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TEXT-BOOK

A

OF

PRACTICAL
WITH

MEDICINE,
TO

ANATOMY.

PATHOLOGICAL

AND

PHYSIOLOGY

REFERENCE

PARTTCULAE

BY

FELIX

DE.
LATE

OF

PROFESSOR

PATHOLOGY

FROM

NIEMEYER,

THERAPEUTICS,

AND
THE

TRANSLATED

YON

UNIVERSITY

THE

DIRECTOR

OF

EIGHTH

PERMISSION

GERMAN
OF

MEDICAL

THB

OF

CLINIC

OF

TUBINGEN.

BY

EDITION,

SPECIAL

AUTHOR.

THE

BY

GEORGE
ONE

OF

THE

PHYSICIANS

H.

TO

SOCIETY,

INFIRMARY,

TRINITY

FELLOW

OF

M.

HUMPHREYS,

THE

MEMBER

YORE

NEW

OF

ACADEMY

THE
OF

NEW

D.,
YORK

MEDICINE,

COUNTY

MEDICAL

ETC.,

AND

CHARLES
ONE

OF

THE

PHYSICIANS

TO
NEW

THB

E.
NEW

YORK

HACKLEY,

YORK
COUNTY

HOSPITAL
MEDICAL

REVISED

NEW

INFIRMARY,
ETC.

I.

YORK:
AND

AND

ETC.,

D.,

EDITION.

APPLETON
1, 3,

TRINITY

SOCIETY,

VOLUME

D.

AND

M.

5

BOND

1884.

COMPANY,
STREET.

MEMBER

OF

THE

according

ENTERED,

D.

in

Clerk's

the

Act

to

Office

according

the

Office

to

of

Court

District

D.

In

"

District

Southern

ENTERED,

the

in

Congress,

APPLETON

the

of

of

Act

of

of

Librarian

of

the

in

United

States

the
year

Congress

1869.

by

for

York.

New

"

of

year

CO.,

Congress,

APPLETON

the

CO.,

at

Washington.

1880,

by

the

PEEFACE

TRANSLATOES'

"

his

by

profession

medical
for

teaching

life

and

the

made

of

amount

in

book,
charm
has

the

as

bringing

to

seemed

the

out

as

have

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to

abilities

a

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in

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perience.
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rare

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by

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Alcohol

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Grsecorum,

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to

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upon

additions
to

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articles
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to

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transla-

the

fore,
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original

Niemeyer's

to

of

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have

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work

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other

and

as

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the

sources

useful

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inserted

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;

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old.

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Seitz.

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editor

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by

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text-book

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by

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of

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death

Germany,

text

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in

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war.

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Niemeyer's

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having

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fifty years

about

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mental

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a

united

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was

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1871,

French-German

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during

labors

death

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died,

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translation

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"

Medicine

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of

edition

last

EDITION

1880.

OF

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well

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as

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sis
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chapter

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EDITION

THE

TO

PREFACE

TRANSLATORS'

iv

OF

1880.

compiled
edited

States,"

from

chiefly

Alonzo

by

Clarke.
made

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in

the

sections

readily

one

to

NEW

the

YORK,

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there

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1880.

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readers

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with

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edition),

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importance
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pains

science,

conviction

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to

probation,

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rand

revision

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owing

of

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present

on

valuable

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to

existing

"

somewhat

edition

unaltered

revision

first

its

own

Important

rendered

editions,

branches,

purpose

thorough

The

arrived.

have

the

to

kindred

longer

a

her

pathological

chemistry.

points

important

discoveries

many

in

sion
acces-

recognized.

renewed"

been

rich

a

only

not

of

appearance

owes

physiology,

previous

most

this

only by
from

up

its

for

allowed

made,

obscure

errors

well
the

medicine

pathological
;

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of

medicine

time

and

book

my

account

of

and

settled

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corrected,

theories

of

provinces

physiological

questions

to

the

in

but

and

clinical

first

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since

elapsed

investigations

to

EDITION.

