of Tuberculous Cavities.—That this is not a very rare occurrence Laennec proved in his early researches into the termination of tuberculous disease. Indeed, from this we learn that phthisis sometimes terminates favorably. This happens when the deposit is limited in extent. But sometimes, at the apex of the lung we find an old adhesion, sometimes a crust of fibro- cartilaginous deposit, or even a fibrous band passing from the lung ' Phthisis. 297 "to the ribs. Adjacent to this pathological change, the lung is puckered, and drawn inward. To the touch it feels firm and con- solidated ; to the eye it appears dark, from an abundant deposit of black pigment. On making an incision we find a cavity, lined by " gray fibrous membrane, semi-transparent; or thick, whitish and fibro-cartilaginous; or soft and pliable, like the mucous mem- brane." This cavity is usually about the size of a pea or a plum, and not unfrequently opens into the bronchi. It contains' a transpar- ent viscid fluid, and in some cases tuberculous matter partly trans- formed into cretaceous substance. Around the cavities, the lung is more or less indurated by chronic inflammation. In some cases they are filled with fibro-cartilaginous formations, which almost obliterate the vomicae. At the summit of the lungs, other evi- dence of the previous existence of a curative process, sometimes exists. There are adhesions, and indurations similar to those in other parts of the pulmonary parenchyma, but in the vomicae there are also small masses of a chalk-like appearance, of stony hardness, feeling gritty or earthy to the touch. These small bod- ies have been called ossifications, but they are effects of progres- sive changes in tubercles. Galen and Paul of Egina, Bonnet and Schenck saw them in great numbers; and Bayle considered them as one of his six forms of phthisis. By Laennec these concre- tions are divided into cartilaginous, osseous,petrous and cretaceous. These are seldom numerous, and are most often found at the sum- mit of the lungs. Their size and number are so small that we may reasonably conclude that they must have originated from a limited deposition of tubercle. Every thing connected with their history, would seem to prove that they are the effects of that nat- ural process, which nature institutes to remove the disease. Laen- nec well remarks "that they show in a train of diseased action that tubercles are cured." Sometimes they remain in a latent state, not exciting irritation or inflammation. > But how are these concretions formed ? To this question Dr. Swett replies, " they are effected by the deposit of mineral matter, the chloride of sodium, the sulphate of soda united with "a little phosphate and carbonate of lime, and sometimes with cholesterine in the place of the proper matter of tubercle. But every stone- 38 298 THORACIC DISEASES. like concretion that is formed in the lungs is not necessarily a con- verted tubercle. This condition may result also from a deposit of lymph which passes gradually into a cartilage-like or bone-like condition, or it may be owing, as some think, to a partial ossifica- tion and obliteration of the smaller bronchial tubes." Andral's opinion was that they are formed by the solidification of mucus in the minute branches of the bronchi. The seat of tubercles has been a subject of much diversity of opinion. Some have located them in the glands. Of this, Dr. Wood remarks that there is no proof. Some contend that they are the result of effusion into the air-cells; others that they have their seat in the radicles of the veins, and still others that their location is in the bronchial tubes and inter-vesicular tissue. These diverse opinions should lead to the conclusion that tuberculous deposition takes place in many, if not in all of the tissues of the lungs. More often tubercular cavities are situated towards the posterior part of the lung, than the anterior. One lung according to Louis, is more liable to this deposition than the other. " Modern observ- ers have collected numerical statements showing that this really is so. Why it should be so, I know not. Thus Louis, whose volume is the result of immense labor in observing, and is full of the most instructive matter, had met with seven cases in which tubercles were confined to a single lung; in two of the seven cases it was the right lung that was thus exclusively affected, in five it was the left. Of 38 instances in which the upper lobe was totally disorganized by the disease on one side, 28 were of the left, and only 10 of the right. Eight times he had known the pleura perforated by the extension of tubercular disease ; and seven times out of the eight the perforation happened on the left side of the chest. So also Reynard met with 27 cases of pneu- mothorax on the left side, to 13 on the right. No less curious is it that here also the facts ascertained with respect to pneumonia, are just the contrary of those which belong to phthisis. I men- tioned, in a former lecture, Andral's conclusion, derived from the observation and collection of 210 examples, that pneumonia is more than twice as common on the right side; as on the left. M. Lombard, of Geneva, found the ratio somewhat less than this, but PHTHISIS. 299 still great. Of 868 instances of pneumonia, 413 occurred on the right side alone, 260 on the left alone, and 195 on both sides at once. That is, there were three on the right side alone, for every two on the left alone." [Watson's Lectures.] In very many cases, however, tubercles are found in both lungs, in each, the severity of the disease being about equal. Tubercles vary greatly in number and in the form of their dep- osition. Sometimes they are nearly isolated, at other times, they are found in successive crops, and in every stage of development. Indeed post-mortem examinations, often reveal several cavities, miliary, crude tubercles, and tuberculous infiltration existing to- gether in the same lung—the marked effects of successive crops of tuberculous deposition. Bayle described certain semi-transparent oval, flattened bodies, about equal in size, and scattered through the lungs, to which he gave the name of accidental cartilages. Their appearance is somewhat similar to miliary tubercles; from which they may be distinguished by their more uniform size and their more equal distribution. Adhesions are almost always present in phthisis. In 112 cases examined by Louis, there was only one in which no adhesion was found. To some extent their location corresponds to that of tubercles. In rare cases, the entire surface of the lung is bound down to the costal pleura, and to that of the diaphragm. These have the effect to prevent pneumothorax. The trachea and bron- chial tubes often are the seat of extensive lesion. Those are most often affected which form a way of exit to vomicae. Their posterior, more often than their anterior internal surfaces are af- fected. The larynx and epiglottis are sometimes the location of tuberculous disease. Among other lesions attending phthisis, are partial emphysema of the lung, dilatation of the bronchi, and en- largement of the bronchial glands. This latter effect is most com- mon in children. Appearances in other parts of the body.—The origin of tuber- cles being in the blood, their distribution throughout the entire system, is a necessary result. But according to Louis, this gener- al law is established, that when tuberculous deposit exists in other organs, it always exists in the lungs. The converse of this, is i 300 THORACIC DISEASES. far from being true; and the law itself, is occasionally subject to exceptions, the occurrence of which is most frequent in children. Without the lungs the tuberculous depositions most often are com- posed of the yellow, opaque tubercle. Gray granulations or mil- iary tubercles, have also been observed in various parts of the body. From some form of tubercle, scarcely an organ of the body is wholly exempt. They are found in the liver, intestines, mesentery, prostrate gland, testicles, heart, bladder, uterus, spleen and kidneys, and in the membranes and substance of the brain. It was the conclusion of Louis that, of all the cases of tubercles occurring in persons over the age of fifteen years, one third had them in the small intestines, one fourth in the mesenteric glands, one ninth in the large intestines, one tenth in the cervical glands, one twelfth in the lumbar glands, and one fourteenth in the spleen. The stomach becomes larger than natural, more thin, and is subject to chronic inflammation of its mucous surface. The glands of Peyer,—those near the caecum,—become the seat of tubercles. The mucous glands of the small intestines sometimes ulcerate, causing perforation and the admission of the faecal secre- tions into the cavity of the peritoneum. A similar diseased state of the large intestines sometimes occurs. The mesenteric glands are very much enlarged. In the brain, tuberculous deposition gives rise to hydrocephalus. Section II. GENERAL SYMPTOMS AND COURSE OF PHTHISIS. Since the discovery of the physical signs by Laennec, the ten- dency of some minds has been to disregard the general symptoms in the formation of a diagnosis. Among such, an unnecessary delay is often caused in the application of remedial agents; for the general symptoms very frequently are the first indications of approaching disease. A diagnosis should not then be wholly de- pendent upon the physical signs in the first „stage; for these are seldom manifest until the disease has so far progressed as to make a prognosis unfavorable. Certain general symptoms are grouped together, and said to be PHTHISIS. 301 indicative of the scrofulous diathesis or tuberculous cachexia. What this condition of the system is, or what its influence, in the development of phthisis, it may be difficult to accurately ascer- tain, and yet the description of some of its more important symp- toms may be of utility in detecting that first pathological change in which phthisis begins. Among the more important symptoms, are a pale, pasty, appear- ance of the countenance, large upper lip and alae nasi. In persons of a dark complexion, the skin is sallow, in those of fair com- plexion, it is unnaturally white, resembling blanched wax rather than the healthy countenance. The veins are large and conspic- uous, the pupils of the eyes are large, eyelashes long, with a fair, florid complexion. In persons of a bilious temperament, the skin is coarse, its color dingy. The form of the body is often desti- tute of symmetry. The head is large, trunk small, abdomen, tumid, limbs unshapely; the growth of the body is irregular, the functions of nutrition are feeble, and deranged. The intellect is often very active, there is great sensibility to impressions and acuteness of mind. The bowels are usually more or less irregular, more often slow in their action than the reverse; the urine turbid, the skin soft, dry and flaccid, or dry and harsh. The muscles are soft and desti- tute of much firmness of texture and the circulation is feeble. There is a great tendency to catarrhal affections, which are prone to con- tinue a long time and to cause a discharge of thick yellow mucus. In children, the eyelids and ears are often subject to chronic in- flammation. The fauces and tonsil glands are seldom free from chronic disease. The lymphatic glands enlarge on slight expos- ure. The catamenia in females are tardy in their appearance, ir- regular in their return. Stages.—For convenience in description, phthisis has been di- vided into three stages. Between these no line of demarkation is accurately drawn. The first stage begins with the onset of the disease, and ends when softening of tubercles, has commenced. General Symptoms.—The pulse is accelerated, especially after eating, towards evening, or by slight exercise. A burning sensa- tion is felt in the palms of the hands and soles of the feet. To- wards evening a slight chilliness comes on, towards morning per- 302 THORACIC diseases. spiration supervenes. The febrile paroxysm is sometimes very slight, scarcely attracting notice, sometimes severe, causing un- pleasant sensations, and exciting alarm. Sleep ceases to refresh, food to give strength and vigor. The aspect of the patient chang- es ; the countenance is pale, expressive of languor or red with the hectic flush. The skin is less elastic, the muscles less firm, men- struation is tardy or entirely wanting ; emaciation becomes evi- dent. If these symptoms have appeared in the spring time, by the use of proper remedies, and regimen, they are almost entirely removed, until the returning autumn and winter, bring them on with increasing severity. Occasionally they seem to arise from bronchitis, pleuritis, pneumonitis or some febrile disease. When they succeed to measles or scarlet fever, they frequently progress with unwonted rapidity. The rational symptoms, are subject to much variation. In most cases, however, a short dry cough is one of the first symptoms that excites alarm. Often very slight, a mere hacking in the morning, it steadily increases, and at length, is accompanied with an expectoration of frothy, transparent mucus, and afterwards of yellow, opaque matter. Slight dyspnoea occurs when the patient exercises. About the sides and shoulders there are fugitive pains. Slight hemorrhage from the lungs occurs ; at times, it may be somewhat copious, but often small in quantity. As the disease progresses, the cough increases, preventing sleep, and sometimes occurring in paroxysms. The expectoration is correspondingly increased, becoming thicker, more yellowish, or greenish, and pur- ulent. The other symptoms usually advance with equal pace. Sometimes, the disease is very insidious in its approach. Sud- denly without any premonition, a violent attack of haemoptysis occurs, immediately succeeded by all the appearances of confirmed phthisis. These rational symptoms are intimately connected with the tubercular deposition. The tubercles are in a state of crudity. Softening has not yet commenced. They are in the form of small, roundish homogeneous bodies, collected in clusters, or more widely disseminated through the lungs in the form of miliary tu- bercles. Sometimes they are more or less firm, of a grayish color, or translucent. When closely collected together, they cause a consolidation of PHTHISIS. 303 the pulmonary* tissue which gives rise to obstruction to the ingress and egress of air and to the pulmonary circulation. Hence the shortness of breath, and the occasional emphysema, that some- times occur. Other effects resulting from a consolidation of por- tions of the lung by the deposition of tubercles, are sanguineous congestion, oedema, gangrene, haemoptysis and effusions into the pleura. Haemoptysis in the early stage of consumption is gener- ally from this cause, and it is a serious symptom, not only because it may endanger life by the loss of blood, or by suffocation, but because it is accompanied by hemorrhagic consolidation, and rup- ture of pulmonary tissue. Physical Signs.—In the nascent state of phthisis, we cannot derive positive information from physical exploration. In order to produce abnormal sounds on percussion and auscultation, the deposit of tubercles must be considerable, or there must be in some one part of the lungs,—^be it ever so limited,—a deposit suf- ficiently great to interfere with the pulmonary functions. If the tubercles are small and scattered, the physical signs will not be so sure to detect the morbid change. If on the contrary they are large and clustered together, abnormal sounds will be the more readily developed. So that it is evident that the physical signs cannot determine the absolute amount of tuberculous deposition; since the arrangement of tubercles, as well as their number, has a modifying influence. Shall we therefore, conclude that the phys- ical signs are of no practical utility? As well might we deny the usefulness of the telescope because it does not reveal all the minute phenomena of the heavens. Because no one of the phys- ical signs is absolutely pathognomonic we should not conclude that their evidence, added to that afforded by the general symp- toms, is not of great value. These signs found at the points most subject to tubercular disease, the comparative rarity of any other lesions capable of producing the same physical phenomena, enable us to arrive at a degree of probability which is almost equiv- alent to certainty. The existence of the two-fold evidence given by the general symptoms, and the physical signs, makes the diag- nosis far more sure than it could be when founded only on one class of symptoms. Inspection has been considered of some value in the diagnosis 304 THORACIC DISEASES. of phthisis. An unusual immobility of those parts of the thorax adjacent to the location of tubercles, is mentioned by Andral, and again by Dr. Clark, as affording valuable evidence. Laennec never placed much dependence upon this symptom, nor does Louis re- gard it as of much importance. Inspection is often a valuable means of diagnosis. Prominence of the clavicles, contraction of the intercostal spaces, a flatness of the chest in front, an unequal height of the shoulders, a depres- sion of the ribs,—all these When present in a tuberculous patient, indicate the presence of phthisis. Palpation is of no practical utility. In the last stages, a mo- tion of the fluids in the bronchi, may sometimes be heard; but in the early stage, nothing definite should be inferred from this kind of physical exploration. Percussion is usually somewhat dull in the early stage, Under the clavicles. An inequality in its degree on opposite sides of the chest, and at points equally distant from the median line, adds much more significance to this physical sign, and especially if the dullness is greater on the left side. In emphysema and pneumo- thorax, a similar inequality of sound may exist. In these instan- ces the diseased side is most sonorous, but the respiration is most feeble where the resonance is greatest,—a circumstance which distinguishes this condition from phthisis. An emphysematous condition of the lung occurring adjacent to the location of solidi- fication from tubercles, may cause the percussion to remain nearly normal. Were this coincidence common, it would certainly dimin- ish the value of percussion in diagnosis. But it is of very rare occurrence. The signs derived from percussion, should be sought about the clavicular and acromial regions. Obscurity of resonance being detected beneath one or both clavicles, or at any point of the chest near to the apices of the lungs, what conclusion should be formed as to the nature of the disease ? To this question Chomel replies:—"Obscurity of sound and feeble respiration un- der one of the clavicles, give strong reason to suppose the exist- ence of tubercles, for partial effusions take place in the immense majority of cases at the inferior and posterior parts of the chest, and it is almost never that' chronic pneumonia is primitive and without the presence of tubercles." PHTHISIS. 305 In'the early stage, the slightest difference of note or pitch on opposite sides of the chest, if confined to the clavicular and acro- mial regions, should excite suspicion. Although the dullness may be confined to a small locality over the top of the shoulder, and the scaleni muscles, yet if it be clearly perceptible it is a very sure indication of the existence of phthisis. Auscultation in the first stage, reveals a feebleness of the respi- ratory murmur in the sub-clavicular region. This occurs where the percussion is dull, and at the same place the resonance of the voice is greater than normal. While in one part of the lung these signs are heard, in another, the respiration is blowing. A slight difference of sound in relative situations on both sides does not necessarily indicate phthisis. The anatomical relations of the lungs have a modifying effect. A sound in the right lung of a phthisical patient, should not be considered as indicative of tuber- cles, unless it is decidedly blowing. But if the respiration is more blowing at the apex'of the left, than at that of the right lung, there can be but little doubt that tuberculous disease is present. With the advance of the disease, the respiration becomes some- what rough or even bronchial, with a prolongation of the expira- tory sound which is one of the most striking characteristics of tu- berculous deposition. Inspiration is at times somewhat jerking. The cardiac pulsations are more audible than usual. Bronchial respiration and bronchophony are heard out of their natural local- ity ; thus becoming indications of pulmonary lesion. The hand applied to the sub-clavicular region, sometimes is able to feel an increased vibratory motion from the voice. In general these signs may be perceived over the upper portions of the scapu- lae behind. These are indicative of solidification of the pulmon- ary tissues; and, when this condition of the lung is present be- neath the sub-clavicular region, and, when, at the same time, there is no evidence of acute pneumonitis, the probability is very strong that it is caused by tubercles. Second stage.—The second stage of phthisis may be consid- ered, as beginning with the softening of tubercles, and terminat- ing when cavities are fully formed, aud all the physical effects arising from them, are fully developed. In other words it is the formative stage of vomicae. 39 306 THORACIC DISEASES. The circumstance which has been considered, as marking the passage from the first to the second stage of phthisis, is a remark- able change in expectoration. General symptoms.—In the second stage, the general symp- toms for the most part, are the same as those in the first, differing mostly in degree, and not in kind. That there is an arbitrary line of division between the different stages, is an erroneous idea. And we should, therefore, consider the various changes occurring in the progress of phthisis, as but a continuous chain of abnor- mal phenomena,—a chain the links of which cannot, and should not be considered as separated by any division made for the sake of convenience in description. Of the general symptoms collectively, I remark that they are more severe. The evening chills are more constant and trouble- some, the succeeding heat is more intense, and more general, the morning sweats, more regular and copious. Hectic is more con- stant, and, in the words of another, "hangs out upon the cheek the red flag of death;" the pulse is more frequent, the respiration quick and laborious even when the patient is at rest. Languor and weakness increase, emaciation is rapid, the muscles are soft and flabby, and the patient can no longer endure his wonted amount of mental or physical exertion. Paleness of the countenance fre- quently remains during the early part of the day. Sometimes there is a greater tendency to chills shown by an increased sensi- bility to cold, and the evening exacerbation brings on an increased heat of the palms of the hands and soles of the feet. The coun- tenance, under the influence of the morbid excitement, is for a while more animated, the eye brightens, and the red blush of hec- tic gives to the features new beauty and loveliness. When speak- ing, the lips of the patient slightly quiver, there is a breathless- ness which interrupts him in the middle of a sentence. Sleep is more disturbed. Not unfrequently the mind, even in this stage of the disease, is buoyant and hopeful. The least and most tempo- rary amendment in his symptoms, or the delusive promises and boasts of quacks, inspire him with the joy of hope. Special symptoms.—At the beginning of this stage, a change is observed in the expectoration. The frothy, colorless sputa which had before attended the cough, now contain small specks of opaque PHTHISIS. 307 matter of a pale yellowish color, that gradually increase forming patches, surrounded by the transparent portion in which they seem to float. Streaks or specks of blood are also seen in the expectoration. With this change, the other rational symptoms in- crease, the cough becomes more harrassing, and respiration is hur- ried. Haemoptysis is likewise a frequent occurrence, amounting sometimes to a slight streak of blood in the expectoration, at other times, to a considerable quantity. Darting pains are frequent around the chest—the result of pleuritic inflammation excited by the extension of the tubercular disease to the pleura. These are, therefore, usually confined to that part of the lung in which the tuberculous disease is most developed. The Physical signs in this stage are more marked. As the disease advances, the tubercles soften, and become diluted with a morbid secretion from the pulmonary tissues. Particles of curdy or cheesy matter, pass from their locality in the parenchyma of the lungs, into the bronchial tubes and are expectorated. The exit of this matter from the lungs, gives rise to the formation of little vacuities, called caverns, cavities, vomicae, or excavations. A careful examination of the chest, at this time, affords posi- tive evidence of the internal mischief. The upper parts are less freely raised, during respiration than in the healthy state; this phenomenon frequently being more evident on(one side than on the other. The sub-clavicular regions on both sides, give a dull sound on percussion. To the mind, the ear, or stethoscope, when applied to those portions of the chest situated where percussion is dull, reveals a slight crackling noise—the crepitating ronchus. After vomicae are formed, the cavernous rale or the gurgling is heard, when the cavity is partly fiiled with liquid. Resonance of the voice and cough, and at length pectoriloquy follow. If a solidified portion of lung, enclosing a considerable bron- chus, comes near to the surface of the chest, then bronchial breath- ing and bronchophony will be audible. Percussion, too, will give the same sound, whether the lung be hepatized or blocked up by tubercular matter. This condition of the lungs may be present in one part, while cavities exist in another, and therefore, different parts of the chest will present different physical signs. I have said that the gurgling sound is heard in case the vomica contains 308 THORACIC DISEASES. liquid. But does this sound necessarily prove in all cases, the ex- istence of cavities ? Dr. Watson remarks " that where we hear during inspiration or coughing, the gurgling rale,—called by Laen- nec gargouillement—we may conclude, that there exists a cavity. But the cavity will not necessarily be a vomica. In ninety-nine cases out of a hundred, it will be so ; but in the hundredth case, perhaps it will not." Dilatation of the bronchi, sometimes pro- duces a considerable globular expansion. In case these cavities, formed by such an expansion were filled with a liquid, the same sound would be produced, as that caused by the tubercular vomica. Another morbid condition of the lung might cause the same sound, and that is an abscess formed by inflammation. When the cavity is empty, cavernous respiration would be heard. The size of the vomica will modify the nature of the sound. When very small it may be and often is "a mere click, like the opening and shutting of a valve, or a chirp, or a creaking." By Dr. Watson, all these modified sounds, are called by the same name,—cavern- ous respiration. The voice is generally more resonant than usual, amounting, in some cases, to bronchophony. Distinct pectoriloquy is sometimes heard in one or more points of the clavicular and scapular regions. These indications are very generally more evident on one side, than on the other, and hence the necessity of attending to this circumstance, in order to form a correct diagnosis. The length of time during which a person may continue in this state, varies in a great degree. In some cases, a few weeks bring him to the brink of the grave; in others many months and even years may pass away without any apparent increase of the symptoms. Third stage. The third stage is that period which, commenc- ing when cavities are already formed, and all their attending phe- nomena developed, continues until the termination of the disease. This has been called the colliquative stage, from the copious per- spiration, the frequent attacks of diarrhoea, and the abundant ex- pectoration with which it is attended. The feet and ankles become oedematous, the vital powers gradually decrease, one after another, the functions of life fail; the body by aifacilis descensus, falls to the earth and the soul rises to eternity. PHTHISIS^ 309 General symptoms.—The most important of these are the'col- liquative sweats, the diarrhoea, extreme emaciation, anasarcous swelling of the lower limbs and high febrile excitement. A sure forerunner of approaching dissolution is an apthous condition of the mouth. This usually comes on during the last weeks, or days of existence. , The mental faculties, at this period of phthisis, are more or less deranged. Reason remains, but it is not the reason of health. Slight delirium sometimes occurs; the patient becomes indifferent to what is passing around him and to his own state, when a little while before, his attention was aroused by every unfavorable symptom. Special symptoms.—The expectoration is very copious, con- sisting of a heterogeneous mass of mucus, pus, softened and oc- casionally solid tubercle, blood, shreds of lymph, rarely portions of pulmonary tissue; sometimes very fetid. The cough and dys- pnoea increase. The shoulders are raised and brought forward; the chest is narrow and flat. During respiration, the clavicular regions are less movable than natural, and when the patient at- tempts to make a full inspiration, the upper part of the thorax, instead of expanding with the appearance of spontaneous ease peculiar to the healthy state of the lungs, seems to be forcibly dragged up at each respiratory effort. Perforation is most fre- quent on the left side. Louis found it on that side in seven cases out of eight. There is an accident which tends to ruffle and hasten the course even of the quietest forms of consumptive disease ; this is perforation of the pleura, and the consequent pneumothorax and acute pleuritis which it produces. This lesion is already de- scribed. But it may perhaps be well to point out the sudden dys- pnoea and accession of sharp pleuritic pain, occasioned by this morbid accident. This occurs more frequently in males than in females. Dr. Williams says, " that he never has seen one instance of this lesion in the female, while he has seen at least, twenty cases in the male sex. The place where it usually takes place, is the lower and back part of the upper lobe of the lung, opposite the angle of the third or fourth rib, that is, just beneath the false membrane, by which the summit of the lung is generally ad- herent. 310 THORACIC DISEASES. Physical signs.—The physical signs in the third stage, are sim- ilar to those of the second. The gurgling rale, the increased res- onance of voice, bronchophony, and pectoriloquy, amphoric resonance and metallic tinkling, may be present in different cases, and at different times. Some of these signs are more frequently heard than others. The metallic tinkling is oftener present in a large than in a small cavity, and since large cavities are formed in the third stage, this symptom is observed only when the disease is far advanced. But what are we to infer from the presence of metallic tink- ling? A cavity must exist, and liquid be present in it. This condition exists in pneumothorax. How can we distinguish the metallic tinkling of tubercular cavities from that arising from liquids in the pleural sac ? 1st.—By the location. In phthisis, the largest cavities are usually at the apices of the lungs. In pneumothorax the cavity is towards the sides of the chest, and the sound is heard nearer the lower part of the thorax. 2nd.— By the absence of resonance. When the pleural sac is filled with air, the sound on percussion is drum-like, there is a remarkable resonance. But over tubercular cavities, percussion is dull, and the cause giving rise to that dullness, is the induration of the layer of lung between the internal surface of the chest and the cavity. The amphoric respiration, too, is another symptom which re- quires for its production a large vomica, with hardened and smooth walls. This then, on account of the nature of the physical lesions, must be most frequent in this stage. Another lesion may give rise to its production. It is a perforation of the pleura, in which case the amphoric tone is extremely well marked, or the cavity is much larger than one formed in the lungs, and its walls are large and elastic. Its different location and distinctness, to- gether with the other symptoms of pneumothorax, will prevent a wrong diagnosis. Pectoriloquy also more frequently occurs in this stage of the disease than in any other. A cavity most generally gives rise to cavernous respiration in breathing, and to pectoriloquy in speak- ing. But this modification of the healthy sound of the voice, should not be considered as pathognomonic of the existence of a cavity. Solidification of the lung around the larger ramifica- PHTHISIS. 311 tions of the bronchial tubes, may give rise to the same sound of voice. Of the relative value of this physical sign, Dr. Stokes ob- serves "that alone it is of little or no value. Cavernous respira- tion is far more alarming. Whenever actual pectoriloquy from a cavity is heard, there also will be heard cavernous respiration. But the converse of this is not necessarily true. There may be, and there often is, cavernous respiration, and a cavity, and yet no pectoriloquy. The cavity is not large enough, or not near enough to the surface of the chest, or not of such a kind as to reverberate the voice. " Often when pectoriloquy is absent, and cavernous respiration is doubtful, and gurgling even cannot be heard—because the com- munication with the bronchi is not free,—a slight splashing sound will occur, when the patient coughs; nay, we may sometimes hear it, as he holds his breath, with every beat of the heart, which causes a little succussion in the cavity; but its contents must then be thin." [Watson.] When these sounds are present, what may we infer? In all cases the existence of a cavity is indicated, but is that cavity nec- essarily a tuberculous vomica ? Not always. A cavity formed by pulmonary abcess, or by dilatation of the bronchi, may give ' rise to the same physical signs. This latter condition is deceptive, but it seldom occurs. Dr. Watson's advice, in such cases, is appropriate. " When the sounds are not well marked take time before you pronounce a decided opinion respecting them. Strong bronchophony comes very near to weak pectoriloquy : bronchial respiration may closely resemble some varieties of cavernous breathing: large crepitation confined to a small spot, may similate gurgling. It is better, when the sounds are thus equivocal, and when they may denote conditions so very different in their nature and tendency, to suspend one's judgment, and to give a guarded opinion. A little time in such cases will clear away the doubt." Particular consideration of the General and Rational Symptoms. 1. Cough. This is the first symptom which claims our atten- tion, being in most cases the first that causes alarm. It is often slight and dry, occurring chiefly in the morning when the patient rises from his bed, or during the day, when he makes any uncom- 312 THORACIC DISEASES. mon exertion. In this state it is scarcely noticed. To the patient it appears to be of no consequence. But its increase soon be- comes evident. In some cases it is slight, in others, severe. In some rare instances it appears only a few days before death. Louis gives two cases of this; and Portal affirms that the disease can exist without the slightest cough. In general it is most com- mon at night, in the morning, or soon after meals. Catarrhal cough simulates that arising from tubercular disease. In general, however, it may be easily recognised. The catarrhal is deep, implicating the respiratory muscles, attended with sore- ness of the chest, frontal headache, and other symptoms of ca- tarrh. It is soon followed by expectoration, at first colorless, but soon becoming opaque, then assuming a yellowish mucous char- acter. From this time the cough and expectoration begin to di- minish, and under ordinary circumstances soon cease. When the catarrhal disease assumes a chronic form, more difficulty will be found in learning its true character. In case the patient before the catarrhal symptoms come on, has been subject to dyspoena or haemoptysis, tubercular disease should be strongly suspected. Another kind of cough which in some respects simulates that of phthisis, is one which has been called stomach cough. It arises from gastric irritation. In general it is louder and harder than the phthisical cough, and frequently comes on in paroxysms or fits. The sensation which excites it is felt deep in the epigastric region, and the irritated state of the stomach, is manifested by the ordi- nary symptoms of gastric derangement. In some cases this is complicated with phthisical cough, in which case means should be used to remove the gastric derangement. Symptomatic cough may arise from other causes. Disease of the heart, irritation of the liver and duodenum, intestinal worms, and disease of the uterus often give rise to this symptom. The cough which is present in chlorotic females may generally be distinguished from the phthisical cough by the other symptoms, and by the effect of remedies; those means which relieve the former, having no last- ing effect upon the latter. Another variety of cough is the nervous. This is produced by excitement, has a peculiarly sharp, barking sound, repeated in quick succession, and often continues an hour without intermis- sion. It is frequently the effect of hysteria. PHTHISIS. 313 Expectoration.—The expectoration, in cases of suspected phthisis, has attracted much attention. It was thought if a patient spit pus, he was in a state of con- firmed consumption. This opinion, however, has now become obsolete, and few physicians now base a diagnosis upon this symp- tom alone. Various tests have been discovered in order to detect its presence in the sputa. Pus globules when examined through transmitted light, will exhibit prismatic colors, while mucus af- fords no such appearance. The liquor potassae liquifies mucus, but converts pus into a viscid, stringy mass. The sputa come from the bronchi, composed of mucus and yellow or greenish matter. From disease of the trachea and bronchial tubes, a puru- lent or muco-purulent discharge often takes place. And hence the presence of pus, in the expectoration, does not necessarily indicate the formation of tubercular cavities, or even the softening of tubercles. Sometimes the sputa appear in the form of globu- lar flocculent masses, resembling little portions of wool. Dr. James Clark, divides the sputa into two varieties; the first, he terms the striated state of the expectorated mass, with a mix- ture of whitish fragments in it; the second, the ash-colored globu- lar masses which are observed in the more advanced stage of the disease. When spit into a vessel, the masses composed of the latter kind mentioned by Dr. Clark, assume a flattened round appear- ance ; they are adhesive, and, from their resemblance to a piece of money, are called by the French nummular. Each sputum in general preserves a distinct form, so that the number of expectorations may be known by counting the number of sputa. This is not perfectly pathognomonic, but is nearly so. Louis saw two cases in which this kind of sputa was found without any connection with tuberculous disease. Chomel had one case of a similar character. In the latter stage of phthisis it is some- times fetid, and, more than other kinds of expectoration, attracts flies. The quantity of the expectoration varies remarkably in differ- ent cases, and is by no means to be considered commensurate to the extent of pulmonary disease. Sometimes the quantity is very 40 314 THORACIC DISEASES. small, although after death large excavations are found. This may arise from a cavity around which inflammation has so com- pletely blocked up the larger vessels, even the ramifications of the bronchi, as to entirely prevent any communication of the cavity with the external air. A case of such a character recently came under my observation. In the right lung around the ram- ifications of the bronchi, was a very large cavity, filled with muco-purulent matter, but not communicating with the bronchi. No expectoration, at least, not enough to call the attention of at- tendants, existed during the progress of the disease. Dr. Portal likewise speaks of similar instances. When tubercles are crude the expectoration comes from the bronchial membrane. Later in the disease it comes mostly from the bronchial membrane, but partly from the softened tuberculous deposits. The surface of cavities affords an additional amount of morbid secretion. The quantity generated from this source is sometimes great, but often it is extremely small. In reviewing the facts already stated concerning the expectoration, its variations in quantity, in appearance, and the various lesions from which it originates, we may safely draw the conclusion, that, unless com- bined with other symptoms, it cannot, especially in the early stage of phthisis, be considered of very great utility in forming a cor- rect diagnosis. Later in the disease, in conjunction with other symptoms, it has value in enabling us to ascertain the presence of tubercles, and the changes which occur in the course of their de- velopment. Dyspnoea.—This symptom varies greatly in the degree of its intensity in different cases. In some instances it occurs early in the disease, being among the first phenomena which attract the patient's attention ; and it is one of the most constant and remarka- ble symptoms in that form of the disease, called Febrile Phthisis. More frequently it is not troublesome until the malady is far ad- vanced, and it generally becomes very distressing in the last stages. When the tuberculous disease makes slow progress, the dyspnoea is seldom great; and, in persons who, from their quiet mode of living, use little exercise, it is scarcely noticed, even when the respiration is more than double its usual frequency. In such cases the oppression in breathing experienced during mo- PHTHISIS. 315 tion, is very often attributed to debility. Indeed, it is by no means an unfrequent occurrence, to find the patient unwilling to admit the existence of such dyspnoea until minutely questioned on the subject. Although we shall not err far in stating that the degree of dys- pnoea, or hurried respiration, will generally be found proportionate to the rapid progress and extent of the tuberculous disease of the lungs, still this will not always be an invariable occurrence. We are not yet acquainted with all the causes of dyspnoea. Of one hundred and twenty-three cases reported by Louis, three only presented examples of severe dyspnoea, and a careful examination of the whole contents of the thorax after death, de- tected nothing to explain it. A degree of congestion of the lungs commonly exists in persons of a tuberculous constitution, both before and after the formation of tubercles. This may be one cause of dyspnoea; and hence we frequently find that an attack of haemoptysis relieves the dyspnoea for a considerable time. On the other hand it not unfrequently happens that the origin of the difficult breathing is dated from an attack of haemoptysis. Dyspnoea, although not much to be relied upon as an indication of phthisis, is frequently present, and should always be a subject of inquiry. It is chiefly during exertion that the oppression of breathing is experienced, and as it differs little from that which in a slight degree always accorhpanies such exertion, it seldom attracts attention. It occurs most frequently when sudden and large deposits are made, or when there is tuberculous infiltration. Congestion, accumulations of mucus in the bronchi, pneumothorax, extensive pleuritic adhesions, so binding down the lungs to the parietes of the thorax as to prevent their normal expansion, are among its causes. Hcemoptysis.—This is the most important rational symptom which occurs in phthisis. In other diseases and conditions of the lungs it is so rare, that it very certainly indicates the nature of the case. Haemoptysis, to be sure may be produced by other causes; by certain forms of heart disease, by cancer, by cirrhosis of the lungs, and, in females, by vicarious menstruation. But these latter conditions of the lungs are very rare, and, therefore, 316 THORACIC DISEASES. haemoptysis should always be considered a strong evidence of the existence of phthisis. Sometimes it occurs very early in the disease, often it is the first symptom. The quantity of blood expectorated varies greatly in different cases. When it exceeds two or three ounces it may be called a free hemorrhage. When less than this, it is moderate. Profuse hemorrhage often excites gagging, and causes some of the symptoms of haematemesis. From the latter, the pulmonary hemorrhage may be distinguished by waiting until it has nearly ceased, when the coughing will indicate that the blood is expec- torated. Not unfrequently the blood seems to come from the throat, and the patient very often is inclined to refer its source to that locality; and hence the physician should seldom rely upon his statement in forming his diagnosis. The hemorrhage need not be copious in order to be indicative of danger. A teaspoonful of blood, mixed with a little mucus may be occasionally expectorated without pain or effort. But lit- tle anxiety is excited on the part of the patient, and yet when re- peated it is quite as diagnostic of phthisis as a more copious dis- charge. " Hemorrhage, although so important as a diagnostic sign of tu- bercles, very seldom proves fatal by its immediate effects; neither does it seem, as a general rule, to act unfavorably on the general progress of the disease. On the aontrary, statistical tables prove, that those phthisical patients who experience hemorrhage, usually live longer than those who do not. Oftentimes the flow of blood is attended with a feeling of decided relief, especially if it as- sumes the character of a passive hemorrhage. Sometimes, when it assumes an active character, attended with febrile excitement, and induces a condition of lung analogous to inflammation, it may produce injurious effects—an active period in tl.e progress of the disease seeming to coincide with its occurrence. Thus hem- orrhage is not always to be regarded in the same light, when you look at individual cases. But when you look at this symptom hi the mass of cases, its existence must be regarded as exerting rather a beneficial influence than otherwise. There are many per- sons, more or less tuberculous, who, from time to time, expector- ate even large quantities of blood, who after a little rest, to recruit PHTHISIS. 317 the exhausted strength, return to their occupations, and live on, year after year, without any apparent loss of health. The most protracted case of phthisis I have ever known, lasting thirty-five years, was marked by occasional returns of, sometimes, very,copi- ous hemorrhage during this long period. " 1 have stated to you that hemorrhage from the lung's did not marli the stage of the disease. It may occur early or late in its progress. Formerly, hemorrhages were attributed to two causes, exhalation from a free surface, as the mucous membrane, or rup- ture of a blood-vessel. But'microscopic observations have estab- lished the fact that there can be no such thing as an exhalation of blood, it must always escape from a ruptured vessel. It may take place from numerous capillary vessels ramifying upon the surface of the bronchial mucous membrane, and this is probably- the fact in a great majority of the cases of hemorrhage connected with tubercles—always indeed, when it occurs at an early stage of the disease. Its mechanism is simply this:—The tuberculous deposit, by pressing upon the capillary vessels of the lungs, obstructs some of them, while others become congested in consequence. These congested vessels, when seated in a mucous tissue, become rup- tured from distension, and discharge blood. There is no reason to believe that the capillaries of the air-cells or of the common cellular tissue of the lungs are ruptured. If they were ruptured, you should find pulmonary apoplexy in fatal cases. But this is not the case. Hemorrhage may, indeed, occur from a ruptured vessel of considerable size, from ulceration. This can only hap- pen in an advanced stage of the disease; even then it rarely oc- curs from this cause. When it does occur, it is usually very abun- dant and difficult to control. " When patients are questioned as to what may have excited the hemorrhage, they can seldom state any thing which seems likely to have acted as an exciting cause. In a large proportion of cases it occurs quite unexpectedly, without premonitory symptoms. Sometimes an unusual effort, especially of the chest, seems to act as an exciting cause ; and in women, the occurrence of the men- strual period may induce the same result. " Hemorrhage would undoubtedly occur more frequently and co- piously than it does in the progress of phthisis, and as the lungs 318 THORACIC DISEASES. become filled with the tuberculous deposit, was it not that the quantity of blood circulating in the lungs is materially diminished. The blood emaciates like the other parts of the human system. This influence is felt also by the heart, which does not increase in size with the progress of the pulmonary obstruction, as you might suppose, but it rather diminishes in size, with the dimin- ished quantity of blood in the circulation. " I am not afraid that I have dwelt too long on this important symptom. Its frequency, its diagnostic value, its influence on the prognosis, the great alarm it usually excites in the patient, and in the family, make it worthy of the most careful consideration." [Dr. Swett's Lectures.] Pain.—In the early stage of phthisis, this is seldom very severe, and in some cases is not sufficiently so to excite attention. Usu- ally there are flying pains through the shoulders and sides. Their source probably is the external intercostal nerves. In many re- spects they may resemble rheumatic pains. But their history and their complication with other symptoms, will easily distinguish them. Another source of pain is inflammation of the pleura, aris- ing from the extension of the pulmonary disease to that mem- brane. This is more local than the former ; and from the ordin- ary locality of the pathological changes by which it is produced, we know, that it should be confined to the sub-clavicular or adja- cent regions. In general its locality points out the place where the tuberculous disease is most early developed. Combined with other symptoms, it is of some value. As the disease advances, the pain increases. When confined to the lower part of the chest, and to the epigastric region, it frequently arises from inflammation of the pleura of the diaphragm, and, therefore, cannot be a valu- able diagnostic sign of phthisis. The pain caused by catarrh, dif- fers from that caused by phthisis. That arising from the former disease is more confined to the sternal region,—being a sensation of soreness rather than of acute pain, extending through the chest to the spine. At first, the decubitus is on the most healthy side. Late in the disease, it is often the reverse; and for this reason:— When the patient lies on the diseased side, the matter collects in the vomicae, and does not pass into the bronchial tubes and excite PHTHISIS. 