SEVENTH

Meanwhile,

knowledge

province,

have

years

text-book.

my

THE

TO

foi

me

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size.
few
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nearly

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parts

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enriched

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portions

of

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attention

all

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work

undergone
received

have

copious
to

the

tions.
addiim-

I wish

partly because
investigations,

it has

which

confidence

I

physicians; partly because
made,

therapeusishas
last ten

I attribute

science

My

I then

true.

medicines, and

pronounced
the

for

denounced

the

that

goal

a

medicaments

to

our

all their

experiments

declared,without

gave

no

;

from

nor

is

in the

new

scarcelymore

therapeuticsuccess,

unless

that

after

should

be

I
it
be

the

promote
the

tutes
insti-

laboratoryof

the

even

been

low-creatu
afflicted fel-

an

experiments made

as

yet

of but

of

been

that

a

continuation
I

finally

dazzling progress
little

our
discoveries,

use

present

than

direct

no

service.

the

with

healthy human

upon

prospect of such

that

of

to

peutics
thera-

success

at

fiftyyears

pathological
investigation
promote

directed

more

requirements of general medicine, than
Thus,

of

but
ingenious suggestion,

favorable

future would

action

declared

aid from
the

animals, or

had

cal
all medi-

quantities. T

in the relief of

reservation,that

that,in spiteof

bedside

known

treatingdisease,and

pathologyhad made,
;

ago

lower

have

self-evident.

be

seek

an

showed

liant
bril-

ago

of the

strivingto

scientific value,had
of

means

then

serviceable

the

upon

beings,with

the

of

peutic
thera-

prescriptionshould

computation of

and

now

I further

of such

medical

a

should
efforts,

own

idea

gaining an

years

unattainable,and

be

to

when

of

chemist,obtaining

which

the

years,

it with

postponing

would

cure

physiologyand pathology,or

of

service

of

late

which

followed

knowledge

our

of

means

time

a

their

healingart by

that,of

of ten

error

physicians,instead

that

have

assertions

simple resultant

lamented

and

outspoken

ideal

this

hope

to

never

which

progress

insightinto pathological
processes,

our

advanced,

the fact

mainly to

disease,until

of

treatment

idle

practical

of
important acquisition

most

advanced,

be

can

results.

far

happy

recognizedthe only path by

explorershave

medical

so

the

the

maintain

to

for itself among

won

recent

years.

This progress

come

book

my

regard

the

as

therapeuticsby

of

in the domain

portant results obtained
honorable

EDITION.

SEVENTH

THE

TO

PREFACE

vi

in

accordance

has been

showing that therapeusis must

done

with

the

hitherto.

expect

no

aid

PREFACE

itself

by

as

the

either

of

already possessedfor

we

of

or
therapeutics,

science, I pointed

natural

the

rational

only

out

the

it must

to be

how

done, and

and

proper

any

other

I then

establishment

that

the
and

if
therapeusis,

natural

of

branches

the

remedy

has done
in

worthless

a

good

I

therapeusis as
still remained

the

much

be, and

of

treatment

careful

upon

has

that

the

or

; that

medicaments

no

until this shall
those
particularly
the

accessories

task

the

head

due

of

symptoms

administration

of

a

a

because
of

no

study ;

be

to

one

but

of the

for

that these

any

of

and

; that
been

by

a

cal
empirirules for
the

most

healing effects
and

lished
be estab-

all

their main

subsequent

such

of

physicians,

that

(no

doubt

lyze
ana-

to the

very

totallyneglected,

results from

pessimistviews

brilliant progress

that

to
objectively)
possible,

hitherto

obtain

and

science,familiar with

of the

supposed remedy

expected to

that

useful

obtained
the

turies,
cen-

inexact

to

therapeusiscan

disease,prior to

have
laborious)investigations

ancient

disease,is utterly

that

shall comprehend
diagnosis,

to

in other

experienceof

; until clinical teachers

occur

carefully(and,where

is,most
the

at

basis

sure

prolificof

I declared

view.