319 coughing. Severe pain, and dyspnoea, coming on suddenly, are indicative of that important lesion—the perforation of the pleura. Constitutional symptoms.—The state of the pulse is a symp- tom which has attracted much attention. Its real value in diag- nosis has been overestimated. An opinion is too prevalent that the lungs are safe when the pulse does not rise above its normal standard. Some-times it remains steady nearly up to the period of dissolution. In such cases, the disease progresses slowly. Dr. Watson relates a case in which the pulse never rose above sixty- eight beats in a minute. More commonly, however, the pulse is habitually above ninety ; and often much quicker. Whenever it is so, and for its increase in frequency no other cause save tuber- cular deposition can be assigned, it is a suspicious symptom. In the early stage, the excitablity of the pulse is often a strik- ing characteristic. When the patient is tranquil, the pulse is tran- quil, but the least excitement carries it up ten or twenty strokes in a minute. When the disease has taken a strong hold, the pulse indicates it. It is permanently and decidedly accelerated with a sharp and quick stroke. In the second stage it increases in frequency often rising to one hundred and thirty beats in a minute. A slow pulse is a good omen in tuberculous disease, inasmuch as it is usually associated with a condition of the system favorable to recovery. Fever.—In the incipient stage, this is of an irritative character. Towards evening slight chills come on, which are followed by fever during the night. It increases insidiously, and at length ter- minates in morning perspiration. As the disease advances, the fever occurs in paroxysms, and the heat, instead of being confined to the hands and feet, is more generally diffused over the whole body. This latter kind of fever is the proper hectic, being caused by the softening of tubercles, and attended with frequent pulse not so hard as that which attends the irritative fever in the first stage. Night sweats.—A marked symptom of hectic is nocturnal per- spiration. This is not proportioned to the severity of the previ- ous chill and fever. It has a close connection with sleep. Louis found the night sweats wanting in one-tenth of his cases. They are most copious about the time the diarrhoea appears. These 320 THORACIC DISEASES. two symptoms—the diarrhoea and perspirations, have been consid- ered supplementary. Of this, however, there is not good evi- dence. Louis found no reciprocal influence existing between them. At first they usually are confined to the head, neck and breast. Subsequently they extend over the body as the disease approaches its termination. "They are often very distressing, pro- ducing much discomfort and exhaustion upon the awakening of the patient. They evidently depend upon a debility of the capil- laries, which allows the watery portions of the blood to pass with- out resistance; and they occur during sleep, because then the vital forces, and among them contractility are at their lowest ebb." Emaciation.—This is one of the cardinal symptoms of phthi- sis. Frequently it precedes the other symptoms. Between the ages of forty and fifty, Dr. James Clark found it among the earli- est symptoms of phthisis. Indigestion is regarded by the patient and his friends, as one of the principal causes of this atrophy. It is frequently associated with anaemia. There is many times a pe- culiar physiognomy, the cheek is pale and thin, and the eye bright. Every organ in the body, except the liver and heart, even the blood itself, emaciates. And this is often the first symptom no- ticed. At length, slight disturbance is manifest, a little dyspnoea, a little chillness towards evening, and a tendency to cough. This symptom, emaciation is not always progressive. The patient may gain flesh, but he soon loses it again; then perhaps gains awhile in weight, and so on alternately. This, however, is observable; the patient seldom gains as much flesh as he loses. There is a gradual though not continuous descent. It is true also that while there is an increase of weight, the tubercular disease in the lungs advances ; and while the patient and friends are elated with hope by the apparent amendment, a fatal termination steadily approach- es. Loss of appetite and diarrhoea very much increase the ema- ciation. Diarrhoea.—The rapidity of the progress of consumption de- pends much upon this. With the number of evacuations, Louis found that the loss of strength and wasting corresponded. This fact should militate against the employment of cathartics in phthi- sis. " A tablespoonful of castor oil," says Dr. James Clark, " I have seen throw a phthisical patient into an alarming state of de- PHTHISIS. 321 bility." In those who have in health had a costive habit of body incipient phthisis produces regularity of the action of the bowels. Diarrhoea is usually confined to the advanced stages of the dis- ease. In one eighth of the cases treated by Louis, diarrhoea com- menced with the disease and continued until its termination ; in the majority it occurred in the later stages, in others during the last days of life, and in four out of one hundred and twelve cases, it never appeared. The distress attending this symptom, is often severe. Before each evacuation, there is often a severe pain, and immediately after it a deadly sensation of sinking. It has an ef- fect upon the cough and expectoration. The severity of these symptoms, is usually in the inverse ratio to that of the diarrhoea. As a diagnostic sign it is not of great value. The nature of the disease is known by other means, before this becomes fully devel- oped. The cause of the diarrhoea, is the ulceration or the soften- ing of the tuberculous matter deposited among the coats of the intestines. After death, we find ulceration of the mucous mem- brane, tuberculous deposits, thickening and softening, and en- larged mucous follicles, especially near the termination of the ileum and in the colon. (Edema.—This is an invariable attendant of the last stage.of phthisis. In young delicate females, it may supervene in the ear- lier stages. Generally it shows itself first in the lower extremi- ties, and is for the most part confined to them. In the morning there is sometimes an oedematous appearance in the face. For diagnosis, this is of no value ; but it is a prognostic of ap- proaching death. Cerebral and Nervous symptoms.—The intellect is usually un- clouded. The mind when the disease is not complicated with any affection of the stomach and liver, is hopeful. The unwil- lingness of the patient to believe himself in danger, is one of the most remarkable symptoms of consumption. Even those who have a good knowledge of consumption, even physicians who have died of this disease, have exhibited the same peculiarities of mind. In the first stage there is a nervous irritability, a tremb- ling of the hands, and the mind is in a peevish and irritable state. ^Symptoms arising from derangement of the digestive and men- strual functions.—The symptoms of dyspepsia are not usually 41 322 THORACIC DISEASES. very prominent. Very often the digestive functions are well per- formed until they fail from constitutional debility. The stomach secondarily becomes weakened, and the usual symptoms of indi- gestion supervene- In some rare cases the stomach seems to be primarily affected. Its mucous membrane, after death presents a "thickened, mammillated, softened" appearance, indicative of the existence of chronic inflammation. At times, the gastric symp- toms become severe. Extreme tenderness over the epigastrium, vomiting of bile and mucus, and a burning sensation occur. Sexual symptoms.—In male patients nothing remarkable occurs in connection with the sexual functions. In females it is far oth- erwise. The occurrence of pregnancy arrests for awhile the de- velopment of tubercles; lactation also exercises a favorable influ- ence over it. During gestation the most alarming symptoms of phthisis often disappear; and it sometimes happens in young mar- ried women, that the disease is warded off, many years by child bearing and nursing ; and sometimes even the predisposition seems to be overcome. After delivery, in most cases, its return is speedy, and it appears to compensate in the rapidity of its march, for the time during which its progress was arrested. It is probable that while pregnancy arrests the progress of phthisis, it only renders it latent, and thus a mere temporary and not a permanent advantage is gained. Sometimes there is good evidence to believe, that it does not produce much temporary benefit, and the practitioner who recommends it to his patient, may be disappointed in its effect. "Even supposing that the progress of tubercles is retarded during the existence of pregnancy—what is the final result ? As soon as delivery has taken place, the pulmonary disease usually advances with great rapidity, and, in addition, a child with a strong tuber- culous tendency is born. Certainly there is no great advantage in these results, and you will, I hope, be disposed to adopt the opinion that I have formed,—never to advise pregnancy to a tu- berculous patient. Cases of this kind will occur often enough, and the evil consequences be experienced, without, or in opposi- tion to your advice." [Swett's Lectures, p. 263.] The condition of the menstrual function in females, is a con- sideration of much importance. Many young females cease to menstruate, they become pale and feeble, they emaciate somewhat, PHTHISIS. 323 and the whole attention is directed to the cessation of this men- strual function. This abnormal condition, is supposed to demand for its removal, active emmenagogues, which are uselessly pre- scribed. The desired effect is not obtained, and the symptoms of phthisis are gradually developed. Some diversity of opinion now exists in regard to the influence of gestation in arresting the progress of phthisis. " But independ- ently of the general belief," remarks Dr. Wood, " my own per- sonai observation has been such as to render it impossible for me to have any doubt on the subject. I have repeatedly seen the dis- ease, even in its somewhat advanced stages, apparently quite ar- rested on the occurrence of pregnancy. Two cases are promin- ent in my recollection. The patients were admitted into the Pennsylvania Hospital, with cavities in their lungs, and all the symptoms of decided phthisis. After a time they began to im- prove wonderfully, and unaccountably. The general symptoms vanished almost entirely, and they became fat and quite healthy in appearance. This change was found to be coincident with the occurrence of pregnancy." Is the suppression of the menses the cause of the tubercular disease ? Some have thought that it might lead to the deposit of tubercles in the lungs. The menstrual suppression, is for the most part, the effect of that general debility, that deficiency of the nutritive properties of the blood, which precedes the deposition of tubercles. If this theory is true, then the treatment, instead of being wholly directed to the restoration of the uterine function, should be directed to the removal of that deficient nutrition, and its consequent debility which cause the menstrual suppression, and the tuberculous deposition. The cessation of the menses is sometimes one of the first, if not the first prominent symptom of phthisis, and a careful examination of the case will often discover this to be the fact. Attendant upon this symptom, there are, in most cases, a slight cough, a little chilliness and fever, and some of the physical signs of incipient phthisis. In general, this func- tion continues, but decreases in quantity, during the early stage of the disease. At a later period, about the time when tubercles be- gin to soften, it sometimes ceases abruptly. There are cases in which the menses continue during the whole progress of the dis- 324 THORACIC DISEASES. ease. From a great variety of causes, this function is so liable to derangement, that as a diagnostic sign it is not of much value. Duration of Phthisis.—Tuberculous phthisis is essentially a chronic disease, the range of its duration being considerable. Cases have been recorded, which have terminated in eleven days, while others have "lingered for twenty and even forty years. These, however, are extreme cases. The majority of cases ter- minate in one or two years, the average duration being eighteen months. Various circumstances modify its duration, such as age, sex, the constitution of the patient, the climate, season of the year, &c. Louis found the mortality greater among females dur- ing the first year than among males, in the proportion of forty- two to thirty. After that time the ratio was the same in both sexes. When patients have all the advantages derivable from proper regimen, change of air, and good medical treatment, the medium duration of phthisis is probably not much short of three years. Section III. VARIETIES OF PHTHISIS. Although tubercular disease is essentially the same, in its ana- tomical characteristics, and constitutional origin, it varies greatly in the duration of its course, and in the external features which it assumes. Five forms of phthisis, differing from the ordinary form of the disease, are described by Sir James Clark. I pro- pose to consider the acute, the chronic, the phthisis of children, and the latent. Acute Phthisis.—The usual duration of phthisis has been sta- ted to be about eighteen months. In the present variety, it fre- quently runs its course in two or three months, and sometimes in a still shorter period. The acute form, admits of a useful divi- sion into two varieties : The first variety, in which the short duration of the disease depends chiefly on its violence. The sec- ond variety, in which the feeble powers of the constitution sink under the pulmonary disease, long before it has reached that stage at which it generally proves fatal. PHTHISIS. 325 The former variety, is manifested by symptoms which, from their onset, are usually severe ;—the pulse is quick, the heat of the skin considerable, and the patient at an early period of the disease, is confined to his bed. All the symptoms of phthisis suc- ceed each other with great rapidity. The cough increases, expec- toration goes quickly through its various changes, hectic fever is violent, the morning perspirations copious, and diarrhoea hastens on the patient to the termination of life; and in six or eight weeks he dies of what is expressively called by the public, " a galloping consumption." Of this variety, young people are usually the sub- jects. It frequently comes on soon after the cessation of some acute exanthematous disease, as scarlatina and rubeola. This variety, in general, occurs in those persons whose consti- tutions are so highly tuberculous, that any slight cause, easily ex- cites a deposition of tubercles in the lungs. In other cases, the tuberculous deposits exist in the pulmonary tissue, anterior to the development of any external manifest symp- toms. The disease is latent, and an attack of haemoptysis, or of catarrh, produces pulmonary congestion. Generally some inflam- mation in some part of the lungs follows, complicating the tuber- culous disease. Henceforth the disease puts on its usual symp- toms, and rapidly passes through its course. The latter variety is observed most frequently in delicate young persons, and according to Dr. Clark, more frequently in females than in males. Their highest degree of health is below the ordi- nary standard. Possessing the tuberculous cachexia they are hab- itually weak, easily fatigued, and have a feeble circulation of the blood. The symptoms in such, are not violent, the real condi- tion of the patient is somewhat concealed, and, before suspicion in respect to the disease is excited, the tuberculous lesion is far advanced. Debility is considered the cause of the accompanying symptoms. The breathing is quick, cough troublesome, and the expectoration sometimes tinged with blood. The pulse becomes rapid, and the morning perspiration copious. The countenance is pale and of a leaden hue, the lips are of a bluish color, and the albuginea, of a slightly dull, pearly tint. Without much apparent increase in symptoms, such patients sometimes sink rapidly under 326 THORACIC DISEASES. an attack of diarrhoea, producing such extreme syncope as to ter- minate life. Chronic Phthisis.—Laennec and Bayle first described the na- ture of this variety of phthisis. They showed its identity with the other forms of the disease. The acute form, as I have men- tioned, occurs, for the most part, in the young. The chronic form occurs in the old. After the fortieth year it usually takes place. In the acute, the hereditary predisposition is strongly marked; in the chronic, scarcely apparent; or if so, it has been kept in check by a train of causes, adverse to tuberculous deposi- tion. The disease, in most cases, is scarcely cognizable in the early stage. The patient may be a little languid, have a slight cough, attended by no fever or anorexy. He is a little dys- peptic, the stomach is the organ blamed for his indisposition. A visit into the country, change of air, and good food, dispel for a while, all appearances of the disease. The next winter and spring, however, cause a return of the old symptoms. So the disease may alternately recede and ad- vance, during a long period. But at last, after an attack of ca- tarrh, it assumes more of the appearances of phthisis. Cough, dyspnoea, expectoration, emaciation and fever all arise, and threat- en to terminate existence. From all these symptoms, sometimes he recovers, and during the summer months, enjoys a tolerable degree of health. In general, such patients while attending to business, are subject to occasional attacks of catarrh, pleuritis, or pneumonitis. Physical exploration of the chest will seldom fail to reveal the true condition of the lungs. The respiratory move- ments are more limited, percussion under the clavicles is dull, the voice more resonant than natural, and pectoriloquy is sometimes present. In such cases, cavities are formed, some of which have been emptied of their contents, others are in progress of cure, or are actually cicatrized. Regular and temperate habits may often cause the patient to live to the ordinary age of man. Ordinary causes, those which would have either no effect or but a slight one upon the healthy constitution, give rise to the most serious diseases of the thorax. The influenza which pre- vailed in the summer of 1832, and spring of 1833, proved fatal to many such invalids. How can we account for this slow pro- PHTHISIS. 327 gress of the disease, when no exciting causes develop it, and its speedy termination when such causes exist? Evidently, the con- stitutional predisposition to such a disease is slowly induced by certain long-continued habits, and not by any hereditary influence. That this view of the subject is true, seems to be evinced by the great prevalence of this form of phthisis among persons in the upper ranks of society. In those who labor, the acute forms are more prevalent. A form of phthisis somewhat chronic in its nature, is, however, occasionally observed in the lower ranks of society. One attack of pneumonitis, or pleuritis, or ca- tarrh succeeds another, until the lungs become completely adher- ent to the parietes of the chest, the thorax scarcely moving dur- ing respiration. Post mortem examinations of those who die of this form of phthisis, reveal a variety of pathological changes, in one part inflammation has left its morbid products, in another tu- bercles in their various stages of development have disorganized the pulmonary tissues. This form of phthisis, from practical con- siderations, should be studied more than other varieties. In the first place, because it is liable to be overlooked until it has made considerable progress, and remedial agents have become compara- tively ineffectual in its cure. And secondly, it demands thorough investigation, because, in this form more than in others, time is given for the operation of remedies, and for effecting its perma- nent removal by the formation of proper habits of life. The in- fluence of its exciting causes, may be warded off, all derange- ments of the digestive organs, all irregularities of the circulation of the blood, can be removed before tubercles are deposited in the lungs. Phthisis in Infancy and Childhood.—Phthisis is more common in childhood and infancy, than was once supposed. Dr. Guersent, one of the physicians to the Hospital des Enfans Malades',—an Institution appropriated to the treatment of patients between the ages of one and sixteen years—gives, as the result of his obser- vations, that five-sixths of those who die in that establishment, are more or less tuberculous. [Le Blond, sur me espece de phthi- sie particuliere aux enfans. Paris, 1824.] Early in life its existence is manifested by symptoms somewhat different from those of adults. The cough occurs in paroxysms; 328 THORACIC DISEASES. hectic, expectoration and hemorrhage from the lungs, are not so apparent. The tuberculous cachexia, rapid pulse and breathing, emaciation and derangements of the digestive organs, tumid abdo- men and irregular action of the bowels, at one time constipated, at another, affected with diarrhoea, and the pale unnatural color of the evacuations, point out to the physician, the nature of the dis- ease. In children, the mesenteric glands are more subject to disease than in adults. But the most frequent seat of tuberculous affec- tions, is the bronchial glands, and next in frequency, the lungs. The relative frequency of tubercles in the bronchial glands of children compared with the lungs, is not less than five to four; which is of course more than reversed after the age of puberty. The relative ratio existing between the frequency of tubercu- lous disease in the bronchial glands, lungs cervical and mesenteric glands is as the numbers 49. 38. 26. 25. [Journal de progress des sciences Medicales, t. ii. p. 93.] Respecting the development of tubercles in the bronchial glands, Dr. Gerhard, says " it occurs nearly as in other solid structures of the body; scattered points of tuberculous substances are gradu- ally deposited in the structure of the glands, surrounded by the original tissue, which remains for a considerable time nearly in the healthy state ; sometimes, however, it is swollen and more vascular than usual, but more frequently it is quite pale, and in- filtrated with the gelatinous substance which is in many cases the early stage of. tuberculous matter. As the quantity of tubercle increases, that of glandular structure gradually becomes less, until the whole tissue of the gland is absorbed, and is replaced by tu- bercle. It is then much larger than the original gland, and the capsule which encloses it, gradually thickens, during the process of softening. After softening has followed, adhesion occurs be- tween the glands and the nearest large bronchial tube, so that the contained matter is evacuated by an opening into it. In most in- stances, however, no softening occurs, but the tuberculous matter becomes hard and dry, and is converted into a calcareous substance, surrounded by a capsule. This substance often becomes ex- tremely hard and solid, and generally remains in this state during life. The tuberculous disease of the bronchial gland, is, there- PHTHISIS. 329 fore, much less unfavorable than that of the lungs, and is essen- tially curable." The symptoms, of tubercles in the bronchial glands are very obscure. They can be recognized better by the existence of the tuberculous cachexia, than by any other means of diagnosis. Since this state of the system rarely exists in children without a deposi- tion of tubercles in those glands, we may safely predict the exist- ence of the local when the constitutional disease is present. Respiration is extremely feeble in one or both lungs, while per- cussion is quite resonant. The only permanent sign is the feeble- ness of respiration, which is often caused by the contraction of the larger tubes in consequence of the pressure of the enlarged glands. Expiration is at times wheezing and protracted. • The glands sometimes enlarge so as to produce a swelling on the sides of the trachea. This, however, is rare. In case the child expec- torates tuberculous matter, and no symptoms of cavities in the lungs are present, the diagnosis is nearly certain. Latent Phthisis.—Of phthisis there* are cases in which the rational symptoms, such as cough, expectoration, haemoptysis, 'pain and dyspnoea, do not exist. The development of tubercles is slow, it being from six months to two years before their exist- ence is indicated by any local symptom. Out of one hundred and twelve cases of phthisis, Louis found eight in which the dis- ease was latent. By closely examining the history of many cases of phthisis, we find satisfactory evidence, that tuberculous disease -had commenced in the lungs from one to two years before proper attention was given to it, or its nature was understood. The constitutional symptoms should excite the suspicion of the practitioner. Whenever these are present, without any visi- ble cause, local disease must be their source of development. Under such circumstances, let an examination of the chest be made, and very probably the seat of the difficulty will be found in tuberculous disease. An attentive observer, will, in general, be able to detect it by. the physical signs, by the general appear- ance of the patient, and by his peculiar diathesis. But difficulties in diagnosis sometimes occur, which are not so readily overcome. The physical signs, as well as the rational symptoms, may be obscure, indistinct, or even absent. When 42 330 THORACIC DISEASES. they are so, repeated examinations of the chest should be made. By so doing the true nature of the case will finally appear. This variety according to Dr. James Clark, is most frequently met with in the latter part of life, but it is not wholly confined to any pe- riod. Sometimes attacks of phthisis cease, the patient becomes comparatively well, and years elapse before any of its manifest symptoms again show themselves. Laennec affirms, "that the greater number of cases of phthisis are latent at the beginning, since nothing is more common than to find numerous miliary tubercles in lungs otherwise quite healthy, and in subjects who have never had any symptoms of consumption. On the other hand, from considering the great number of phthisical and other subjects in whom cicatrices are found in the summit of the lungs, it is more than probable that hardly any person is carried off by a first attack of phthisis. Since the adoption of this opinion on anatomical grounds, it has fre- quently appeared quite clear to me, from carefully comparing the history cf my patients with the appearances on dissection, that the greater number of those first attacks are mistaken for slight colds, and that others are quite latent, being unaccompanied with either cough or expectoration, or indeed with any symptom suffi- cient to impress the memory of the patients themselves." If this opinion of Laennec is true, it seems very important that the physician should be able to detect the disease in its nascent state. Were he able so to do, appropriate remedies could be im- mediately prescribed, the salutary effects of which would so for1 tify the system against repeated attacks, as to secure to the pa- tient health and the enjoyments of life. If, then, we see a patient who, on the slightest exposure takes cold, who is thin, and pale, whose food affords but little nourishment on account of a de- ranged state of the digestive organs, whose form and tempera- ment are favorable to the production of phthisis, latent consump- tion should be looked for, even though there are no rational symptoms manifested. Certain conditions of the system disguise phthisis. Of these, one is pregnancy of which I have already written. An attack of mania is another condition which arrests the pulmonary disease. Dyspepsia sometimes draws off the attention from the phthisical PHTHISIS. * 331 condition of the lungs. Diarrhoea is another disease which dis- guises phthisis. Not unfrequently when the intestines are sup- posed to'be extensively diseased, on account of the presence of diarrhoea, a post-mortem examination reveals the existence of tu- bercles in the lungs. In such cases, the primary affection is gen- erally in the lungs, the diarrhoea is for the most part secondary. Section IV. COMPLICATIONS. Tubecular phthisis affects nearly every organ, but plays its most conspicuous part in the lungs. In them is its focus, and from them it seems to radiate. To this there are exceptions. But were we to consider the aggregate number of deaths from phthi- sis, whether occurring in childhood, during adolescence, in middle life or in old age, we should find that in a majority of instances, the lungs were primarily affected, and other organs secondarily. Other diseases so disguise its existence and so complicate with it, > that, in order to arrive at perspicuity m diagnosis, it is necessary to consider the more important of those complications. Cerebral Complications.—The phthisis of adults is usually at- tended with no great derangement of the cerebral functions. In children, however, it is different. The tuberculous meningitis of children is one of the most interesting lesions produced by tuber- cles. In them this form of cerebral disease is sometimes devel- oped, antecedent to pulmonary derangements. It may be recog- nized by the severe pain in the head, followed by vomiting, pros- tration of strength, agitation alternating with stupor, convulsive movements, paralysis, and coma; arid, by the termination of the case in death, while the thoracic symptoms seem to diminish. The tuberculous deposit is found, sometimes, in the pia-mater, at the base of the brain, and in its substance. Effusion of transpar- ent, or turbid serum into the ventricles, is in some cases noticed. The disease called acute hydrocephalus, is the effect of the tuber- culous disease, attacking the membranes of the brain; and chronic hydrocephalus, has probably an intimate connection with tuber- cular deposition in the cerebral substance. 332 'thoracic diseases. Ulceration of the Epiglottis, of the Larynx and of the Trachea. —The epiglottis, in the latter periods of the disease, is frequently affected, and simultaneously with it, the larynx. The lingual surface of the epiglottis is rarely ulcerated. Louis mentions only one case of this kind. The symptoms by which it may be known, are pain in the region of the os hyoides, and difficult deglutition, fluids being ejected through the nostrils in the attempt to swal- low. Sometimes there is oedema of the epiglottis. The larynx frequently ulcerates, the attending symptoms often being so prom- inent, as to lead the inexperienced to give a wrong location to the whole difficulty, and not to suspect any pulmonary disease. That variety of phthisis which is called laryngeal, is nothing more than pulmonary consumption accompanied by a morbid condition of the larynx, the symptoms of which predominate, and mask those of the pulmonary disease, upon which the emaciation, hectic fever, night-sweats, and other symptoms of phthisis chiefly depend. A constant symptom of ulceration of the larynx, is hoarseness, which often terminates in complete aphonia. The cough has a harsh grating sound, and sometimes resembles a kind of whist- ling. The symptoms of ulceration of the trachea, are very obscure. Louis saw only one patient in which heat and obstruction, was complained of in the region of the sternum. Ulceration of the trachea is almost exclusively confined to phthisis, and the side of the trachea corresponding with the lung, in which the greater amount of disease exists, is most frequently and severely affected. The bronchial membrane presents an abnormal appearance. It is reddened, thickened and sometimes ulcerated. This condition of the membrane is chiefly confined to the surface of those tubes which communicate with caverns. The sputa passing over the surfaces of the lining membranes of the bronchi, trachea and larynx, according to the opinion of Louis, cause the membranous disease. These ulcers seldom penetrate below the mucous membrane, although they sometimes involve the muscular and cartilaginous rings of the trachea, the vocal cords, the arytenoid cartilages and epiglottis. That these lesions are closely connected with phthi- sis, is made evident by statistics. Out of one hundred and twen- PHTHISIS. 333 ty-two patients who died of chronic diseases, not phthisical, Louis found only one case of ulceration of the epiglottis and larynx; whereas, in those who died of phthisis, he found ulceration of the epiglottis and larynx in one-fifth, of the trachea, in 07ie-third of the consumptive cases which came under his observation. These lesions, are found much more frequently in males than in females. Affections of the Pleura.—In the article on pleuritis, I have spoken of the connection of tubercles with pleuritic inflammation. That this connection is intimate, morbid ahatomy has clearly de- monstrated. When these adhesions are extensive; they some- times present the appearance of a cap, composed of semi-cartilag- inous crusts, covering the apices of the lungs, in which tubercu- lous matter is sometimes deposited. Diseases of the Abdominal Viscera connected with Phthisis. —During the course of tubercular consumption, the mucous mem- brane of the alimentary canal, is usually affected. Andral re- marks, " that softening of the mucous membrane of the stomach, hyperaemia of the different portions of the intestines, accompan- ied in many instances by a development of tubercles, are all of such frequent occurrence in phthisis, that they may be fairly con- sidered as constituent parts of the disease. Morbid condition of the Stomach.—Inflammation of the stom- ach occurs at a late stage in the disease, and gives rise to anorexia, heat, pain, and tenderness in the epigastrium, and, in some cases, to nausea and vomiting. This condition of the stomach, accord- ing to Louis, was an attendant of phthisis in eight cases out of one hundred and twenty-three. When the symptoms- arise from gastritis, there are anorexia, pain in the epigastrium, increased by pressure, and other symptoms of gastric derangement; but when from the cough, the appetite is usually good, no epigastric tender- ness or pain is present, and the vomiting comes on early in the disease. Another variety of gastric derangement sometimes exists. It is known by pain and vomiting. But little food can be borne on the stomach ; sometimes not more than a spoonful of fluid two or three times a day. Ulcerations of the Intestines.—The location of the intestinal lesions, is in the ileum, near that part which is adjacent to the 334 THORACIC DISEASES. mesentery, and where the glandulae agminatae are most numerous. In the colon, the ulcerations are somewhat irregular, often extend- ing to contiguous tissues, and coalescing together. Louis found them extending to the length of nine inches. Caeteris paribus, the more early and extensive these ulcerations of the intestines, the more speedy is the termination of the disease. The cause of this is found in the great emaciation produced by the diarrhoea which is attendant upon these abdominal lesions. The mesen- teric glands are very often involved in the constitutional disease. In about half of the cases of the phthisis of children, they are affected; in about one half of the cases in adults. When ulcerations of the intestines, cause perforation, the result is acute peritonitis, the symptoms of which are often obscure, but rapid. Usually there is a tumid, tympanitic abdomen, with or without pain and tenderness, a sudden prostration, a very rapid pulse, and speedy collapse which soon terminates in death. A chronic form of peritonitis is sometimes the result of tuberculous disease, and a concomitant of phthisis. Its existence may be known by the pain in the abdomen, not very severe, but wander- ing, moderate in degree, often transient, and followed by tympani- tic distension from gas in the intestines. " After a time the distension diminishes, from an absorption of the liquid effusion, and from a partial removal of the gas, and the abdomen remains enlarged with a dough-like feeling, or with firm ridges, giving the sensation of an unequal firmness on pressure; in addition to these local symptoms, the constitutional symptoms of tuberculous disease are present,—emaciation and loss of strength, hectic, accelerated pulse, and especially, if the rational or physical signs of tuberculous disease' of the lungs exist, we need have no hesitation in referring the abdominal symptoms to a tuberculous peritonitis." "After death we find our diagnosis confirmed by an abundant deposit of tubercles in the peritoneal cavity—false membranes loaded with tubercles and gluing the folds of the intestines to- gether. Sometimes we find tubercles under the peritoneum, and perhaps a considerable effusion of serous, sero-purulent, or even purulent matter in the cavity of the abdomen." [Swett's Lectures.] Disease of the Liver. A remarkable fact in the history of PHTHISIS. 335 phthisis is the fatty degeneration of the Liver. To phthisical dis- ease it is peculiar. Out of forty-nine cases Louis found forty- seven in which this condition was present. Out of two hundred and thirty that died of other diseases, there were only nine. From these statements of the French Pathologist, it appears that a de- posit of fat in the liver is an almost constant attendant upon phthisis. The presence of the fatty matter may be known by cutting the liver and observing the appearance of the scalpel; or by putting a piece of it upon tissue paper, and applying thereto a moderate heat, when the stain of melting fat will appear; or by placing portions of the liver in ether, which, after evaporation, will leave particles of fat. With the microscope we can detect its existence. This condition of the liver -is marked by a pale yellowish color, by its enlargement and by its softened texture. It is most common in females and in drunkards. Why this is so, it is difficult to explain. The functions of the liveware but little impaired, when a large portion of its tissue is converted into fat. Another condition of the liver, occurring just before the devel- opment of tubercles, is cirrhosis. This is most frequent when phthisis occurs in countries where intermittents prevail. Fistula in Ano.—This affection frequently exists in phthisis, and is thought by some authors to be connected with it. Louis, Andral, and Dr. Clark do not find this opinion satisfactorily con- firmed. The latter author suggests that its dependence, may be on the venous plethora of the abdomen, which often precedes pulmonary consumption. Dr. Morton, on the contrary, thinks, from facts which have come under his observation, that there may be a connection. Dr. Gerhard also recognizes the existence of such a connection, and says that cases of fistula ought very rarely to be treated by a surgical operation. "I have often," he remarks, " thought that I was rendering an important service to patients by preventing them from allowing industrious surgeons to tamper with cases of the kind mentioned." Differential Diagnosis.—While treating of the general course of phthisis I described the more important symptoms and their bearing in the formation of a correct diagnosis. Occasionally the varieties and complications of the disease increase the difficulty 336 THORACIC DISEASES. of detecting its existence, and, therefore, I deem it best to take a summary view of the more common sources of diagnostic error. In the first stage the greater amount of accurate discernment is necessary. Before the general symptoms are fully developed,— the physical signs at the same time being scarcely observable,— the diagnosis must be dependent upon the temperament, the con- stitution and the nature of the predisposing causes, together with the slightest appearances of constitutional debility, hectic fever, cough, and haemoptysis. Seldom do all of these symptoms occur in conjunction, and hence a diagnostic error often results from the greater dependence upon several variable, uncertain symptoms than upon one or two nearly pathognomonic. The first appearance of haemoptysis in a scrofulous constitution is a very suspicious symptom, and, if it occurs alone, with no other external phenom- ena, it should be considered of much more value, than the hectic fever, the excited pulse and dyspnoea. It is very seldom that sev- eral symptoms do not exist coetaneously. After one prominent one appears others soon accompany it, and make the diagnosis more and more certain. Bronchitis sometimes complicates with phthisis, the symptoms of the former sometimes simulating those of the latter. In the former there is more fever, in its first stage more expectoration, but no haemoptysis. Bronchitis gives rise to the development of the physical signs in the lower parts of the chest, but phthisis in the apices of the lungs. But in some cases miliary tubercles equally disseminated through the lungs give rise to symptoms almost identical with those of bronchitis. Under such circum- stances we have in phthisis the continued presence of the mucous or sub-mucous rales, emaciation, night-sweats, unchanged by the treatment which would prove decidedly efficacious in bron- chitis. In the advanced stage of phthisis, the existence of cavities and their attending physical signs, the steady advance of emaciation, the pulmonary hemorrhage, and the non-appearance of these symptoms in bronchitis will afford sufficient evidence to estab- a correct diagnosis. Phthisis, too, is most often accompanied with a hopeful state of the mind, but bronchitis with despon- pency. PHTHISIS. 337 Chronic bronchitis may in some instances resemble phthisis. This form of the disease usually occurs in old age—is attended by morning expectoration, the sibilant rale, dyspnoea, and slight fever after exposure to cold. Sometimes emaciation, hectic, and great debility attend it. In such cases, the physical signs indi- cate the nature of the malady. The sub-clavicular regions, give a good sound on percussion, and to the ear the respiratory mur- mur. While over the sternal region, and the lower part of the chest, the sibilant or mucous rale will frequently be heard. There is a complication of this disease, which when it occurs —and its occurrence is very rare,—will puzzle the most experi- enced physician. The physical signs then become deceptive. It is the complication of chronic bronchitis with dilatation of the bronchi. As before remarked, dilatation of the bronchi may pro- duce a cavity, and that cavity may be partly filled with liquid; and we have the cavernous respiration,.and the gurgling rale. In case there is, around this dilated portion of the bronchi, pulmon- ary congestion, then slight hemorrhage sometimes supervenes, and thus simulates haemoptysis from tuberculous disease. And again, these dilatations sometimes occur near the apices of the lungs, and thus still more nearly simulate phthisis. When the complication exists it is almost impossible to form a correct diag- nosis. Emphysema sometimes causes difficulty in the formation of a correct diagnosis. If existing at the summit of the lung, it be- comes more resonant than normal, and consequently the healthy lung by contrast, seems to be dull on percussion. But this con- dition of the air-vesicles, gives rise to a feebler respiratory sound, than is heard over the healthy lung; so that the coincidence of great resonance on percussion, with an absence of the respiratory murmur on one side, while on the other the respiratory sound is normal, with apparent dullness,—though not real,—will afford dis- tinguishing characteristics of the nature of the internal lesion. Pneumonitis, in a chronic form, may sometimes simulate phthi- sis. The distinctive symptoms, are the crepitant rale followed by bronchial respiration, the rusty sputa, the location of the pneu- monitis which, very rarely attacks the upper lobes of the lungs ; the absence of the haempptysis of the expectoration of consump- 43 338 THORACIC DISEASES. tion, of the night-sweats, and of the febrile exacerbations aud re- missions. But suppose the pneumonitis to attack the upper lobes, as an effect of tubercular deposition. How then can the kind of lesion be determined ? With the rusty sputa, is mingled an unu- sual amount of blood, which arises from slight haemoptysis. The crepitant rale is present, and after the pneumonitis has subsided, some physical signs remain behind. This latter effect is strongly indicative of tuberculous disease ; for pneumonitis leaves no phy- sical signs after it. And so it is with bronchitis. The mucous rale which, when it exists at the base of both lungs, unattended by dullness on percussion, indicates the presence of bronchitis, may be heard only in one lung, and in its apex in case phthisis is present. When this is the case, and especially if the pulmonary disease is chronic, the existence of tubercles is soon evinced. The mucous rale exists at the apices of the lungs, in which case tubercles, of course, are known to be deposited in both. This physical sign marks the period of tuberculous softening. When this process commences, the contiguous bronchi are inflamed, a mucous secretion is its effect, which gives rise to the mucous rale, as the air passes through the tubes partially filled with the secre- tion. When this sound is heard at the place which tubercles usu- ally occupy, it removes doubt, and establishes a true diagnosis. But there are on record, cases of pneumonitis of the superior lobes of the lungs, which give rise to a mucous rale that deceives the attending physicians. This result, however, may be obvia- ted by attending to the history of the disease ; pneumonitis pas- sing rapidly through its different stages; phthisis progressing slowly, and surely to a fatal termination. Section V. CAUSES OF PHTHISIS. Inquiries into the causes of phthisis have been very extensive, and have brought to light much useful knowledge respecting its prevention. But certainty is not as yet attained, and many influ- ences which have been supposed to give rise to phthisis, are not after all proved to be the real causes of- its production. In draw- PHTHISIS. 339 ing conclusions in medicine, many mistakes are made. From too limited observation of a few phenomena, varied by modifying cir- cumstances, deductions are often drawn, in which there is neither truth nor reason. One very prominent cause why so much diver- sity of opinion prevails in relation to the nature and treatment of phthisis, is the different manner, and the degrees of caution, used by physicians in making their investigations. In determining the causes of phthisis, the same difficulties that meet the philosopher in arriving at any definite conclusions,—conclusions the truth of which can be demonstrated,—meet also the physician. We should then, when examining statistics in relation to the causes of dis- ease, before drawing conclusions, inquire into the character of the circumstances, under which the statistics were made. Among the causes of phthisis, hereditary predisposition occu- pies the most important place. And yet this hereditary tendency explains nothing in relation to the real cause of the disease. It is the name of a fact not a cause, which is sure to produce specific results. We must, therefore, in order to arrive at anything defi- nite or practical, seek to find that in which the fact has its origin —whether it be a peculiar state of the blood, a want of func- tional power,—in the digestive organs, or in the respiratory appar- atus. Vitality is the effect of so many conditional causes, each liable to vary in intensity and thus by that variation, to influence the result,—the degree of vitality,—that it is difficult to tell in what ultimate change phthisis has its origin. But the nearer we ' can ascend to the sources of knowledge, the more general and conditional that obtained knowledge becomes, for all other knowl- edge, related to it, as species to genera. Accordingly it is evi- dent, that, if chemistry or optics could detect that condition of the blood,—whatever it is—which is most prevalent in the pro- geny of tuberculous parents, before deposition of tuberculous matter takes place, a general fact would be obtained of more value than many particulars often spoken of by medical writers. From pathology or from chemistry, we gain no evidence, that those who are predisposed to phthisis, have blood differing essen- tially from that of others. And the existence of the hereditary tendency has been questioned by some recent observers. But be- cause of the non-appearance of an abnormal change in the con- 340 THORACIC DISEASES. stituents of the blood, except in rare cases, or because the exist- ence of that tendency is denied, we should not, therefore, con- clude that hereditary influence does not exist. It may exist, but not as an ultimate cause, ever producing a certain result. In all the blood probably contains the elements of tubercle. Why then do those elements leave the mass of the blood, and lo- cate, as foreign or heterogenous matter, upon the surfaces of mem- branes or in the texture of organs ? And why does this effect take place more frequently in the children of phthisical parents ? To answer these questions according to science will require a more philosophic spirit than mine. And yet, to me it seems ra- tional to suppose that the constituents of the blood are held to- gether, by an affinity—be it chemical, or vital,—the strength of which is modified in degree by any cause which can debilitate the system,—which can lessen the nutritive properties of the blood. Certain constituents of the blood, by that affinity, are held together by a stronger force than others, or, certain of them, have a stronger affinity for surrounding elements than others. And whenever from any cause, from deficient nutrition, or from impure air, this affinity is lessened, then upon the surfaces of those membranes, in which exosmose is easily effected, certain elements of the blood,—those having a strong affinity for other textures, not being at all within the control of vital affinity,—are exuded. The second question it seems to me, involves nothing more than this general principle in all animal life;—the tendency to impart to the progeny the attributes of the parent. As is the character of the germ, so is that of its natural completed prod- uct. Hereditary predisposition seems on analysis, to resolve it- self into this origin. A. certain train of causes, acting for a long time and in one direction, will give rise in those not predisposed to phthisis, to tubercoulous disease, or at least will cause a condi- tion of things, approaching to that which will give rise to tuber- cles. A parent has been under certain influences, but they may not have produced in his system, tuberculous disease in its devel- oped form. This same condition is handed down to the pro- geny, and then the same causes act upon the latter which did upon the former. But in the latter, at the beginning of life, the condition of the system is already less adverse to the development PHTHISIS. 341 of phthisis than was that of the parent at the beginning of his existence. And hence the acting of that train of causes upon the child, which, in the parent did not produce phthisis, but which had he lived long enough, would have done so, develops phthisis in the child. I ask, then, if we seek for an ultimate cause, to what shall we attribute the beginning of the predisposition? Does it not spring from the other causes of phthisis? and is it anything more than a continuation of the effects of exciting causes ? If not, our prophylactic treatment, in order to strike at the root of the tree, should be directed to the removal of those causes which, when long continued, give rise to any disease whose tendency is to produce, in the parent, depression of the vital forces, and thus secondarily to beget in the child that predis- position of which authors speak. There is some variation in the statistics of different authors, concerning the number of phthisi- cal patients in a given number, who have been born of consump- tive parents. Dr. Swett, deducing his conclusion, from private practice, thinks that seventy-five in a hundred of phthisical pa- tients, belong to consumptive families. "The influence of age in the production of phthisis is very remarkable. A large proportion of those affected, die between the ages of twenty and thirty years. Dr. Walshe includes forty- one per cent, of the whole number between these periods. Bri- quet states that three-fifths of those who suffer from the disease are attacked between the ages of twenty and thirty-five years. Children are by no means exempt from its ravages. While all admit the rarity of tuberculous deposits in the lungs of the foetus, still they are sometimes noticed. The lungs of a new-born in- 'fant may be completely studded with tubercles. Although the tendency to the disease rapidly diminishes after the age of thirty or thirty-five years, yet it is sometimes met with even in advanced life. " Sir James Clark places the mortality, between the ages of fifty and sixty years, at 108, as compared with 285, representing the mortality between the ages of twenty and thirty years. My own impression is, that when individuals who have passed the middle period of life are attacked with phthisis, the disease progresses less rapidly than at any earlier period of life, and that many thus 312 THORACIC DISEASES. die, after having suffered from the disease for a considerable por- tion of their lives."—[Swetfs Lectures.) Occupations of Life.—Concerning the causes of phthisis, Lombard, of Geneva, has given us some valuable statistical infor- mation. The result of his researches is thus stated :—" The cir- cumstances which increase the tendency to phthisis are poverty, sedentary habits, violent exercise of the chest, an habitually bent position of the body, impure air in workshops, the inhalation of certain mineral and vegetable vapors, or air loaded with a coarse or impalpable dust, or with light, thready, elastic substances." " The circumstances which seem to exert a favorable, preserva- tive influence, are easy circumstances, an active life in the open air, regular general exercise, the inhalation of watery vapor, and finally, animal and vegetable emanations." This general summary of the results of extended observation is worthy of consideration. The influence of poverty in the pro- duction of phthisis is considerable. But the attending circum- stances, anxiety of mind, exposure, poor food and deficient cloth- ing, have without doubt much to do in producing the result. The proportion of deaths from phthisis in those professions practiced by the higher classes of society is, according to Lom- bard, only one-half as great as among the poorer classes. In Ge- neva only fifty in one thousand deaths occur from phthisis among those living on their incomes, while the average number of deaths among all classes is one hundred and fourteen in one thousand. Sedentary habits are prone to produce phthisis. The practice of sitting with the body inclined forward, thus preventing the free expansion of the lungs, and the action of the stomach, and other abdominal vircera, is one cause of the injurious tendency of a studious life. Among shoemakers, and tailors the proportion of phthisical patients is very large. The influence of the inhalation of various substances is a sub- ject of interest. The inhaled substances operate in two ways: by absorption, and by the mechanical irritation which they pro- duce. Of the former class are gasses and vapors. Of the latter, minute particles of dust. The inhalation of the mercurial vapor tends most of all to the production of phthisis. It is the general opinion of physicians that mercurials are injurious to phthisical PHTHISIS. 343 patients, and that its use tends to produce that state of the system favorable to the development of phthisis. Sir James Clark says " that long courses of mercury on the constitution, may give rise to the scrofulous constitution." Those exposed to the vapor of lead, and other mineral agents are not particularly liable to phthisis. Among those who inhale the vapor of lead the number of deaths from phthisis, in one thousand is only twenty-one, while among those who inhale that of mercury there are fifty-three in a thousand. The inhalation of dust whether animal, vegetable or mineral, oftener produces a fatal form of chronic bronchitis, than a depo- sition of tubercles. M. Lombard 'thinks, that mineral dust is the most injurious of all. Those agents which exert the most injuri- ous influence are the dust arising from flints, sandstone, and from steel; and hence stone-masons, miners, coal-heavers, brass polish- ers and metal grinders are more liable caeteris paribus than others to phthisis. Among animal agents, the dust arising from flax- dressing, or from feathers and hair is most injurious ; among vege- table agents the dust arising from the dressing of cotton. Lombard's opinion, that the inhalation of watery vapor is a preventive of phthisis, should be somewhat modified. An at- mosphere, warm and damp, may perhaps have a beneficial influ- ence in phthisis. But in our country in which moisture and cold are often combined, such a result is seldom found to be true, but, on the contrary, the moisture and cold tend to produce phthisis. All along the Atlantic coast, those cold chilly winds, accompanied with dampness, are among the most powerful causes of consumption incident to this climate. From phthisis M. Lom- bard thinks that butchers, tanners, and leather dressers are re- markably exempt. Of late it has been asserted that those whose occupation tends to keep the surface of the body covered with oily matter, are not so liable as others to phthisis. According to the observations of M. Lombard vegetable emana- tions are useful to prevent tuberculous disease. " But," observes Dr. Swett "the truth of his statement may well be doubted. In certain regions, the healthful influence of vegetable emanations may be true enough. But if the various forms of malarious dis- ease, are dependent upon this cause, then we must class these 344 THORACIC DISEASES. emanations among the most unfavorable influences in the produc- tion of phthisis. There is, indeed, a popular opinion in this coun- try, that a residence in a malarious region is favorable to phthisi- cal patients. But this opinion is the very reverse of the truth. Malarious diseases by impairing the general health, favor the development of phthisis, and much increase its mortality." M. Lombard, from his investigations, drew the conclusion, that exercise of the voice, exerts a favorable influence. Phthisis is usually less rapid in its progress in feeble constitu- tions than in those more vigorous. Louis is of the opinion that the lymphatic temperament predisposes to phthisis. But it is evi- dent that an attempt to distinguish the different temperaments could not lead to definite conclusions. In estimating the amount of influence which climate exerts in the development of phthisis, we are chiefly dependent upon sta- tistics. Of late some light has been thrown upon this subject by the valuable reports of the surgeons of the British army, and those of the late Dr. Torrey of the United States army. By them many erroneous ideas have been corrected. Formerly it was supposed that phthisis prevailed almost exclusively in temperate latitudes, in central Europe, in the northern and middle parts of the United States. Accordingly phthisical patients have been advised to re- move to tropical countries, in order to receive protection. But these reports prove that a permanent residence in tropical clihiates, instead of preventing the development of phthisis, tends rather to an opposite result. There is a difference, however, in the unfavorable tendency of tropical regions, on the same parallels of latitude. The West Indies are more favorable to the produc- tion of phthisis than the East. In the army in Great Britain the number of phthisical patients was six and one half in every one thousand men. In the West Indies, in Leeward and Windward Islands, the number was twelve in one thousand; in Jamaica, thirteen; in the Bermudas, nine. In the Mediterranean the aver- age number of phthisical patients is six in one thousand. The climate of the East Indies is more favorable to the preven- tion of phthisis than that of the West. In Ceylon and along the Bay of Bengal it is seldom known. The climate of Sweden al- though cold, is more favorable to the prevention of phthisis than PHTHISIS. 345 that of England. In Canada, too, there are less deaths from this disease than in many parts of the United States and England. "Contrary to general belief," says Dr. Swett, "consumption is more common along the Atlantic coast, from Delaware Bay to Savannah, and at the southwestern ports, than at the northern Atlantic ports, and at those situated on the great lakes. While the least ratio is found at those parts in the northern division of the United States, remote from the ocean and the lakes. Thus, so far as our own country is concerned, the regions least predis- posing to phthisis, are the inland states in the northern division, removed equally from the influence of the ocean and of the great lakes." To those localities, then, we should send consumptive patients, rather than to those which they have formerly visited for the im- provement of their health. But it is not under all circumstances best to advise a removal from home, in order to obtain the benefit of a new residence. The stage of the disease, during which such a removal will prove most beneficial, is its formative one,—that stage in which other remedies have the most beneficial effect. Malaria is a poison which tends to undermine the constitution, and to lay the foundation of phthisis. Phthisis is more frequent in malarious regions. To this, however, there are exceptions. In New England malaria exerts little or no influence, while con- sumption is very prevalent. The favorable effect of a sea-faring life is generally admitted, and is confirmed by good evidence. Acute Inflammations of the Chest—Inflammations of the chest, such as bronchitis, pneumonitis, and pleuritis, have been supposed to exert an unfavorable influence. The two former diseases I shall in the first place consider. Patients often trace their phthi- sical difficulties, back to a neglected cold, or a slight attack of bronchitis or pneumonitis, and, to that source attribute the first cause of the disease. For this opinion pathology has shown that there is but little foundation. Bronchitis and pneumonitis attack the lower lobes of the lungs, or the larger bronchial tubes which are not the ordinary seat of tuberculous deposit. Inflammation is by no means a constant attendant upon the development of tuber- cles. 44 346 THORACIC DISEASES. Pleuritis is sometimes secondary to the development of phthisis, and sometimes is its antecedent and exciting cause. It is much more liable to be so than either bronchitis or pneumonitis. Very often we meet with cases in which the phthisical affection seems to immediately follow the pleuritis. We may safely conclude, that pleuritis is either a cause of the development of phthisis in those who would not have had the disease, were it not for the pleuritic inflammation, or that it has the power to arouse into ac- tivity the latent form of consumption. It is considered much more favorable to the development of tubercles, than the inflam- matory diseases of the air-passages, and parenchyma of the lungs. Caeteris paribus, we should conclude, that if inflammatory af- fections of the thorax were causes of phthisis, the latter disease would be most frequent, where the former prevail to the great- est extent. There should be on this supposition, a certain ratio existing between the prevalence of pneumonitis and bronchitis, and that of phthisis. But it is not so. In their ratio to phthisis, they differ from the malarious diseases. According to Dr. Forry's Reports, where phthisis is least common, there bronchitis is most prevalent. Nor is there any definite relation existing between the prevalence of pneumonitis and pleuritis, and that of phthisis. Is phthisis contagious? Dr. Watson replies:—"No: I verily believe it is not. A diathesis is not communicable from person to person. Neither can the disease be easily generated in a sound constitution. Nor is it ever imparted* in my opinion, even by one scrofulous individual to another. Yet in Italy a consumptive pa- tient could not be more dreaded and shunned if he had the plague. A girl dying of phthisis, is nursed by her §ister, who afterwards droops and dies of the same complaint. Here the presence of the peculiar diathesis is strongly presumable. But the parents may be different in blood. A wife watches the death-bed of her consump- tive husband, and presently sinks herself under consumption; and there may be no traceable, or acknowledged example of scrofula in her pedigree. Yet even here the latent diathesis may be pre- sumed to exist." Other influences aside from any contagious in- fluence hasten on the development of the disease. These are watching, anxiety, and confinement in the ill-ventilated apartment of the sick-room. The effluvia, arising from a patient in consump- PHTHISIS. 347 tion, and the attendant circumstances should be considered as ex- citing causes, the influence of which can hasten the progress of tuberculous disease in others. And hence sleeping with a person laboring under phthisis, especially in its last stage, should be avoid- ed as any other exciting cause of consumption. Intemperance.—This has been considered a cause of phthisis. Sir James Clark remarks :—"we believe that the abuse of spiritu- ous liquors among the lower classes in this country is productive of tuberculous disease to an extent far beyond what is usually imagined. Indeed, it is only necessary to observe the blanched cadaverous aspect of the spirit-drinker to be assured of the condi- tion of his internal organs." This tendency of intemperance is, however, doubted by others in the profession, whose observations are extensive. Of 35 per- sons dying of various diseases, all of whom were decidedly in- temperate, and most of them grossly so, in 26, according to Dr. J. B. S. Jackson, of Boston, [New England Quarterly Journal of Medicine and Surgery, July, 1842, p. 30,] no tubercles were found; in 5, there were tubercles in the lungs; in 1, in the bronchial glands; and only 2 died of phthisis. In several of the most striking, the organs were as free from tuberculous disease, as those of a new-born infant. These results led Dr. Jackson to suggest, whether intemperance may not have some effect as a prophylactic? [Cyclopedia Pract. Med. Art. Phthisis.] Dr. Swett observes—" Two medical gentlemen attached to the public dead-house in this city,—New York,—in which bodies are deposited, that are found in the streets, or without friends,—dis- covered in about seventy post-mortem examinations of those who died of the most confirmed and aggravated intemperance, not a single case of tuberculous lungs. A most surprising result, when we remember that this unfortunate class have probably long suf- fered from poverty, bad nourishment, and exposure to the weather; influences which are regarded as predisposing to tuberculous de- posit. A large proportion of confirmed drunkards suffer from hepatic disease. Is a tendency to hepatic disease antagonistic to the development of tubercles ?" Some authors think so. And yet more extended observation is necessary in order to fully sub- stantiate the truth of such a conclusion. The modus operandi of 348 THORACIC DISEASES. alcohol in acting as a preventive, is not as yet so fully understood as could be desired. And, the opinion, that it really is benefi- cial in the prevention and cure of phthisis, is as yet deficient in demonstrable evidence. And yet, on analysis, we may find some ground on which such an opinion may reasonably be founded. Those means which act as revulsive agents, generally arrest the progress of those diseases to which they are opposed in their ef- fects. Many hygienic means operate in a similar way. It is gen- erally admitted that certain conditions of the system lend to arrest the development of tubercles. Among these are pregnancy, cer- tain chronic bronchial affections, and some diseases of the heart. Now according to Rokitanshy, all these conditions tend to produce venosity of the blood—an effect similar to that produced by hepa- tic derangements. It is also the conclusion of Broide, and others, that alcoholic drinks taken into the stomach, pass by absorption, or endosmose into the blood-vessels and with the blood circulate in a free state. Liebig asserts that alcohol, when circulating with the blood, unites with its oxygen, and forms carbonic acid gas—thus tending to produce a venous state of the vital fluid. Bennet's tes- timony is in accordance with that of Dr. Jackson. Dr. Swett re- marks, "that tuberculous cavities are more frequently found healed, in the lungs of spirit drinkers, than in those of any other class." This fact, however, is far from being absolute proof that the alcoholic stimulus, is alone its cause. Some other stimulant in an anaemic or scrofulous state of the system might be equally as efficacious. If so, we should by all means use the substitute, and not entail upon the patient a pernicious habit by our advice. Under some circumstances,—perhaps in asthenic cases of phthisis —some mild alcoholic beverage combined with nourishing food, is very useful. By its use in this manner the animal tempera- ture is elevated, and the nutritive functions stimulated to increased activity. Concerning, its utility, the discriminating practitioner can learn more by experimental knowledge than by theoretical. Dyspepsia.—In dyspeptic diseases, many authors have placed one prominent cause of phthisis. And well it is that they have done so. For since tubercles depend for their development upon a want of nutrition in the blood, and since dyspeptic diseases de- PHTHISIS. 349 prive the blood of its nutritive properties, there is reason to be- lieve, that in this source, tubercles may have their origin. There are other causes of phthisis which are seldom described in medical works. Of these, one is masturbation which, by its debilitating effect upon the general constitution, tends, in an em- inent degree, to favor the development of tubercles. Another cause is the use of such remedial agents in the cure of disease, as leave after their primary effects have subsided, secondary ones, which, in the end prove worse than the original disease. One week's sickness treated heroically, often lays in the system the foundation of chronic complaints, which in their results termin- ate only with the end of life. It is generally admitted that mer- cury is injurious in scrofulous affections, and that its action rather than otherwise, tends to develop that disease. If this be so,— and the history of thousands of invalids corroborates its truth,— then why may not its action upon the system directly induce tu- berculous disease ? Indirectly, if not directly, by debilitating the system, by destroying the red blood, by inducing emaciation, it so influences the mass of the fluids, as to leave the system liable to the ingress of phthisis,—it leaves the territory unguarded by any vital force—even by that mysterious one, " the vis medicatrix naturcB." A patient somewhat predisposed to phthisis, takes a severe cold in the autumn. Febrile symptoms supervene. There is accord- ing to the opinion of some, an exalted condition of vital action; and consequently all the instruments of the anti-phlogistic regi- men and treatment are immediately used to subdue the inflamma- tion. After a number of weeks the patient may slowly recover. But his digestive organs do not seem to be healthy. Strength does not return; a slight cough begins, and in from six months to a year, phthisical symptoms are fully developed. Such cases often occur, and so often, that the more judicious physicians of all creeds, even those standing on the conservative platform, now be- gin to abandon the use of dangerous remedies, not because—as some often pretend—diseases are now so different in their nature as not to require the same treatment, but because the application of science to the study of medicine has exploded the idea, that it is necessary to hazard life, by the use of deleterious agents in or-* der to produce a speedy and complete cure. 350 THORACIC DISEASES. Prognosis.—In those cases in which the disease is far advanced, the prognosis is always very unfavorable. So small is the chance of recovery, that the physician has no good reason to encourage the patient or the friends. But morbid anatomy has demonstrated that even in the last stages recoveries do take place ; the cavities are filled with the chalky concretions, their parietes contract and cicatrices are produced. What else, than the curability of phthi- sis do such facts teach? On this subject Dr. Swett remarks, "I never shall entirely despair of the life of a patient with phthisis, when I recollect what I once witnessed in this Hospital. A pa- tient was admitted with phthisis. The disease was perfectly well characterized, and in its most advanced stage; a large and well marked abscess existed under the right clavicle. Indeed, the signs of this lesion were so distinct, that I was in the habit of calling the attention of students in attendance to them as perfect in their characters. On one occasion as I approached the bed for this purpose, I found the patient who had been gradually sink- ing, in such a state, that it seemed to me improper to disturb him. He was bolstered up in bed, with his head falling upon his shoul- der, breathing with great difficulty, bathed in perspiration, and with a rapid and feeble pulse. The next day my attendance ceased, and after two months, was again commenced. On enter- ing the ward, the house physician called my attention to a man, dressed, walking about the ward apparently stout and well, al- though spmewhat pale. To my great astonishment I found that it was the very case of phthisis I had left two months before ap- parently dying." The same author testifies that he has known a number of patients who have had all the evidences of phthisis, and yet have recovered. In such cases, however, the subsequent health is not so good as it would have been had they not been injured by the phthisical lesions. At times, a little cough and dyspnoea continue, but the patient is able to attend to ordinary business. The number of those whose lungs evince, after death, indications of the effect of the curative process, is much greater than has been supposed. Indeed, it is not uncommon to find in the lungs of those who die of almost every form of chronic disease, chalky concretions, ancient traces of tuberculous disease. A French physician found PHTHISIS. 351 in one hundred women, all above sixty years of age, and dying of various diseases, fifty-one who presented the curative indica- tions of tuberculous disease, and chiefly by the formation of chalky concretions. To such testimony, the common reply is, that they were not after all, cases of phthisis. If so, and if no case ever did recover after cavities were fully formed, how I ask does it happen that the lungs in so many cases show the indica- tions of cured phthisis? No one who has any knowledge of tu- bercular consumption will affirm, that it is not always a formida- ble disease, that its prognosis is not always unfavorable. But it is not, therefore, the part of reason, to deny facts, plainly testify- ing that the disease, under favorable circumstances, and especially when early treated by the most appropriate human means, does occasionally terminate favorably. Dr. Wood of Philadelphia, mentions two instances of this kind in medical men of that city. One of the patients was affected, when a young man, with all the symptoms of phthisis, including frequent attacks of haemoptysis, severe cough, hectic fever, &c., from which he completely recov- ered, and continued exempt up to the time of his death, which occurred many years afterward of typhoid fever. [See N. Am. Med. and Surg. Journal, viii. 277.] The second case was the late Dr. Joseph Parrish, who in early life had phthisis, and recov- ered. At an advanced age he died, and cicatrices were found in the upper part of one lung. Section VI. TREATMENT.' The indications in the treatment of phthisis are first, to pre- vent the further deposition and development of tubercles, and, secondly, to protect, as far as possible, the lungs and other organs from their injurious results. 1. To prevent the development and deposition of tubercles.— The means both prophylactic and remedial, which can be of any utility for this purpose, must be directed to the attainment of this result;—the production of that state of the solids and fluids which is most adverse to the development of tubercles. The primary 352 THORACIC DISEASES. pathological changes in phthisis, are few and simple. And so they remain until the sequences of the repulsive powers of the system, produce lesions of textures, more difficult to be removed, than even the primary changes. The remedies which alter the primary state of the tissues, are also of a simple character, and only a few are required, when seasonably and properly applied. These agencies must excite absorption and secretion. A diminution of the nutritive properties of the blood in phthi- sis, is now a well established fact. In order to remove this con- dition, Ave must therefore direct our remedial and hygienic means to those sources, whose condition determines the character of the blood. The air is one source—the chyle the other. Whatever tends to keep these sources of life pure, must tend to keep pure their product, the blood. Pure air then is indispensible to the preven- tion and cure of phthisis. And since exercise in the open air, in- creases respiration, thereby tending to expose the blood to the ac- tion of atmospheric elements, it becomes a potent means of pre- venting the progress of tubercles. To be effective, this must be long continued. A short walk now and then is not sufficient. It must be persevered in, in order to have any permanent effect. At first it should be gentle, and not continued until exhaustion is produced. Its increase should be in proportion to the increase of strength. The state of the weather, should not often be considered an insurmountable obsta- cle. Let the clothing be adapted to the circumstances, and proper care be taken after exercise, not to take cold by exposure to cur- rents of cold air, or by too quickly taking off the clothing, and there need be no fear as to the result. There is prevalent in the community a great error, in regard to the prevention of catarrh by close confinement. Close confinement, instead of being a preventive, is an actual cause of catarrh, and many other pulmon- ary difficulties. Experience fully confirms this opinion. Those who are most sedentary in their habits, the least exposed to the vicissitudes of the weather, are caeteris paribus, most liable to pul- monary consumption. These remarks as to exercise, of course, apply to the early stage of phthisis, when there is no great de- bility. PHTHISIS. 353 The character and degree of exercise must depend upon cir- cumstances. Severe exercise has in some cases proved beneficial, by arousing to activity the vessels of the minutest tissues. By this, sudden changes in the secreting and excreting vessels have been effected. Dr. Salvadori directed his patients in the morning to climb, as quickly as they could, some eminence, till they were out of breath, and bathed in sweat; and then to place themselves near a large fire to increase the perspiration. Afterwards they • were directed to change their linen, and gradually withdrawing from the fire, to partake freely of salted meat and wine. Dr. Parrish, who, having no faith in the treatment of the pro- fession in this disease, threw all their remedies aside, and followed the advice of Sydenham,—makes the following remarks:—"Vig- orous exercise and free exposure to the air, are by far the most ef- ficient remedies in pulmonary consumption. It is not, however, that kind of exercise usually prescribed for invalids—an occasion- al walk or ride in pleasant weather, and strict confinement in the intervals—from which much good is to be expected. Daily and long-continued riding on horse-back, or in carriages over rough roads, is, perhaps, the best mode of exercise ; but, where this can- not be commanded, unremitting exertion of almost any kind in the open air, amounting even to labor, will be found beneficial. Nor should the weather be scrupulously studied. Though I would not advise a consumptive patient to expose himself reck- lessly to the severest inclemencies of the weather, I would, nev- ertheless, warn him against allowing the dread of taking cold to confine him, on every occasion, when the temperature may be low or the skies overcast. I may be told, that the patient is often too feeble to bear the exertion ; but, except in the last stage, when every remedy must prove unavailing, I believe there are few who cannot use exercise out of doors; and it sometimes happens that they who are exceedingly debilitated, find upon making the trial, that their strength is increased by the effort, and that the more they exert themselves, the better able they are to support the exertion." The temperature of the body should be equal, not exposed by a want of clothing, or sudden changes of heat and cold. The clothing, therefore, should be such as not to permit the body to be , 45 354 THORACIC DISEASES. suddenly chilled. Flannels, and woolen clothes generally are best adapted to sustain an equilibrium in the heat of the system, and thus to keep up an equal circulation of the blood. The influence of climate, in accomplishing this indication, is often considerable. The mild winters of some tropical regions, in two respects, are beneficial to a phthisical patient. First, they tend to promote, more than a cold, changeable climate, the cutaneous capillary cir- " dilation, and secretion, and also, in the second place, afford to the patient better facilities for exercise in the open air. " In choos- ing a place of residence," says Dr. Wood, " preference should be given to those situations which are at the same time dry and of a uniform temperature." In Madeira, the climate is very favorable to the cure of phthi- sis. It is perhaps least prevalent in Ceylon and along the shores of the Bay of Bengal. But the increased liability existing in those localities to hepatic and abdominal diseases, makes a resi- dence there, dangerous. In the West Indies, Santa Cruz is perhaps the best place ; and the accommodations there derivable are good. In our country the interior of Florida, is thought by Dr. Swett, to be the best place for a consumptive patient. He recommends, the patient at the approach of Spring, or as soon as the heat becomes a little oppressive, to move a little northward, keeping back from the sea coast. To spend a month or two at Aiken, in South Carolina, to reach Richmond, Virginia, about the beginning of May. and to return to the Northern States about the tenth of June. He, also, recommends patients to go South sometime in October or early in November. In some cases,—in those who bear well the cold of autumn,—he thinks that they may stay North until December or even January. What kind of patients most frequently receive benefit from a change of climate ? They are, in general, those in whom the disease has not far advanced, in whom there is no hereditary pre- disposition, but, on the contrary a strong tendency to health, a strong constitution. Those in whom the phthisical affection is not complicated with any other disease, in whom its progress is slow, located on one lung only, and confined to a small portion, showing a strong tendency to pause in its development. PHTHISIS. 355 The regulation of diet is also an important part in the treatment of phthisis. This should consist of those articles which, while they are easily digested, afford a rich supply of nutriment to the blood,—enough to combine with the oxygen of the air and pro- duce that condition of the circulating fluid most adverse to the development of tubercles. Among the more nutritious articles allowable in the first stage, are beef, eggs, oysters, mutton; among those less nutritious, are milk, fish, farinaceous articles and diges- tible fruits. The greater the amount of exercise, the more nutritious should be the diet. Moderately stimulating drinks, such as porter, ale, and pure wine, are often very useful. To the use of any alco- holic beverage in this stage, some object; saying that it tends to produce inflammatory action. This may be so to some extent. But it should be recollected, that phthisis is in an eminent degree a disease of debility, and its attendant, fever,—especially in the first stage, is of an irritative character, arising, not from phlogosis, but from anaemia, or from defective nutrition. It is the opinion of Prof. William Tully, that pure natural wine,—the venous prin- ciple independent of the water and other substances with which it is mixed,—is digestible to a limited extent, and affords to the system a small amount of nutriment. (Tully's Materia Medica, Vol. I, No. 1, p. 4.) Mental influences are frequently important therapeutical agents in this disease. Disnppointment, anxiety, and grief produce a depressing influence, directly tending to arrest digestion, and thus deprive the blood of its normal amount of chyle. Intense study, or any sedentary business which occupies the attention too con- stantly, should be avoided. Hope should be encouraged. The patient should not be told by every friend whom he may chance to meet, that his case is consumptive. Let his mind be diverted, by amusing incidents, and by a variety of pleasing and interest- ing novelties. To this diversion of the mind, traveling owes much of its utility as a remedial agent. Short sea voyages may be useful for this purpose. Medicines in this disease are extremely limited in their influ- ence. Sometimes, when judiciously prescribed, and when the best possible selection is made, they arrest the progress of the 356 THORACIC DISEASES. disease, or at least, when combined with proper hygienic means, they render a cure more probable than it otherwise would be. But every agent which tends, either primarily or secondarily to produce debility,—such as those comprised in the antiphlogistic regimen,—powerful cathartics, diaphoretics, in short all general evacuents, are in my opinion contra-indicated, and, therefore, their use should be entirely abandoned except in cases complicated with other diseases. Among many practitioners of experience, the practice of ad- ministering frequent emetics, has been prevalent. There is un- questionably a period in which these, when properly given, have a beneficial effect. That period is in the incipient stage, when tuberculous matter is not softening, and when the capillary circu- lation, and the digestive functions are first deranged. My opinion is, that, in incipient phthisis emetics are serviceable, chiefly through their power of exciting capillary action, and of diverting from the pulmonary tissues, all morbid matter. With them it is necessary to use the hot air or vapor bath, followed by long con- tinued frictions, and by strong tonics, and nourishing food. One prominent cause of failure, in this as in other courses of treatment, is this:—the patient is prone to think, that the medicine will do the cure without exercise, arid the adoption of other hygiemc means. It would be well for the consumptive, if physicians, while regulating the kind and administration of medicine, would pursue a course with the patient, similar to that adopted in hydro- pathic establishments,—a course of exercise, and rigid physical discipline. When such complications exist as to make emetics, cathartics, or other evacuant remedies necessary, they may be given. In febrile phthisis, diaphoresis should be promoted, and the stomach, if in a morbid state, cleansed by an emetic. Other organs should receive such attention as their pathological condition may seem to indicate. The efficacy of repeated emetics in all cases, or even in a majority of cases of phthisis, I very much doubt. When the stomach is not particularly dyspeptic, they, after softening has commenced, seem to me decidedly injurious; in the first place, they tend to increase the bronchial secretion which, diluting the tubercular masses in the minute ramifications of the bronchi, PHTHISIS. 357 produces a tendency to the softening of tubercles. And secondly, they debilitate the system, by the relaxation which they occasion, and by the prolonged diaphoresis which they induce. I very well know that they often relieve the dyspnoea, and many times other rational symptoms. But this is merely the primary or pal- liative effect; the secondary, is the production of debility. Phthi- sis demands the use of revulsive means,—means which determine away from the lungs, all matter that may seek an exit from the system through the bronchial membrane, but those means should not tend to produce debility,—the bad effect of emetics. Consump- tion, consequent upon the recession of some exanthematous erup- * tion, demands, in a special manner, the use of such agents as tend to throw upon the surface morbid matter. But this revulsive effect must be produced, if produced at all, not by such cutane- ous evacuants as act at the expense of the strength of the patient, but by those which call to the surface the full and normal quan- tity of blood, and do this too, without producing debility. How can this be done ? My method is to place the patient over the vapor of water and alcohol, until the superficial veins are full, and a warm glow is felt over the entire body. I then apply with a sponge, either tepid or cold water, according to the reacting power in the system, and follow by continued and brisk friction. There is no need—and indeed it is decidedly injurious, to continue the bath until relaxation follows. The tonic, stimulat- ing and cleansing effect is all we want. This, in the early stage, should be frequently repeated, especially, if the circulation is fee- ble, in the extremities. In most cases this remedial agent causes the pulse to diminish in frequency, but to increase in volume, in short, it changes for awhile the small jerking pulse of irritative fever, to the more full, slower pulse of health. For stimulating the surface, after the bath, mustard water is often highly service- able in cases of debility. Dr. Gallup, speaking of the efficacy of the universal warm bath in phthisis fully corroborates the utility of this mode of ap- plying caloric to the system. " In nine cases out of ten," he ob- serves, " the disease is excited by cold, and the'first treatment requires the application of caloric in some form to the surface. Capillary action should be excited on the surface by caloric, by 358 THORACIC DISEASES. frictions and by such exercise as the patient can bear. Of the utility in phthisis of the warm bath I am fully convinced. I think it indispensible in recent cases, and enjoin it every, or every other evening, before retiring to bed. It may be continued a month or two, and occasionally for a much longer time, if there should be chilliness, or dryness of the skin. It even moderates the hectic paroxysms, and converts the colliquitive sweats into a warm perspiration. A temperature of about 100° Fahrenheit may be employed, but always such as to be agreeable, and easily borne by the patient. Sometimes the bath may be impregnated with chloride of sodium. The warmth on the surface should be sustained by occasional rubbings with warm flannel, by a suffi- ciency of clothing, with flannel next the skin and some agreea- ble nutriment mostly in a fluid form." For internal remedies at this stage I use preparations of iron, the carbonate, prussiate, or iodide, according to the indications. The sirup of the iodide of iron mixed in an alterative sirup, con- taining a considerable quantity of sugar, is a very excellent com- pound. It may be prepared and administered as directed in the article on pleuritis. The wild-cherry bark, the primus virginiana, is highly recom- mended as a tonic to the digestive and nutritive functions, and as a sedative to the nervous system. A very convenient form of administering this remedy is in the form of the officinal infusion, which may be given in the dose of a large wine-glassful, two, three, or four times a day, and continued for a long time in case the remedy seems to be adapted to the exigencies of the case. Should this become offensive pipsissewa, or simple bitter tonics may be used with benefit. Among these are salicin, hydrastin, quinine, columbo, quassia and gentian and ginseng. When the pulse is very frequent, to either or all of these tonics a suitable quantity of hydrocyanic acid may be added in order to lessen the rapidity of the pulse, and allay the irritability of the system. Tonic and alterative compounds should be composed of those arti- cles which seem best adapted to the removal of the symptoms. The following is very useful:— PHTHISIS. 359 R Rumicis Stillingiae Inulae helenii Xanthoxyli Pruni virginianae Solani dulcamarae a a ,gj., Aquae pluvialis Oij., Bulliant. Decanta. Adde Sacch. alb § iv., Potassae hydriodatis § ss., Spirit! vini q. s. Dose—one table-spoonful three times per day. " The remedy which has of late had the greatest reputation as a curative agent in this disease, is the cod-liver oil,—oleum jeco- ris aselli. This oil is brought to market in three principal varie- ties ; the best and most tasteless is nearly or perfectly transparent, with but a slight odor or taste, and is almost always taken by patients without much difficulty." " The dose of the cod-liver oil, is a table-spoonful three times a day, taken in a little of the froth of beer or porter; any other liquid not possessing any positively medicinal properties may, however, be used in place of the froth of malt liquors. A very good, and perhaps a better mode of taking the oil, is to chew a small piece of orange peel, then to swallow the oil, either pure or floating in some aromatic infusion, or a little rose or orange-flower water, and afterwards again to chew a fragment of the orange peel. " Many persons are not able to take the oil three times a day without repugnance ; it may, however, often be given to them twice a day without difficulty. In these cases it should be given about eleven or twelve o'clock in the morning and again in the evening. It is in general best to begin with a less dose than a table-spoonful, and as soon as the patient becomes a little accus- tomed to the remedy, it should be increased to the usual dose. The doses should not be so large as to excite purging. Some consumptive patients are not able to take the cod-liver oil; in 360 THORACIC DISEASES. some it produces much nausea and an insufferable disgust. This, however, sometimes subsides, and the patient acquires, by chang- ing the manner or vehicle of administration, the power of retain- ing the medicine on the stomach. Diarrhoea contra-indicates the use of the oil, especially when it cannot be arrested by a few drops of laudanum-" " When the cod-liver oil does good the patient increases in flesh, and loses, to a certain extent, the characteristic physiognomy of phthisis. The pain and cough also, diminish—sometimes are scarcely to be perceived at all—while the physical signs of the disease are also sometimes lessened, although generally not in proportion to the decline in the general symptoms. But in one patient who entered the Pennsylvania Hospital last autumn, under my charge, there were decided crackling, imperfect cavernous respiration, and dullness on percussion at the summit of one of the lungs, together with fever, cough, and emaciation. He was put under the influence of the oil ; at first the only kind tried was the dark colored; this, however, produced nausea and could not be taken regularly; the white oil was afterward given; the remedy was continued by Dr. Wood, during his term of duty. In March, 1850, about six months after he had commenced the treatment, he had become much fatter, so as to present the ap- pearance of a person in, at least, the average condition of health ; the pain had subsided ; the cough was nearly gone; and the physical signs much improved. This was the only case of those treated during my term of service or that of Dr. Wood, in which the amelioration was so decided as to merit the title of cure." [Dr. Gerhard.] So far as I have used this remedy, I have reason to conclude, that in some cases, it produces a decided improvement in the strength of the patient, changing the expression of the counten- ance, and removing many of the general and rational symptoms. Undoubtedly its value as a curative agent has been overrated. This, indeed, is almost always the case with every new remedy. But after the excitement has past away, and the calm of reason returns, we can judge better as to its real merits. In one case of incipient phthisis which I treated with this remedy, I am satisfied that it produced such a radical change in the system as to at least PHTHISIS. 361 give the appearance of a cure. There can be ho doubt asUo the phthisical state of the patient before the remedy was prescribed. Belonging to a family in which the scrofulous diathesis prevails, having severe cough, dyspnoea, and the physical signs, a number of physicians, among whom was Prof. Newton, considered the symptoms as clearly indicative of phthisis. The paler variety of the oil was used several months. The amendment was gradual and permanent. The person now, after four years, is as free from phthisical symptoms as before the attack. Such favorable effects, however, are rarely witnessed. In the majority of cases in which the remedy is used, the amendment is but temporary, and the patient sinks under the influence of the disease. Its utility is probably greatest as a preventive, or as a remedy to re- move that hereditary tendency to phthisis, sometimes manifested by a voracious appetite, existing coetaneously with emaciation. When the disease progresses slowly, the patient gradually losing flesh, having at the same time slight cough, and alteration of the sounds of respiration at the summit of one of the lungs, we may sometimes succeed in eradicating the disease. If this be so, cannot this remedy cure consumption in its ad- vanceo! stage ? The answer must depend upon what we mean by a cure. If it be this, that by the use of the remedy when the system is in the most favorable condition for the deposit of calcareous matter, we can so aid the reparative process, as to effect cicatrization, when without the remedy the case would have ter- minated fatally, then. I think we can safely say that, sometimes, it may cure, even in the latter stages. But we never can know how much of the effect is due to nature, and how much to the influence of the remedy. All we can say is this:—that the use of this remedy, when it can be tolerated, places the system in a condition more favorable to restoration than it would be without it. We may safely conclude that this remedy has no specific influ- ence in phthisis, and that its modus operandi is similar to that of good nourishment. Other kinds of oil probably would have sim- ilar effects. But on account of this we should -not deprive our patients of all the benefit, whether it be as nourishment, or as medicine, derivable from its administration. 46 362 THORACIC DISEASES. The various'preparations of iodine have been considered very serviceable, but their virtues to some extent, have been over-esti- mated. In the first stage their utility is greatest. When given in large doses they sometimes produce irritation of the stomach. This, however, may be prevented by giving in conjuction with the remedy, sugar. Their operation when favorable, tends to produce absorption, an object always to be sought in the incipient stage of phthisis. Whenever either by remedies or by prophylac- tic means, we can cause absorption to exceed deposition, a curative process is commenced, whose continuance will result in restora- tion. Lugol's preparation of iodine is perhaps as good as any. It should be taken in a large proportion of water or half a pint of some demulcent drink, well sweetened with sugar. Various other remedies have been used at different times, to enumerate which would be entirely useless. Prof. C. Newton sometimes adminis- tered equal parts of common salt and precipitated carbonate of iron, beat up with an egg. The amount of the two former arti- cles should be from two to three drachms a day. It is not so much my object to tell what is not as what is use- ful in the treatment of phthisis. To me, however, there seems to be a necessity for caution in the use of narcotics in the first stage of this disease. Their operation is directly adverse to the promotion or restoration of the secretions, absorptions, and exhal- ations of the system. Internal engorgments are "increased by their use, even in small doses; and every post mortem examina- tion in subjects destroyed by narcotics, shows a violent state of congestion in the internal tissues of the head, thorax, and abdo- men similar to those produced in the internal tissues in most ma- lignant fevers. 