disease,is only

rect
cor-

general impression

in this

point of

the

been

intelligent
investigationof

and

more

tions
that observa-

imperfect,are

matter, capable of affordingtrustworthyand
the

facts,and

explained that, when

error

harm,

or

scientific

material

proceedings,just as

sometimes

incomplete observation;

of

else,empirical knowledge

or

erroneous

the
proved false,

the

department

what

deduction

science.

therapeuticlaws, based
have

all

inaccurate

of

and

conclusions

of

for

one

of

observation,so

trustworthymust

in
false

the

accurate

more

method

thorough acquaintancewith

and

requiresa profound

edge;
knowl-

is stilllackingis to be obtained.

that,before

demonstrated

of

preciselywhat

more

that which

conducted

empirical

independent empirical study; showed

an

be

peculiar branch

showing, farther, that

investigationis

vii

EDITION.

that

and

independent

an

after

study

SEVENTH

incomplete sciences,and

other

from

THE

TO

evince

such
an

a

method

tion
undervalua-

of physiol
physicaldiagnosis,

in the last ten

the

to

of

branches

learning,yet

knowledge, from
of

enabled

now

are

we

only by

state

of

relation

tions
modifica-

phases-and

authentic

and

obtaining sure

of

of which

means

comparison of results,is

accurate

unfavorable, but, judging

means

no

of

dint

therapeuticfacts,by
not

of

disease,the prospect

of

disease,

origin and

the

various

the

follow

to

of

present

by
improved accessories,

the

from

symptoms

deeper insightinto

our

the

from

tends

operandi

'modus

the

these

its way,

knowledge

our

of

is, that

conviction

My

medicines.

improving

of

any

discovery,in

new

comprehension

by assistingour

or

of

expected

be

to

every

art, either by

that

to benefit

is not

healing

of

art

advantage

immediate

direct and

Although

years.

pathologicalchemistry, made

and

pathologicalanatomy,

ogy, of

EDITION.

SEVENTH

THE

TO

PREFACE

Vlll

from

present

certain.
experience,is positively
Seven

difficulties are

"

"

following words

the

with

smallest well-authenticated

"

importance, will inspirethe

"

to make

"

equal

now

A

therapeusisan

that

say

researches
not

fail in

means

of

hitherto

with

a

The

valuable

long-neglectedfield

which, already,the

has
ill-appreciated,

value

been

generalrecognition,and
to the

dominion
as

success,

an

of the
etc., and

have

the

in
digitalis

of

a

example

requisite

which

take

may
I

may

well-nigh surpassed.
these

out

under
of

treatment

of certain

ous
labori-

which

perseverance

labors,now

a

could

tion,
prosecu-

disease,by

important articles,

final blow

has

been

which

establishment
of the

of

I will
of

merely

mention

This

the

covery
dis-

quinia in typhus,pneumonia,

precise indications

heart, has

ceived
re-

given

dishearteningtherapeutic nihilism.
of

the

profound

accuratelydetermined, have
thus

antipyreticaction

disease

of

research

carried

of

that

physical study."
been

thoroughnessand

its effect.

the

in

anticipationshave

my

teachers
distinguished

of

band

of

branches

other

sole

is the

this

science

; the

one

conviction

in

science,a

exact

that

therapeuticsis

perseverance

Tubingen

at

laborious

a

goal, the

fact in

"

with

knowledge

wished-for

the

to

the

is

task

The

:

but

great ;

"path leading

rank

inauguraladdress

ago, I closed my

years

caused

the

for the

zeal

for

use

of

therapeu

PREFACE

TO

experimentation to

tic

great results.