'Dr. Gallup observes, " If compelled to use lauda- num, Dover's powders, opiate cordials, or cough drops, I would never attempt a radical cure of phthisis pulmonalis, in any of its varieties." The best possible way to produce freedom from ner- vous irritation, and quiet sleep, is to restore the circulation of the blood in the most minute capillary vessels. A warm bath, or al- cohol and vapor bath, properly administered at bed time, and fol- lowed by friction, will secure to the patient more natural repose than all the narcotics in the Materia Medica. In case a nervine is needed, the cypripedium, Scutellaria lupu- PHTHISIS. 363 lin, together with the bath will be sufficient. Lobelia tincture combined with either one or more of the above articles, will often produce a still better anodyne effect. In this disease there is little or no need of cathartics. The tendency of the mucous membrane of the intestines to become tuberculated, and ulcerated, contra-indicates their use. For a mild laxative, a cold infusion of eupatorium perfoliatum, the inspi- ssated gall pill recommended in the article on pleuritis, or some other mild laxative may be administered. The cod liver oil usu- ally has a.tendency to overcome costiveness. 2. To obviate the effects of Tubercles.—The development of tubercles in the parenchyma of the lungs gives rise to the rational symptoms, to modify the severity of which during the last stage is all that human means can effect. Cough.—When this becomes very troublesome, entirely pre- venting sleep, means should be used to allay it. Demulcents freely given, sometimes prove palliative. Of this class of reme- dies, ulmus, acacia, flax-seed etc., are among the most important. An infusion of one, or all these articles containing a little licorice and lemon-juice, will often be sufficient to assuage the violence of this symptom. [n case the disease is so far advanced as to make any perman- ent improvement entirely hopeless, sedative and narcotic agents must be resorted to. The dose of these should be as small as possible to secure the desired effect. The anodyne, or sedative, more than the narcotic power should be sought. Accordingly my practice is to combine the acetate of morphia with some form of lobelia, or with inspissated gall, in order to prevent as far as pos- sible the narcotic effect of the opiate. Five or six grains of the latter remedy—the gall—neutralizes the constipating and narcotic effects of one grain of opium, without injuring its sedative influ- ence. Digitalis is sometimes useful to allay arterial excitement, and to mitigate uneasy sensations. Dr. Chapman makes the fol- lowing statement in relation to this remedy. "As the result of no slender experience witli digitalis, I am prepared to state, that the only case of phthisis in which it can be much relied on, is the incipient stage, usually attended with a slight haemoptysis, small, quick, irritated pulse, extreme debility of the system, short 364 THORACIC DISEASES. impeded respiration, and hard, dry, diminutive cough, where evac- uent means are precluded." Lactucarium, hyoscyamus, conium, stramonium, and belladonna may be used , as substitutes for opiates. Dyspnoea.—So far as this is dependent upon organic lesion, no permanent benefit can be derived from remedies. But whenever, either partly or wholly, it arises from nervous derangement, ner- vine, sedative and narcotic remedies must be used. Tincture of lobelia and extract of stramonium, are often serviceable. Occa- sionally relief may be obtained by the inhalation of ^vapors—of tincture of conium, or of the smoke of stramonium, or vinegar of lobelia. Hcemoptysis.—In case this arises from congestion, an anti-in- flammatory regimen should be resorted to,—that is the use of lo- belia in nauseating doses, the application to the chest of cold alco- hol and water, the use of baths to determine the blood to the sur- face, which in too great a quantity flows into the pulmonary tis- sues. In case there are no febrile symptoms, a little common salt, taken undissolved into the mouth, and swallowed in that state, will often at once check the hemorrhage. Astringents are often of great utility, especially those containing styptic properties. Tannic acid, kino, rhatany, aiid matico are highly recommended. Oil of turpentine has been successfully used for this purpose. The best styptic with which I am acquainted is the geranin, the ac- tive principle of geranium maculatum. This in severe cases of haemoptysis given in doses of ten grain s every half hour, exerts a very beneficial influence upon the hemorrhage. To prevent a re- currence of this symptom, an infusion of lycopus virginicus, tril- lium, and geranium maculatum, is perhaps the best means that can be used. Of the lycopus virginicus, as a remedy for haemop- tysis, Dr. H. Jacobs of Chicopee, thinks very highly. Pectoral Pains.—These may be removed or assuaged by lin- iments of various kinds. If the pain is of a rheumatic character, bathino- the side in a liniment composed of one part of tincture of capsicum, and four of tincture of arnica, will usually give re- lief. If of a nervous character, the tincture of aconite in a suit- able proportion may be added to the above mentioned compound, and applied to the side. In case the pain is caused by pleuritic PHTHISIS. 365 inflammation, other remedies may be applied. But, in my opin- ion, all powerful irritants, such as setorrs, tartar-emetic issues, do more injury by producing constitutional excitement, than good by their revulsive effect. If any thing of this kind is used, it should be the irritating plaster, composed of some adhesive mixture and podophyllum, and phytolacca. These latter cutaneous irritants, are most beneficial in those cases in which secondary inflamma- tion, and chronic pleuritis exist with effusion. All the liniments, and plasters and irritants used in this disease, should not supersede the application of water and alcohol to the chest. Whenever there is much heat, or when the skin is dry, this should be freely applied, the temperature of the application being varied according to the heat of the chest, and the reacting power of the system. Bronchial Inflammation.—This should be combatted by the use of relaxants and expectorants. That used by Prof. Newton, the compound sirup of sanguinaria and lobelia is very useful. The extract of lobelia pill, should be given to lessen the general febrile action, and proper attention directed to promote cutaneous circulation and secretion. The expectorant compounds should be varied according to the exigencies of the case. No one formula should be followed in the compounding of medicine for this complication of phthisis. When the symptoms are somewhat inflammatory, the preparation made by Dr. G. M. Nichols, is as useful as any:— R Sirupi glycyrrhizae § ii.,* Sirupi ipecacuanhas 5 vi., Tincturae sanguinariae Tincturae lobeliae a a 5 iii., Tincturae opii camphoratae 5 iiss. Tincturae olei gaultheriae 3 iss. Misce. °For the preparation of the sirup of glycyrrhiza, no directions are given in the U. S. Dispensatory. It may be prepared by macerating the bruised root in water until a strong iufusion is obtained, and then using this, instead of the water, in the formula for preparing the sirupus simplex, in the U. S. Dispensatory. 366 THORACIC DISEASES. Dose,—one teaspoonful once in six hours or oftener in case the severity of the symptoms demand. This may be used once in four hours, alternately with a two grain pill of extract of lobelia, if there is high febrile excitement. The proportions of the sub- stances in the formula, should be altered according to the necessi- ties of each individual case. When the bronchial inflammation assumes an asthenic form, and the febrile symptoms are much less manifest, the relaxant means should for the most part be discontinued, and in their stead slightly tonic, stimulating and balsamic remedies should be used. Under such circumstances, an expectorant compounded accord- ing to the following formula, will better fulfill the indications of treatment:— R Sirupi glycyrrhizae Sirupi senegae Sirupi pruni virginianae a a § i., Tincturae sanguinariae Tincturae lobeliae a a 3 ii., Tincturae germinum pop. balsamiferae § iv., Morphiae sulphatis gr. i. Misce. Dose,-?-one tea-spoonful once in six hours, or .oftener accord- ing to the exigences of the case. With the more stimulating expectorants, tonics may be combin- ed. In anaemic cases, attended with amenorrhoea and gastric irri- tation the compound mixture of iron of the Pharmacopoeia, may be given either alternately or combined with expectorants. The inhalation of certain substances is often of some benefit. The vapor of tar, is highly esteemed by some physicians. The air of the sleeping-room of the patient may be impregnated with it by placing a little tar in a cup which is to be immersed in water, contained in another vessel, and heated by a spirit lamp. The common nurse lamp answers this purpose very well. The inhalation of chlorine and iodine, is somewhat irritating to the lungs, With the chlorine the air may be impregnated by letting some sulphuric acid fall drop by drop on chloride of lime. Am- monia has also been inhaled for a similar purpose. PHTHISIS. 367 " In order to saturate the system with ammoniacal gas and at the same time to acquire an increment of the electric fluid, the following method of application may be used. Take a piece of quick lime as large as a playing marble and pour over it water sufficient to slake it, so that it will fall into fine powder. Rub this powder in a mortar with a piece of sal-ammoniac—muriate of ammonia—as large as a piece of lime till the articles are finely pulverized and mixed. Put the powder in a small vessel, and pour in a pint of boiling water. Set the vessel in an empty box, so that the vapor can be inhaled at a little distance from the vessel. Put in the water a piece of heated iron to make it boil and throw off vapor. Let the patient inhale the vapor for half an hour." [Dr. Wm. Tell Parker.} Night-sweats and Hectic Fever.—Since the night-sweats are caused by debility of the capillaries, tonic and stimulating reme- dies are indicated to effect their suppression. Among the inter- nal remedies most efficient are the mineral acids, and especially the sulphuric which is usually employed in the form of elixir of vitriol, or the aromatic sulphuric acid of the Pharmacopoeia. From, five to fifteen drops may be administered in cold water, three or four times a day. The internal administration of astringents is sometimes of use. Among these, alum, and tannic acid are per- haps as good as any. But the best remedy that can be applied, is a hot bath, made excitant by the addition of capsicum, mustard and common salt. It should be followed by brisk friction with a solution of alum in hot brandy in the proportion of two drachms to a pint. M. Delioux highly recommends the tannate of' quinine for arresting night-sweats. The quantity which he prescribes is from seven to fifteen grains daily, dividing it into three or four doses, taken at intervals, the last being taken three or four hours before sleep: An efficient remedy is the following :— R Acidi sulphurici aromatici § i. duinae sulphatis 9i., Misce. Dose,—from fifteen to twenty drops, two or three times per day, administered in a wine-glassfull of cold sage tea. 368 THORACIC DISEASES. For hectic paroxysms, no remedies are more effectual than sulphate of quinine, and the salicin, the active principle of the salix. Vomiting and Diarrhoea.—These symptoms are sometimes very troublesome. The vomiting is often one of the most obsti- nate symptoms, and very seldom yields to the influence of reme- dies. The amount of food taken at a time should be reduced to a small quantity. Sometimes lime-water gives temporary relief. A sinapism applied over the epigastrium is often serviceable. Di- arrhoea is another symptom which cannot be remedied perma- nently by medicine. Dr. Parrish considered a milk diet good to prevent its development. The most benefit that can be derived may be had from the administration of a powder containing two drachms of myricin and one of geranin; or tannic acid given in two or four grain doses once in four hours. With this, alternate- ly, in very obstinate cases, opiates may be administered. When the debility is great, and there evidently is a large col- lection of purulent matter in the bronchial tubes'to be thrown off by expectoration, and yet not power enough in the system to effect this, the carbonate of ammonia, will prove to be a useful remedy. Wine whey should also be given to sustain the system. For a similar purpose milk punch and wine should be used. Various other remedies have been used by the profession. In- haling tubes have been invented the utility of which has not been very great." Forcible expansion of the lungs should be chiefly practised in the early stages, and especially in those cases in which pleuritic effusion has pressed upon one or both of the lungs, and, to a certain extent, destroyed their functions. Jeffries' Respirator has been highly recommended in phthisis. Its benefit arises from the power of the instrument to prevent the entrance of very cold air into the lungs. In cold weather those having irritable lungs need something of this kind in order to prevent the ingress of very cold air, until it is heated. The instru- ment consists of a fine wire gauze which, during expiration becomes heated by the passing breath, and that heat so received, serves to warm the air of inspiration. The treatment of the several varieties of phthisis should be essentially the same as that laid down in the general treatment. PULMONARY CANCER. 369 In the acute variety, remedies should be applied with more vigor, especially when the disease is somewhat inflammatory. The chronic variety needs a longer course of alteratives, and general tonics, nourishing diet, and the temperate use of wine, porter, or ale. In this variety there is more hope, and therefore, the physi- cian should take the greatest care to keep up an equable circula- tion of the blood, to induce the patient to take exercise, and to associate with cheerful company. These remarks apply equally well to the latent form of the disease. The phthisis of children should be treated with general tonics and afteratives, combined with the sirup of the iodide of iron. All these means without free exercise in the open air and good substantial food, and a proper attention to the functions of the digestive organs and the cutaneous secretion, will be ineffectual. In fine, the hygienic and dietetic means are of primary impor- tance, the medicinal of secondary. CHAPTER XVI. PULMONARY CANCER. Besides tubercle -there is another heterologous deposit in the lungs, called carcinoma or cancer. This very seldom occurs, even among those who have died of the disease in other parts of the body. M. Tanchou states that out of 9118 deaths from cancer, there were only seven cases of cancer of the lungs. Most frequently pulmonary cancer has its seat in the cellular tissue. The encephaloid variety is most common. Out of twenty cases, sixteen were of this variety; three encephaloid and scirrhus united, one scirrhus and colloid. Sometimes the cancerous matter is deposited in the cellular tissue of the anterior and posterior mediastinum, and forms a tumor which presses upon contiguous structures, upon the trachea, great blood-vessels of the heart, and upon the oesophagus. The * tumor sometimes grows to so great a size as to distend the parietes of the chest. 47 370 THORACIC DISEASES. When the disease is located in the pulmonary tissue, it converts the parenchyma of the lung into its own substance. The effect of its extension, is to compress adjacent textures, and to produce an actual atrophy of the diseased lung. The progress of the disease may excite secondary inflammation; sometimes implicating the pleura. Cancer, like tubercle, sometimes has a period of soft- ening, during which it not unfrequently excites bronchitis. But the softened masses, unlike tubercles, are seldom expectorated. The duration of cancer of the lungs is usually about fourteen months. But it may terminate life in two months, or may linger in its progress until years pass away. Cancer of the mediastinum seldom terminates so speedily, as that of the lungs; its average duration being sixteen months. Pulmonary cancer is divided into two varieties : cancer of the lungs, and cancer of the mediastinum. Pathology.—The general appearance of encephaloid disease, is that of a brain-white solid of varying consistence, with a pinker hue than that of tubercle, occurring in tumors sometimes en- cysted, or infiltrated through the tissue of the lung. Sometimes, the tumors are soft, and cellular; sometimes tough, resembling the pancreas in appearance. A predominance of the vascular, and cellular structure, with patches of extravasated blood, constitutes the fungus haematodes. Encephaloid matter infiltrated into the parenchyma of the lung, in some cases, presents an appearance intermediate between those of tuberculous and hepatized consoli- dations. Sometimes melanosis is combined with encephaloid dis- ease. The black matter may occur infiltrated in a natural struc- ture or in distinct tumors or deposits of an irregular cellular or- ganization. Care is necessary, in order not to confound with melanosis, the accumulations of black, pulmonary matter, which take place to a great extent in the lungs of old people, especially among the inhabitants of large towns. This black appearance is supposed to be caused by the inhalation of particles of dust, of a carbonaceous nature from the atmosphere. Diagnosis.—In the commencement of this disease there are no very manifest symptoms developed. There may be a little dyspnoea, slight cough, and a little expectoration. With the advance of PULMONARY CANCER. 371 the disease the symptoms become more marked, the cough is in- creased, the expectoration is more copious, and there is an almost constant pain in the chest. Haemoptysis, too, may occur, in con- sequence of the lesion of the pulmonary vessels. The constitu- tion sympathizes with the local disease ; the pulse is excited, there are emaciation, increasing debility, and a peculiar straw color to the countenance, and the superficial veins become enlarged. Dropsical swelling is observable in the extremities, and the system gradually sinks under a low, asthenic form of inflammation—going on in the chest or abdomen. The cancerous deposit, gives rise to dull- ness on percussion, sometimes to bronchial respiration, and vocal re- sonance, or to a ronchus and mucous rale. The cancerous disease tends to produce contraction of the affe6ted side, which, of course, is porportioned to the extent to which the disease has progressed. The pulmonary tissue becomes condensed and the bronchi some- times are obliterated, in which cases there will be no respiratory murmur. Cancer of the Mediastinum.—^-Pathology.—The growth of the tumor may be so great as to compress the vessels of the heart, and induce signs of valvular disease, or by retarding the free cir- culation of the blood may produce oedema, or may fill so large a space in the chest as to cause the physical signs of an empyema. These cancerous tumors vary in size, sometimes weighing several pounds. They present the three forms of cancerous growths. The diagnosis of cancer of the mediastinum is difficult. There are only a few distinctive symptoms, among which are the straw color of the skin, the oedema of the face, and upper extremities, a tendency to anasarca in the lower limbs; cancerous tumors on other parts of the body, the contraction of the side accompanied by bronchial respiration, heard over it, instead of the dilatation so characteristic of hydrothorax, and empyema. Phthisis usually affects the upper parts of the lungs; cancer may attack any portion, although it oftener affects the upper por- tions, than the lower. Neuralgic pain often extends down the arm, which is not the case in phthisis. The pulse is also less ex- cited, hectic seldom severe, cavities are not formed. Tubercles in general before the case terminates fatally, affect both lungs, 372 thoracic diseases. while cancer usually affects one only. Cancerous tumors are usually larger than those of a tubercular nature. This disease may simulate thoracic aneurism or even disease of the heart. This results from its location near some large blood-vessel, in which case it may obstruct the flow of blood, and hence, produce those physical conditions which excite the bellows murmur. Its recognition under such circumstances must depend upon the exis- tence of the cancerous tendency in the general system. The heart is not so enlarged as in hypertrophy. From aneurism it may sometimes be distinguished by its location:—aneurism being on the course of the aorta, and being attended by pulsation, a thrill and bellows murmur; cancer is not prone to give rise to these phenomena. It is evident, however, that nothing very defi- nite can be determined by the symptoms in those cases in which complications exist; and under the most favorable circumstances the diagnosis must be uncertain. The Prognosis may be readily inferred from the fatal results following cancerous disease in other parts of the body. The Treatment must be almost wholly palliative; the great object is this; to remove urgent symptoms by sedative and re- laxing agents. Complications should be treated according to the nature of the disease with which it is associated. Dyspeptic symptoms should be removed by gentle emetics of lobelia, and by tonics. To purify the blood the best alteratives may be used in conjunction with other means, to produce a normal action of the cutaneous vessels. DISEASES OF THE HEART. 373 DIVISION II. DISEASES OF THE HEART. Formerly, diseases of the heart were very imperfectly under- stood. In their organic forms they have been considered very rare, and their results almost always fatal. Very frequently they have been confounded with other diseases of the thorax, such as pulmonary congestion, and hydrothorax, and sometimes with those of other parts of the system, such as dropsy and apoplexy, and va- rious other affections. By the discoveries of Corvisart, Laennec, Louis, Cullen, and Bouillaud, in France; of Hope, Williams, La- tham and Stokes of Great Britain, and of Dr. Pennock of this country, the nature of cardiac diseases, and their diagnosis and treatment, are now made as intelligible as that of the majority of other diseases. Before the discovery of auscultation, diseases of the heart could not without great difficulty be distinguished from those of the lungs. But physical exploration, and pathological anatomy have to a considerable extent removed the impediments to their diagnosis. The investigations into their causes have also pro- duced many valuable results, and have clearly shown, that in a majority of cases especially in young persons they arise from in- flammation. General symptoms.—The pulse is nearly synchronous with the pulsation of the heart, following it at a very slight interval. Sub- ject to all the irregularities of the cardiac pulsations in relation to duration and irregularity of beat, it often enables us to detect the derangement of the central organ of the circulation. But it is not always a sure indication. Intermission of the pulse may exist, when there is none in the heart. The ventricu- lar contraction may be too feeble to transmit the impulse along the arteries of the extremities. The quantity of blood in the heart may be so small as not to cause vigorous contraction, and a feeble, irregular pulse may be the consequence. Irregularities of 374 THORACIC DISEASES. the pulse independent of cardiac disease may exist for a long time, but caeteris paribus they are more apt to occur in connection with it, than independent of it. Dyspnoea is another symptom of cardiac disease. Sometimes it is partly dependent upon nervous derangements, but more often upon direct interference with the functions of the lungs, either by pressure upon that organ, or effusion into the parenchy- matous tissue or pleural sac. Pain.—In disease of the heart, painful or disagreeable sensations often occur in the cardiac region. Sometimes it is very acute, felt near the left nipple or at the extremity of the sternum. This is sometimes attended with dyspnoea ; sometimes extending across the chest and passing down the left arm. Palpitations, which are pulsations so violent as to be trouble- some to the patient, are often experienced in disease of the heart. They arise from nervous irritability in which case they are often the cause of needless fear to the patient, and sometimes of per- plexity to the physician. This symptom, unless attended with other indications of cardiac disease should not be much depended upon j—for when alone, it presages no certain organic derange- ment, and should excite suspicion only when it continues for a long time. The secondary symptoms resulting from cardiac disease are nu- merous, and such as would naturally result from irregularities of the circulation of the blood. The blood may be driven with too great force into the brain, as in hypertrophy of the left ventricle, into the lungs in a similar condition of the right ventricle, or it may be retarded in its return from the abdominal viscera by im- pediments in the right side of the heart, and finally it may be feebly propelled throughout the entire system in consequence of the cardiac obstruction. Hence, congestions in one organ, and anaemia in others ; hence apoplexy, vertigo, epistaxis and haema- temesis occur. These symptoms vary according to the nature of the cardiac disease, the constitution of the patient, and various other modifying circumstances. If active congestion is present, we have the turgid, distended state of the blood-vessels, the prom- inent eye, the flushed and swollen face; if the passive, then wc have the purple lips, livid complexion, and the general tendency DISEASES OF THE HEART. 37-"> to oedema. The whole heart is seldom diseased at once. It may be confined to a single valve or cavity. Causes of Heart Disease.—Inflammation, attacking the mem- branes of the heart, whether external or internal, becomes a fre- quent cause of cardiac lesions. Pericarditis has but little tendency to produce organic changes, while endocarditis is very prone to produce such a result. Of all the causes tending to produce dis- ease of the heart, acute articular rheumatism is the most frequent. More than half the cases of this variety of rheumatism, accord- ing to Dr. Gerhard, are more or less complicated with cardiac dis- ease. There are other causes, which, although not so important as the one above mentioned, are, nevertheless, worthy of notice. These are violent nervous excitement, sudden injuries inflicted by a strain, a sudden propulsion of the blood into the heart in an ab- normal quantity and with great force, advanced age, ossific deposits in the valves or internal membranes. Functionar diseases of the heart are produced by causes as vari- ous as those of all nervous disorders. In general anaemia, ner- vous irritability, gastric derangements, and a suppression, or inter- ruption of the menstrual discharge, give rise to violent palpita- tions. In young men, particularly those of a nervous tempera- ment, of studious habits, accustoming themselves to excess in study, the same series of symptoms is sometimes developed. Termination of Heart Disease.—Inflammatory affections of the heart may terminate in recovery, and the patient experience a complete restoration to health. Dr. Hope remarks:—" Many think that the expectation of effecting an improvement in the treatment of diseases of the heart, is chimerical; and they think so, because, not being accustomed to recognize the diseases in question before they have attained an advanced stage, they are preoccupied with the old and popular idea of their incurability. To such it might, perhaps, be a sufficiently philosophical answer to reply, that an improved knowledge of the nature and causes of a disease, must alone necessarily lead to an improvement in the treatment, and that therapeutic weapons are dangerous, when wielded in the dark. But here we may go much farther; we may say that, by the improved means of diagnosis, the maladies under 376 THORACIC DISEASES. consideration, may be recognized, not only in their advanced, but in their incipient stages, and even, when so slight as to constitute little more than a tendency. We may say, on the ground of in- contesjable experience, that, in their early stages, they are, in a large proportion of instances, susceptible of a perfect cure, and that, when not, they may in general be so far counteracted as not materially, and sometimes not at all, to curtail the existence of the patient. We may, accordingly, predict that the term " dis- ease of the heart," which at present sounds like a death knell when uttered by the physician, will hereafter become by familiar- ity, not more alarming than the term asthma, under which it is frequently disguised." This description of the curability of disease of the heart, is somewhat too hopeful. Chronic organic affections in general do not terminate so favorably. They may continue for years, not increasing in severity, until some exciting cause adds new force to the disease and causes sudden death. When once the disease has commenced on the internal membrane, it is prone to extend; one difficulty leads on to another; hypertrophy produces valvular disease and inflammation of the endocardium. So that, when endocarditis in the young ends in apparent recovery from the acute attack, it leaves behind in most cases a disease in the valves which, by impeding the circulation of the blood, produces an un- natural action of the heart, and at last terminates in disease of the muscular tissue. Functional disease of the heart is seldom dangerous, except in those cases in which it .generates organic affections. The influ- ence of age is considerable in the production of cardiac disease. Cardiac affections are usually slow in their access, and consequently they are more often observed in the old than in the young. They also depend for their production, upon that feeble circulation of the blood arising from deficient nutrition, which is more frequent in the aged. On account of their greater exposure, males are more subject to organic diseases of the heart than females. Their frequent muscular exertions both in labor and amusement, tend to produce permanent lesions. The functional derangements of the heart, are more common in females than in males, because they are more subject to symptomatic affections, on account of their greater nervous irritability. EXAMINATION OF THE HEART. 377 General Diagnosis.—The nature of the origin of the disease, has important bearings on its diagnosis. If inflammation of a rheumatic character preceded the attack, if disease of the heart is hereditary, or if the gouty or rheumatic diathesis is fully devel- oped, then, the existence of organic affections of the heart should very strongly be suspected. But if, on the other hand, there were peculiar marks of deranged nervous action preceding the cardiac symptoms, a probability exists, that the case is one of functional, not of organic disease. To this probability is added more evidence, if the patient presents strong signs of a nervous temperament. Pain in the region of the praecordia, and a sensation of weight and stricture there felt, are indications of this disease; likewise, orthopnoea. fullness of the cervical veins, increased dyspnoea in ascending a hight, blueness or lividity of the lips. A thrilling pulse, and oedematous effusions are also somewhat characteristic. General Prognosis.—In organic disease of the heart the prog- nosis is unfavorable. The effects of extensive disorganization of the valves, and of the internal membrane of the heart and aorta, and of hypertrophy and dilatation must from the nature of all such changes be attended with danger to life. In acute inflam- matory cases, the proper application of appropriate remedies gen- erally gives relief; sometimes very soon, sometimes after a longer period. In those cases which seem to presage a fatal termination, the symptoms sometimes abate by degrees, until the disease is finally, so far as external phenomena can be perceived, verging on towards a cure. The prognosis then must depend upon the character of the modifying circumstances, and not upon any one symptom exclusively. CHAPTER I. EXAMINATION OF THE HEART. In making an examination of the heart, several points need par- ticular attention. The most important of these are its position 48 378 THORACIC DISEASES. size, impulsion, sounds, rhythm, and the mode in which the heart acts, whether regularly or spasmodically. Position of the Heart.—The heart lies in the centre of the chest, inclining a little to the left side and to the lower portion of the sternum. Its direction is oblique from right to left. Superi- orly, it extends to the intercostal space between the third and fourth ribs; inferiorly to the base of the thorax, or to about the ninth dorsal vertebra. To the left it extends nearly or quite to the nipple, to the right it extends a little beyond the edge of the sternum. The apex is between the cartilages of the fifth and sixth left ribs, at a point about two inches below the nipple, and one inch on its sternal side. The base of the ventricles corresponds nearly with the middle of the third rib. According to Dr. Pen- nock, the only fixed and stationary point is at the valves of the aorta; other parts being movable more or less around that as a centre. And, therefore, the exact situation of those valves—the aortic semilunar—becomes of some importance. A needle pierc- ing the middle of the sternum opposite to the middle of the car- tilages of the third ribs, and perpendicular to the plane of the sternum will pierce them. A needle introduced perpendicular to the tangent of the curved surface of the thorax, between the car- tilages of the second and third ribs, half an inch from the left margin of the sternum, pierces the semilunar valves of the pul- monary artery. " The septum between the ventricles, coincides with the osse- ous extremities of the third and fourth and fifth ribs, and on the fourth rib is midway between the left margin of the sternum and nipple." The positions of the orifices of the aorta and pulmonary artery, of course, correspond very nearly with those of their valves, the valves being situated a little superior. The left auric- ulo ventricular orifice, is under the lower edge of the cartilage of the third rib, and a little to the left of the median line. The memory of these facts is very necessary in the diagnosis of valv- ular disease. The heart is in contact with the diaphragm below, and the lungs, on its right and left sides overlap it, leaving a small triangular space uncovered, of variable dimensions, under the car- tilages of the fourth and fifth ribs of the left side. examination of the heart. 379 Size of the Heart.—Much care has been taken to obtain by ac- curate observation the exact size of the heart. Laennec com- pared its size with that of the fist of the individual. This, though a simple comparison, and one which may always be easily made, is by no means accurate. Others have with great precision, weighed the heart, and brought forth the conclusion that its weight is about seven or eight ounces. It is always greater in males, than in females.* Bizot in order to arrive at a still greater degree of precision, has adopted the method of measuring the heart. His conclu- sions are, that the heart increases in size as age advances, that its size corresponds with the breadth of the shoulders, and not with the height of the individual, that it is larger in males than in females. To ascertain the normal size of the orifices, is very important. Dr. Taylor has suggested a method of very easy application. The mitral orifice just admits according to his measurement, the first two fingers of the hand; the tricuspid orifice, the three first fingers. This, like the comparison of Laennec, is not accurate, but is of some practical utility, where great precision is not nec- essary. In order to ascertain whether the valves will close the orifices the experiment suggested by Dr. Swett, is useful and conclusive. Having removed an inch or two of the aorta and pulmonary arte- ry with the heart, he then makes a transverse section of the heart near the apex, so as to open the cavities of both ventricles. The heart being suspended by hooks passed into three different points of the aorta, so as to keep the vessel open, water is poured into it. If the valves are in a perfectly normal condition, they will shut, completely closing the orifice against the passage of the liquid. The same experiment may be successfully tried with the pulmonary artery; likewise, with the mitral valve, it is equally satisfactory, but not completely so with the tricuspid. Through °The normal heart may be assumed to average for the whole life, above puberty, about 9 oz. in absolute weight, and 8£ oz. in bulk, for the male; and 8 oz. or a little more in weight, and 1\ oz. or a little more in bulk for the female; and to bear after death, to the weight of the person, for the male, the proportion of about 1 to 160, and for the female, of 1 to 150. [Clendinning, Croonian, Lectures for 1838.] 380 THORACIC DISEASES. this latter valve, Dr. King of London contends that regurgitation even in health, lakes place. The size of the heart is modified by disease, and consequently the physical signs, especially percussion, are changed. Impulsion.—The beating of the heart may be felt by placing the hand upon the chest, as nearly as possible over the apex of the organ. The impulsion is caused,by the striking of the apex against the ribs, and is generally supposed to arise from the con- traction of the ventricles, and to be synchronous with the systole. The truth of this opinion, however, is disputed by Dr. Alfred Stille. On the contrary he contends that the impulse of the heart is synchronous with, and produced by the diastole of the ventri- cle. [Vide Stille's Elem. Gen. Path. p. 319.] The impulse is given almost exclusively by the apex of the heart. The sensa- tion is, therefore, sharp as if caused by the quick stroke of a small hammer. Exercise or nervous irritability, increase its violence. Hypertrophy also tends to make the impulse greater, and by the increase of the bulk of the heart, extends the shock over a much greater surface. Great muscular debility, arising from asthenic diseases, may cause the impulse of an hypertrophied heart to be less powerful than natural. Its degree varies even in health, according to the activity of the circulation. In those of a phlegmatic tempera- ment, and the corpulent, it is often almost imperceptible, while in those of a nervous temperament, and not fleshy, it is very strong. In pregnancy, too, it is subject to great variation. It corresponds with the beating of the arteries, both being dependent upon the same cause. The radial pulse, as well as the pulse of the larger arteries, is nearly synchronous with the beating of the heart, there being a very short interval between them. The number of pul- sations bears a relation to the number of respirations, the former being to the latter as four and a half to one. Irregularities in the cardiac pulsations are sometimes observed in healthy persons; and this phenomenon often ceases when the patient is laboring under an attack of disease, and returns again with the return of health. A very feeble systolic contraction oc- curring in connection with a stronger one, may give rise to inter- missions in the radial pulse when there is none in the heart. The EXAMINATION OF THE HEART. 381 heart, however, is subject to true intermissions. Its impulse is much changed by disease ;—sometimes becoming very frequent, strong or weak, or frequent and irregular. Hypertrophy is thought to augment its force ; in some cases to such a degree as to make the impulse seem like the stroke of a hammer within the chest. Debility diminishes it, and the removal of the heart from the surface of the thorax by pleuritic effusions or by other similar causes. The location of the impulse is changed by any cause which can displace the heart. Its'character varies greatly. Among these common variations is the " short, sharp, quick stroke of irritation which is wholly different from mere frequency of beat; the former referring to the individual pulsations, the latter to their succession. Instead of re- sulting from the striking of the apex of the heart against the ribs, the impulse is sometimes produced by the whole organ rising up, as it were, under the hand, and giving rise to the sense of a slow heavy motion, rather than of a blow. This happens in dilatation and hypertrophy." In relation to the repetition of the impulse, it may become so frequent that it cannot be counted, even exceeding 200 strokes in a minute, or may be reduced even as low as 15 or 20, in the same length of time. The relation of the successive impulses to each other, is liable to excessive irregularity. Sometimes a stroke is now and then omitted, either at stated intervals or quite irregularly. In such cases, the pulsation is said to be intermittent. Occasionally, it is remittent, one or several strokes being more feeble than those which precede and follow. " Not unfrequently the rapidity of succession varies greatly; the pulsations being now very short and rapid, almost running into one another, then again prolonged, slow, and distinct; and all these diversities may be combined in the same case. " The double or triple impulse which is sometimes in quick succession, may be owing to as many partial contractions of the ventricle, before the full systole is accomplished. Some have sup- posed that the diastole is concerned in these irregularities, as there . is at that period a sudden and apparently active swelling out of the ventricle, which must make some impression upon the parie? 382 THORACIC DISEASES. tes of the chest. It has been maintained, that there is in health a double impulse of the heart, scarcely sensible in its ordinary state, but becoming obvious in excitement, the first impulse being dependent upon the systole, the second, much feebler, upon the diastole, and felt between the second and third ribs." [Belling- ham and Sibson, Lond. Med. Gaz., March 1850, p. 445.] "Palpitation sometimes gives the peculiar thrill called fremisse- ment cataire," or the purring tremor. It is so called because it gives to the hand when applied to the thorax, that peculiar sensa- tion felt on the chest of a cat while purring. Over aneurisms of the arch of the aorta, it is most distinctly perceived In valvular diseases it is also felt. It may be excited in nervous persons by agitation of mind. Unless the origin of this symptom can be traced to that cause, serious obstruction to the passage of the blood through the heart should be considered as very probable. 1. Physical Signs.—Signs by Inspection.—Inspection alone is of little value in the diagnosis of diseases of the heart. In health a slight movement over its apex may be seen. In disease sometimes this becomes very manifest, being visible through the clothing. This abnormal movement sometimes extends to the carotids and jugulars, and even the body seems to be jarred by the cardiac impulse. But the difficulty is, to distinguish between the causes of the palpitation, whether they arise from organic lesions or from functional derangements. In cases of great effusion into the pericardium, the external form of the chest may be somewhat altered. In the praecordial region a prominence is then often seen, and the left nipple is a little more projecting than the right. 2. Signs by Percussion.—" In percussing the praecordial re- gion, the best pleximeter is the fore finger of the left hand, and the best hammer, the first two fingers of the right hand." Over that part of the thorax with which the heart is in contact, there is dullness on percussion. But as the margins of the lungs extend over a part of the surface of the heart, the percussion is modified, as we recede from the portion of the heart in contact with the chest, becoming gradually less and less dull, until the normal resonance of the parts of the chest over the lungs is heard. examination of the heart. 383 This change is gradual; so that the precise boundary line cannot be marked out by the sounds of percussion. The sound elicited by percussion over the praecordial region, varies according to the position of the body, the degree of expan- sion of the chest, and the nature of the diseases which affect ad- jacent organs. Before deducing any practical inference, we should, therefore, take into consideration all these circumstances. The dullness is increased by pronation of the body, decreased by supination. Certain affections directly interfere with the indications on percus- sion. On the one hand, pleuritic effusion, hepatization of the lung, tumors and enlargement of the left lobe of the liver increase the dullness; on the other, emphysema, pneumothorax and great gastric flatulence, decrease it. After making proper allowances for all these conditions, percussion may be of practical utility by indicating the existence of hypertrophy of the heart, cr of effu- sion into the pericardium. But how does percussion indicate the existence of that condition of the heart, or of hydropericardium ? " In the natural state, the extent of dullness does not exceed a space of about three inches in length, measured along the ster- num, and about two and a half inches laterally; that is, the dull- ness extends to a short distance within the nipple, and at about the middle of this space, just at the left margin of the sternum, it amounts in most persons almost to perfect flatness. The great- est dullness of sound extends over a breadth of one inch and a half to two inches; that is, over the space which the lung does not overlap; so that there are two sounds of percussion,—one nearest the sternum which is flat, and the other more external, which is simply dull. The difference depends upon the percus- sion being made in the latter case over both the tissue of the lungs and heart." [Dr. Gerhard.] Now if the heart be enlarged, or if there is any effusion into the pericardial cavity, the dullness is increased in the direct pro- portion to the increased enlargement. When the dullness results from hypertrophy of the heart, it is more rounded in shape,—the heart preserving for the most part its original form—than when it depends upon pericardial effusion. In the latter case the peri- cardium, though distended with liquid, still preserves its pyramid- 384 THORACIC diseases. al form, the apex being towards the upper part of the chest, With these preliminary remarks, I now answer the question above proposed. Hypertrophy is indicated by the extension of dullness over a space larger than that over which it is perceptible in health, and also by the form of that space which by percussion, and per- haps in some cases, by inspection also, is proved to be nearly round. Pericardial effusion is indicated by the abnormal exten- sion of dullness, and by the pyramidal form,—apex upward, base downward,—of the space over which the dullness is perceptible. 3. Signs by Auscultation.—The action of the heart gives rise to sounds which, though not audible in health, are so by the ear when applied to the chest. Some persons especially after exer- cise can hear the beating of their hearts. In making examina- tions of this organ, a stethoscope should be used, whenever the sound from a very limited space is desired. But the ear should be applied directly to the chest, whenever we wish to detect all the slightest murmurs. In order to prevent the interference of the pulmonary sounds we should, during a very limited interval, di- rect the patient to stop respiration. Dr. Swett prefers the solid stethoscope. During the examination the position of the patient should be fixed and erect, and the praecordial region fully exposed. In fe- males a very thin covering may be allowed. The sounds of the heart may be divided into normal and ab- normal. These in some cases so blend together, as to make it difficult to detect the precise limit of the former, and the begin- ning of the latter. A full acquaintance with the former, must al- ways precede all practical knowledge of the latter. And I cannot too strongly urge the necessity of studying the physical condition of the heart in health, and of becoming familiar with all the phe- nomena of its normal action, before beginning the study of the diseased heart. 1. Normal Sounds.—The normal sounds of the heart are two : the first—synchronous with the impulse, and, in vessels near the heart, with the pulse—is duller and longer; the second is shorter and clearer. The latter immediately follows the former; and af- ter the second, an interval of silence succeeds. The first sound, heard during the systole, and hence often called systolic, is most examination of the heart. 385 distinct over that part of the chest in contact with the ventricles. The first sound has been compared to that produced by jerking a cord as thick as a swan-quill. The second sound, accompanying the dilatation of the ventri- cles, and the contraction of the auricles, and hence sonii'times called the diastolic, bears a close resemblance to that produced " by lightly tapping with the soft extremity of the finger of one hand near the ear, the knuckle of a bent finger of the other hand." It is heard most distinctly over the semilunar valves; that is " upon the sternum opposite to the inferior margin of the third rib, and thence for about two inches upwards, along trje diverging courses of the aorta and pulmonary artery respectively, the sound high up the aorta proceeding mainly from the aortic valves, and that high up the pulmonary artery, being mainly from the pulmonic." The causes which produce the first sound, have been the sub- ject of discussion, and much theorizing. Of their true nature, Laennec was comparatively ignorant, and Magendie broached a theory, not founded on facts. Mr. Turner, of Edinburgh, first pointed out the true connection of the sounds with the move- ments of the heart. He maintained that the first sound occurred during the systole, the second during the diastole. Magendie maintained, that the first sound was caused by the striking of the heart against the ribs; Rona met, that the two sounds were valv- ular, the first caused by the tension of the auriculo-ventricular valves; the second by that of the semilunar or sigmoid valves. In relation to the cause of the second sound, nearly all patholo- gists agree with Ronannet ; in relation to that of the first sound, authors, in general, agree, that it is compound, the result of sever- al causes, among which the principal is the muscular contraction of the ventricles. That muscular contraction generates sound, is not a matter of theory, but of fact. Dr. Wolloston and many others, have demon- strated it. A stethoscope, applied over a contracting muscle, brings sound to the ear. By applying the stethoscope to the heart of a calf, taken from the body after sensation is destroyed, but before the animal is quite dead, a sound may be distinctly heard. A cause of minor importance, is the friction of the blood against the semilunar valves. 