of the

"

of the

cold-water

we
results,

effect

produced by

of

done

much

men,

who

of

from

control

of educated

how

of Paracelsus

of

number

the

"

and

words,

facts

In
friends

friend
counsel
new

and

its immediate

alone

"

and
and

with

tender

and

object
"

my

colleagueProfessor
he

experienced
has

sign

offspring
traditional
ings
teach-

obsolete

the

still

better,that

no

small.

grown

of my

book,

the

more

of the

use

clinical

aid

path by

which

peutic
of thera-

the establishment

has

cordial

thanks

to

favor; especiallyto

my

me

in

the

honored

my

Seitz, of Giessen, for

assisted

numerous

the

preparation

good
of

(Signed)

edition.

FELIX
TUBINGEN,

in

it has

favorable

a

doses,make

contents

for their

patrons

which

good

attained !

is to be

conclusion,I

great

a

homoeopaths, who, implicitly
and

more

main

and

extinct ; and

devout

the

in pursuing
investigation

for

wonderful

to

developments of therapeuticresearch,has
these

ture
temperais

failingsof

and

submission

trustingin homoeopathic tenets
May

the

laity,where

It is

that

"

become

and

pure

of the

it
regulateits effect,

to

errors

of blind
have

"

gation
abne-

support formerly enjoyed by the

of Eademacher

therapeuticrules,and

the

of the

tem
sys-

Among

alone

the hands

recognitionand
perception of

laudable

powerful

that

the

to

upon

This

property of science.

doctrine

and

knowledge

of heat

weapon,

capacityand

common

warm
"

its

Such

dation
foun-

some

water

accurate

febrile disease.
a

have

cure

richly rewarded.

more

harm, and, under

clear

a

our

all-healing
power

supply of

been

its means,

taken

know

so-called

has

to

experience

hydropathictreatment

active abstraction

By

is
peril,

the

that

to it

in acute

body

the

of

the

lead

to

rude

"

bread

of the

pride

owe

achievement.

become

effects both

sectarian

other

time

"

the

the

even

belief in

jx

destined

subjectedto rigidanalysis.

been

of the

and

limitation

continued

of

direction

a

their

cure

fact,the

have

EDITION.

Rightly supposing that

ignorant laityand
in

SEVENTH

assume

of the

"

THE

October, 1807

VON

NIEMEYF.R.

HIT

.

II. the of the of Trachea the of to Respiratory the III. Tubercular VII. " " " Laryngeal Perichondritis 45 OF . Additions CHAP. the 134 Lung RESPIRATORY 144 ORGANS . 108 Emphysema " Senile 109 110 Lung 130 Lung (Edema " HAEMORRHAGES . .. Larynx Ulcers Variolous Disease Syphilitic " 1 15 the of Ulcers and Larynx the Membranacea Angina " Catarrhal " IV. .. THE OF AFFECTIONS PAGE CHAP. 49 DISEASES III." " " Bronchial Pulmonary Apoplexy 145 Haemorrhage Haemorrhage of the Lung 157 . IV.94 Convulsiva of of Hyperaemia the Revised Edition OF THE the Lung Lung the of . . SECTION LARYNX. V. . I. 57 TRACHEA THE OF Whooping-cough " . Typhous " V. PARENCHYMA OF THE LUNG. VI. Glottidis Palsy I.. IV. 43 SECTION " . of THE . VI. I. .. AND . II. RESPIRATORY I.95 . ORGANS.. " " VIII.OF CONTENTS OF TABLE THE OF DISEASES VOL. 31 the of . SECTION II. . 107 1880 III... Larynx in Additions CHAP. " IX. VIII. BRONCHI. V. Croup " III.. . .. 165 . " " XL" of Larynx Growths the of (Edema 35 Larynx the 38 . of Catarrh and Hyperaemia " FROM ... AFFECTIONS LARYNX THE 51 Glottidis Spasmus 51 of Muscles the of the to Glottis the 54 of Edition Revised 1880 Hyperaemia and Catarrh Croupous Inflammation Essential Asthma Spasm II. . 33 Larynx the Ulceration NERVOUS X. VII. Air-passages Tussis " Muscles . .. of Hypertrophy " " " " " Atrophy the of Emphysema Collapse 61 Bronchi and 86 88 DISEASES I.