49 386 THORACIC DISEASES. The other causes, adduced by authors, the tension of the auri- culo-ventricular valves, the striking of the heart against the ribs, the auricular contractions, may have some tendency in conjunc- tion with the more important causes, to produce the systolic sound. The second sound of the heart is simple, and caused, as is fully demonstrated by experiments* by the tension of the semilunar valves of the aorta and pulmonary artery during the diastole of the ventricles. "From the commencement of the first sound until its return, a little less than a second of time is occupied. The duration of the several parts of the series which constitutes what may be called a beat, is the rhythm of the heart. The beat, as described by Laennec, consists of three periods:—1. The ventricular systole which occupies nearly half of the time of a whole beat.—(Mr. Bryan says a third only.)—2. The ventricular diastole occupies a fourth ; or at most a third.—3. The interval of ventricular repose occupies a fourth or rather less, during the latter half of which the auricular systole takes place.—[Hope on the Heart.] The first and second sounds together are compared by Dr. Wil- liams, to that produced by the pronunciation of the monosyllables lubb dup. Dr. Bowditch prefers this alteration, lubb tuk. The French have used a very wrong sounding word tic-tac, to repre- sent the double sound. In duration, extent and loudness, the sounds of the heart differ in health. It is probable that the sounds produced by the two ventricles are not -identical; but since the contraciions of both sides of the heart are synchronous, nothing very definite in rela- tion to this can be easily determined. The quicker, and more energetic the ventricular contractions, the louder is the sound. The thickness of the thoracic parietes has a modifying influence. The loudness of the ventricular con- tractions, caeteris paribus, is inversely proportional to the thickness of the parietes of the chest. By the influence of mental emotion, or bodily exertion, the in- terval of repose may sometimes be almost annihilated. Hepatiza- °In the New York Journal of Medicine and Surgery for April, 1840, is a detailed account of experiments establishing the mechanism of the sounds of the heart. EXAMINATION OF THE HEART. 387 tion of the portions of the lung contiguous to, and overlaping the heart may cause its sound to extend over a space unnaturally large. Abnormal Sounds:—The sounds of the heart may be altered in character, or increased in intensity. The alteration may con- sist in a slight abnormal harshness, or the natural tone may be wholly changed. The first sound is most frequently altered. A nervous temperament may increase its loudness, or a hardening in its muscular structure, conjoined perhaps with slight ob- struction of the semilunar valves. In the former case, the symp- tom is temporary, in the latter it is continuous. The phrase " in- creased loudness," and the word "roughness," are, as used by Dr. Gerhard, nearly identical in meaning. "If the roughness is in- creased," he continues, "it passes into the bellows or rasping sound. The former of these is less marked than the latter. A bellows sound is generally described as a prolonged and purring sound, usually heard in the first sound of the heart, and, there- fore, produced chiefly by muscular contraction, although it may also arise from alterations at the auriculo-ventricular valves, in which case it occurs during the diastole of the heart." The term bellows has been applied to this sound on account of its resem- blance to that produced by blowing strongly into a bellows. It differs in the degree of its harshness. In its simplest form it is "slight, short and breezy," the slightest prolongation of either sound of the heart {bruit de souffle, Fr.). A still greater degree of harshness constitutes the pure bellows sound {bruit de soufflet, Fr.). Next is the filing or rasping sound, {bruit de rape, Fr.,) resembling the sound of a rasp forced through soft wood. The loudest and roughest of all is the sawing sound {bruit de scie, Fr.). Dr. Pennock very properly suggests, that as sawing is a double motion, the name should be restricted to the double murmurs produced by the alternate motion of the heart. The bellows sound may be short, or so continuous, as to nearly fill up the space between the impulses. This sound in its pure form may exist without any organic change ; pressure upon a vessel, or any pathological change causing sufficient contraction to alter the di- rection and velocity of the blood in the arteries, and to cause it to 388 THORACIC DISEASES. be reflected upon the sides of the blood vessels and produce vibrations, gives rise to its development. By anaemia, or chloro- sis, or excessive blood-letting, this sound is liable to be produced. A watery state of the blood is favorable to the production of vibratory motion. Its particles in that condition move so readily upon each other, that a little pressure of the stethoscope upon an artery, or even excitement, very often gives rise to the bellows murmur. " When the bellows sound depends upon an hypertro- phied ventricle urging the blood rapidly through a narrow or non- dilated semilunar valve, or driving it back through a dilated auri- culo-ventricular opening, it is more persistent, more uniform, and is less musical, but more harsh than when it arises from a mere nervous disorder; the same character is found when the sound is heard during the diastole from regurgitation through the semi- lunar, or contraction of the auriculo-ventricular valves." The variety of the bellows sound termed filing or rasping, is produced by the inequalities of the surface over which the blood flows. These inequalities arise from depositions of lymph, ex- crescences of various kinds, osseous and cartilaginous productions. This sound indicates an organic disease in the valves. Another cause of these cardiac sounds is some defect in the valves. Such as thickening, dilatation of the orifice, or loss of substance, pre- venting their complete closure, and thus inducing regurgitation. This variety of bellows murmur is scarcely ever heard during diastole, for its production requires considerable force in the cur- rent of blood,—more force than regurgitation through a narrow orifice produces. But when the aorta is much dilated, the reflux of the blood during the ventricular diastole, is almost as powerful as its forward current during systole. And the blood, passing both forward and backward over the irregular surface of the diseased valves, causes the sawing sound {bruit de scie) instead of the rasping. This sawing sound is a diagnostic sign of aneurism of the aorta. The degree of softness or loudness depends upon the force of the circulation of the blood. The systolic ventricular murmurs are louder than the diastolic. The key or tone, according to Dr. Hope, is higher or lower, according as the sound is generated at a less or greater depth, by a less or greater force, or in a less or EXAMINATION OF THE HEART. 389 more contracted orifice. Roughness of sound is proportionate to the irregularity in the surface producing it. Dr. Hope found the musical note most frequently an attendant on regurgitation. By changing the force of the heart's action, the sounds are made more audible, and their character is altered. A slight bellows murmur may be rougJiened by any excitement of the heart which increases the rapidity of the current. The quantity of blood, ac- cording to Dr. Williams modifies the murmurs, increasing and prolonging them when excessive, and rendering them loud and short when defective and attended with excited action of the heart. To ascertain in which of the valves the murmur originates whether it is dependent upon obstruction caused by the deposi- tion of some morbid product around the orifices of the heart, or upon a deficiency or imperfect closure of the valves, is very im- portant. This desirable information as to the valves affected, may in most cases be obtained by carefully noticing the seat of the murmur, as perceived by the stethoscope. " When the sound is loudest on the sternum, immediately below the insertion of the third rib, and thence extends upward for about two inches along the course of the great vessels, it may be considered as having its source in the semilunar valves. If the sound be perceived most distinctly along the course of the ascend- ing aorta upon the right, it is probably seated in the aortic valves; if along the pulmonary artery on the left, it is in the pulmonic valves. When the murmur is most distinct over that part of the chest on which percussion is dull, that is, where the ventricles are in contact with the walls, it may be inferred, that it is generated, either in the mitral or tricuspid valve; in the former, when the point of greatest loudness is a little to the right of the left nipple and an inch or so below it, in the latter, when the analogous point is on or near the sternum in the same horizontal line." The solution of the second question, whether the sound de- pends upon contraction or any other obstruction of the valvular orifice, or whether upon an abnormal condition of the valves themselves, causing their imperfect closure, is mainly effected by the observation of the course of the sound, the relation of the 390 THORACIC DISEASES. time of its occurrence to the time at which the ventricular systole and diastole take place, and by the character of the sound itself. The course of sound in moving liquids, as in the atmosphere, f is in that direction in which the current flows. Confining my remarks, for convenience of description to the left side of the heart—let us suppose that there is contraction of the semilunar valves, or any other obstructing cause at the orifice of the aorta, or that the mitral valve is not in a normal condition so as to pro- duce a closure of the auriculo-ventricular orifice. In either of these physical conditions, the sounds,—in the former case arising from a contracted orifice, in the latter, from imperfect closure.— will be made during the ventricular systole. What then does the existence of murmurs during systole indicate ? It may in the first place indicate contraction of the semilunar valves, or of the orifice at which they are located ; or secondly, regurgitation through the auriculo-ventricular opening into the auricle in consequence of deficiency of the mitral valves. But how distinguish the one physical condition from the other? In the former, the sound is heard along the course of the large vessels, the aorta and pulmon- ary artery ; in the latter the sound does not extend up those ves- sels. Let us now suppose an opposite physical condition of the valves and orifices. Suppose a dilatation of the aortic orifice, or an insufficiency in the aortic valves to exist, or suppose that the mitral valve, instead of being unable to produce complete clos- ure, to be so contracted as not easily to open, or the auriculo-ven- tricular opening to be obstructed, what sounds will then be pro- duced during the ventricular systole ? Evidently none. And why ? Because the mitral valve very readily closes during ven- tricular systole, and the passage into the aorta is not obstructed. What sounds occur during ventricular diastole ? and what do they indicate ? As the blood regurgitates from the aorta, it produces some variety of the bellows murmur; in case the aortic orifice, is dilated, rough, and irregular it may produce the sawing— bruit de scie—sound. If the lesion be at the mitral valve, producing obstruction to the ingress of blood into the ventricle, the bellows murmur is heard over the left ventricle, but it is more obscure and feeble. The same orifices may at the same time be contracted, and ad- EXAMINATION OF THE HEART. 391 mit of regurgitation, and more than one orifice may be simultane- ously affected. Hence the blowing sound may be either single or double ; single when produced at one orifice, double when at two orifices. The orifices of the left side of the heart are much more frequently affected with organic disease than those of the right. The sounds produced during the systole, are louder than those during the diastole. "First, in relation to the aortic valve, if it be obstructed, the murmur will be heard during the systole, will be rather loud, re- sembling according to Dr. Hope, the whispered letter r, and will follow the course of the aorta; sometimes even as high as the carotid, without being perceived, or but faintly so, over the ven- tricle. If the valve be insufficient, so as to occasion regurgita- tion from the aorta, the murmur will be heard during the diastole, will be of a lower key than the preceding, resembling, according to Dr. Hope, the word awe whispered in inspiration, and will be most distinct over the ventricle into which the regurgitating cur- rent from the aorta is directed, though it may also be heard for some distance up the aorta. Secondly, in relation to the mitral valve, obstruction is indicated by a diastolic murmur, heard over the left ventricle, very feeble and low-toned in consequence of the weakness of the auricular contraction, and the depth of the valve, and compared by Dr. Hope to the word who, whispered feebly. Insufficiency, producing regurgitation, is attended with a louder sound of the same character, is systolic, and may be heard near the apex of the heart, but does not, like the semilunar mur- mur extend far up the aorta. Thirdly, the same rules apjjly to the murmurs of the right side of the heart; namely, those of the pulmonary semilunar valve, and the tricuspid. They are usually higher toned than those of the left side, because nearer the sur- face. They will be sought for, of course, along the direction of the pulmonary artery, or over the right ventricle. They are comparatively very rare." [Wood.] The auriculo-ventricular sounds, depending upon auricular con- traction and the suction power of the diastolic ventricles, some- times are almost wholly wanting, even where there is considerable constriction of the orifices. The cause of this is the feeble con- traction of the auricle. The sounds may occur immediately after 392 THORACIC DISEASES. the systole, during the diastole, at which time the suction force of the expanding ventricle operates, or after the period of repose, and just before the returning systole. If the murmur continues during the ordinary period of silence, it indicates a deficiency of one of the semilunar valves in most cases that at the commence- ment of the aorta, and consequent regurgitation. To distinguish organic from functional affections of the heart, is often highly important. The pure bellows murmur is an at- tendant of both forms of the disease. But the rough rasping varieties of that sound, indicate some organic disease of the valves. The sounds produced by regurgitation are also in most cases consequent upon organic changes. By the pressure of an enlarged heart upon some part of the bronchial tubes, a sound is sometimes produced simulating the bellows murmur. This sound is suspended by holding the breath and by this it may be distinguished from the cardiac sound. 1. Pericardial Sounds.—Friction sound:—The motion of the two surfaces of the pericardium upon each other, when the membrane is inflamed, and covered by exudations of coagulable lymph, gives rise to a friction, or rubbing sound, analogous to that of pleurisy from which it may be distinguished by its con- tinuance during suspended respiration. A great stiffness and roughness of the membrane give rise to a slight modification of this friction sound, called the creaking leather sound, from its supposed resemblance to the noise made by new leather when in motion. The friction sound, like the bellows murmur, may be single or double. It may accompany either the diastole or systole. 2. The churning or washing sound is sometimes heard in case of an effusion of fluid into the pericardial cavity. This, how- ever, is but rarely the case, and the sound is of little importance. In general these pericardiac sounds are more superficial than those belonging to the heart itself. Strong pulsation of the heart, by moving the air in inflamed bronchial tubes, may develop the mucous and sibilant rales, and, in large tuberculous cavities, may produce metallic tinkling. On applying the ear to the praecordia, there is sometimes noticed with EXAMINATION OF THE HEART. 393 the impulse, a metallic ring which is in the ear of the listener, and not in the heart. A violent and abrupt impulse causes it. Irregularities in the rhythm of the heart:—These arise from both organic and functional disease. The debility consequent upon fevers,, or upon anaemia may cause this symptom. Asa diagnostic sign it is of little importance. Dr. Gerhard speaks of an alteration of the rhythm that is confined almost exclusively to organic valvular disease, and mainly to concretions at the mitral valve. The proportion as well as the normal character of the sounds, is then nearly destroyed, and there is a confused churn- ing or purring sound. The first and second sounds of the heart cannot then be distinguished, the one from the other. This vari- ation of the rhythm indicates the gravest lesions and is connected with dilatation of the cavities and disease of the valves. Vascular Sounds.—-The movement of the blood in the arter- ies when their inner surfaces are rough, or contracted by pressure, or enlarged by aneurism, often gives rise to sound. An anaemic condition of the blood favors its production. Indeed, so strong is this tendency in certain conditions of the circulating liquid, that the pressure of a finger or stethoscope upon an artery produces it. It is synchronous with the systole of the heart, and conse- quently, takes place during the diastole of the arteries. Some- times a double murmur is produced in the arch of the aorta, the first corresponding with the systole, the second with the diastole of the heart. The diastolic murmur is supposed to be produced by a regurgitant movement of the blood from the great arterial branches in consequence of want of due elasticity in the diseased and dilated aorta. (Bellingham, Lond. Med. Gaz. Sept. 1850, p. 399.) M. Bean thinks that the arterial murmur is caused by an increased wave of blood thrown into the large vessels. In the large veins, and especially in the internal jugular of anaemic individuals, a peculiar murmur is sometimes heard called by M. Bouillaud bruit dediable, or deviVs sound, from the name of a certain humming toy, the noise of which it resembles. It is more continuous than the bellows murmur, is subject to swells and remissions, and sometimes has a slight musical tone. 50 394 THORACIC DISEASES. CHAPTER II. Section I. PERICARDITIS. Pericarditis, from the Greek *spixap5iov, pericardium, and itis, denoting inflammation, is a disease which has not until recently been well understood. It is much more frequent than was for- merly supposed, and in its termination is often favorable. Late investigations have shown that pericarditis is not much more severe than pleuritis, and that by rational symptoms it is not easily known., The researches of Louis published in the year 1826, have thrown much light upon the obscurity of its diagnosis. The adhesions of the pericardium, so often visible after death, evince the frequency of the disease, and also the frequency of its cure. But very mild forms of pericardial inflammation may exist, and yet no anatomical lesions be apparent. In a majority of cases the symptoms are not dangerous or severe; they are so only in a minority of instances. So that it very frequently happens that the disease cannot be recognized, except by the physical signs, and even these in its mildest form are by no means conclusive. Pathology.—The pericardium is a serous membrane, and is also, like the pleura, a shut sac. It is, therefore, liable to similar pathological change.s. These in the pleural sac are not necessa- rily the cause of immediate danger, but in the pericardium they lead to more serious results. At first, the natural secretion is some- what lessened, and a preternatural dryness succeeds. Coetane- ously with this change, a slight deposition of lymph takes place, and this increases until it extends over the surface of the pericar- dium. In the first stage the lymph is soft, not much thicker than wrapping paper. The lymph on the heart causes a roughness, and an appearance similar to a honey-comb, or according to Dr. Wat- son, like the rough side of a piece of tripe. The effusion of serum sometimes is great, distending the pericardium, and inter- fering with the motion of the heart. Sometimes the lymph pro- PERICARDITIS. 395 duces adhesion of the heart to the pericardium, and thus effects an obliteration of the sac, in which case apparent recovery takes place. Sometimes serum and lymph and fibrin are mingled together ; and, as in the pleura, so here partial adhesions are the result. A copious effusion if not reabsorbed, generally causes the death of the patient in a few days. In cases suddenly fatal, the serum is sometimes clear, often turbid, and tinged with blood, and the membrane presents a fibrinous or albuminous appearance. At the commencement of the curative process the serum is absorbed, the false membranes become consolidated into newly-formed tissue. In favorable cases absorption is often very rapid, the serum quick- ly diminishing to such an extent as not to exceed in quantity the exudation of lymph. While the effusion remains and the inflammation exists, the dyspnoea and partial action of the heart may soon terminate life, If the absorption is slow, and no adhesion of the pericardium is effected, the effusion gradually changes to the character of pus. In the majority of cases, however, pure piis is not formed, proba- bly because the patient dies before the suppurative process is fully established. The redness of the pericardium is similar to that induced by inflammation in other serous membranes. It resembles scarlet specks, and arborizations in the membrane, Sometimes it is stel- lated in appearance ; sometimes uniform, like a continuous stain. The membrane covered with a fine vascular net-work sometimes presents the bright redness of arterial blood. Pericarditis is rarely complicated with tuberculous disease. In some instances, however, it is met with, and then the pathologi- cal changes are similar to those of tuberculous pleuritis. Diagnosis.— General symptoms.—The general symptoms are very obscure. The ordinary symptoms of inflammation usually attend pericarditis, a full enumeration of which will be of no ben- efit. Those symptoms which more particularly point out pericar- ditis, are the following:—Pain in the region of the heart, palpita- tion, pulsation and sometimes soreness of the carotids, a ringing in the ears and vertigo ; the breathing is spasmodic, dyspnoea con? 396 THORACIC DISEASES. siderable; pulse jarring, jerking and peculiar. The pulse accord- ing to Dr. Hope, is the most sure of all the general symptoms to guide the physician to a correct diagnosis. Whenever it is feeble, faltering, intermittent, unequal, this sign, especially if continued, affords evidence of the strongest description. Fever is almost always present, unless the case is very mild. Pain is a very uncertain symptom. It may be a feeling of slight uneasiness, not causing any decided suffering, or very acute shoot- ing from the praecordia to the back between the shoulders, and extending down the left arm, sometimes as low as the elbow or even the wrist. As in pleuritis, so in this disease, the acute pain is most severe in the first stage of the disease, diminishing in in- tensity as the effusion increases. Dyspnoea is moderate in simple cases, but more severe in those complicated with inflammation of the internal membrane of the heart, or with pneumonitis and pleuritis. Cough, in pericarditis, a disease involving the lungs indirectly, is not a prominent symptom unless in complicated cases. Physical Signs.—In mild cases, and in the early stage, these are often insufficient for accurate diagnosis. 1. Signs by Inspection.—The distension of the pericardium, gives rise to an abnormal fullness of the praecordial region. This assumes a pyramidal form, and extends beyond the ordinary limits of the praecordia. Sometimes there is a prominence of the left breast, when compared with the right, and the position of the left nipple is usually higher than the right. A stronger impulse is felt over the region of the heart than is usual. The intercostal spaces are often bulging and tender to the touch. The upper portion of the epigastric region is likewise sensitive to pressure. 2. Percussion.—The distension of the pericardium with fluid, causes dullness on percussion. The impulse becomes undulatory, and not exactly coincident with the systole; because the heart must displace the fluid between itself and the thoracic walls before it can impinge upon the parietes of the thorax. 3. Auscultation.—Copious effusion impedes the free motion of the heart, and by preventing its contact with the thorax, prevents the conveyance of the sounds to the ear. They, therefore, be- PERICARDITIS. 397 come indistinct, the degree of the feebleness depending upon the amount of effusion. On account of the increased velocity of the blood, and the abrupt jerking contractions of the ventricles, the first sound becomes even louder than natural, but somewhat changed and altered to a bellows or rasping character. But in- flammation confined wholly to the pericardium, seldom gives rise to those sounds, and when it does so, the cause is more in the ex- cited circulation which it induces than in the actual lesion of the endocardium. In certain stages of pericarditis there is a friction sound, the conditions for the production of which are similar to those of pleuritis. Accordingly, we hear this sound when there is an effusion of lymph, roughening the membrane, and but little se- rum. This condition usually occurs at the beginning of the disease, and, consequently, then this sound compared by some authors to that produced by the bending of new leather, ( bruit de cuir neuf) the creaking leather sound, is most frequent. After the fluid is absorbed and the roughened membranes are in contact, this is again produced. It is then an indication of returning health; because it shows that absorption has taken away the ab- normal quantity of fluid, and that the membranes again approach to jutaxposition. This friction sound is sometimes more rough ; and then it receives the epithets grating or rasping. These sounds may be double, occurring at every contraction of the heart, and sometimes according to Dr. Pennock they become treble or even quadruple. There is a degree of danger of confounding these friction sounds with the valvular murmurs which indicate the existence endocarditis. But the former are more superficial than the latter, are rougher, especially when coincident with the second sound of the heart,—are more apt to change their position with a change of posture, and are inaudible at the distance of two or more inch- es up the pulmonary artery or aorta, where the murmurs of the sigmoid valves in endocardial inflammation, are heard distinctly, and are not like the murmurs of the auriculo-ventricular valves, uniformly loudest near the apex of the heart. With the friction sound there is often a vibratory tremor felt by 398 THORACIC DISEASES. the hand placed over the heart. W nether this friction sound is caused by the rubbing together of the pleura, or of the surfaces of the pericardium can be determined by the suppression of res- piration, which, in pleuritis arrests the sound, in pericarditis it does not. When there is effusion in the pericardial cavity the washing or churning sound is sometimes heard. This symptom, however, is of minor importance. The friction sounds may in some instances be confounded with the mucous rales of bronchitis, but the latter cease when respiration is suspended, while the former remain unaffected. Pericarditis, carditis and endocarditis often exist, together.— When this is the case the friction sounds and the valvular mur- murs will be produced. Course and termination of the sthenic form of pericarditis.—In violent cases the disease quickly runs its course, and, in less than forty-eight hours may terminate fatally. In mild cases, it some- times continues for weeks, not entirely losing its acute character. Ordinarily the disease yields in the course of a week or ten days. Under the influence of energetic and appropriate treatment it may terminate in less time. In case it ends in recovery, the fluid is absorbed, the friction sounds return, respiration and the impulse of the heart become more audible, adhesion is effected and the cure completed. If unfavorably, general weakness, oppression, and the symptoms of imperfect circulation are the premonitors of death. Section II. CHRONIC PERICARDITIS. When the disease assumes an asthenic form, or when the vio- lence of the acute attack subsides, leaving a low degree of con- tinuous inflammation, the term chronic is usually applied. The difference between this and the acute form is one of degree rather than of kind. The symptoms of chronic pericarditis, like those of the acute form, are somewhat variable and obscure. And yet thereare certain points of difference, that-it may be well to notice. Not unfrequently there is no pain, and the patient com- PERICARDITIS. 399 plains only of a sense of weight, oppression, or stricture in the praecordia. A little dyspnoea may be present. The pulse is some- what frequent, irregular and feeble, rather than strong and active. The countenance is of a livid hue, or pale and puffy; there is an absence of the respiratory sounds, they being distant and obscure, dullness on percussion and enlargement of the praecordial region. The impulse too is less than in the acute variety of pericarditis. This may be confounded with dilatation of the heart, and hy- dropericardium. But dilatation is usually attended with a pecu- liar impulse, and increased loudness of the cardiac sounds, but never with the friction sounds. Hydropericardium is without local pain or febrile action, and is usually attended with anasarca and with dropsy of other parts of the system. The causes of chronic pericarditis are found for the most part in a depraved condition of the blood, in general debility, aud in a tuberculous cachexia. Causes of Acute Pericarditis.—The slighter cases are caused by exposure to cold and dampness. The retrocession of eruptions, suppression of hemorrhages, or other morbid discharges, may give rise to this disease. Scarlatina, erysipelas and granular disease of the kidney, are sometimes connected with its production. Inflam- mation of the lungs, and its investing membrane is also influen- tial in exciting pericardial disease. Out of 265 cases of pneu- monitis, pleuritis, and pleuro-pneumonitis, there were according to Dr. Ormerod, 33 cases of pericarditis. But of all the causes acute articular rheumatism is the most frequent. By the highest authority it is asserted that at least one-half of the cases of acute rheumatism are accompanied with pericarditis or endocarditis, or with both together. Out of 161 cases of acute rheumatism; according to Dr. Ormerod, there were 61 cases of pericarditis. [Half-Yearly Abstract Med. Sci. No. 17, 1853, p. 78.] The age has some influence upon its production. Persons be- tween eight and thirty-five, are more subject to this disease than others. Diagnosis.—Pericarditis may be confounded with pleuritis, pneumonitis, endocarditis and pleurodynia. From pleuritis it may be distinguished by the confinement of the dullness to the 400 THORACIC DISEASES. praecordial region, by the absence of egophony, by the friction sounds which accompany the movement of the heart, and con- tinue while respiration is suspended. Pneumonitis gives rise to no projection of the chest, no friction sounds, nor to the altered condition of cardiac sounds. And be- sides it presents its own symptoms, the crepitant rale, bronchial respiration and resonance, the rusty and viscid sputum. Pleurodynia has but few symptoms in common with pericar- ditis, and these are acute pain in the side, difficulty of breathing, tenderness on pressure between the ribs. This has no physical signs which in any degree are characteristic of pericarditis, and therefore, there is no necessity for mistaking this affection for per- icardial inflammation. Endocarditis affecting the internal membrane of the heart it- self, must necessarily produce many symptoms in common with pericarditis. And yet when inflammation is wholly confined to the external membrane of the heart, there are signs which with much certainty distinguish it from disease confined wholly to the inter- nal. These are the dullness on percussion over the praecordia, the prominence of the chest, the faintness or distance of the car- diac sounds, and absence of the respiratory. And besides, there are the friction sounds superficial and often distinct, and the purr- ing tremor, and the absence of those valvular murmurs which arise from morbid changes of the internal membrane. Prognosis.—In general the prognosis is favorable. In its mild form it yields to the influence of remedies very readily. Not un- frequently without any interference from medicine, it spontane- ously terminates in health. The treatment adopted by the phy- sician has much to do in determining the nature of the prognosis. If it be that of M. Bouillaud—free and repeated venesection—the physician will seldom lose credit by presaging a fatal termination. Drs. Latham, Todd and Watson, seldom employ the lancet, and their prognosis has been more favorable than that of others In its simple form in all probability Dr. Wood remarks, "it would subside spontaneously, like so many other inflammations under a proper regimen, as relates to' diet and rest." The simple cases may in a majority of instances be considered as curable by ap- PERICARDITIS. 401 propriate remedies. Like all other inflammatory diseases of serous membranes, it often even in its most uncomplicated form, requires a vigorous application of anti-inflammatory agents in order to ward off its speedy termination in death. When it occurs in per- sons worn out by previous disease, or when it supervenes upon organic affections of the heart or other organs, its termination is generally unfavorable. If the friction sound ceases after a short existence, and coinci- dent with its cessation, we find decreasing dullness in the praecor- dial region, increasing steadiness in the action of the heart, and clearness and loudness of its sounds, the prognosis must be favor- able. If the friction sound continues for considerable time, it in- dicates that the amount of effused serum is not great, and that the effused lymph is of so low a degree of vitality, as to prevent a speedy adhesion. If, on the contrary, the friction sound disap- pears early in the disease, and the dullness increases, and the im- pulse and sounds of the heart become weaker, and almost invari- able, if the pulse at the same time is fluctuating and-intermittent, then the prognosis is doubtful. Great dyspnoea, syncope, the sar- donic expression of countenance, severe darting pain through the praecordia to the shoulder,—all these; when occurring at the same time, indicate speedy dissolution. There are two modes of termination, one adhesion, the other resolution. The termination by adhesion has been considered by some authors, among whom was Dr. Hope, as only a temporary cure. This is probably true in'relation to those cases in which the deposition of lymph is great, resulting in the formation of a stiff, fibrinous envelope. But this view of the effect of adhesion is not always correct, according to the best and most reliable au- thority. The effect of pericardial adhesion is similar to that of pleuritic, and as the latter is often present without materially in- terfering with the functions of the lungs, so the former may exist without producing organic lesiong>f the heart. Treatment.—This disease being an inflammation of a serous membrane, requires the general course of treatment adapted to the cure of pleuritis, or peritonitis. A proper discrimination should be made as to the character of 51 402 THORACIC DISEASES. the disease, whether sthenic or asthenic, and also as to the causes of the disease, whether proceeding from rheumatism, affections of the lungs or of the kidneys. Attention should also be directed to the stage of the disease. The first object is to remove those exciting causes,—whatever they are,—which immediately produce the inflammation ; secondly, to arrest the progress of the local disease ; and thirdly, to obviate the ill effects arising from the products of the pericardial inflam- mation. Among the exciting causes, cold and dampness are fre- quently found. To overcome their bad effects, a warm or vapor bath followed by brisk rubbing, will very materially aid in arrest- ing the inflammation in its nascent state. Whenever, therefore, any symptoms of pericarditis supervene after a sudden check to perspiration, the first object should be by baths or by diaphoret- ics, to restore capillary action. For the purpose of promoting cu- taneous exhalation, and producing a sedative effect upon the gen- eral system, the extract of lobelia pill, should be given in alterna- tion with some diaphoretic compound. If the cardiac symptoms arise coetaneously with acute articular rheumatism, and are evidently produced by that acid state of the blood which is so characteristic of rheumatic affections, the rem- edies should be directed to the removal of that condition of the circulating fluid in which the pericarditis has its origin. In such cases nothing will prove so serviceable as a vapor bath, followed by an emetic given in combination with alkalies, and then the administration of leptandria and podophyllin, in combination with neutralizing mixture. The above course of treatment when adopted before the dis- ease has far progressed, will in most cases arrest its further pro- gress. But if the fever is of a sthenic form, the pain in the prae- cordia severe, and the friction sounds are audible, and at the same time the patient is somewhat plethoric, no time should be lost in the vigorous application of anti-inflammatory agents. Means should be immediately used to produce general relaxation of the system. For this purpose, administer once in fifteen minutes a pill containing from two to six grains of the extract, or an equiv- alent quantity in some other form of lobelia, until the muscular system becomes relaxed, the pulse reduced in frequency and the PERICARDITIS. 403 heat of the surface subsides. A strong sinapism should be placed over the praecordia, or a fomentation of bitter herbs. After the constitutional effects—that is the general relaxation and perspira- tion,—are produced the remedy may be carried to such an extent as to produce emesis, after which an interval of rest should be al- lowed. Subsequent to the production of emesis, some diapho- retic powder or anti-febrile remedy should be used. The surface should be bathed in an alkaline solution, whenever it is dry and hot. In case there is costiveness, a mild cathartic composed of the following articles may be administered. \% Leptandriae virginicae gr. xx., Senuae gr. xx., Podophylliae gr. i. Misce. Take in sirup or molasses. This course of treatment vigorously applied at the beginning of the disease, will usually cause it to terminate in resolution. If, however, the friction sounds diminish, and dullness on percus- sion increase over the praecordia, and the general symptoms do not abate but rather increase, effusion has probably taken place, and means should then be used to remove the fluid in the peri- cardium. The third indication, the removal of the products of inflammation should then, if possible, be accomplished. In com- bination with the anti-inflammatory agents, diuretics should then be used. This compound produces diaphoresis, and diuresis, and may in some cases be used with profit:— K Tincturae lobeliae 3h., Tincturae digitalis 3 i- Misce. Dose—from twenty to thirty drops once in 8 hours. By high authority, the following course of treatment is recom- mended. In the first place, administer medicines to promote ab- sorption into the veins, such as the iodide of potassium, and in about twenty-four hours after produce its removal by free diapho- resis, catharsis or diuresis. In the iodide of potassium, I have but 401 THORACIC DISEASES. little faith. A vapor bath, with the internal use of diaphoretic doses of lobelia, and a free administration of vegetable diuretics, will excite absorption secondarily by the removal of the normal quantity of serum from the blood vessels. When the case is of a sthenic form, the administration of the following pill to produce a hydragogue effect, will prove efficacious:— R Irisiae gr. x., Podophylliae gr. x., Capsici gr. xx., Potass, bicarbonatis 9ii. Misce. Divide into two grain pills and give from one to two at night and in the morning, if a free hydragogue effect is desired. The diuretics in the chapter on pleuritis are equally applicable in peri- carditis with effusion. In asthenic cases and those of a chronic character, the spirit- vapor bath, should not be so long continued as to cause much prostration. The object is to produce a fullness of the cutaneous capillaries, and to add tone to the general system. More nour- ishment and mild stimulants should then be given than in the more sthenic forms of the disease. For a counter irritant the plaster and poultice recpmmended in the article on pleuritis may be us- ed. A plaster applied over the spine, alternately with one over the praecordia is often useful. It should be continued until the podophyllum or lin, on its surface, has time to produce its irritant and vesicating effects. As soon as there is a return of the friction sounds, and an in- crease in the loudness of the beatings of the heart, together with the general symptoms of amendment, tonics should be used in combination with nourishing, yet easily digestible diet. More es- pecially are these means necessary, when the blood is in an anae- mic state, and when oedema of many parts of the system is manifest. In such a condition of the blood, the preparations of iron administered in combination with hydrastis and pupulus will be effectual means of cure. As a general stimulant and diapho- retic and laxative the following pills are excellent:— ENDOCARDITIS. 405 R. Lob. Sem. pulveris § i., Capsici § i., Sodae bitartratis § i., Extracti bovis fellis q. s. Ft. gr. iv. pil. Dose—from one to three, three times per day. This is a remedy which can be used instead of an emetic. When the pills are contin- ued a number of days they almost always restore the equilibrium of the circulation, and thus tend to prevent those congestions which always precede inflammation; and while they do so they increase the digestive functions, and secure to the patient the for- mation of the elements of the blood. In case no laxative effect is indicated, the last article in the formula should be left out and the gum acacia used in its stead to form a pill mass. Patients laboring under this disease should avoid all kinds of excitement, whether mental or corporeal, and live upon such food as is nutritious but not exciting. CHAPTER III. ENDOCARDITIS. The term endocarditis from the Greek word sv$ov within wpSia. heart, and itis, inflammation, is applied to inflammation of the endocardium, or the internal membrane of the heart. This disease gives rise to alterations in the cardiac valves, and in its muscular structure. In its secondary effects, exist the* dangerous results of the disease, rather than in its primary. This is known from two sources. In individuals previously healthy endocardial inflammation very often terminates in structural changes of the valves. And secondly, in those who have died of valvular disease, traces of previous inflammation almost always exist. This opinion, however, is not in strict agreement with that of Dr. Fuller. He contends that the depositions on the valves are due to the pres- ence of an unusual quantity of fibrin in the blood, and to the weak state of solution in which it is held in consequence of that abnormal degree of acidity in the system, which so often accom- 406 THORACIC DISEASES. panies or precedes endocarditis. The inflammation may make ac- cording to his view, the liability of deposition greater, inasmuch as it tends to roughen the surface of the valves, and in this way tends to favor the adhesion of the particles of fibrin passing along in the current of circulation. From these opposite opinions we may safely conclude that the structural changes are the result of more than one cause, and that medical investigation has not yet accu- rately determined just how much of the result is due to the in- fluence of the one, or to that of the other. That same condition of the blood which favors the deposition also favors the production of inflammation. So that from one cause,—a general one existing in the blood,—more than one injurious effect arises. Pathology.—Inflammation of the endocardium cannot on account of the motion of the circulating fluid leave behind all those prod- ucts which are formed in the pericardium. To the membrane it- self we must, therefore, look for the changes resulting from this disease. On examination we find its natural transparency replac- ed by whiteness and opacity ; fibrin may be deposited upon it forming beaded or wart-like fleshy excrescences, and lymph may be effused either beneath or on its surface giving rise to thicken- ing, rigidity, and puckering. In some cases ulceration ensues, giving rise to irregular vegetations, partly consisting of lymph partly of calcareous matter, producing perforations of the valves or a ragged state of their edges, or extending to the chordae tendi- neae,and eating through them and sometimes causing a perforation of the septum ventriculorum. These morbid changes are found in the different chambers of the heart; but in the majority of instances they are located on the valvular apparatus, or in its immediate neighborhood. The aorta and mitral valves are peculiarly liable to these changes. The right cavities, however, with their tricuspid and pulmonary semi- lunar valves, are sometimes, though rarely, affected. The fibrinous vegetations vary greatly in their appearance. They are often very numerous, and vary in size from a pin's head to a millet seed. They are at one time isolated, and at others partially confluent; and when several spring from a common base, they may form a mass of considerable size. Sometimes when ENDOCARDITIS. 407 fibrinous accretion has taken place rapidly, its form and appear- ance is changed, which in other states of the system might have re- sulted in the deposition of small warty granules along the edges of contact of the valves. In the sigmoid they are arranged in a dou- ble crescentic form ; but when their growth is more luxuriant, they are more widely distributed over the endocardial membrane. The surface of the valves is thickly studded with them. On the edges of contact of the valves, they form festoons or fringes ; the chordae tendineae of the mitral valves are sometimes load- ed with an abundant crop of them ; and occasionally in different parts of the heart, they are scattered profusely over the entire sur- face of the lining membrane. The cases in which the last form of vegetations occurs, are just those in which the accretions manifest a strong tendency to decay, and in which arise those formidable erosions and ulcerations to which allusion has already been made. In color and consistency these accretions greatly vary. They are sometimes gray and friable, sometimes of a pink or reddish color, soft and easily broken down, and can readily be detached from the smooth surface of the membrane on which they are de- posited. At others they are less colored and of a much firmer consistency, but still admit of being separated from the membrane ; whilst in another class of cases they become perfectly colorless, and so firmly adherent, that they can be removed only by tearing the membrane to which they are attached. At a still later period these warty growths or bead-like accretions cease in many cases to exist as such upon the valves. They become by degrees more firmly agglutinated to the endocardial membrane, and incorporated with the structure of the valve; and merging gradually into one another, until the divisions between the several granules are effa- ced, they are ultimately replaced by a laminated ridge of fibrin. This is marked at first by serratures, corresponding to the divis- ions between the original granules, but after a time it also loses all traces of its origin or mode of formation, and becomes smooth and polished like the rest of the endocardium. Another source of impediment to the circulation in endocardi- tis is the formation of fibrinous coagula from the blood, which are supposed to contract adhesions to the lining membrane at any accidentally rough or prominent point, and may be seen twisting 408 THORACIC DISEASES. about the fleshy columns, and valvular tendons. (Bouillaud.) To these Laennec ascribed the origin of warty vegetations. Dr. Ger- hard considers them more frequently the cause than the effect of endocarditis, and ascribes their origin to that fibrinous condition of the blood characteristic of inflammatory disease. The fibrinous-sub-serous exudation that is seen in sthenic en- docarditis is according to the best evidence sometimes changed in- to a fibrinous, cartilaginous or bony structure. Such a deposition on or near a valve, of course, causes permanent lesion. During the progress of endocarditis the muscular structure of the heart is more or less affected. But the precise extent of the cardiac lesion it is difficult to demonstrate. According to Dr. Ger- hard the heart increases in consistence, and becomes harder than usual immediately after the inflammation of the membrane has ended. Diagnosis.— General symptoms.—The general symptoms of endocarditis are very obscure. So nearly do they resemble those of pericarditis, that an enumeration of them cannot be of much utility. It is sufficient to say, that in general, they are not vio- lent, and that in a large number of cases they are so slight, that the disease is quite latent. In the severe cases, the pain may be somewhat acute, but even then it is dependent upon the attend- ing pericarditis, and the obstruction to the free circulation of the blood. So that in simple endocarditis pain is a symptom so vari- able, that it cannot be depended upon for the formation of diag- nosis. Dyspnoea is another symptom upon which we cannot with confidence, rely. It is often violent, causing intense suffer- ing, and attended with signs of obstructed capillary circulation. In such cases, the patient has a haggard, wild appearance. The character of the pulse is another sign of endocarditis. It is tense, though small and irregular. Very great irregularity is indicative of a severe form of cardiac disease, and is usually the result of lesions of the valves. These three symptoms, the pain, the dyspnoea, and the pulse, are the most important, and almost the only ones which are generally attendant upon inflammation of the endocardium. Delirium may arise in the last stage. Physical signs.