375 878 the Heart of the Heart 379 880 . Myocarditis VALVULAR X. APPENDIX THE TO CHAP. 264 Hydrothorax 284 Pneumothorax 287 " Tuberculosis " V. " XIII. 210 ." . CIRCULATORY THE OF SECTION I. ." XL " XII. Membrane Mucous Nasal at the EESPIRATORY CAVITIES. 299 Epistaxis " Revised the ORGANS. " OF Croupous Pneumonia 166 Catarrhal Pneumonia 194 " of the Gangrene XV. LUNGS THE OP 212 Miliaty Tuberculosis of the Cancer Additions 267 Lung the to 253 Revised Edition of SECTION DISEASES " OF THE PLEURA. III.. 839 " Endocarditis V." VII. THE OF DISEASES Hypertrophy of ORGANS. 166 LUNGS THE Additions to Pleura 294 Pleura of the Cancer " of the 295 Revised the Edition of 1880 296 . Heart the III.OF CONTENTS OF TABLE xii VOL." Atrophy of the Heart VI." Lung of the Induration TUBERCULOSIS XIII.. . CHAP. NASAL THE OF DISEASE THE OF DISEASES Fibrinous of the of the of the Heart Substance Heart Deposits in Congenital Anomalies " .. ... HEART. DISEASES CHAP. IV. . CHAP. 311 Dilatation of the Heart IV.310 . PAGE INFLAMMATION IX. of the Bleeding " Additions to Nose 305 of 1880 Edition I. Catarrh I." 330 " 342 354 DISEASE OF Insufficience of the Mitral " Insufficience of the " IX. " II. Consumption Pulmonary Acute XIV. " 199 Lungs 207 . I. " " XII.. 258 1880 of the Pleura Inflammation I. IV. " X." VIII. " II. " 359 Valves Valve 365 Valves Semilunar and of the Mouth Contraction of 373 Pulmonary Artery 374 Insufficience of the Tricuspid Degeneration Rupture " 358 HEART THE Insufficicnce of the Semilunar the XL .. n.

Excoriations V. PAGE CHAP. 458 SECTION II. . " III. .412 .439 . " V. of the IV. 437 Cancrum SyphiliticAffections Soor" DIGESTION. IX. . OF . . " VI. Coats of the Inflammation of the . . Aorta of the Rupture " IV. SECTION CHAP. " 426 Obliteration Stricture and V. " III. . . . I. Ptyalism to . . of the Pericardium . " XL" Muguet" 447 Glossitis Parotitis 449 " .391 VESSELS. . " . Mouth of the Mouth Affections . XIV.." Angina Catarrhalis " ." 461 II. . 413 417 Aorta . Diseases of the Pulmonary Artery Diseases of the Great Venous 428 429 Trunks to the Revised DISEASES Edition ORGAN'S THE OF of 1880 DISEASES I. III. . DISEASES II. I.. THE GREAT of the Aorta OF 408 410 of the Pericardium Tuberculosis Aneurism .. III.395 Hydropericardium Cancer . II. Pharyngeal Croup of 1880 Edition . . Mumps Salivation" Additions CHAP. .444 ." XV. " IV.." VIII. . . . . .451 . MOUTH. the Revised AFFECTIONS " . 469 . . ." Catarrh CHAP. ." " OF Mouth Stomatitis " I." Neuroses of the Heart 384 . . 431 Oris . . . THE Pericarditis Adhesion . III. IV.TABLE CONTENTS OF OF VOL. OF SECTION . . . . Scorbutic of the 441 Mouth X." II. II. " VII. . . 412 . . .. . . 445 ' Thrush Gangrenous Sore Mouth " . ." VI. Disease Basedow's Additions 388 the Revised to of 1880 Edition SECTION DISEASES CHAP. " OF of the Heart and I. Aphthse " DiphtheriticStomatitis" and 430 . of the 470 Pharynx . ". Croupous " " . . . " " Pericardium 406 . . Additions the Pharynx ." of the 427 Aorta . ." THE . . Pneumopericardium . . .474 . . 471 of the Pharynx Inflammation SyphiliticAffections THE 463 DiphtheriticInflammation V. Phlegmonous of . PHARYNX." VI. Ulcers of the . . 453 I. PERICARDIUM.