—Usually the impulse of the heart is increased, ENDOCARDITIS. 409 and irregular on account of the irritation of the organ. Dullness extends over a larger space than usual, and is dependent upon an abnormal accumulation of blood in the cardiac cavities. " This dullness is distinguished from that of pericarditis by the sounds of the heart, being louder and less distant, by the impulse appearing superficial to the sight and touch, and synchronous with the first sound instead of fluctuating." Respiration too, is slightly audible in the praecordial region. Another sign is the bellows murmur either with the first or sec- ond sound of the heart. Usually it is heard in a prolongation of the systolic sound ; and when it is so heard, and at the same time there are symptoms of acute inflammatory disease, pain in the praecordia, frequent pulse, and palpitation, the existence of en- docarditis is clearly characterized. Still more evidence of its ex- istence is added if the above symptoms just alluded to occur in an individual previously healthy, and during an attack of acute rheumatism. The murmur is supposed to arise from partial ob- struction or defective closure of the orifices of the valves. The murmur differs much in its degree of roughness. Some- times it is .soft and almost musical, sometimes harsh or rough, and sometimes so powerful as to mask the ordinary sounds. Endocarditis seldom exists in an uncomplicated form, being mingled with pericarditis or myocarditis. It is, therefore, impos- sible to find many cases in which the disease is wholly confined to the endocardium. For the purpose of aiding those who wish to cultivate accuracy in diagnosis, I give the distinctive features of endocarditis. First, then, by the existence of the bellows murmur we suspect the^ac- cession of endocardial inflammation, By the position of the sound, by the direction in which it is heard, by the time of its occurrence. If the murmur is synchronous with the systole of the heart, as before stated in the general description of cardiac sounds, it must accompany the egress of blood from the heart, and must arise either from an obstruction at the aortic valves, prevent- ing the free onward flow of the blood, or from regurgitation through the mitral valve. But if it is coetaneous with the diastole of the heart,—with the ingress of blood into the ventri- cles,__then it must be caused either by an obstruction in the 52 410 THORACIC DISEASES. mitral valve, or by regurgitation through the aortic outlet. But how can we discriminate between the murmurs produced on op- posite sides of the heart ? or how refer each sound to its proper valve ? These questions so far as the nature of the subject permits, I have already answered in the description of the sounds of the heart. But a brief recapitulation in this connection, may not be amiss. Obstruction at the aortic orifice, is marked by a systolic murmur heard most distinctly at its base, and along the course of the aorta, and by a pulse weak at the wrist. Disease of the mitral valve is indicated by a systolic murmur heard towards the apex and to the left of the heart more distinctly than at its base, by irregularity in the pulse, and inequality in its force and fullness. The causes of endocarditis are very similar to those of pericar- ditis. It may be excited by injuries, blows, sudden check to per- spiration and by mental influences. With pneumonitis and pleu- ritis it sometimes is intimately connected. But the most frequent of all its causes, is acute articular rheumatism. Some have sup- posed that the articular affection is transferred by metastasis to the endocardium. Of the truth of this there is not much evidence. The inflammation of the endocardium probably depends upon the same general cause, the existence of too much acidity and fibrin in the blood, that produces the inflammation of the joints. Ac- cordingly we often see the cardiac disease precede or accompany the rheumatic affection of other parts of the system. Mental emotion and irritability may predispose the heart to take on in- flammatory action, and thus give rise to the development of endo- carditis even before any general rheumatic affection is manifest. Under such circumstances a general course of depuratory treatment, a course whose adoption will remove the acidity and the cause of that acidity from the blood, is indicated; and the idea of remov- ing that condition of the blood by venesection, is one which ap- pears to me utterly destitute of reason or common sense. Prognosis.—The acute affection under a good course of treat- ment is rarely fatal, and it progresses to a termination in a week, and in some cases in less than that period. In violent cases death sometimes takes place in a few days. The cause of so early dissolution has been attributed to the for- ENDOCARDITIS. 411 mat ion of coagula in the cavities of the heart. Other cases al- though appearing violent, run on a number of weeks before they arrive at an unfavorable termination. The worst result of endocarditis is the chronic alteration of the valves. It does not, however, follow that cases in which the bel- lows murmur remains, after the subsidence of the acute symp- toms, will necessarily terminate in incurable valvular disease. The exuded lymph is absorbed, and the impediment to the flow of blood through the orifices of the heart, is wholly removed. When it is otherwise, the valvular derangement leads ultimately to lesions which end in hypertrophy and dilatation. The general and rational symptoms indicative of a fatal termination, are fre- quency and irregularity of the pulse, violent palpitations, distress- ing dyspnoea, and syncope. Treatment.—The treatment of endocarditis is almost precisely the same as that of pericarditis. To repeat the several remedies which were recommended in the chapter on pericarditis, would be unnecessary. But a few suggestions relative to treatment, may not be unimportant. Endocarditis involving as it does the mem- brane reflected on the inside of the heart, and over the surface of the valves, and not being liable to the same effects from the prod- ucts of inflammation, should be vigorously combatted at its onset. For, if coagulable lymph is to a great extent exuded upon the endocardial surfaces, it will render the deposition of fibrin more probable, and thus will be more productive of permanent'organic lesion. The baths and diaphoretics, and the other means to re- move that acid and fibrinous condition of the blood,—if such a condition should occur as the effect of rheumatic disease,—should be perseveringly applied. It is best, however, not to administer very large quantities of medicine ; for reaction is apt to be excited, and the difficulty increased. It is better to give small but fre- quent doses, to bring down the arterial excitement gradually, rather than suddenly. The former manner of administration does not so much exhaust the patient, and is not so liable to cause that depression of the heart, which in this disease is always injurious. When the cutaneous heat is great, alkaline bathing will very mucf} aid in the production of diaphoresis. 412 THORACIC DISEASES. In cases complicated with pneumonitis and pleuritis, expector- ants combined with the general anti-inflammatory remedies, shculd be given. When the endocarditis is complicated with rheuma- tism,—and such is the fact in nearly one-half of all the cases of endocarditis,—the remedies for rheumatism should be used, in conjunction with such local means as the exigencies of the case require. If the inflammation is excessive, attended with a full tense pulse, give the extract of lobelia in frequent and increasing doses, until considerable nausea is produced ; and let this nausea be kept constant during several hours. After the nausea subsides, in order to secure to the patient rest, a small quantity of extract of lobelia,—not enough to produce sickness,—may be given in combination with acetate of morphine. It is well known to the eclectic branch of the medical profession, that lobelia contains an alkaloid principle, which without doubt makes its use more valu- able in this disease. It should, however, be here recollected, that in the low grades of inflammation, in asthenic cases, when the muscular fibre of the heart is evidently weakened, the action of lobelia or of any other powerful relaxing means, is contra-indica- ted. If given at all under such circumstances, it should be in combination with stimulants in small proportions. Its complication with pericarditis with pericardial effusion, should be treated with the remedies recommended for the latter disease. In the treatment of cardiac diseases, certain general principles should be observed as guides to the kind of treatment. Every- thing which tends to produce an equilibrium in the circulation of the blood, to expel from it those abnormal products which, arising sometimes from unknown sources, cause cardiac disease, is useful. All exciting causes, so far as possible should be removed, and qui- etness and freedom from mental anxiety enjoined. When the dis- ease assumes a sub acute and chronic form, and there is evidence that the valves are implicated to a considerable extent, relaxants should be wholly avoided, and a mild tonic course of treatment instituted. Some alterative sirup given three times per day, and the use of the lobelia and gall pill at bed time, together with small doses of podophyllin or irisin in case the functions of the liver are not properly performed, and absorption is desired, the occa- MYOCARDITIS. 413 sional use of the alcohol and vapor bath, not continued so as to excite the pulse, these are the' means most effectual in arresting the progress of the disease, or of postponing its fatal termination. When so great irritability exists that the use of narcotics is abso- lutely necessary, and when at the same time there is general de- bility, some tendency to oedema and anaemia, the following com- pound may sometimes alleviate the symptoms:— R Extracti conii 3i., Ferri carbonatis 5 ii. M. ft. pil. xxx. Dose,—one pill two or three times per day. The quantity should be gradually increased in case the narcotic effect is not at first produced. CHAPTER IV. MYOCARDITIS. The term myocarditis, from the Greek pvg muscle, xapSia heart and itis, is an inflammation of the muscular structure of the heart. Of this variety of cardiac disease, our knowledge is very limited; and it is so because paralysis of muscular fibre ap- pears to precede its disorganization. Of this as a simple uncom- plicated disease we know nothing. Extreme pericarditis some- times extends to the muscular structure, and endocarditis likewise implicates the tissue adjacent to its own locality. Pathology.—The results of the pathological changes in myo- carditis, are first, an injected state of the cellular structure fol- lowed by serous or sero-sanguinolent infiltration, and diminished consistence of the muscular fibre. Secondly, a lardaceous trans- formation of the tissues, giving a homogenous appearance to the structures ; the muscular fibres, however, retaining their texture and form. Thirdly, interstitial suppuration analogous to that in the advanced stage of pneumonia. Fourthly, abscess in the" mus- cular structure of the heart. Fifthly, superficial ulcerations, pre- senting a cribriform appearance. These may be seen on the outer 414 thoracic diseases. surface of the heart in connection with severe pericarditis, or on the inner surface, when there is a complication with intense endo- carditis. Diagnosis.—We have no means of diagnosticating any of the forms of suppurative myocarditis. Of other organic changes, such as rupture of the valves, the occurrence of adherent coagula, pur- ulent cysts in the heart, and partial aneurism of the ventricles, we are likewise unable to form a diagnosis. The symptoms of car- ditis or myocarditis, both general and physical, are so nearly iden- tical with those of other varieties of cardiac disease, that no dis- crimination between them can be made. The causes are the same as those of other forms of cardiac dis- ease, and the treatment adapted to their removal, is equally well calculated to remove the inflammation of the muscular tissue of the heart. CHAPTER V. HYPERTROPHY. The term hypertrophy, from the Greek uirgp, beyond, and white wax gss., sul. zinc. 5j- Mix, and apply. The brown ointment is recommended by Dr. W. Beach. When the secretions are acrid, the parts should be sprinkled with flour, or burnt rye-meal, or pulverized ulmus. When ulceration takes place the pulverized ulmus, mixed with milk, will form a TREATMENT OF ERYSIPELATOUS INFLAMMATION. 491 useful application. Dr. W. Beach speaks very highly of a poultice made of the bark of black willow, mixed with cream. The applica- tion of cold water to cutaneous erysipelas is often made by hy- dropathists, and undoubtedly it often relieves the pain, and may tend to arrest the swelling; but if this is used, the heat of the body should be maintained by warm stimulating teas, such as the vege- table composition powders of Dr. Thomson, or ginger. The cold relieves pain by benumbing the nerves, and keeping away the oxy- gen of the air from the tissues by closing the capillaries. The same effect may be obtained by other and safer means, and there- fore I do not consider this necessary. Collodion has been used to guard the surface. Creasote is a remedy highly recommended as an external application by Dr. P. Fahnestock, of Pittsburgh. He applies it pure, with a camel's hair brush, to the whole surface: some recommend the cranberry poultice. But, as before suggested, I will state that I have but little confidence in local applications, any further than they tend to exclude the contact of air. The gly- cerine and mucilage of elm, applied warm, will be as useful as any of the more powerful articles above described. There is another class of agents that are beneficial,—diuretics. The marsh-mallow tea, the cleavers, and the eupatorium purpureum, or the eupurpurin, will be found beneficial. In malarious districts, antiperiodics will be required, the quinine and iron, sulphate of quinoidine, or salicin. The rhus toxicodendron, bryonia and pulsatilla are remedies recommended by the Homoeopathic physicians in this disease. If used, they should be administered in their common medicinal doses, as directed in dispensatories. In the cellular variety of the disease, attended with sudden pros- tration of the system, brandy and quinine should be early admi- nistered ; and in case there is a boggy feeling, indicative of the formation of pus, incisions should be made into the diseased tissues. These are highly recommended by many surgeons with a view to permit of the easy escape of fluids—of serum and pus—and to stop the burrowing of matter between the fasciae and other tissues. Se- veral short incisions near each other will answer the purpose where the object is to relieve the tension and plethora of the part, and the openings should be covered with a warm fomentation of poppies and chamomile, or with a poultice of ulmus and lobelia. The consti- 492 THORACIC DISEASES. tutional condition of the patient must be the guide to the use of medication. If there is plethora, veratrum is indicated; if debility with fever, aconite:—if there is a foul stomach, with a dry skin, and sthenic fever, lobelia. If asthenic fever is present, quinine and iron, egg and brandy, ammonia and wine whey, should be re- sorted to in conjunction with aconite. The wet sheet applied warm will frequently accomplish more good than medicine. Diuretics will be needed when the renal secretion is deficient. When erysipelas occurs upon a wound, and vesicles arise, they should be touched with the comp. tincture of capsicum and myrrh, and the sesqui-carbonate of potassa applied. And in case this does not cause a slough, the caustic potassa should be used to destroy the diseased tissues, followed by a poultice of yeast and slippery elm. The unguentum zinci oxidi compositum of the Eclectic Dis- pensatory will also be useful to remove the vesicles upon the surface of erysipelatous wounds. A plaster of the inspissated extract of Phytolacca decandra leaves will often prove beneficial. These local means should be accompanied by the internal use of stimulants and tonics in connexion with sedative remedies to control febrile action. The treatment of the several varieties of erysipelas does not differ essentially from that described. In the phlegmonous erysipelas of the head, it may be necessary to administer aconite or veratrum to control the fever, and to apply poultices of slippery elm, and pul- verized lobelia wet in tinct. of hyoscyamus or opium. It is, how- ever, absolutely necessary to resort to early incision when it attacks the scalp, causing suppuration. No poultice or other application can be a substitute for this, and the earlier and more thoroughly it is effected after pus forms, the better for the patient. The inci- sion should be in the form of a cross, penetrating down to the bone. In erysipelas of the scrotum, the Eclectic treatment will consist, in addition to the use of aconite, of laxative doses of leptandrin and podophyllin, and the free use of diuretics, and a poultice of ulmus and lobelia. There is another variety of erysipelas which occurs in the summer season among laborers, whose habits of life have been intemperate and irregular, and who consume improper food, such as imperfectly salted meats, decayed vegetables and fermented liquors. These causes, combined with the fatigue and excessive irritability engen- dered by the excitement of day wages, tend to generate that condi- TREATMENT OF ERYSIPELATOUS INFLAMMATION. 493 tion of the blood which is most favourable to fermenting processes. A mower or reaper who a short time before has injured his hand or foot, will suddenly throw down his implements and groan with mor- tal agony. The injured part rapidly swells, becomes livid, vesicles arise, and an unpleasant odour is perceived in the part. The pulse becomes feeble, the skin cold and clammy, and respiration is hurried and irregular. The countenance becomes cadaveric, the eyes glassy, with great distress at the epigastrium. Usually with this train of symptoms the patient dies in twelve to twenty-four hours, with all the appearances of gangrenous erysipelas. Such cases as this occasionally occur in the hay season in our country, and are most difficult to remedy. The treatment that is found most successful, is the prompt evacuation of the stomach by an emetic of the tincture of lobelia and capsicum and myrrh; large doses of ammonia and xanthoxylin; quinine and brandy, with the use of the vapour bath. The affected part should be enveloped in a large poultice of myrrh, lobelia, slippery elm, and yeast, and the nitric acid or caustic potassa should be first employed to destroy the decom- posing tissues. The brandy and egg-mixture will likewise prove serviceable if given internally as food and medicine. The affected part, if in the region of fascia or tendon or beneath thick cuticle, should be lanced, so as to give exit to the poisonous fluids, and a poultice applied to absorb the secretions, and arrest the decomposi- tion of the tissues. The baptisin, pyroligneous acid with quinine will prove serviceable, on account of their tendency to arrest morti- fication. But under the best treatment, many of these cases will terminate unfavourably, inasmuch as the blood itself is in a state of decomposition, and the tissues are, therefore, endowed with but a small amount of vitality. The chlorinated soda in solution may be applied to the affected part, with a view to arrest the decomposition. Suppurative inflammation requires a supporting treatment, as is evinced by experience in the treatment of the hectic fever attendant on phthisis. As this form of fever is intimately connected with the scrofulous diathesis, and tubercular phthisis, the reader is referred to the treatment under that head. Ulcerative inflammation is but a modification of the preceding, but inasmuch as it gives rise to a great variety of ulcers in different parts of the body I deem it proper here to describe the treatment appropriate in this form of inflammation. 494 THORACIC DISEASES. The varieties of ulceration are not dependent merely upon local causes, but are much modified by the condition of the constitution. The character of an ulcer is an indication of the state of the gene- ral system. The characteristics of simple or healthy ulcer are a circular or oval surface, slightly depressed, studded with granula- tions, secreting pus, and presenting a tendency to heal. The prog- nosis in this variety is favourable, and the treatment is simple, con- sisting of water dressings, and slight pressure with adhesive strips, or a bandage. The indications are to maintain the strength of the system and to remove all local causes of irritation, such as the contact of air, or the friction of clothing. The black salve of Dr. Beach, forms a good application. The ulcer should be cleansed with warm Castile soap suds, and cold applications rarely applied. In the application of adhesive strips, or a bandage, care should be taken to give a place of exit for accumulating pus. The weak or sluggish ulcer occasionally occurs, and is fre- quently caused by the continued application of emollient poultices. The granulations are semi-transparent, high, and flabby, rising in large, exuberant, gelatinous, reddish-looking masses, above the surface of the ulcer. The granulations readily slough, having but a feeble vitality. The treatment of this variety should consist of constitutional means to invigorate the system, tonics, stimulants, and nourishing diet, and of the local application of astringent and stimulating compounds, such as the tincture of myrrh, capsicum, and geranin. An occasional ablution of the part in a solution of sesqui-carbonate of potassa, or extract of white oak bark, will be found beneficial, or sprinkling it with finely pulverized sanguinaria or alum, will be of service. Dr. Erichsen highly recommends the following formula:—sul. zinc, grs. xvi.; comp. tinct. of lavender, and spts. of rosemary, a. a. 3ii-; water, sviii., as an astringent application. The limb or part should be elevated, and gentle pressure should be made by means of a roller or adhesive strips. These should be placed so as to leave a space between them for the escape of pus, and over them lint, covered with cerate, and retained by a bandage. The water-dressing is sometimes used, consisting in the application of a piece of patent lint, of the size of the ulcer, dipped in tepid or cool water to the part, and covering this with a piece of oiled silk, somewhat larger, and bound down by a roller. TREATMENT OF ULCERATION. 495 The indolent ulcer is deep and excavated, covered with irregular and imperfectly formed granulations, which exude a sanious pus. The edges are hard, irregular and rugged. The tissues adjacent, are congested, and firmly adherent to the adjacent fascia. The sensibility of the part is diminished, and pain is seldom trouble- some. This variety is caused by feeble capillary circulation, which may arise from a local or a constitutional cause. It most frequently occurs in men about the middle period of life, and is usually located in the lower extremities, in the lower third of the leg, just above the ankle. The treatment should be such as will tend to depress the edge, and elevate the base of the sore. The means of effecting this are stimulation and pressure. For a stimulant a poultice of slippery elm sprinkled with pulverized myrrh and capsicum will be useful. In many cases, however, this will not be sufficient, and it will be necessary to destroy the diseased edges at once, by nitric acid, or potassa fusa, or sulphate of zinc, and afterwards cover the part with a poultice of slippery elm, keeping the limb elevated and sustaining the strength of the patient. Professor R. S. Newton, of Cincin- nati, uses the following formula:—R- Pulv. sulphate zinc, 3ij., pulv. hydrastis, 3j., pulv. podophyllum peltatum, 3ss. Mix, fill the ca- vity of the ulcer with this, and let it remain as long as can be well borne, or until it has destroyed the dead tissue, then apply slip- pery elm, wash in cold water, until the part sloughs. Then apply the lead plaster, or Beach's black salve, or the emplastrum saponis. This treatment, conjoined with proper constitutional remedies, general tonics and stimulants and rest, will usually effect a cure. The application of pressure, however, will often be necessary in cases that cannot be well subjected to the treat- ment described. Before this is applied the limb adjacent to the ulcer should be stimulated with the application of the comp. tinct. of myrrh and capsicum, and elevated, and steamed over medicated vapour; then the ulcer should be filled with the sesqui-carbonate of potassa, letting it remain for some hours; then wash the ulcer with a weak solution of tincture of capsicum, say 3j. to 3 j. rain water. Then the emplastrum saponis should be spread on calico, which should be cut into strips sixteen to eighteen inches in length, and an inch and a half in width. The centre of the strip should' be smoothly laid on the side of the limb opposite to the 496 THORACIC DISEASES. sore, and its ends are to be brought round the limb, and crossed obliquely over the ulcer. A sufficient number should be applied to cover the sore and the limb for two inches above and below the ulcer. Each strip should overlap about one third of the adja- cent one, and all should be evenly and equally adjusted, so as to make equal pressure upon all parts of the diseased limb. A roller should then be applied to the limb, from the toes to the knee. The lead plaster may be used as a substitute, or the adhesive, or emplastrum resinae, although this is thought by most surgeons to be more irritating to the ulcer. The application of these strips should be renewed every forty-eight hours, and if the discharge is considerable, holes should be made in the strips for the escape of pus. The inspissated juice, evaporated to a salve of the phytolacca decandra leaves, forms a valuable remedy for producing a slough. Likewise that of the rumex crispus and of the sanguinaria Cana- densis. These should be applied on linen cloths, until there is a line of demarcation between the diseased and healthy tissue. The ulcer may afterwards be healed by means of the black salve. Pressure may be made upon these ulcers by means of collodion. It should be applied so as to form a thick impervious covering; its contraction by means of the evaporation of the ether, produces a degree of pressure that is many times highly beneficial. The irritable ulcer is most often found in females of a nervous and bilious temperament about the middle period of life. It is usually situated about the ankle or shin, and is small in size. Its edges are not elevated, but are irregular, the surface is grayish, covered with a thin layer, and discharging a thin sanious secre- tion. It is quite painful, preventing sleep, and thus injuring the general health. The treatment should first be constitutional. The alcoholic vapour bath should be used twice a week, and if the stomach is inactive and digestion impaired, an emetic of lobe- lia will prove highly beneficial. This should be followed by the administration of tonics and stimulants, the hydrastin, and xan- thoxylin, and euonymin, are valuable remedies for this purpose. If there is evident anaemia, iron should be administered. If the ulcer appears during lactation, especial care will be required in order to sustain the system by nutritious diet, tonics, and porter, or ale. The compound syrup of stillingia, or Beach's anti-mercu- TREATMENT OF ULCERATION. 497 rial syrup with the muriatic tincture of iron will be highly ser- viceable. Especial attention should be given to restoring the se- cretions of the skin and kidneys, by baths and mild diuretics. It is impossible to cure these cases unless the excretions are properly restored, and the organs of circulation properly stimulated. Pure air, good food, and cleanliness, are very important means of cure. Rest at night should be procured by hyoscyamin, scutellarin, and cypripedin either separately or alone. These are preferable to opiates, inasmuch as they do not arrest the secretions. To allay pain and irritability, a poultice made of equal parts of pulverized lobelia herb and slippery elm, with laudanum, will be useful, or the application of a thin plaster made by spreading the inspissated extract of conium on soft linen, and applied, will relieve the symptoms. Sometimes dry applications will be better than moist. These should consist of flour, or finely pulverized chalk, or the powder of the lycoperdon bovista. But when the ulcer re- sists all these means, it should be washed in a strong solution of nitrate of silver, followed by some sedative, and emollient applica- tion. It may be necessary in some cases to entirely destroy by means of the chloride or sulphate of zinc, the ulcerating surface, and then to apply a poultice of ulmus and pulverized myrrh, to favour the healing process, followed by the use of the black salve of the Eclectic Dispensatory. When the granulations are spongy, and discharging watery fluid, it may be necessary to apply an as- tringent compound, for which purpose the extract of quercus is admirably adapted. Dusting the surface with very finely pulve- rized nut galls will likewise be beneficial. The inflamed ulcer is sometimes spoken of and fully described by medical writers. It is characterized by symptoms of in- flammation, redness, swelling, pain and heat. The discharge is often thick, and offensive, and bloody. The treatment should consist of cold applications, the elevated position of the part, and the use of poultices of ulmus, wet with cold water and fre- quently changed so as to keep down the heat. At the same time, the patient, if there are symptoms of constitutional excite- ment, should take aconite and veratrin internally, an occasional warm bath, a cathartic of the fluid extract of senna and jalap, or of some other effectual purgative. After the local symptoms are reduced, the constitutional and local treatment that is recom- mended'for other varieties of ulcers will be appropriate. 498 THORACIC DISEASES. The sloughing ulcer is a variety not included in common classi- fications. It is described as having a great tendency to spread, a dusky red blush forms around the sore, the edges are sharp cut, the surface is grayish, and is attended with irritative fever. This is usually found in persons of a cachectic constitution, and is allied to gangrene, the vitality of the part, and the constitution being much reduced. The treatment should • consist of a nourishing diet, the use of quinine and iron, hydrastin and other vegetable tonics should be given freely; and when the constitutional poAvers are greatly reduced, the strongest diffusible stimulants should be used, capsicum, xanthoxylin and carbonate of ammonia. The brandy and egg mixture of the Eclectic Dispensatory will be ex- cellent. The local applications should be such as will cause a slough. Sulphate of zinc, and the chloride should be applied on lint, followed with slippery elm and charcoal poultices if the ten- dency to gangrene is marked. The carrot and spikenard poultice will likewise answer a good purpose. The specific ulcer has characteristics dependent upon its cause, which may be scrofula, fungus, or syphilis. The particulars of each should be described under the heads of their respective causes in surgical works. The varicose ulcer takes its name from its cause, which is a va- ricose condition of the veins in the circumjacent tissues. The skin gradually undergoes degeneration, becomes of a brownish or purple colour, and the veins in the part become enlarged and tor- tuous. Near to one of these congested spots the ulcer forms by the breaking down of the softened, and partially disintegrated tisssue forming a sore, in which the surface is sometimes irritable, sloughing or indolent. In case the ulcer penetrates one of the tor- tuous veins, it gives rise to hemorrhage, which sometimes proves alarming. The recumbent posture, elevating the limb, and com- pression of the part by lint and rollers will speedily arrest the hemorrhage. The causes of this condition of the veins are various. Phlebitis by destroying the valves will produce it. ,:. Pressure upon the ascending cava—or upon the femoral or saphenous veins, or a want of tonicity in the parietes of the veins on account of general debility—all these frequently are the direct causes. Treatment:— The indications are to remove the cause if possible. The general circulation should be stimulated, the liver should be excited, if por- TREATMENT OF ULCERATION. 499 tal congestion is the cause. The heart should receive attention if it be diseased. Capillary circulation throughout the body should be increased by baths, and stimulants and tonics. To the affected parts, astringents and pressure should be applied. The limb should be elevated—and a strong solution of extract of quercus mixed with French brandy used for a wash. The patient should wear a ban- dage applied from the toes to the knee, or even above, if the veins are distended. An elastic, laced stocking will accomplish the same object. In difficult cases some surgeons recommend passing a liga- ture under the vein adjacent to the ulcer, and tying it so as to cause it to slough. Care should be taken in performing this operation not to pierce the vein. The same object may be attained by means of the application of caustic to the vein, thus causing an eschar and slough, by which the vessel is occluded. Other remedies may be beneficially used to increase capillary circulation in the parts. Tinc- ture of myrrh and capsicin, kino, catechu, marsh rosemary, and the various astringent remedies will fulfil this indication. The tannic and gallic acids containing the essential elements of astringents can be beneficially used in solution as directed by the Eclectic Dispen- satory. The hemorrhagic ulcer is a sub-variety, known by a dark purple sore, occurring in females, from amenorrhoea, and consequently tending to bleed most at the menstrual periods, or at those times at which the female should menstruate. Its cause being constitu- tional, the treatment should consist of the use of tonics and stimu- lants. Xanthoxylin, macrotin, oil savin, sulphate iron, caulophyl- lin, with hip-baths, and nourishing diet, and occasional purges, con- taining a portion of aloes, will be effectual in restoring the cata- menia. The local treatment is comparatively unimportant, and should generally be the same as that recommended for the irritable ulcer. The general principles in the treatment of ulcers of every variety are to restore the action of the organs of digestion and as- similation, and the circulation of the blood. So that their treat- ment should be constitutional to a great extent. Nothing can be of permanent benefit unless the general system is in a proper con- dition to furnish the healing material. The local treatment is such as will aid nature in hastening on the formation of a slough, and enabling the system to cure the ulcer quicker than it would do un- aided. Undoubtedly, by means of rest, the elevated position, and 500 THORACIC DISEASES. proper diet, and the judicious use of water-dressing, the majority of ulcers can be cured; and, indeed, in many cases these are almost the only means that can be brought to bear upon patients on ac- count of prejudice, or want of faith in medicines. Dr. Chapman of London speaks very favourably of these water-dressings, which are valuable when the surgeon can be in constant attendance, and have the entire control of the patient. But unfortunately this is seldom the case in general practice, and it therefore becomes all the more necessary to use medicines and other means not hydropathic in their treatment. " When scrofula complicates the ulcer—the ampe- lopsin—scrofularia marylandica, phytolaccin, and the iodide of po- tassium, and compound syrup of stillingia, will be the best remedies. If the ulcer arises from syphilis the treatment should consist of the use of stillingia, iodide of potassium, phytolaccin, and iridin, with a generous diet. The muriated tincture of iron will then form a use- ful local application. Gangrenous inflammation" is a variety which rapidly tends to de- compose the tissues, causing gangrene and mortification. The treatment must be perseveringly applied early in the disease. The cause should be removed if possible, and the febrile symptoms con- trolled by aconite and lobelia, the strength maintained by the use of quinine, and muriated tinct. of iron, and nervous excitement al- layed by scutellarin and hyoscyamin. When asthenia is marked, carb. ammonia and xanthoxylin should be combined with quinine, and charcoal and yeast, baptisin, myrrh, and pyroligneous acid should be administered to arrest the progress of the gangrene. The local applications to the affected parts should consist of charcoal, yeast, ulmus, myrrh, pyroligneous acid, creasote, spikenard, carrot, chlo- rinated soda, etc. When the part is completely dead, the slough should be formed by applying dilute nitric acid, chloride of zinc, sul. zinc, caustic potassa, followed by emollient poultices. The ge- neral system should be sustained during this treatment with tonics and stimulants, and albuminous and alcoholic drinks. CHAPTER IV. The treatment of softening or ramollissement as the effect of inflam- mation, should consist of stimulants combined with tonics, and such TREATMENT OF SOFTENING. 501 remedies as aid to increase the activity of the absorbents. A ge- nerous diet is generally indicated. The use of iron, quinine, xan- thoxylin, are valuable adjuncts. When caused by anaemia, iron and nourishing diet are especially indicated; when arising from disease of arteries, which tends to arrest the passage of the normal amount of nutrition to the part, the flow of blood to that^locality should be favoured by position, by local stimulants, and collateral circulation, and that by anastomosis should be favoured by gentle friction and heat. Atrophy resulting from inflammation should be combated by a nutritious diet, by restoring the powers of digestion and assimila- tion, so as to enable the system to manufacture an amount of fibrin and corpuscle sufficient to cause the supply of nutriment to equal the amount of waste or disintegrated tissue. The capillary circu- lation and capillary force should be increased by stimulating baths if the atrophy is general; if it is local, arising from paralysis, sti- muli should be applied to the nerves and muscles of the affected part, such as electricity, friction, and rubefacients, in conjunction with the use of a general stimulating and tonic treatment. If the atrophy arises from lead, the sulphuric acid should be taken internally, and applied externally over the affected part. When atrophy results from pressure upon some vital part, by a tumour, the cause should be removed if possible, otherwise the disease cannot be removed. If atrophy of the muscular system arises from inaction—nutritious diet and exercise in the open air are the best means of relief. Atro- phy complicated with a deposition of fat in the tissue of organs, as in the heart, liver or kidney—can be combated only on general principles__by supplying to the blood a sufficient amount of nutri- tion in order to build up the weak and degenerating tissues. So that the digestive organs will require stimulation, the excretory or- gans will need attention, especially the skin, and liver, and kidneys; tonics and nourishing diet, and the inhalation of a pure atmosphere will aid much in arresting its further progress. If it arises from ossification or obstruction of arteries from any cause whatever, and that cause cannot be removed, the atrophy is irremediable, as is often the case in gangrene senilis. The treatment of hypertrophy musl depend much upon its cause. Hypertrophy dependent*upon vicarious action is best removed by the restoration of the original 502 THORACIC DISEASES. function of the organ that causes it. Hypertrophy of the heart, caused by disease of the valves, requires no debilitating means, for so long as the obstruction exists, the heart needs a greater than nor- mal strength of tissue in order to produce arterial circulation. When there is hypertrophy of particular tissues, as of bone, or muscle, it is best arrested by removing the cause which called it into exist- ence; if this is not possible means should be used to prevent the nutrition of the part by pressure upon the vessels conveying blood to it, at the same time stimulate the local absorbents by iodine or other appropriate remedies. CHAPTER V. DIATHESES—THEIR PECULIARITIES AND TREATMENT. The rheumatic diathesis, says Dr. Wm. B. Carpenter, tends to result from an excess of farinaceous elements, especially when com- bined with a deficiency of albuminous food, and is favoured by the mal-assimilation of saccharine compounds. This condition of the body manifests itself in inflammation of joints, and ligamentous and muscular tissues. There is a foul tongue, loaded urine, which contains the lithate of ammonia. The secretions of the skin are acid, and the blood contains an excess of fibrin. The danger attendant upon this condition of the system arises from its tendency to produce endocardial and pericardial inflamma- tion, by which the valves of the heart are rendered incompetent to perform their office, and the circulation of the blood is impeded. The treatment for this diathesis consists in a proper change of diet; the use of more albuminous and less farinaceous food; in lessening the action of the heart by aconite and lobelia; in cleansing the sto- mach by podophyllin and neutralizing mixture; in the continued use of leptandrin, and euonymin, and macrotin, and in the administra- tion of the comp. syrup of stillingia with iodide of potassium. Much attention should be given to the skin and kidneys. A warm bath should be taken two or three times a week, and apocynin, marsh- mallow, eupurpurin, should be prescribed to excite the renal secre- tion# Colchicum, guiacum, xanthoxylin, and cannabis Indica, should be used according to the indications. The veratrum viride will su- persede the use of digitalis, and the podophyllin, and phytolaccin, that of mercury in these rheumatic affections. DIATHESES. 503 The arthritic or gouty diathesis results from an excess of albu- minous or histogenetic substances in the blood, which are imper- fectly assimilated, and wrongly metamorphosed, and do not fully pass off from the body in the excretions. This disease occurs among high livers, who take too little exercise to remove the impurities of the blood from the body. It predisposes to urinary calculi, to arthritic inflammation, often manifested on the joint of the great toe. The uric acid increases abnormally, which by combining with soda, produces the urate of soda, the chalk-stones in joints, and in the bladder, one form of calculi. Treatment:—This should con- sist in taking away the albuminous animal diet, and restricting the patient to farinaceous vegetable substances, and in enjoining the use of exercise in the open air. The medicines should consist of purgatives, to act upon the liver, diuretics, to remove uric acid, and diaphoretics, to expel the poison through the skin. Colchicum is often useful combined with apocynin. THE SCORBUTIC DIATHESIS Is a disease characterized by livid spots, petechiae, scattered over tbe arms, breast and legs, found also at the roots of the hair. The teeth are loose, the gums swell, and become spongy and bleed- ing, the breath is fetid, and the debility is universal and extreme. In the limbs and joints there are rheumatic pains, and in some cases there is excitement in the organs of circulation, and the ap- pearance of general anaemia. Hemorrhages are apt to take place in various parts of the body, on account of the deficiency of fibrin and red corpuscle in the blood, which is supposed to be one of the most important pathological changes in this disease. It may occur on land or sea, indiscrimi- nately, provided that the conditions which call it into existence are present. The cause of this affection is a deficiency in diet of fresh vege- tables, and fresh meats. Salted meats and dry bread, with but little or no fresh vegetables, eaten for a long time, will cause it. A lady sick with land scurvy, who had long lived on bread and tea, was recently introduced into the Pennsylvania Hospital. The characteristic symptoms were fully developed, the gums enor- mously enlarged, there were petechiae, and anaemia. Not long since another patient with the same disease, died suddenly in that 60 504 THORACIC DISEASES. institution, from pulmonary hemorrhage, occasioned by slight over exercise. In these cases the prognosis is uncertain. In order to cure the affection, the blood must be thoroughly renovated, for hemorrhage is liable to occur at any time into the tissues of organs, or into shut sacs, or alimentary canal. The treatment must be for the most part dietetic. The use of fresh venison, fresh beef, oysters, eggs, with potatoes, cabbage, oranges, lemons, spinage, asparagus, etc., and other fresh vegetables, will constitute the more import- ant means of cure. The use of quinine and iron, the vegetable acids, the acetic, citric, or the mineral, such as sulphuric and ni- tric acids, are useful. Strong vegetable tonics, hydrastin, and po- pulin, quassia, or the mild laxatives, leptandrin, and euonymin, will be needed to regulate digestion. The skin should be bathed frequently, with friction. Exercise must be gentle, in the open air, and freedom from excitement enjoined; for the object is to build up the organism, to restore the fibrin and corpuscle. Little heed needs to be given, therefore, to the local symptoms, since they will of themselves subside as soon as the general health is improved. The gums, however, may be washed in a solution of tannic acid, and hydrastis. In case of sudden hemorrhage, the ligatures should be applied to the limbs, and oil of turpentine and erigeron, given internally, or tannic acid, geranin, matico, or some other astringent substance. I have found gtt. x. of oil of erigeron with gtt. ij. oil capsicum, gtt. xv. oil turpentine, triturated in two table spoonfuls of sugar, and administered in cold water, operate admirably in arresting internal hemorrhage. The treatment should be continued a long time after the patient is apparently well, and care should be observed lest some sudden excitement should give rise to hemorrhage, and thus destroy the patient. The bilious diathesis, caused by excess of the hydro-carbons or the oleaginous elements, alcohol, etc., in the blood, is manifested by a marked tendency to hepatic derangements, especially in warm climates and in the summer season. The symptoms, of course, are those of hepatic derangements generally, and the treatment is that which is best adapted to the removal of the carbon from the blood; cholagogues to act upon the liver—laxatives, such as hydrastin, leptandrin, and euonymin, taraxacum, etc.,—bathing the surface, and an abstemious diet, consisting for the most part of farinaceous articles,—and a small quantity of albuminoid compounds. The SCROFULOUS DIATHESIS. 505 avoidance of oleaginous and saccharine substances should be en- joined, especially in warm climates, and in the summer season. A more active life will be beneficial in burning off the excess of carbonaceous material in the blood, by the increase of oxygen in- troduced into the lungs. Cutaneous oxydation should be favoured, and the kidneys kept active by marsh-mallow, apOcynin, and eupurpurin. Periodic ten- dencies should be combated with antiperiodics. The scrofulous diathesis or cachexia tends to result from a defi- ciency of oleaginous food, or the hydrocarbons, or respiratory ele- ments in diet, the oil, and sugar and starch. The symptoms cha- racteristic of this condition are described in the article on phthisis, page 301. The treatment may be divided into preventive and curative. The former is perhaps the most important, inasmuch as it tends to reno- vate the fluids and solids of the body most effectually. When this is commenced early and continued perseveringly it will overcome the power of hereditary predisposition. This treatment rests upon the facts and principles of physiology. The fibrin and red corpuscles beino' deficient or not sufficiently vitalized, the object should be to introduce through the assimilating organs that nutriment out of which healthy blood can be made, and to favour the ingress of the requisite amount of oxygen in the lungs, to generate animal heat. The digestive apparatus should first receive attention. If the stomach is inactive, it will need gentle stimulation by tonics. The use of hydrastin, populin, iron, and the various vegetable and chalybeate tonics will be indicated. At the same time the skin should receive attention. A bath, either warm, cold or tepid, should be used according to the indications, two or three times a week, exercise in the open air, warm clothing, the full and frequent expansion of the chest, the use of oleaginous and saccharine sub- stances in diet; and in cases where there is great debility of the stomach, porter and ale; these means will constitute the main fea- tures of the preventive treatment. The proper use of water in scrofula is exceedingly beneficial. The question, however, will arise, what is the proper use of this agent? Some contend for the application of cold water, while others prefer warm. The temperature should be modified according to the strength of the patient. When digestion is much enfeebled, and 506 THORACIC DISEASES. the circulation is languid, the warm vapour bath, followed with the cold dash and brisk friction, will prove most beneficial. The tem- perature of the water for the cold dash should be gradually de- creased in order to give the nervous system a healthful shock, and thus tend to the increase of tonicity in the tissues. The wet sheet will answer a similar purpose. The object being to restore capillary action and to render perspiration free, nothing can be any more philosophical than the judicious use of water in some form. It is through the medium of water that all the vital functions are per- formed. It alone acts as the solvent for the various articles of food which are taken into the stomach. It is this element that forms the fluid portions of the blood, and thus serves to convey the nutri- tive material through the minutest capillaries into the substance of the solid tissues. It is this which, when mingled with the solid components of the body, gives them the consistence which they se- verally require, removes from the body the disintegrated tissues, or products of decay, through a complicated system of excretory ves- sels. Since these are scientific truths, the application of water in scrofula, a disease in which the powers of assimilation and nutrition are weakened, becomes of primary importance. This, combined with healthful exercise and pure air, is an indispensable pre-requisite to success in the treatment of scrofula. We may practise all kinds of experiments, recommend bacon, mutton-chops, beef-steak, pre- scribe quinine and iron and the use of malt liquors without any permanent benefit, unless we insist on the proper and judicious use of water and exercise, and the inhalation of pure atmospheric air. Much has been written concerning the use of alcoholic beverages in scrofula and tuberculosis. Those who fear stimulation object to them almost in toto, while others consider them as indispensable. In general the appetite for food is proportionate to the demand for nutrition in the blood, and when this is the case there is no need of artificial stimulus from without. But frequently in scrofula the depressing influence of the disease lowers the functional activity of the stomach to such a degree that it cannot supply the system with sufficient pabulum with which to generate heat, and supply fibrin end corpuscle to repair and build up tissues; and thus there is a progressive diminution in the nutritive solids of the blood which still further depresses the power of digestion. Experience shows that in such cases alcoholic liquors may be beneficially employed, SCROFULOUS DIATHESIS. 