OF 489 Catarrh Gastric Chronic 479 III. THE INTESTINAL OF PerforatingDuodenal " Contractions IV. to 628 638 . . " Strictures of the Dilatation cf the (ESOPHAGUS. " III. 698 Carcinoma Worms " 655 . THE (Esophagus 480 482 . I. " X. Dyspepsia Addition the Revised Edition CHAP. X. I." " Retropharyngeal Abscess 476 Angina Ludovici Addition . OF (Esophagus Growths Morbid Nervous VL" of the Inflammation " VI. VIII.""." Peritonitis " Mesenteric 604 SECTION III. " Carcinoma of the Stomach " IX.CONTENTS OF TABLE xiv I. VII. of 1880 . VI. " Ulcer 583 Closures 586 Tuberculous Diseases of the Intestines of the Intestines 607 Haemorrhagesand Vascular Colic" Enteralgia 609 Dilatations 617 in the Intestines 622 Gastric Fever to 631 the Revised Edition DISEASES OF of 1880 THE PERITONAEUM." III. " II. of the Stomach . Inflammation III." Ascites 649 Tuberculosis Additions 636 VI. 477 and to Cancer the Revised 654 Edition of 1880 656 . OF PAGE VI. " IV. Edition Revised the to of 1880 SECTION AFFECTIONS CHAP.651 ." Catarrhal SECTION V. VOL. CHAP. (Esophagus 488 of the Rupture (Esophagus (Esophagus of the Affections 486 (Esophagus in the and Perforation SECTION DISEASES CHAP. and and Periproctitis Perityphlitis Additions CHAP. . Acute " II. CANAL." Gastritis 624 Phlegmonosa Inflammations from Chronic of the Ulcer 624 Caustics and Poisons 625 Stomach . I.663 565 Glands VII."'. " V. " Haemorrhage from Spasm the Stomach 645 . AFFECTIONS . 493 Catarrh Gastric 611 Croupous Inflammation " IV. I." . " Scrofulous V. THE STOMACH." II. 490 IV. . " and and " VIII. VII." IX. 638 II." V.

I. X. I. " II. " Liver Lardaceous Cancer VIII. . 726 DISEASES CHAP. " OF Suppurative of Cirrhosis Liver THE V. Portal the Vein 683 Fatty Liver VI. . II. . OF THE LIVER." 685 the of 690 Liver 692 the of Tuberculosis Liver 696 ." 667 LIVER Inflammation of 681 . " IX. . 756 . " III. IV. Catarrh of the " " Obstruction I. THE Diphtheritic Inflammation and Gall-Stones II. Gall-Ducts and Croupous " OF 722 " 754 THE DISEASES Leucocythaemia OF THE SPLEEN. . Carcinoma. " V. PAGE CHAP. . xv BILE-DUCTS. " IV." XL" XII. " the INFLAMMATION II. III. . XIII. Spleen 739 Spleen 745 750 Infarction Tuberculosis. " XIV. GALL-DUCTS." Hyperaemia of Closure their the of Hypertrophy Lardaceous of I. . 730 etc." VI. Wandering " the the 729 Spleen Haemorrhagic TO Leuchaemia of the Spleen 751 Hydatids 754 Spleen APPENDIX CHAP. " 665 Hepatitis 665 the 670 Liver Syphilitic Hepatitis IV. .TABLE DISEASES CONTENTS OF OF OF LIVER THE AND SECTION DISEASES VOL. of Hyperaemia I.717 of 1880 SECTION DISEASES CHAP. " Excretory Gall-Ducts. . " Echinococci of Multilocular Hydatids the Liver 697 701 Icterus Hepatogenous 705 . " and II." VII. " III. Melanaemia Addition 761 to the Revised Edition of 766 1880 . Consequences OF 732 THE SPLEEN. I. ." Icterus Hematogenous Acute Yellow Additions 714 of Atrophy the to Revised the Liver Edition . .

. COMPARATIVE TABLE OF THERMOMETRIC SCALES.COMPAKATIYE TABLE OF ENGLISH AND FRENCH WEIGHTS.

CHAPTER ITYPEE^EMIA AND CATARRH ORGANS. an and of their individuals. to form. of who this one rapid evaporation robust the greatly among in point people. cause than are epidermis readily are sweat too.] that. a to tarrh ca- instances predisposition others. catarrh to liability cases. who Special predisposition. see hurtful of favorite seems varies . or be as one. active or passive. OF THE MUCOUS MEMBRANE OP THE LARYNX. main the so-called catarrh purulent intense . ally live continu- weather. to that coexist persons and whatever clew affection. of resisting prone other At it.DISEASES OF THE EESPIEATOEY SECTION AFFECTIONS L OF THE LARYNX. thin a persons surface. the now to a catarrh processes prevail. and to perspire chilled full-blooded no the cachectic Badly-nourished. changes thus . or condition this are and mucus round in as there character watery of usual the exposed that find we the to in some strong tendency apt be to suddenly the action than there is this we that exposed less those Effeminate country to frequently who are by but epithelial yet even which of infiltration an oedema " more imparts instead " the those of habits of affected with are. mucous moderate more Now the mucous another now pus-corpuscles excessive an to within serum the may catarrh blenorrhcea. or cases else or of succulence. there cells. serous exciting cause same in may In more characterizing changes to brane. Here the distinctlyobservable. is always in another be exudation. less is there [Whenever " to all events. mem- is also diversity of great a feature discharge. I. are and . stress who of sedentary exposure. and more more intense and the capable In aggravate temperature rarely subjected less whole. shepherds. mucous attack. the on of to seem persons to such to of perspiration. liberation a causes itself membrane the them mucus-corpuscles. ETIOLOGY. habits. very thus predominating.due may cells glandular crude a of flow a imparting known morbid The of hypersemia condition manifold. for agents.

in severe cases visible upon in which catarrhal its extent. are one constantlyseeing some who. in the the severe skin forms " and mucous mem portion of a very grippe.an injuryquiteas great as that occasioned by other agencies.singing. that.in of the catarrh cause agent which.chinkof narrow irritants the are acrid vapors coughing.catarrh to the the or pharynx that form have we a give a to genetic connection is sometimes of the often the next the between two events affected almost always have not may membrane have catarrh takes any is of shouted of the or sung new thus from irritant.is inexplicable.after repeated attacks. In a constitutional disturbance . woollen or denied. chilling We will give rise to this disease. voice. Among exanthematic the chronic. extensive and its onset. affeccontagion. the latter procedure the air is driven forcibly In .LARYNX.also. other sign of acute debauch. and the disease the affection. of is the Difficult Thirdly. loud screaming too.as catarrhal coryza. subject. in an vulnerable.becomes more causes trifling excite to serve weak a of fresh disease the organ. Among these and of dust violent are through the which act the upon breathingof very cold air . free having left off his laryngealcatarrh. among disorders the maladies thus to localize themselves are especially prone the larynx. those Fifthly. to be not neckcloth a Indeed. inva- will.local " the friction upon glottis. The will almost Of THE OF AFFECTIONS 2 always give rise to thing alone one we be may membrane mucous laryngeal diarrhoea. place. The exciting causes larynx. The the especially case in which spirituous liquors.stridulous a catarrh.laryngeal catarrh disease resulting from infection is a symptom common constitutional of the acute tions. causing severe its edges.the " remains that and it were. of the skin. first.or sure to bronchial a riably.particularly Secondly. the most form of laryngealcatarrh ensues. pharynx.suffers it may as a occurrence.or in consequence on it extend pharyngeal mucous hoarse. This the upon often the induced malady notice We membranes. that of the neck and feet. of membrane.syphilitic measles and typhus . that fact. one another larynx. without bronchi direct action may be day from nation explaphysiological unfrequentlyspreads from not laryngealmucous nose stockings. intense If acrid liquidsor hot water penetrate into the organ. although Habitual much. coming person the abuse by neighboring organs see superventionof point of origin.as catarrh. and shouting. in which the ryngeal lathe topers cous laryngealmu- part Fourthly. the inhalation and . We still lack a thorough insightinto the physiological upon connection between the blood-changes at the root of the disorders and or the nutritive branes in these derangements complaints."or influenza.