507 not so much to stimulate the heart, and nervous system, or to take the place of solid food, as to augment the power of the stomach to digest solid material, and thereby furnish to the blood the requi- site amount of nutrition with which to invigorate the entire system. The best forms in which alcoholic beverages can be used are those of porter, and ale, or the weaker wines. By combining a bitter tonic with the alcohol, a more salutary effect is produced upon the digestive apparatus. The quantity that should be used will depend upon its effects. It is not necessary to produce excitement or even stimulation, but simply to bring up the heat of the body, and the activity of the organs to the normal condition. One indication of the beneficial effects of alcoholic beverages, in these cases, is that they, unless used to excess, do not produce over-excitement, but a genial, healthful glow throughout the system. The curative treatment, like the preventive, should be directed to the increase of the functions of digestion and assimilation, and through these to the augmentation of constitutional vigour. The re- medies used should be continued in conjunction with the hygienic mea- sures that are recommended under the head of preventive treatment. When the tongue is loaded, and there is deficiency of biliary secre- tion, podophyllin, xanthoxylin, and phytolaccin, should be pre- scribed in small doses, or leptandrin and euonymin should be given with a view to excite the secretion of bile, and act as mild alteratives. If the stomach is evidently overloaded, and there is a tendency to nausea, an emetic should be given of infusion of lobelia, with large draughts of warm water, to make emesis free and easy. They should be repeated according to the indications, and followed by a bath and brisk friction. Three times a day the comp. syrup of stil- lingia, or the comp. syrup of sarsaparilla, or of rumex crispus, and Phytolacca should be used in order to produce an alterative effect upon the secretions. These syrups should be .alternated, one for the other, in order to affect the system most beneficially. The formulas are found in the Eclectic Dispensatory. To any one of these, the iodide of potassium, or the muriated tinct. of iron, or the syrup of the iodide of iron may be added in their usual quantities. The comp. syrup of corydalis, and the syrup of wild-cherry, will likewise prove valuable. The vegetable remedies which have a high reputation for their alterative effects, are rumex crispus, ampelopsis, quinquefolia, solanum dulcamara, arctum lappa, the menispermum 508 THORACIC DISEASES. canadense, aralia nudicaulis, scrofularia marilandica, and stillingia sylvatica. These remedies variously compounded and combined with sugar and alcohol will prove beneficial. Guaiacum and xan- thoxylin will be valuable when the circulation is much enfeebled. To promote digestion the stronger tonics will be necessary. When the blood is decidedly anaemic, iron should be mingled with the syrups; when the glands are indurated, or there are hypertrophies of organs or tissues, the preparations of iodine should be used; wdien the bones are deficient in phosphate of lime, producing rickets, this element should be administered in syrups or otherwise. When there are abscesses, and suppuration is extensive, quinine and iron and alcoholic beverages should be prescribed in conjunction with the brandy and egg mixture; or a diet of beef steak, or other nutri- tious articles. Scrofulous ulcers should be treated according to the principles laid down in the treatment of ulcers. Hardened tumours may be discussed by pressure, and the dis- cutient ointment of the Eclectic Dispensatory, and ointments of iodine. The application of a lotion made of gj. each of the iodide of potassium and carbonate of potassa, to 3J. spirits of wine and §xij. water, applied by means of lint covered with oiled silk, will answer a similar indication. The preparations of iodine should be administered in syrup of sugar, to prevent their liability to irritate the stomach. The various forms of iron may be used; the citrate is perhaps as convenient as any; the syrup of the iodide is easily administered in the liquid form. If it is desirable to give the me- dicine in powders, the concentrated articles should be used, the stillingin, xanthoxylin, sanguinarin, irisin, prunin, podophyllin, phy- tolaccin, and menispermin. To procure rest, hyoscyamin, lupulin and scutellarin are the preferable remedies, as they do not tend so much as opium to arrest secretion. Another good remedy is the cannabis Indica. This may be obtained in the form of an inspissated extract, prepared in London, which should be triturated with sugar. It produces exhilaration without exciting the circulation or lessening the appetite, and tends to tranquillize the system under the influence of pain and nervous irritability. Enlarged lymphatic glands some- times resist all remedies designed to promote their absorption. The means for their removal consist of making an opening with caustic into the centre of the mass, and in producing a slough of the entire gland. A surgical method by subcutaneous incision is TREATMENT OF CARCINOMA. 509 recommended—yet I have seen this tried in Pennsylvania Hospital without the least benefit. The caustic method is as effectual as excision, but when the gland is subcutaneous, and not in connexion with important vessels, its extirpation should be practised. I have treated several cases of enlarged lymphatic glands on the neck, existing in connexion with tubercles in the lungs. In those cases I never venture to freely apply iodine and discutient and astringent articles, lest the disease should be diverted to the lungs. I have several times seen the fatal effects of such a practice. It is best to promote the suppuration of the cervical ganglia, and sus- tain the system by nutritious diet and alcoholic beverages, cleansing the skin by hydropathic appliances, and acting upon the blood by phosphate of iron, quinine and iodide of potassium. CHAPTER IV. TREATMENT OF CARCINOMA. The treatment for cancer is still a subject of dispute among the most learned of the profession. The conservatives have taken the negative of this question, and admitted that they can do nothing that is sure, or that promises to be of permanent benefit. On the affirmative are the progressive party, who claim that it is curable when favourably situated and modifying conditions are favour- able. Without assuming to know enough of the subject to draw a true line of demarcation between error and truth, I simply state my own convictions upon the subject without reserve. That true cancer has been cured there can be no doubt. But as to how it was cured, there may be a difficulty in ascertaining. Cancer, as the majority admit, is sometimes arrested by extirpation, and proper subsequent treatment of a constitutional character. Extirpation, however, is the resort of the allopathic profession, while the "irregulars," and "cancer doctors," depend more upon caustics. Between these parties there is a constant warfare going on, so much so, that one party will not admit the experience of the other to be valid. It is generally admitted, however, that the people suffering under this disease, seldom go to the regular physi- cian with the expectation of being cured, for the promises and in- ducements held out by the antagonistic party give to them the ma- jority of the patronage. In every large city of our union, some one has by advertising or otherwise, brought his name before the 510 THORACIC DISEASES. public as able to cure cancer, and to these that patronage goes which, were it not for the egotism and aristocracy of the profes- sion, would be directed into its legitimate channel. There is so much jealousy and envy between the members of the profession, and so much of a disposition to underrate everything not dis- covered by the regular profession, that it is difficult for the disin- terested to learn where the truth is, in regard to this important and fatal disease. Cancer has been treated by compression with a view to cause the atrophy of the cancerous mass, and several cases of reported cures are recorded. Dr. Walshe relates a cure effected by this means. This will sometimes retard its growth, by arresting the passage of the usual amount of blood to the part, relieving pain by overcoming turgescence. In the early stage it is most useful, and ought not to be employed in ulcerated or in- flamed cancer, lest it tend to increase vascular excitement, and cause the infiltration of the cancer germs into surrounding tissues. The application of ice or freezing mixtures has been highly praised by some, and undoubtedly does good by contracting the vessels in the part, and thus arresting its growth. Dr. R. T. Trail, of New York, thinks that even freezing the part would be benefi- cial. Extirpation should be practised in the early stage if at all. When the tumour is circumscribed, it does not involve contiguous tissues, glands, vessels; when it is of the encephaloid character, the extirpation should be early and complete, if attempted at all. This treatment is best, when the disease seems to have originated from a local cause, in strong constitutions with no constitutional or hereditary taint, in cases of scirrhus in which the progress is slow, without adhesions. The opinion now is, that extirpation of scir- rhus is most successful late in the disease, when it becomes more localized and circumscribed, and that extirpation of the encepha- loid variety is most successful in the early stage. In cancer of the eye, testes, and tongue, this is almost the only remedy that promises even temporary relief. The caustic plan has, of late, at- tracted considerable attention both in this country and in Europe. The chloride of zinc is made into a paste with two parts of flour, or the Vienna paste, composed of fused potassa and quicklime, moistened with alcohol, and thinly applied over the part to be de- stroyed, have been used. In epithelial cancer, the caustic treat- ment, if thorough, will soon cure the disease. Among the various substances in use by the " Cancer Doctors," TREATMENT OF CARCINOMA. 511 are arsenic, corrosive sublimate, red precipitate, caustic potassa, chlo. zinc. sul. zinc, sul. cuprum, acet. cuprum, chromic acid, oxalic acid, oxalate of copper and tin, chloride of bromine, chloride of antimony, chloride of gold, etc. Many of these are too poisonous to be safely applied even to the surface of the body. But for the purpose of bringing before the profession all the various recipes in common use by the secret cancer doctors, I give the following formulas most of which do more injury than good:— R-. Sul. cupri, ^j. " zinci, a. a., 5j. Morphia; sulphatis, 3J- Mix and apply. R. Adeps, ^iij. Cupri acetatis, Jzi). White wax, gij. Scotch snuff, ^j. Melt together, and apply. R. Ext. trifolii preten., q. s. Sul. zinci, 3J- Phytolacciae, 3J- Sanguinarise, gJ1 Make a plaster, and apply. R. Chlori. bromini, 3 ij - " zinci, a. a., ^ij. " aurii, 3j. " antimonii, 3j- To be mixed in the air on account of the fumes disengaged. [Landolfi.~\ R. Acid, arsen., 9ij. Cinnabar, 3ij. Pulv. carbo. ligni, grs. xij. Sang, draconi., grs. xvj. This is spread and placed over the tissue to be cauterized, and let remain for twenty-four hours, or as long as the patient can bear it, after which time apply H. Bals. fir, Ij. Ext. conium, a. a., Ij. Plumb, acet., Ivj. Ung. cctace., 3vj. Another remedy, containing mercury, is sometimes used. 512 THORACIC DISEASES. R. Hydr. sulphuret., Ij. Acid, arsen., oij- Ung. cetace., 51J. This is followed by the use of the litharge plaster. Another is equal parts of the ranunculus acris root, pulv. sublimated sul- phur, and chloride of zinc; another, chloride zinc, 9j., sweet cream, f3j., ext. aconite, 9j. Spread on thin leather, and applied as long as can be borne. The sulphate of zinc, and the nitrate of mercury, are recommended; the potassa fusa, the scsqui-carb. of potassa, a ley made of the ashes of the oak, the extract of sorrel, (oxalis acetosella,) extract of clover, the sulphate of iron, all these have been used as escharotics. Recently Dr. Fell, in the Middle- sex Hospital, London, has been pursuing the following treatment for cancer: he first makes incisions into the tumour about an inch apart, in wdiich he inserted strips of cloth covered with his paste, letting them remain as long as possible to be borne. His com- pound is the following:— R. Pulv. sanguinaria), Iss., add Ij. Chlo. zinci, . ^ss., add lij. Aquae, lij. Pulv. sem. tritic. hibcrn. Mix, and form a paste as thick as molasses. Says Dr. Fell, " This is spread upon strips of cloth, cotton or wrool, and inserted daily into the incisions; generally in the course of two to four weeks the disease is destroyed, and the mass falls out in the course of ten or fourteen days afterwards, leaving a flat, healthy sore, which generally heals with great rapidity. This treatment refers chiefly to those cases that are well marked, or that have made some progress in their destructive career'; but we often meet with other cases of an incipient nature, where the dis- ease, although fully developed, is still in a quiescent or dormant state. In such cases, he often accomplishes a cure by means of absorption, giving no pain to the patient, and not injuring or re- moving any important part, as the breast, which must occur if the first mode of treatment is referred to. Not only is this of use in incipient cancer, but I have seen it of much use when applied to the lymphatic glands, which had become secondarily affected. In such cases, I remove the part primarily affected en masse, by means of the sanguinaria paste, applying at the same time the TREATMENT OF CARCINOMA. 513 following ointment spread upon cotton, over the enlarged gland or secondary tumour. This ointment is composed as follows, (and is called the brown ointment:) R. Sulph. zinc, Ivi. Sanguinariae, lij. Myricae ceriferae, gj. Extr. opii. (aquos.) Ext. conii, a. a., gvi. Ung. cetacei, §vi. Misce, et fiat ungt. " In conjunction with this preparation, I use an ointment of the iodide of lead, generally applying each twelve hours alternately. The following is the formula used: R. Iod. plumbi, 9j. Glycerine, 3j. Ungt. cetacei, gij. Misce, et fiat ungt. " With a steady, persevering use of these two ointments, I have often dispersed incipient tumours, which I have no doubt were cancerous. " These are the external means of treatment I employ, which, although in themselves eminently successful, yet I am not content with them alone, but also pay particular attention to the general health, ordering a nourishing and sustaining diet, besides giving internally the puccoon in small and repeated doses. A remedy that exerts so much influence when applied externally, must be exhi- bited with caution. I therefore seldom exceed half grain doses,. three times daily. This is given in the powder or decoction; in the former cases, I give it alone or combined with the sixteenth or twentieth of a grain of iodide of arsenic, and one grain of the extract of cicuta, made into a pill; or, if given in decoction, I gene- rally combine it with the fluid extract of taraxacum. " The ointment of the sulphate of zinc I have been in the habit of applying with marked success in cancer of the womb. Unlike the Vienna paste, it can be applied not only with safety, but with impunity, as it does not injure the adjoining tender parts." Prof. R. S. Newton, who has an extensive reputation for curing cancer, gives the following as his experience in this disease:—"Of the treatment I shall be brief, for I have already occupied my al- lotted space. It is universally admitted that the mere removal of 514 THORACIC DISEASES. the tumour with a knife will not effect a radical cure. If a cure is to be effected in this way, it is when the tumour is in its first stage, and a large part of the sound tissues surrounding it have been re- moved therewith. It is evident that no operation of any kind should be attempted until the constitution is in the best possible state— nor until every function is in a state of activity. The disease is both constitutional and local, and in its treatment our remedies must be both general and special. For this reason, when a patient comes to me for treatment it is my first care to put her on a pro- perly nutritious diet; to regulate the functions of the skin, liver, kidneys, etc., to effect which objects of course a variety of remedial agents are to be employed. Comp. syrup of stillingia, iodide of potassium, and prussiate of iron are usually given, along with such other agents as may seem to be indicated, as narcotics in extreme irritability, stimulants in great depression, etc.; particularly should we look to the digestive functions, and when we have removed the anaemic habit of the patient, she is then ready for an operation. For the sake of economy the patient is put under the influence of chloroform, and the entire diseased mass is at once removed with the knife, after which I usually cover the surface with some tonic escharotic, as chloride of zinc, which seems to act more rapidly and greedily on the carcinomatous tissue. This is followed by poul- tices to slough the surface; and again, time after time, while a vi- sible shred of the diseased tissue remains, this plan is followed, du- ring which time the system is toned up to the highest pitch, and the functions are all closely watched. In this way, by the union of constitutional and local treatment, if the constitutional stamina is good, we shall often, nay, if we proceed judiciously, nearly always effect a cure. Nor is the cure temporary, as can be demonstrated by cases now in this city, whom I discharged ten or twelve years since. As every case will differ from the common type, we shall be compelled to vary our plan of treatment. What I have thus writ- ten I know by experience, and I ask that attention to the subject which its great importance demands. The practice here given has been pursued by many who have witnessed my operations and at- tended my clinic lectures, and I am proud to say with great success." The viburnum dentatum, nymphea odorata, rumex crispus, in combination have been recommended for an external application. Conium maculatum with iron has often been used as an internal re- TREATMENT OF CARCINOMA. 515 medy. The extract of cynoglossum officinale, combined with conium and nymphea odorata is thought to be of service. Stramonium, hyoscyamus, tobacco, have been used with a view to relieve pain. For antiseptics to apply to the ulcer, solutions of pyroligneous acid, creasote, yeast, muriated tinct. iron are among the best. Dr. Gilbert is said to use the following agents. Strong vinegar, 1 gallon, acet. cuprum, 1 lb., honey, 1 quart, place in a copper kettle with eight or ten bars of pewter solder. Boil slowly till reduced to half the quantity. Keep in an air tight vessel. Before using it wash the ulcer, and use caustic potash to remove granulations of a fungous character, then moisten lint with the above and fill the ulcer with it, over which a compress and bandage should be placed. It should be dressed two or three times a-day. The treatment which I depend upon for the most part is the chlo- ride of zinc, combined with early extirpation, according to the rules described. I have sometimes used a plaster of extract of conium and lobelia with pulv. phytolaccin, and sul. zinc. During the past win- ter, I cured a case of fungus haematodes on this plan, that had re- sisted every other treatment. The inspissated extract of the leaves of phytolacca decandra, and that of the rumex crispus, I have al- ready described as a good remedy on page 472. This is a mild escharotic, not acting injuriously upon living tissues, but producing a slough of the cancerous mass. 516 THORACIC DISEASES. APPENDIX. DIVISION I. APPENDIX, CONTAINING THE TREATMENT OF THE DIS- EASES OF THE BRONCHIA, LUNGS, PLEURA, AND HEART, BY NEW METHODS AND REMEDIES. Treatment of bronchitis.—In the inflammatory stage the tinct. of aconite, or veratrum, should be used to arrest the fever; asclepin, taken once in four hours, a tea of pulverized glycyrrhiza and gum acacia, drank freely, and the rubbing wet sheet applied as often as indicated, or the vapour bath; these are the best means to arrest the disease. Enveloping the whole chest in the chest wrapper, or in a large sinapism, will prove a valuable substitute for the bath. Mild laxatives should be given, of which euonymin, leptandrin, and eupatorin,,are among the best. To allay arterial excitement, and aid in expectoration and hepatic secretion, sanguinarin is a useful remedy. In ague districts where periodicity is evident, Prof. Paine uses the following after the inflammatory symptoms are sub- dued:—R. Sul. quinine, grs. xv., gelsemin, gr. J; divide into 8 powders. Give one every four hours until the periodicity is arrested. The phosphate of ammonia is sometimes serviceable. It may be given in connection with asclepin and apocynin. The treatment of Chronic Bronchitis should consist, of the use of veratrum viride, to control the fever, friction baths of mustard water every morning about two hours after eating, and a vapour bath at bed-time, every other night. The bowels, if there is hepatic or renal derangement, should be kept open by the use of podophyllin and apocynin, and by the use of leptandrin and euonymin, when the mucous membrane of the alimentary canal is irritable, and the system is debilitated. For mild expectorants and tonics the prunin, or syrup of wild cherry, and asclepin, are excellent remedies. For an alterative, the compound syrup of stillingia and iodide of potas- sium has a good reputation in these cases. For anaemia give the following:—Quinine, grs. xx., iron by hydro- gen, grs. x. Divide into ten powders, and give one three times a-day. For a nervine, tincture of hyoscyamus, or the hyoscyamin, is pre- ferable to opium. In the last stage, the stimulating expectorants, senega, tolu, and sanguinaria, should be given in combination with hyoscyamin or scutellarin. treatment of bronchitis. 517 To assist jn detaching the mucus from the tubes, carb. ammonia, xanthoxylin and capsicum are useful. The inhalation of a very weak vapour of capsicum has been recommended as valuable to aid in removing the thickened bronchial secretions. In bronchitis, Dr. Paine uses the phosphate of lime, phosphate of ammonia, and phosphate of iron, the iodide of bromine, bromide of potassium, compounded with other remedies as occasions seem to require, in cases of chronic bronchitis and in consumption. These remedies may be given in glycerine, which also makes a good vehicle for the administration of the concentrated remedies, such as the asclepin, prunin, etc. Dr. Paine, moreover, applies to the chest in chronic bronchitis a salt pack, made by placing salt be- tween two thick layers of cloth, and quilting it in; and then pouring on to this a small quantity of tincture of iodine, diluted, one part of the tincture to six parts of water. The chemical action produced, he thinks, causes the elimination of gas, the inhalation of which proves beneficial to the patient. A preparation, I learn, has been manufactured in this city, of phosphorus, iron and quinine in che- mical combination; this must be an excellent article to fulfil the indications in this disease. There is a difficulty in the administra- tion of phosphorus, wdiich consists in its liability to irritate the mucous membrane of the stomach. I have been accustomed to use it in combination with castor oil, or glycerine. Prof. Paine uses it in this formula:—R. Dry phosphoric acid, grs. xij., quinine, grs. xx., ext. centaurea ext. althaea, or marsh-mallow, q. s.; divide into one hundred pills. Dose; one, three times a-day. Another form of administration is in connexion with iron:—R. Dry phosphoric acid, grs. x., Vallet's mass, grs. xx., quinine, grs. xx., ext. taraxacum, q. s.; divide into one hundred pills, and administer one three times a-day in connexion with mucilaginous drinks, such as the marsh- mallow or gum acacia. In the bronchitis of children the same means should be used to control fever. A towel wet in mustard water should be applied around the chest, and covered with oiled silk, or dry flannel, to prevent rapid evaporation. The bowels should be kept open by enemas of sweetened water, or by a teaspoonful of fluid extract of senna. The syrup of lobelia, combined with sweet spirits of nitre, two parts of the former to one of the latter, is useful to act upon' the skin and kidneys. The dose is from fifteen to thirty drops once in four hours. In severe cases an emetic of an infusion of lobelia and ipecac, should be administered. For the chronic form in children the milk of sulphur is sometimes useful. One drachm should be triturated with ten drachms of sugar,' of which give five grains of the compound every four hours. When great prostration is present, stimulants are indicated with quinine. The comp. spirits lavender or the spirits of Mindereri, or tinct. of xanthoxylin and capsicum are indicated; and if these re- 518 THORACIC diseases. medies cannot be given into the stomach, they should be used by enema. Wine whey and brandy toddy should, likewise, be used, with cutaneous friction, with cloths wet in hot mustard water, until reaction is produced. In the chronic bronchitis of children, pure air, warm clothing, exercise, and a light diet of vegetables, and a moderate quantity of meats is necessary. The tonics that prove serviceable are hydras- tin, quinia, citrate of iron. Various other remedies are recommended, the balsams of tolu and copaiba, benzoin, and the sulphurous mine- ral waters. Counter-irritation, sufficient to accomplish all that can be effected by this means, may be derived from St. John Long's Li- niment:— R. Turpentine, lijss. Rose Water, lij. White of two eggs, gtt. x. 1 table-spoonful acetic acid, gtt. x. 01. lemon, gtt. x. Rub well over the chest, and cover with flannel or with oiled silk. The treatment of epidemic influenza is similar to that for com- mon cases of bronchitis. The tinct. of aconite and veratrum should be used to control the fever—pediluvia, the warm pack sheets, or the vapour bath once a day—will be necessary in most cases. An expectorant should be used as indicated by the cough, but the most important remedies are the aconite, veratrum and lobelia, of which a very good compound is the following:— R-. Tinct. lobeliae, Tinct. aconiti, Tinct. veratri viri., Aquae, Dose, a teaspoonful every one or two hours until the fever abates. The patient should drink freely of a tea of the marsh-mallow and gum acacia, and the nourishment should consist of toast water, gruel and the lightest farinaceous articles. When there are periodical symp- toms the febrile drops should be given to reduce the frequency of the pulse, and the quinine should be given to arrest the return of the exacerbation. When this is not applicable, use salicin, eupatorin, and cinchonin. To arrest nervous symptoms, use scutellarin and hyoscyamin. In the treatment of the bronchitis of old people, the anti-febrile remedies should be used to allay fever—the stimulating expectorants are more often needed, and the inhalation of medicated vapours are frequently of service. These vapours should be laden with some stimulating substance, such as ammonia, chlorine, creasote or cap- sicum, so as to discharge the thick mucus. The vapour of vinegar and hops is often useful. Treatment of Pertussis.—In addition to the remedies recom- 33- gtt. x. gtt. x. liv. treatment of pertussis. 519 mended for this disease, several others are useful. The hydrocyanic acid, though a dangerous remedy, is useful when prescribed with proper caution. Dr. Meigs recommends carbonate of potassa as occasionally beneficial. Dr. Goulding Bird prescribes alum in the following formula: R. Aluminge, 9ijss. Sanguinariae, can. grs. x, Syrup of zingib., Syrup acaciae, Aquae fontis, aalj Mix. Dose one teaspoonful three times a day. When complicated with pneumonia, emetics should be given, fol- lowed by the administration of veratrum viride to lessen fever. If convulsions are present, they should be treated with warm baths and enemas of tinct. of lobelia, or by the administration of anti- spasmodic tincture. Enemas of lobelia are the most effectual of any means within my knowledge to control pulmonary inflammation in children. They should be given until emesis is produced in se- vere cases. Cold affusion is valuable to allay excessive dyspnoea. When dropsical effusions are the result of this disease, the best means of relief are vapour baths, and the administration of apocy- nin, and squill to act upon the kidneys. The value of belladonna in pertussis is now generally conceded. Its use is contra-indicated by the existence of fever and bronchial inflammation, when lobelia is a preferable remedy. The ledum palustre, musk, assafcetida and the rhus vernix, are all recommended by medical observers. But these substances are not superior to others, and may be dispensed with, when scutellarin, cypripedin, and the ictodes foetida, the tinc- ture or the oil, are at hand. When complicated with chronic bronchitis balsams of tolu and copaiba are useful. After the acute stage has passed, tonics will be required. The diet should be simple and nutritious, the clothing warm, exercise frequent, and the air pure. The hydropathic appliances consist of the use of the wet jacket, made of several layers of cloth fitted to the form of the chest. This is wet in water and applied and covered with dry flannel or oiled silk. This is changed several times a day. Sometimes the pack is re- sorted to. These appliances may be used in connexion with pro- per medicines. . . , t In the treatment of asthma the principal remedies are recom- mended on page 171. Several others, however, are useful; and, therefore, I here allude to them. Prof. Paine uses a combination of tinct of 'lobelia and gelseminum to break the paroxysm, and to prevent a return, prescribes quinine, cornin and phosphate of lime When complicated with hysteria, with deranged menstrual functions, macrotin, caulophyllin, helonin, senecin and aletrin, are 61 520 thoracic diseases. the remedies best adapted to restore the uterus to its normal con- dition. The tonics that are useful, are those of a nervine character. Valerianate of quinine and scutellarin are excellent. If there is anoemia with menorrhagia, the citrate of iron with geranin, trillin or oil of erigeron, will be indicated to restore corpuscle to the blood and arrest the debilitating discharge. When the hysterical symp- toms are marked, an irritating plaster or a liniment of olive oil and chloroform should be applied to the spine to lessen the morbid sensibility of the spinal cord. Chloroform is sometimes given in- ternally for asthma, but inasmuch as we have other remedies equally as efficient, I do not think its general use should be adopted. When administered, it should be mixed with olive oil or the yolk of an egg. When asthma is complicated with neuralgia, aconite should be prescribed. In treating this disease I have seldom been com- pelled to resort to any other remedies than the antispasmodic tincture with the vegetable nervines, the scutellarin and cypri- pedin. But as there are great diversities in temperaments, it be- comes necessary to resort to a great variety of remedies. Among those sometimes useful, are belladonna, conium, lactucarium, hyos- cyamus, veratrum, etc. The cold dash, rubbing wet sheet, and va- pour baths, are also needed in rare cases. The dioscoria villosa or the dioscorin is a useful remedy in asthma. Among the useful syrups for the intermission between the paroxysms is the syrup of spikenard, aralia racemosa, taken three times a day. For plethoric patients, oleaginous and saccharine substances will prove injurious in diet, while in the debilitated and anaemic the reverse is true. A change of air is often useful* Treatment of Pneumonia.—The remedies which I am accus- tomed to use in the treatment of this disease, aside from those already recommended, are veratrum viride, aconitum, the liga- tures in cases of sudden pulmonary congestion and inflammation, and the concentrated remedies generally instead of the crude ar- ticles. In the first stage, a cold pack to the chest, hot pediluvia, with frictions to the extremities, with mustard water, or whiskey and water, the administration of two to ten drops of tinct. vera- trum viride once in four hours, or of tinct. of lobelia and veratrum, four parts of the former to one of the latter, will be sufficient to arrest its progress. If the stomach is loaded and expectoration is difficult, an emetic of the infusion of lobelia should be given to produce diaphoresis and expectoration. The following pill is valuable:—B- Ext. lobelia, the inspissated juice of the plant, grs. v., sanguinarin, gr. j., asclepin, grs. v., veratrin, (from the vera- trum viride,) gr. J5. Divide into three pills. Dose, one every three hours until diaphoresis is produced and the breathing is im- proved. If the second stage has arrived, the symptoms will be liable to TREATMENT OF PNEUMONIA. 521 return after being subdued by the sedatives recommended. In severe cases, in children especially, I have found enemas of lobelia, repeated until emesis follows, the most efficient means for control- ling the inflammation. The greatest care should be observed to keep the cutaneous capillaries filled with blood, and secreting per- spiration, otherwise deficient decarbonization will be the result, and the pulmonary tissues will become more seriously affected. During the stage of hepatization, sanguinarin is especially indi- cated, with the carbonate of ammonia, in case there is great de- bility and difficulty in expectoration. If the circulation is feeble in the extremities, with lividity of the skin, the antispasmodic tincture, wine whey, frictions, with mustard water and tinct. of capsicum should be used. A good form for an emetic is the acetic tinct. lobelia, sanguina- ria, skunks' cabbage, or the lobelin, eupatorin, and sanguinarin. The diuretics should be the marsh-mallow, eupatorin, and apocy- nin. The antiperiodics should be used in case of relapse, in con- nection with sanguinarin; and give small quantities of veratrum unless debility contra-indicates. In the last stage, and in asthenic cases, when circulation is feeble, a very good expectorant is the following:—Bals. fir and co- paiba, with a little tinct. of capsicum and aqua ammonia. The fluid extract of stillingia is very good, but it is too debilitating to be given alone. In suppurative stages, veratrum should not be used, but aconite is better to allay fever: good nutriment should be allowed with stimulants to the surface, and friction, and counter- irritants. A syrup of horse-radish, syrup bals. tolu, and syrup iodide of iron and aqua ammonia form a good compound. In typhoid pneumonia the tinct. of aconite should be used in- stead of veratrum to reduce the pulse, and quinine, conium, and ceracin given to prevent the return of the febrile exacerbations. Great care will be necessary to support the system, with wine whey, "in toddy, and the brandy and egg mixture. In severe cases, the whole body should be enveloped in cloths wet in Strong mustard and Cayenne tea, and applied hot as can be borne, and covered with flannel to prevent speedy evaporation. Bilious pneumonia will require the administration of podophyl- lin, leptandrin, and iridin, to excite the hepatic function. For pneumonia complicated with bronchitis, the syrup of stillingia is valuable The eupatorin is useful as a laxative and expectorant in this complication. Asclepin and apocynin may be required, the former as a diaphoretic and expectorant, the latter, a laxative and diuretic. The arum tryphillum, hoarhound comfrey, the elecam- pane (inula helenium.) are domestic remedies of value. When here is a discharge of muco-purulent matter, or when abscess of the pulmonary tissues exists, the use of quinine and the muriated tinct. of iron is necessary to prevent collapse and pyemic fever. ' Nutritious, but easily digestible food and cleanliness are impor- 522 THORACIC DISEASES. tant. Phosphate of ammonia and phosphorus are sometimes re- sorted to in the last stage. It is given most safely and easily by dissolving it in chloroform, one part of the phosphorus to four of the chloroform by weight. One drop of this compound added to fifteen drops of sulphuric ether, and half a fluid ounce of wine, may be given every four hours in cases where great prostration exists. Prof. Paine unites 1 gr. with a little castor oil by trituration, and rubs this with 100 grs. of sugar until the phosphorus is tho- roughly mingled. It should be administered in connection with nutritious broths or after a meal. For scrofula, Dr. Glover unites one grain with one ounce of cod liver oil. Bryonia is another remedy that is useful in this disease, and is said by the Homoeopathists to be best adapted to cases of pneu- monia complicated with pleuritis. In asthenic pneumonitis the treatment should be more sustaining and stimulant, and the friction more thorough, and the external applications warmer. Quinine, carb. ammonia, xanthoxylin and capsicum will be necessary early in the disease, to keep the capil- lary circulation equal and free throughout the body. The treat- ment of secondary pneumonitis should be the same as that for the other varieties, proper attention being given to the character of the disease or the injury which calls it into existence. If it be tubercular disease, disease of the heart, or pleura, or the retroces- sion of exanthematous eruptions, the treatment should have in view the removal of the cause of the pneumonia. The treatment of pulmonary, vesicular and interlobular emphy- sema is perhaps sufficiently considered. The principal remedies are the antispasmodic tincture, scutellarin, cypripedin, and hyos- cyamin, or the tincture of hyoscyamus. If occurring in the tuber- culous, quinine and iron combined with sedatives will be benefi- cial. Prof. Paine recommends the inhalation of the vapour of ni- trate of silver, when it occurs in consequence of a fistulous opening into the pleura from the bronchial tubes. The euonymin, eupatorin, and juglandin should be used to re- gulate digestion and the movement of the bowels, and tinct. of lobelia and hyoscyamus to allay spasmodic action. The treatment of pulmonary congestion in the plethoric, should consist of the use of the ligatures to the limbs, veratrum viride, and aconite or lobelia as sedatives, and of oil erigeron, matico and geranin as astringents and styptics in case pulmonary hemorrhage is present. When there is anaemia, iron and quinine, with stimu- lants, the vapour bath, and sedatives will be necessary. Turpen- tine is thought to be beneficial. Opium and hyoscyamus are necessary to control nervous symptoms, and the former remedy is useful also to prevent hemorrhage. Placing the feet in hot water, ligatures around the limbs, and administering a teaspoonful of tinct. of capsicum with ten drops oil of erigeron. has been effec- TREATMENT OF PLEURITIS. 523 tual treatment in my hands in arresting pulmonary congestion and hemorrhage. The treatment of pulmonary apoplexy, should be similar to that for pulmonary congestion. The object is to control the cir- culation, which can be done most effectually by the ligatures, ve- ratrum viride, tinct. of capsicum, and oil of erigeron. Cold appli- cations to the chest, and warm ones to the extremities are indi- cated, and should be thoroughly applied. The treatment of pulmonary gangrene, in addition to the means recommended, should consist of pyroligneous acid, and baptisin, administered internally, in alternation, with quinine and the mu- riated tinct. of iron. The treatment for pulmonary dropsy, or cedema, should be simi- lar to that recommended for dropsy of the pericardium. The apocynin, eupurpurin, with iodide of potassium are the diuretics most valuable. When pulmonary oedema results from obstruction in the left side of the heart, from hypertrophy or other causes — the indications are to promote arterial circulation by acting upon the cutaneous vessels. Friction baths, with mustard water, should be applied twice a day, and at the same time tonics and absorbents should be prescribed with a view to cause the removal of the se- rum in the lungs. Among the best remedies to fulfil this object, are iodide of iron, iodide of potassium, iodide of quinine, and phy- tolaccin. In the treatment of pleuritis I have found aconite and veratrum most excellent remedies; asclepin and gelseminum are likewise valuable to promote diaphoresis. For effusion into the sac of the pleura, I have great confidence in the apocynin, taken freely. It is the best remedy I have ever used. It may be combined with other diuretics, the eupurpurin, eupatorin, and administered m connexion with marsh-mallow tea. The comp. syrup of stillingia and iodide of potassium, are useful to fulfil the same indication. The fever in the chronic forms of the disease should be controlled by veratrum, aconite, or gelseminum. Periodic symptoms are effectually subdued by Prof. Paine's prescription : — R. G-elsemiae, gr- j- Quiniae, gr- xx. Asclepiae, gr. x. Sac. alb. grs. xxx. Divide into ten powders, and give one every three hours until all are taken The ferruginous tonics, tartrate of iron and qui- nine, the tartrate of iron and salicin, and the iodide of iron, are among the best remedies for anaemia. The latter remedy may be used in this manner: — R. Syrup simp., lyj. Phytolaccin, ^ss. Iodide of iron, £ss. 524 THORACIC DISEASES. Dose, a teaspoonful three times a day, or oftener if indicated. To promote absorption of effused liquids, phytolaccin is valuable, after which tonics should be used. Counter-irritation by means of a plaster or otherwise, is necessary in difficult cases. The am- moniated counter-irritants are recommended by Dr. Granville, (See Dunglison on New Remedies, page 203.) ^ The oil of sina- pis is in my opinion preferable. Linen is wet in the oil, and laid on the part over the seat of disease, and suffered to remain from five to ten minutes, or until it produces intense smarting and red- ness, after which it should be removed. It may be applied morn- ing and evening. The parts after its removal should not be rubbed lest it cause too much irritation of the skin. This appliance is useful also in bronchitis, or pleurodynia, in rheumatic or neu- ralgic affections of the chest. When there is great debility and a tendency to phthisis, tonics, or rich animal diet, gentle exercise, porter, ale, or gin toddy, with the syrup of wild cherry, and occa- sional vapour baths, constitute the means best calculated to relieve the patient. In case all the diuretics and absorbents fail to remove the effu- sion in the pleura, the operation of paracentesis thoracis will be necessary as the only means of relief. The treatment of pneumothorax should consist of the antispas- modic tincture in small doses, to relieve spasm. When there is much fever, aconite, or veratrum viride, will be needed. A hot sinapism, or hot cloths applied to the side are necessary to afford temporary relief. Palliative remedies will be required, such as the hyoscyamin, scutellarin, and morphia. The treatment of hydrothorax is quite fully described, page 275 to 280. Besides the remedies there referred to, I will here men- tion as valuable, the apocynin. A full description of other reme- dies applicable in this disease, will be found under the head of treatment for pericarditis and hydro-pericardium. The treatment most successful in empyema, is the use of the muriated tinct. of iron to prevent pyemic fever, and quinine to overcome periodic symptoms. The comp. syrup of stillingia, the syrup of wild cherry, iodide of iron, nutritious diet, the moderate use of porter and ale, are the most successful means to sustain the system. In extreme cases paracentesis is necessary. The treatment of phthisis rests upon the teachings of physiology and pathology. The object should be to introduce into the blood proper nutriment so as to nourish the tissues and produce sufficient animal heat. If the stomach is inactive it will need gentle stimulation by tonics, such as hydrastin, populin, helonin, chelonin, eupatorin, and prunin, or the crude articles of which these are the active principles, and the use of some form of iron. A bath either warm or tepid should be used two or three times a week, which, with exercise in the open air, warm clothing, the full and frequent expansion of the chest, TREATMENT OF PHTHISIS. 525 and the use of a proper amount of oleaginous and saccharine matter in diet, constitute the more important features of the hygienic and curative treatment. In cases of great debility of the digestive functions, the moderate use of porter and ale will be needed. For the purpose of adding nutrition to the body, compounds of the ele- ments of food should be used. Common nutritive fluid.—One pint milk, two pints soft water, two table-spoonfuls of best wheat-flour, two teaspoonfuls of loaf sugar, one teaspoonful of pure saleratus, one teaspoonful of table salt, two teaspoonfuls of lump magnesia; the flour and magnesia to be rubbed together and stirred into the first two ingredients, as soon as they boil, which should be continued for five minutes. Fine nutritive fluid.—Fresh milk one pint, soft water two pints, rye-flour one table-spoonful, one large table-spoonful of rice, ground or pulverized, one table-spoonful of starch, sugar three teaspoonfuls, table salt one teaspoonful, saleratus one half teaspoonful; the flour, rice and starch to be rubbed together with a little sweet cream, and added to the milk and water while boiling, which should be conti- nued five minutes. Extra nutritive fluid.—Fresh milk one pint, rain water two pints, best wheat flour one table-spoonful, two table-spoonfuls starch, one teaspoonful gum acacia, dissolved in warm water slowly, one tea- spoonful of salt, one teaspoonful saleratus, four teaspoonfuls pure white sugar, two teaspoonfuls lump magnesia; the flour, starch and magnesia are to be put together and mixed into a paste with a little milk, and added as before to the liquids while boiling. These fluids are drunk freely during the day,—the quantity varying from one to three pints in twenty-four hours. They are useful to restore digestion, for weakness of the bowels, for general nervous debility, and to prevent the emaciation that attends on tuberculosis. A tumbler half full every hour is the usual quantity directed. The vapour bath, or a pack in a sheet, wet in tepid water, fol- lowed with brisk friction, will be necessary two or three times a week in order to cleanse the skin and promote perspiration. Much has been written concerning the use of alcoholic beverages in phthisis. In my opinion they are useful and necessary in those cases in which there is a greater demand for nutrition m the blood than the digestive organs can supply; in those cases in which the organs of assimilation are depressed, and as a sequence, the blood deprived of its heat-making elements, and of fibrin and corpuscle. But when the digestive organs are able to furnish a proper supply of chyle to the lacteals, and these furnish corpuscle to the blood, in normal quantities, there is no need of any alcoholic stimuli. The preparations of alcohol should be those containing an admixture of albuminous and bitter tonic elements, such as ale, porter, the weaker wines etc. These should be drunk in sufficient quantities to bring up the heat of the body to the normal standard, in which case they 526 THORACIC DISEASES. will not cause over-excitement, but a healthy glow throughout the system. The curative treatment in the premonitory stage aside from the hygienic and dietetic, should consist of the use of an occasional emetic of warm water, an infusion of lobelia and eupatorin, of phytolaccin and podophyllin, for hepatic symptoms,of xanthoxy- lin, leptandrin, and euonymin, for stimulating the circulation and the bowels. Various vegetable compounds in the form of syrups are useful, partly on account of the medicine they contain, and partly on account of the sugar and alcohol that enter into their composition..' Dr. Beach's anti-mercurial syrup, the comp. syrup of stillingia, the comp. syrup corydalis, the syrup of wild cherry, are all useful compounds. To one pint of these, one dram of the iodide of potassium should be added to act upon the absorbents. There are several formulas in the Eclectic Dispensatory for al- terative syrups, all of which are occasionally valuable, and should be alternated. The individual articles that enter into the compo- sition of these compounds are the rumex crispus or yellow dock, the stillingia, ampelopsis quinquefolia, solanum dulcamara or bitter sweet, the arctium lappa or burdock, the menispermum canadense or yellow parilla, the aralia racemosa or spikenard, the scrofularia marilandica, etc. The Treatment of Tubercular Consumption by Inhalation. On this subject there is much diversity of opinion and various methods are in use. "Dr. Snow has shown, in a paper on the inhalation of various medicinal substances, that some must be inhaled by the aid of heat, such as opium, morphia, extract of stramonium, and the gum resins; others with heated vapour, such as iodine, camphor and creasote, and a third class of substances, such as hydrocyanic acid, ammonia and chlorine, at the ordinary temperature. Mead, in his day, re- commended fumigations with the balsams in phthisical cases, and Dr. A. T. Thomson (Cyclopedia of Medicine, Art., Expectorants) has stated that he has seen much benefit derived from them, when inhaled in spasmodic asthma, in shortening the paroxysm, and pro- moting expectoration. Dr. Snow found that ammoniacum gives off a fragrant, rather pungent odour, which can be inhaled very well by most persons. He also found inhalation of the watery extract of opium serviceable in relieving the cough; but that morphia was the most pleasant and suitable preparation of opium for inhalation. Extract of stramonium afforded more or less relief in five or six cases of asthma. He tried iodine in eighteen cases of consumption at Brompton Hospital; in ten of them it was continued for more than a month; and the conclusion to which he came, was that no benefit could be observed to follow its use. Oil of turpentine appeared to relieve the cough in a few cases, and likewise camphor. He used the vo- TREATMENT OF TUBERCULAR CONSUMPTION. 527 latile alkaloid conia in the quantity of one minim, diluted with nine of spirit; the cough was usualty relieved, and in two or three cases the breathing also. It would seem, therefore, from its volatility at the ordinary temperature, to be a remedy peculiarly suitable for in- halation, if it could be obtained more easily. Dr. Snow also found great relief in a few cases of bronchitis with difficult expectoration, from inhaling ammonia, twenty drops of the strong solution being mixed with two ounces of water in a Woulfe's bottle. Chlorine has been used for inhalation; it was introduced for this purpose in France, and there is good reason to believe that it has proved of material ser- vice in cases of chronic bronchitis, and even in some of phthisis. With reference to its use in this latter disease, Dr. James Clark has observed, "We have tried it in many instances, and it has in several, apparently suspended the progress of the disease." He also states that it relieved dyspnoea and cough in some cases, though in the majority it procured no amelioration. Dr. A. T. Thomson has likewise stated, that in cases of asthma, the relief it produced was very striking, and that in phthisis, he had observed the hectic symptoms abate. Of the various remedies now mentioned, it is probable that gum resins and balsams, camphor, conia, and chlorine, are the most suit- able and useful for inhalation; but it does not appear that by in- halation of opium, or morphia, very decided advantage has been gained over the ordinary mode of exhibiting them. The vapour of tar was formerly recommended for inhalation, and few medicines have been more used for this purpose than creasote. Sir Alexander Crichton, in 1823, strongly recommended tar vapour in consumption; but Dr. Forbes, in a report of cases in which he had tried it, published in the Medical and Physical Journal, stated that he found it injurious in this disease, though of service in some cases of chronic bronchitis. He appears, however, to have used it in cases so far advanced, that no benefit could reasonably have been expected from its employment. Creasote has now superseded the use of tar vapour, which does not, from its irritating properties, seem well suited for inhalation, though there can be very little_ doubt, when we consider the healing power it has in external application, that it must exert a similar effect upon the lungs, if it could be used in such a form as to obtain its beneficial influence apart from its ir- ritating properties. Creasote is perhaps more generally used by the profession for the purpose of inhalation, than any other remedy; and I believe that when sufficiently diluted with vapour of water, it is one of the most useful. I have found that it has a sedative in- fluence relieving cough and promoting expectoration, whilst it at the same time not unfrequently lessens the quantity of this secre- tion both in consumption and bronchitis. I have already observed that the pyrogenic bodies act upon the mucous and cutaneous sur- faces • and my attention has been directed to other bodies of this 528 THORACIC DISEASES. class, by the fact that many of them have remarkable healing pro- perties, when applied to ulcers and chronic cutaneous eruptions, a fact which leads me to expect that this class of bodies may, when fully investigated, furnish a suitable remedy for promoting the heal- ing of pulmonary ulcers, and thus supply the desideratum to which I have previously alluded. Many of the pyrogenic bodies possess such healing properties in cutaneous diseases, in a greater or less degree. From my own experience, I know that ointments, made with tar, creasote, spirit of tar, juniper tar oil, and naphthaline, have such properties, and are valuable remedies in the treatment of skin diseases. The inference drawn from these facts, has led me to use for in- halation, some other pyrogenic bodies, viz.: spirits of tar, juniper tar oil, Persian naphtha, and eupione. The spirit of tar possesses the healing virtues of tar without its irritating effects; so much so, that I think it might advantageously supersede the crude substance as an external remedy. It is more readily volatilized than creasote; and when inhaled, it produces generally a mild, stimulating, and often rather a soothing effect upon the lungs. In some instances, however, it has appeared to increase the cough and expectoration, and it is not, therefore, suited for bronchitis, until inflammatory ac- tion has been subdued completely; or for cases of consumption, until progress has been made in arresting the disease. Without wishing to speak confidently of the remedy, I may state that it has appeared useful in some cases of the latter disease, in conjunction with other treatment. Juniper tar oil (oleum codinum,) which is a valuable remedy in skin diseases, and much used on the Continent, is less volatile than spirits of tar, and is less irritating when inhaled. Persian naphtha and eupione possess decided anaesthetic properties; the former, when inhaled along with the vapour of water, has in some instances relieved difficulty of breathing in a very remarkable and decided manner; and this fact renders it worthy of trial in spas- modic asthma. Eupione has decided sedative properties: it has re- lieved cough and difficult breathing, and patients have slept well after using it; but it is not a pleasant remedy to inhale, and it has not unfrequently produced sickness afterwards, so that I should not recommend it to be used for this purpose. I have used several of the essential oils for the purpose of inha- lation. Many of them possess decidedly antispasmodic properties, and I have found that they have a remarkably strong power over difficulty of breathing, a property which renders them peculiarly suitable for relieving spasmodic asthma. The oil should be dissolved in spirit, and inhaled with the vapour of water, so as to dilute its stimulating properties. The oils of cubebs and copaiba, which are hydro-carbons, are mild in their action, and produce very little sti- mulating effect. The oxygenated oils which I have used appeared to be more stimulating in their action on the air-tubes, and some of TREATMENT OF TUBERCULAR CONSUMPTION. 529 them have stronger anti-spasmodic and expectorant properties. The oils of anise and peppermint are very stimulating, and in general cause too much irritation. Oil of spearmint is milder and antispas- modic, relieving difficulty of breathing in asthma, and even in phthisis. Oil of fennel is also mild. The oil of origanum is moderately sti- mulating and expectorant. I have also used the oils of rosemary and pimento, which have similar properties. The hydruret of benzyle, which is the oil of bitter almonds deprived of its prussic acid, is very irritating and much too stimulating for inhalation. Chloroform is a remedy which has been much used by some medical men for the purpose of inhalation, not only in asthma, but, in a small quantity, in consumption, in order to relieve irritable cough. In some cases I have dissolved the essential oils in chloroform, and used them in this way for inhalation, their volatility being thus so much increased that they may be given on a handkerchief, as chlo- roform is usually administered. In addition to the remedies spoken of by Dr. Turnbull, carbo- nate of ammonia, nitrate of silver, sanguinaria and veratrum viride have been quite extensively used by different physicians, and in some cases to much advantage. The oil of erigeron, spoken of by Dr. Turnbull, I have used quite successfully in several cases of haemoptysis, connected with phthisis, but whether it acts more effi- ciently in this way than when introduced into the stomach, I am not prepared to say. If the inhalation of medicine be resorted to, the introduction of medicine into the stomach should not be neglect- ed. We can readily conceive how ineffectual a treatment exclusively by inhalation must prove, since the well established pathology of this disease shows the local affection of the lungs to be only one of the unhealthy products of the constitution. Sir Alex. Crichton, in 1823, met with remarkable success in the treatment of pulmonary diseases by the inhalation of the vapour of boiling tar; and many nostrums since his time have been origi- nated on this principle. These observations show that the old authors understood quite as well as, if not better than, the moderns, the advantages to be de- rived from inhalation in pulmonary diseases. Scudamore* gives the following formula for an iodine inhalation: R. Iodine, gr. v.; iodide of potash, gr. iij.; alcohol, 3ij.; distilled water, 5 v.; and saturated tincture of conium, 3vj. M. Of this he directs usuallv two drachms as the total quantity for each inhala- tion; two-thirds"for the first half of the time, and theother third for the remainder; the period being fifteen or twenty minutes three times a day, and the vehicle, water of about 120° Fahr. If ex- pectoration be very difficult, from fifteen to twenty minims of a saturated tincture of ipecac, should be occasionally added. The * On Inhalation. London, 1834. 530 THORACIC DISEASES. best times for inhalation, he thinks, are before breakfast, before dinner, and before going to bed. The smallest dose of iodine for each inhalation is one-tenth of a grain, the largest five-eighths of a grain, the medium about one-fourth of a grain. The inhalation at first increases the cough a little, but it soon gives relief by facili- tating expectoration. It sometimes causes a thickening and irrita- tion in the posterior fauces, which assume a dark-coloured inflamed appearance, but with hardly any soreness; it commonly passes away even during the continuance of the treatment, but always if the iodine be suspended for a few days. A spongy state of the gums, without ptyalism, as if from mercury, is occasionally produced, which disappears without special treatment. Where moisture is present, iodine sublimes below the temperature of boiling water, and remains diffused in the air even at ordinary summer temperatures. Dr. Murray* prefers the iodine vapour disseminated in an apart- ment, by putting five grains in two quarts of water at 160°. This gives to the air somewhat the smell of the sea-beach at low tide under a hot sun, and will make a vapour so dense as to stain the clothing a deep yellow; double this quantity will make the eyes smart. In order to obtain an artificial sea-air, Laennec sprinkled some of the wards of his hospital with fresh sea-weed, and with much benefit in certain cases. Next to iodine, as an alterative and healing inhalation, Scuda- more prefers chlorine. This was first recommended by the French physicians, who noticed that the workmen in a factory for printed calicoes quickly recovered from any symptoms of phthisis which they had on entering; the rooms were highly charged with the vapour of chlorine disengaged during the various processes. Laen- nec tried this also, in 1823, by sprinkling chloride of lime in the sick room, and with partial success. Chlorine may be readily dis- engaged by burning chloric ether in a common camphene lamp. Scudamore obtains the chlorine from the pure aqueous solution, be- ginning with six minims, and renewing this quantity every three or four minutes, until about a drachm has been used. If it produces much irritation, conium may be added. As a sedative inhalation in bronchitis or phthisis, where the irritation is very great, he prefers the following: R. Acidi hydrocyanici, 3SS«5 tr. conii, gss.; tr. ipecac. 3ij.; aquae rosae, giij. M. Of this he prescribes half an ounce, divided into two portions, three times a day; or, for each in- halation, 30 minims of tr. conii, 20 minims of tr. ipecac, and 2 minims of prussic acid, adding two more for the last half of the process. Dr. Lombard, of Geneva, treats catarrh, accompanied by distressing pain and sense of weight in the frontal sinuses, by opium inhalations—sprinkling a few grains of powdered opium on a metallic plate heated in a spirit lamp, and making the patient * On Heat and Humidity, &c. London, 1829. TREATMENT OF TUBERCULAR CONSUMPTION. 531 hold his head in the fumes, which afford speedy relief. Hyoscya- mus, stramonium, digitalis, and other narcotics, have been used, singly and combined, warm and cold, as sedatives for cough. It having been observed that tanners were not liable to consump- tion, Dr. Murray {op. cit.) recommends the inhalation of the vapours from a decoction of oak bark; other astringents, vegetable and mineral, are also of service in cases accompanied by profuse and exhausting expectoration. Creasote is now much employed in this manner, and acts with advantage both as an astringent and anti- spasmodic, and probably also powerfully disposes ulcers and cavities in the air-passages and lungs to take on a healing process. This substance is the great "cheval de bataille" with the "consumption- curers," as may be perceived on putting the nose within their pre- cincts in any of the large cities. Though much abused, it is an admirable remedy. The inhalation of ether and other antispasmo- dics in asthma and kindred diseases is universally and favourably known. Of the advantage of breathing demulcent vapours in croup, the well-known experience of Dr. John Ware is sufficient proof. In Part VI., 2d Series of Dr. Simpson's Obstetric Memoirs and Contributions,* (pp.441—462,) are given very interesting facts, showing the comparative immunity of wool-workers in Scotland from phthisis and scrofula and from pulmonary diseases generally. It is also shown that this immunity is in proportion to the more or less "oily" nature of the departments of work in which the operatives are engaged; the more oily the work, the more marked is the ex- emption from disease. The oil enters the system not only through the cutaneous absorption, but also "by inhalation through the mu- cous membrane of the lungs," (p. 456.) The author gives rules for the external application of oil in scrofulous and tuberculous dis- eases, which deserve the attention of physicians; anything which promises to stay the progress of this "opprobrium medicorum," especially when coming from such a high authority, should at least no tri6cl. Any diseases which tend to enlarge the chest are said to be pre- ventives or curatives of phthisis—such are diseases of the heart, asthma, or any affection of the throat which prevents the free pas- sage of air from the lungs, and consequently causes their enlarge- ment. Mr. Ramadge f has met with remarkable success in curing pulmonary diseases by causing his patients to fill the chest many times a day, through tubes about five feet long and half an inch in diameter; and I think there can be no doubt of the utility of fre- quently inflating the lungs to their utmost capacity with pure air, as a preventive of disease. It would be interesting to ascertain if players on the cornet-a-piston, bugle, clarionet, and other wind in- struments requiring long retention of the breath, are not less sub- * Edition of Drs. Priestly and Storer, Philada., 1856. f F. H. Ramadge-,N.Y., 1839. 532 THORACIC DISEASES. ject to phthisis and its kindred complaints than are the members of other trades and professions. In connection with simple inhalations, I would repeat what I said before, (Jan. 7, 1858, p. 461,) with regard to the superiority of a dry steady cold, even of considerable intensity, to a warm moist air accompanied by sudden changes, as a preventive and curative of pulmonary disease. In other words, the climate of Lake Superior, Canada, or Northern Maine, I consider far preferable to the Brazils, the Indies, the Mediterranean, or the Atlantic Islands. Perhaps the cold climates might not answer for their own native residents; it is undoubtedly true, as Celsus said of the affections alluded to, that " the worst air for a patient is that which has given rise to the disease." It has thus been seen that the results usually expected from al- teratives, narcotics, antispasmodics, astringents, and expectorants, taken into the stomach for the relief of pulmonary diseases, may be more directly, speedily and effectually obtained by the inhalation of the same substances through the lungs. The chief articles, and the principles on which they are used, have been sufficiently de- tailed; any intelligent physician can add to the list as his cases require. Without undervaluing the constitutional treatment of phthisis—the use of cod-liver and other oils to correct the deficien- cies of nutrition and assimilation—the administration of salts of lime to favour the cretaceous transformation of tubercle—or the employment of suitable remedies as general tonics and alteratives— I wish most earnestly to call more attention to what may be called the "curgical treatment''' of pulmonary diseases. I maintain that the cavities in the lungs, and the ulcerations in any part of the air-passages, should be treated by direct medication to the morbid surfaces, just as much as any cutaneous lesion should be treated by external applications; and the only way to do this is by medicated inhalations, either of the temperature of the surrounding air, or raised to blood-heat. Diseased surfaces may in this way be stimu- lated to take on the healing process; and the parietes of cavities, by the constant pressure of the air-cells, enlarged by inhalation, from without inward, may be brought in contact so as to favour the formation of cicatricial tissue. Such auxiliary treatment, based on reason and experience, is, I think, a great addition to the armament of the physician in his battle with the "great destroyer." Says Prof. Paine,—"When a person exhibits premonitory symp- toms of phthisis, every exciting cause of the disease should be re- moved. The patient should exercise freely in the open air, and be placed upon a full and nutritious diet, such as beef-steak rare cooked, &c. He should also take a reasonable quantity of some stimulant, as brandy toddy, or some malt liquors, before each meal. If this does not remove those early symptoms, chalybeates, in connection with sugar, may be given as follows: TREATMENT OF TUBERCULAR CONSUMPTION. 533 R. Precipitated carbonate of iron, gij. White sugar, gvij. Mix and triturate, take one teaspoonful three or four times a day. Should the beef, and other articles of food, not be well digested, on account of a dyspeptic habit which frequently precedes this disease, slightly cooked eggs and rich animal soups may take their place. This course has been efficient in my hands in a large number of cases, where the early symptoms of phthisis were developed. But where the disease is farther advanced, with more or less anaemia, cough and expectoration, with depression beneath the clavicle, fee- ble respiratory murmur, and dulness on percussion, and especially if there is connected with this a tubercular diathesis, then much effort will be required to prevent a disastrous encroachment of the disease. In this condition and stage of symptoms, the following treatment should be instituted. "A large double flannel cloth, within which has been quilted a liberal quantity of coarse salt, should be placed over the chest and back in such a manner as to protect both the anterior and posterior portions of both lungs. This salt pack should be changed from time to time, but should be worn until the disease is removed. And for supplying those deficiencies of the blood, which are such a pro- lific cause of pulmonary consumption, give the following compound: R. The white of eggs, xij. Iron by hydrogen, gr. xx. Phosphate of lime, 3 iij. Chloride of sodium, giij. Mix with one pint of best brandy, one pound of sugar and one pint of water; dose, one tablespoonful three or four times a day. In connection with this, the patient should exercise freely in the open air, and should make a liberal use of warm or cold baths, as the case may seem to indicate. If there are chills, R. Quinine, gr. xx. Phosphate of iron, gr. x. Morphine, gr. iss. White sugar, gr. xxx. Mix, triturate, divide into fifteen powders, and take one every three hours. If the first fifteen powders fail to interrupt the chills, they should be repeated from time to time, until they cease entirely. If there is troublesome cough, with dyspnoea, give the following mix- ture: , „ .... . T... R. Simple syrup of stillingia, guj. Syrup of tolu, In. Lupulin, gr- v. Mix; dose, one teaspoonful three times a day, and oftener if re- 534 THORACIC DISEASES. quired. If there appears to be bronchial irritation, from one-eighth to one-half a grain of gelsemin should be taken at bed-time. If the salt pack should be removed at any time during the treatment, the chest should be well protected by oil silk or flannel. In nearly all cases of pulmonary consumption, there is a deficiency of the na- tural covering, the hair. In fact, so generally is this the case, that I have come to regard a deficiency of hair on the chest as one of the indications of a tuberculous diathesis. For the hair is not simply an ornament, but it serves to separate certain proportions of car- bon, silica, sulphur and other materials from the blood. As the disease advances to the latter part of the second stage, other symp- toms make their appearance, as diarrhoea, and a muco-purulent matter and pus, constituting the sputa, indicating a breaking down of the tuberculous deposit, with more or less affection of the glands of the bowels. To control the diarrhoea, no medicine is more effec- tual than the following: R. Sub-nitrate of bismuth, gr. xx. Quinine, gr. xvj. Pulverized gum arabic, gr. xxx. Mix, triturate, divide into twenty -powders, and give one every five or six hours until tbatlsymptom is controlled. In this disease, much benefit will be derived from the use of diu- retics to relieve the blood from the excess of uric, and other acids, with which it becomes overcharged, and also of the disintegrated tissue which accumulates in the system, owing to imperfect respira- tion. Among the best diuretics to accomplish this object is the fol- lowing: R. Pipsissewa, gj. Indian hemp, Jjss. Marshniallow, Ij. Bruise all together, and make one quart of syrup with white sugar, and add one half pint of best gin, and let the patient take from one half to one wine glass full four or five times a day. For the purpose of procuring rest at night, R^ Quinine, gr. x. Scutellarin, gr. xv. Gelsemin, gr. ij. Iron by hydrogen, gr. xij. Mix, divide into ten powders, and give one every night at bed-time. Where there is great emaciation and debility in this stage, for supplying material for combustion, and for increasing the quality and quantity of blood: R. Cod liver oil, Oj. Good brandy, Oss. Chloride of sodium, 3,ij. Phosphate of iron, gjss. TREATMENT OF TUBERCULAR CONSUMPTION. 535 Mix, and shake well before using. Dose, one tablespoonful three or four times a day. If there is much bronchial irritation in con- nection with tuberculous affection, R- Syrup of stillingia, gij. Tinct. of veratrum viride, gss. Mix, and give thirty drops three or four times a day. For the purpose of promoting absorption of the already existing tuberculous deposit, Prof. John Fondey, Emeritus Prof, of Theory and Practice of Medicine in the Eclectic Medical College of Penn- sylvania, who has had great experience in the treatment of this class of diseases, places much reliance on the use of electricity. In his treatise upon this subject, he thus remarks: "The electro- magnetic machine constitutes one of the most powerful means that we possess, to accomplish the results so desirable in the treatment of this disease. What we want in the remedies which we employ, is some power that will excite the contractility of the coats of the vessels, of the enlarged absorbent glands, as well as of the lymphatic vessels; give strength to the magnetic organization of the part, and promote the absorption of the deposits that may have occurred in and around these glands and vessels. Dr. Cartwright, of New Orleans, who has published several very interesting articles upon the nature and treatment of tuberculous affections of the lungs, cites quite a number of cases where absorp- tion of the tuberculous deposition was affected by the inhalation of the vapour of sugar. I have generally obtained the most satisfactory results in pro- moting the absorption of tuberculous deposits by the use of iodide of potassium, in connection with mucilage. The mucilage prevents the irritating effects of the iodide of potassium on the bowels. The chest should^ be thoroughly bathed twice a day with a liniment made as follows: R. Oil of stillingia, Ij. White of three eggs, Oil of turpentine, lij. Chloride of sodium, 3ij. Mix, and shake well together. During the entire treatment of this disease, the strictest attention should be given to bathing, diet, and exercise in the open air. Every means should be resorted to which has a tendency to improve the general health of the patient. Where the disease assumes a periodic character, the greatest_ benefit will be derived from administering a liberal quantity of quinine and iron every seven or eight days. When the disease is complicated with other local difficulties, such as leucorrhoea, spermatorrhoea, &c, thev should receive especial attention. 3 62 536 THORACIC DISEASES. The veratrum viride I consider invaluable in this disease, in order to control secondary inflammation. Its use should be con- tinued for weeks, prescribing it wdienever the pulse rises in fre- quency above the normal standard. It does not contra-indicate the use of quinine, iron, and generous diet at the same time. In the morning the patient, if cold and chilly, should take freely of gin toddy, with valerianate of quinine; and if the pulse is frequent, from two to four drops of the veratrum should be given every two to four hours. When the fever rises, the quantity should be in- creased. The muriated tinct. of iron is the best remedy with which I am acquainted, to prevent pyemic fever, which is always liable to arise when large surfaces are pouring out pus, which is liable to poison the veins and absorbents, and produce a rapid retrograde metamorphosis in the elements of the blood. When tubercles are rapidly softening, 15 gtt. of this should be given three times a day. The extracts on the treatment of consumption, show a diver- sity of opinion in regard to treatment; and yet there are certain general principles which direct the physician in his choice of re- medial agents. In my practice, I use a tonic course, arresting intercurrent pneumonia, with veratrum viride. I stimulate the nervous system with cannabis Indica, a remedy which of late has been extensively advertised as a patent medicine. This compound is composed of liquorice, cream of tartar, and the cannabis, with some form of spirit. I frequently use the cannabis in combination with veratrum. To allay nervous symptoms, I do not use opium in any form, but prefer hyoscyamus, and its preparations, or lupu- lin, and scutellarin. A pill I use very much for producing sleep and preventing night sweats, is this:— R. Sul. quiniae, grs. xx. Ext. hyoscyami, grs. xx. Vallet's ferruginous mass, q. s. Mix. Divide into twenty pills. Dose, one at bed-time, and re- peated once in four to six hours. For the treatment of laryngeal complications, the reader is re- ferred to the article on laryngitis. Dr. Green of New York, re- commends inserting into the trachea, a gum elastic catheter, down below the larynx, and injecting a solution of nitrate of silver; 3j. of the salt, to Ij. of water. There is much discussion as to the propriety and benefit of this treatment. It is, to say the least, of doubtful utility. Says Dr. Green, "The instruments I use consist of an ordinary flexible or gum-catheter, and a small silver or a glass syringe. The catheter is Hutching's gum-elastic catheter (Nos. 11 or 12,) which is 12| inches in length; and, as the distance from the inci- sor teeth to the tracheal bifurcation is, ordinarily, in the adult, about eight inches, if this instrument is introduced so as to leave TREATMENT OF TUBERCULAR CONSUMPTION. 537 only two inches of the catheter projecting from the mouth, its lower extremity must of course (if it enters the trachea) reach into one or the other of its divisions. I first prepare my patients by making applications with a sponge-probang, for a period of one or two weeks, to the opening of the glottis and the larynx, until the sensibility of the parts is greatly diminished. Then, having the tube slightly bent, I dip the instrument in cold water (which seems to stiffen it for the moment, and obviate the necessity of using a wire,) and with the patient's head thrown well back, and the tongue depressed, I place the bent extremity of the instrument on the laryngeal face of the epiglottis, and gliding it quickly through the rima glottidis, carry it down to or below the bifurca- tion, as the case may require. It is necessary that the patient continue to respire, and the instrument is most readily passed during the act of inspiration. The tube being introduced, the point of the syringe is inserted into its opening, and the solution in- jected. This latter part of the-operation must be done as quickly as possible, or a spasm of the glottis is likely to occur. Indeed, if the natural sensibility of the aperture of the glottis is not well subdued by previous application of the nitrate of silver solution, or if the tube in its introduction, touches roughly the border or lips of the glottis, a spasm of the glottis is certain to follow,_ which will arrest the further progress of the operation. The epiglottis is nearly insensible (and this you may prove on any person, by thrusting two fingers over the base of the tongue, and touching or even scratching with the nail.) This cartilage should be our guide in performing this operation. The strength of the solution for injecting is from 10 to 25 grs. to the oz. of water. Com- mencing with 10 or 15 grs. to the oz. its strength is subsequently increased, and the amount I now employ is from i to J drachm of this solution. " In cases of bronchitis, asthma, and in phthisis, even the employ- ment of the tube once or twice a week, diminishes the cough and expectorations, with great certainty, especially in the two former diseases; and many cases have recovered under the local treatment after other means have failed. The applications of the sponge- probang are continued in the intervals of the employment of the tube." Pleuritic complications should be treated with mild counter-ir- ritants over the seat of pain, and the chest-wrapper should be worn. , „ -, , • >j. t j Abdominal complications are benefited by counter-irritants, and the use of the liquid nutriment recommended in a previous part of this article. Diarrhoea should be arrested by geranin, astrin- gent and nutritious enemas, and a little brandy toddy. Gastric irritation is best treated with mucilages and liquid nutriment and counter-irritants externally, with a weak infusion of hydrastin internally. 538 THORACIC DISEASES. For ulceration of the intestines, the general treatment should be tonic, and mild nutritious diet in a liquid form should be used, and the patient kept quiet lest perforation of the bowels be pro- duced. Fistula in ano should be healed after the general system is properly restored, and the blood enriched by tonics, exercise, and good diet. When this is effected, it may be healed with safety, but it should not be, until the blood is enriched in fibrin and corpuscle by previous treatment. Chronic bronchitis complicating phthisis should be treated as de- scribed in the appendix under that head. Phosphorus should be used according to the directions there given. The climate best adapted to the cure of this disease, is that away from the sea-coast, in Northern Canada, Vermont, or in Northern Wisconsin and Iowa or Nebraska Territory. The nearer one is to the Atlantic coast, the more tendency there is to tubercular phthisis. Patients should, therefore, go to those sec- tions of our country, in case they are in the incipient stage of the disease, and not delay until the lungs are nearly destroyed. If dyspepsia complicates phthisis it should be treated accord- ingly, and an out-door life recommended, with the use of our ordi- nary treatment for gastric disturbance. DIVISION II. TREATMENT OF CARDIAC AFFECTIONS. CHAPTER I. In pericarditis the treatment should be evacuant; so that jala- pin, podophyllin, and bitartrate of potassa are indicated. After the cathartic, the veratrin or aconite should be used, or a combi- nation of lobelia, scutellarin and cypripedin. On the praecordia, a piece of linen wet in oil of sinapis should be placed and permitted to remain ten minutes to produce counter-irritation. When there are nervous symptoms use aconite, hyoscyamus, and scutellarin. When feeble capillary circulation in extremities is present, use the cutaneous frictions and vapour bath. Gelseminum is pre- ferred by some practitioners in these cases, instead of the above- mentioned sedatives. The hydrocyanic acid is sometimes recommended in these cases and thought to be efficacious. The general treatment should be nearly the same as that for pleuritis. In the stage of effusion it is necessary to use diuretics, the apocynin, eupurpurin and digitalin. Various domestic remedies of this class have been recommended by authors. Such as the aralia hispida, the apium or parsley, cy- tisus or broom, the Indian hemp, apocynum cannabinum, etc. When the case is somewhat chronic a syrup of these, made with gin, will be very valuable. TREATMENT OF CARDIAC AFFECTIONS. 539 The syrup of the horse-radish and mustard, and stimulating diuretics generally are most beneficial in the sub-acute variety or in the last stage. Squill has long been used in this, and with benefit. For the purpose of removing the water in the pericardium, the following compound is valuable:— R. Potass, bi-tar., giv. Scillae pulv., 9ij. Digitalis pulv., 9j. Apocyniae, grs. x. Podophyllias, grs. v. Divide into thirty powders. Dose, one every four hours. After the removal of the effused fluid, tonics should be pre- scribed. Hydrastin and eupatorin for simple debility, the muri- ated tinct. of iron in case there is evident anaemia. Five to fifteen drops is the usual quantity. For periodic symptoms, quinine should be used. Sulphate of cinchonin or quinine should be given every three or four hours until the symptoms are controlled. If the pulse should remain frequent, and there is hepatic de- rangement with feeble digestion, sanguinarin and prunin will be found serviceable. If there is a tendency to dropsical effusion, the apocynin should be added. When pericarditis becomes chronic, and is complicated with phthisis, the sanguinarin and prunin be- come most valuable agents. In this condition the circulation should be controlled by veratrum viride in combination with qui- nine and iron. Digestion should be stimulated by tonics, and the kidneys by diuretics. The heat of the body should be maintained by a generous, but unstimulating diet, and by gentle exercise in the open air. In extreme pericardial effusion, the puncture in the pericardium has been performed. This operation consists of plunging a trocar between the fourth and fifth ribs, on the left side near°the sternum, or by trepanning the lower part of the sternum after the manner of Laennec. This operation, however, is seldom successful, and should never be resorted to, unless there is the best evidence that there is a large collection of pus or sero-puru- lent matter in the sac, and all other means have failed to relieve. The consequences of this, are similar to those following paracen- tesis thoracis; inflammation, and its long train of sequences, caused by the contact of air with the pericardium. Laennec describes cases in which the gas was found accumulated in this sac in consequence of disease. But recent observers have seldom met with similar cases. The symptoms are unnatural reso- nance on percussion over the praecordia, with the same distention and enlargement that characterize liquid effusion. Sometimes gas and fluid co-exist, in which case the symptoms vary according to the position of the patient, the air rising to the highest part of the 540 THORACIC DISEASES. cavity causes resonance there, while the dulness corresponds to the position of the liquid that gravitates to the lowest part of the sac. The treatment for these peculiar cases needs no essential modi- fication. If pus is collected in the sac, the muriated tinct. of iron should be given more freely, either alone or in conjunction or al- ternation with quinine. The hygienic treatment should be more strictly tonic, and the diet nutritious. Every means that tends to destroy the fibrin and corpuscle of the blood should be avoided, and every remedy and means that tends to increase them is bene- ficial, so that iron, quinine, nutritious diet, and cleanliness are the philosophical means of cure. The treatment of endocarditis and carditis is similar to that for pericarditis, but endocarditis sometimes needs a variation in medication. In the first stage, the remedies should be more ener- getically applied, and the neutralizing mixture, and podophyllin, and jalapin should be used earlier, and a large sinapism placed, on the chest. Of late, lemon juice has been much used in rheumatism, and is thought by many to have a specific tendency to neutralize that peculiar condition of the blood which is characteristic of that disease. If such were the case, this remedy would be beneficial secondarily in endocarditis. The remedy is thought to be seda- tive to the circulation, and to act similar to nitrate of potassa. The dose of citric acid is from five to ten grains, or twenty grains may be added to one pint of water, and used like lemonade made in the usual way. In the treatment of cardiac inflammation, the utmost care should be taken to promote capillary circulation, and cutaneous friction with a tea of mustard should be enjoined. In the plethoric, the hydropathic appliances will be useful to remove the abnormal fulness of the blood-vessels. If the febrile symptoms are very marked, the wet sheet should be resorted to, and repeated accord- ing to the degree of superficial heat, the sensations of the patient being the guide. When the local pain is considerable, the chest- wrapper should be worn covered with a dry cloth, and changed five or six times a day. When the pulse is feeble and the heat of the body unequal, the warm or tepid or vapour bath should be taken. Stimulants at this period should be administered. The indications for their use are the following:—feebleness, intermis- sion and irregularity of the pulse, or when feebleness of pulse coincides with a diminution of iuipulse, turgescence of the jugular veins with or without pulsation, feebleness of the first sound of the heart; the symptoms of weakened circulation, pallor, coldness of the surface, oedema of the extremities, and a tendency to syncope. When these symptoms occur, no local inflammation should prevent the administration of general stimulants, such as wine, brandy toddy, the brandy and egg mixture of the Eclectic Dispensatory, carbonate of ammonia, tinct. of capsicum, and xanthoxylin. TREATMENT. OF CARDIAC AFFECTIONS. 541 Atrophy of the heart requires a tonic treatment. The object is to replenish the corpuscle and fibrin of the blood, for which pur- pose, the following prescription is admirably adapted: R. Phos. ferri, 3j. Hydrastiae, 3ij. Sac. alb., giij. Vini, Oj. Aquae, Oss. Dose, a table-spoonful three times a day. To regulate the circulation of the blood, veratrum or aconite should be used, and malt liquors allowed in moderation, especially in the aged. In the treatment of hypertrophy of the heart in addition to that described on page 422 to 424, aconite and veratrum viride are valuable remedies. The usual dose of aconite should be given until the cardiac pulsations are regulated. The veratrum viride may be given for a similar purpose three or four times a day. Five grains of the iodide of potassium should be given three times a day. If the disease should not yield to this plan of treatment, give small doses of podophyllin and phytolaccin to act upon the secreting functions. The rubbing wet sheet judiciously applied, an occasional pack, followed by friction, will prove valuable to remove plethora, and equalize circulation. In cases unconnected with dilatation, in which there is great muscular strength, and full plethoric habit, it will be necessary to administer a hydragogue cathartic. The common anti- bilious physic will fulfil the indications very well. But I prefer the following:— R. Sanguinariae, gr. ss. Jalapiae, gr. ij. Podophylliae, gr. ss. Bi-tart. potassae, ^ij. This should be repeated as occasion requires. Administer at bed-time. The diet should be abstemious, and free from spices, and much oleaginous and saccharine matter. When the circulation is extremely rapid, give tincture of veratrum viride. The tempera- ture should be regulated according to the amount of superficial heat of the body. A simple diet is necessary; the avoidance of tea, coffee, tobacco, and all nervous excitants should be enjoined; the exercise should be regular, and gentle, and the mind kept free from depressing mental emotion. This is the treatment best adapted to remove simple hypertrophy without dilatation.^ When enlargement of the heart co-exists with dilatation of the ventricular cavities, with feeble cardiac impulse, and slow and feeble pulse, cold extremities, and passive congestion, the treatment should be more tonic and stimulant. Under these circumstances, 542 THORACIC DISEASES. hydrastin, valerianate of quinine and iron are indicated. Then give muriated tincture of iron, hydrastin and valerianate of ammonia and quinine, in simple syrup three times a day. Dilatation without hypertrophy requires tonics and stimulants. In case there is great relaxation of the muscular tissues, use as- tringents in combination with tonics. Among these, the best are myricin, geranin, gallic and tannic acids, trillin, etc. In these cases of debility of the heart, a nutritious diet is indicated, and the tonic effect of an occasional bath of salt and mustard water applied with brisk friction. Dr. J. II. Hero, of the Westborough Water Cure, Mass., applies to the naked body a sheet wet in water as hot as can be borne, until redness of the surface is produced, and im- mediately follows this with a sheet wet in cool water, with brisk friction, and then rubs with a dry towel, until the tonicity and acti- vity of the superficial capillaries are fully established. Regular habits, freedom from excitement, a generous diet, gentle but not continued exercise, fresh air, the avoidance of all powerful evacuant remedies of every kind are the more important hygienic influences that should be brought to bear in these cases. If the digestive organs are exceedingly feeble, and the animal heat very low, the moderate use of ale and porter will prove beneficial. In very low conditions of the circulation administer xanthoxylin, tinc- ture of capsicum and carbonate of ammonia. If the nervous system is greatly depressed give the cannabis Indica in sufficient quantities to produce slight exhilaration. When hepatic derangement com- plicates hypertrophy, sanguinaria is indicated with minute doses of podophyllin. If there is dropsical effusion the apocynin should be prescribed. The treatment for functional diseases of the heart must depend upon its cause. Simple nervous palpitation is best allayed by hy- oscyamus, scutellarin and cypripedin. If connected with hysteria or derangement of the menstrual functions, proper remedies should be used to restore that secretion, such as macrotin, caulophyllin, sulphate of iron, etc. If the blood is anaemic, ferruginous tonics are indicated, and a rich and nutritious diet. If there is plethora, then hydragogues, jalapin, cream of tartar, and podophyllin should be administered with occasional baths or packs, and the use of veratrum viride. If palpitation arises from dyspepsia, hydrastin will be found an excellent remedy, with sanguinarin and prunin. If there is any periodicity manifest, the valerianate of quinine is necessary. If connected with spinal irritation, dry cups should be placed over the sensitive ganglia of the back, and an irritating plaster applied to produce counter-irritation. If neuralgia causes the palpitation, macrotin, aconite, dioscorin, and cannabis Indica are the proper remedies. If the cause is rheumatic, tincture of colchicum is occa- sionally beneficial, given in sufficient quantities to cause a laxative effect. IN Abdomen, regions of, 87. Adventitious sounds, 124 Amphoric respiration, 112 Resonance, 128 Aneurism of aorta, pathology, diagnosis and treatment, 436—441 Angina pectoris, 434, 435 Aortitis, pathology, diagnosis and treat- ment, 435 Aphonia,, treatment of, 463 Aphthae, thrush, 454—460 Apoplexy, pulm., diag. and treatment, 211—214, 523 Appendix, 516 Asphyxia, path., diag., treat., 441—444 Articulo mortis, cause of, 135 Atrophy, 501; of heart, 541 Auscultation, defined, 97; mediate, im- mediate, 101 Auscultatory percussion, 100 Biographical sketch, 9 Blastema, 39 Bronchi, morbid changes in, treatment, 173—176 Bronchial tubes, structure of, 103, 104 " respiration, 110 Bronchitis, acute, path, diagnosis, 143— 147. Prognosis, 148. Treatment, 148, 149, 516—518. Bronchitis, chronic, 150—156. Of chil- dren, 156—518 Bronchitis, Epidemic, 156, 518 Bronchophony, 126—127 Cancer, pulmonary, 369—371, of medi- astinum, 371. Prognosis and treat- ment, 372. Larynx, 463 ; treat. 463 Cancrum oris, 452. Cantus omnium avium, when heard, 152 Carcinoma, treatment of, 509—515 " nuclei of, globules of, 74, 75, cancer, varieties of, 70 63 EX. Carditis, 413—540 Cavities, size and form of, 297, concre- tions in, 297 Cells, forms of, 41 Cicatrix, 44 Cicatrization of tuberculous cavities, 296 Classification of disease, 17 Clergyman's sore throat, 462, treat. 470 Concretions, kinds of, how formed, 297 —299 Concentrated remedies, nomenclature of, 239 Congestion, pulmonary, 208, pathology, diagnosis and treatment, 209—522 Congestion, path, of, 23, kinds of, 34, 35. Corpuscles, white and red, 25,26, 45—49 Considerations of a general character, 18 Coryza, 449—451 Cough, varieties of, 132—135 Cough, whooping, 160, 518 Cracked pot sound, 92 Croup, 464—466 Cyanosis, 447,448 Cynanche tonsillaris, 456—457 " maligna, 458,459 Cytoblastema, 39 Diagnosis, general, 83 Diatheses, rheumatic, 502, arthritic, 503. Treatment for the scorbutic, 503, bilious, 504, scrofulous, 301,505-509 Dilatation of the heart, 424—427, 542 Disease defined, 17, general treatment for, 139—141 Dull Sounds, 91, 92 Dyspnoea, table of causes of, 130, 131 Effusion, kinds, how produced, 35, 36 Egophony, 128 Empyema, 280—283, 524 Emphysema, varieties of, 199—207, 522 Encysted tumors, 81 Endocarditis, 405, 406,'treatm't, 411, 540 OEX. 544 ini Erectile tumours, 82 Erysipelas, 487, 493 Expectoration, 68, 69 Fainting, or syncope, 444, 445 False membrane, 44 Fever, definition, varieties of, 19, treat- ment of, 473 Fibrin, 24—28 Fluid, nervo-vital, 28, hyaline, 39 Friction sound, 124 Fungus, 44, hsenaatodes, 510 Gangrene, varieties of, 57, pulmonary, 216—220, treatment of, 220, 523 General treatment of disease, 139 " " inflammation, re- medies for, 475—487 Globulin, 46, 47 Granules, 41 H.&MASTASIS, 481 Hsematine or Haunatocine, 46, 47 Heart,'diseases of, 373, symptoms of, 373—375, causes, diagnosis and prognosis of, 377, examination of, 377, its position, size, impulse, 378 —381, physical signs, 382—384, normal sounds of, 384—38*7, abnor- mal sounds, 387—393, functional disease of, 433, 434, 542, dilatation of, 424—427, disease of valves or- ganic, 427—432, atrophy of, 541 Hydatids, 81, 82 Hydropericardium, 433 Hydrothorax, 272—275, 524 Hypertrophy, kinds of, 414—421, 424, 501, 541 Immediate percussion, 92 " auscultation, 101—102 Inflammation, definition of, 20—22 theories of, 21 nature, causes and effects, 23 Inflammation, difference between itself and congestion, 23 Inflammation,increase of fibrin in, 24,33 " white corpuscles, 33 " effeots of, 28—29 " redness, 29 " swelling, 29—30 " pain, 30 " heat, 31 constitutional excitement in; cause of, 32 Inflammation, loss of appetite in, 33 Inflammation of lungs, 177 '' ulcerative and suppurative, 493, gangrenous, 500 Influenza, 156—518 Inspection, mode of using in diagnosis, Laryngitis, varieties of, 4">9, pseudo- membranous, 4C0, spasmodic, 461, erythematous, 461, chronic, 462, treatment, 464—469, syphilitic, 469 Larynx, foreign bodies in, 464 Lymphatic swelling, 58, treatment for, 508—509 Malignant tumours, 80 Mediate percussion, 92 " auscultation, 101—102 Melanosis, pathology of, 77—80 " forms of, 78 " symptoms of, 79 Membrane pyogenic, 55 Metallic tinkling, 125 Mensuration, 91 Modelling process, 42 Morbid changes in the bronchi, 173 Mortification, pathology of, 57, varieties of, sphacelous, gangrene, 57, dry and moist, senile, effects, 57—58 Myocarditis, pathology, 413, Diagnosis and Treatment, 414 NERvo-vital fluid, 28 Nomenclature of concentrated remedies, 239 Non-malignant tumours, 80 Nuclei, 40 (Edema, pulmonary, 220—222, treat- ment of, 523 ffidema in phthisis, 321 Palpation, 89 Pathology, 18 Pectoriloquy, 127 Percussion, sounds of, 91—92, uses of. 94-96 Pericarditis, pathology, diagnosis, treat- ment, 394, treatment, 401—404— 538—540, operation for, 539 Peripneumonia, 157 Phthisis, definition of, 283, symptoms, stages, 301—302, rational and phy- sical signs in first stage, 302—305, second stage, symptoms, 306—307, third stage, 308—310, cough in, 311, sputa, 313, dyspnoea in, 314, he- moptysis, 315, pain, 318, pulse, 319, sweats, 319, emaciation and diar- ihcea, 320, oedema, 321, mind in, 321, dyspepsia, 321, sexual symp- toms, 322, duration of, 324, varie- ties of, 324, complications, 331—338, causes, 338, prognosis, 350, treat- ment, 351, medicine in, 355—356— 363—364—366—368, nutriment in, 525, inhalation in, 526—532, medi- cal treatment, 532—538 INDEX. 545 -245, treatment, Pertussis, 100—165—518 Pleuritis, pathology, 223—230, diag nosis, 230—238 asthenic, 244 " chronic, 244- 238—243—249 " latent, 259—262—265, treat- ment, 523 " children, 264 paracentesis in, 249—255 Pleximeter, kinds and uses of, 93 Pneumonitis, pathology of,177—183, Di- agnosis of, 183—188 " asthenic, 192, prognosis, 189 " bilious, 194—521 " typhoid, 194—521 " lobular, 195 " secondary, 198, treatment, 190 193—198—520 Pneumothorax, pathology, 265, Diag- nosis, 266—269, prognosis, treat- ment, 269—270—524 Polypi in larynx, 463, in heart, 446 Pulmonary ^OO^ V*^ NATIONAL LIBRARY OF MEDICINE NLM D3E77bl3 E NLM032776132