are accompanied by which.this epidemic bears great resemblance be regarded as a In influenza. are sometimes varicose and of innumerable distension Sometimes it is covered profuse yellow " purulent membrane blood. like the hyperaemiaabout cases. catarrh must exanthemata.and indistinctly depend. or quence (fromdepositof pigment in consemucous surface larynx. infectious an morbid Sixthlyand finally. ANATOMICAL APPEARANCES. secretion. and to us acute does vascular engorgement redness In " epithelialcells young and follicles. called of under to the the microscope mucous brane mem- mostly uninuclear. 3 accompanies it. deeper layers or of are the and the corpuscles. of the constitutional a These catarrh. remaining extended fibres. after during life. and in particular for the fluctuations account symptoms of ulceration and malignant growths of the skin. The and faction granulated. the surface epitheliumof the most ciliated cylindrical-form superficial layerof the stratified the larynx.upon opacityand yellow color of granulated. having lost its elasIts tissue is generally thickened. are They are quite analogous exist in the to the young this " the muco- their nuclei cells foun .and hypertrophied. sometimes epithelialcells.are wanting in places. ulcers and tomatic symp- carcinomata and remissions.the degree of a of the could This is due symptoms then to tha be strated demon- richness of the which. but which adheres serum slightly-turbid transparent cells.form important subjectto exacerbations certain conditions. membrane In chronic laryngealcatarrh the mucous more or appears brownish less dark.AND HYPERJ3MIA CATARRH. and flabby. which reddened in elastic membrane catarrh the as observation. to the acute which tf not disorder. particularly ulcers of the larynx. (ecchymoses)in of the of present death in the substance either a contract. in many with and with mucous previous ecchymosis). The subtration. The substance of the mucous membrane itself is swollen.firmer.are of exponents the in larynx. of the membrane mucous cadaver and during life would lead such by the blood contained the and expel apoplexiesoccur catarrhs. contents On of the mucous always reveal violence such as the larynx.However.uneven appears. very of the mottled or violent mucous uniformly a aspect. capillaries.dirtybluish-red. The of gorged are secretion oft-en divided.from the tumeplaces.moister.1 by laryngoscopic laryngealmucous not expect. we in after membranes. of which the by The mucous a follicleswhich scanty glairymucus young . infiltissue may serous mucous exceptionallybe the seat of considerable condition to be treated of by-and-by as oedema a glottidis. and growths lous tubercuulcers.the flabbymucous copious admixture are vessels ticity.which numerous detached constitute membrane the find in the are the vessels death which epithelial cells.

a feeling complain patients or. the bronchi symptoms. thrown into vibration by the current of a strong expiration.LARYNX. as we become inaudible. disease of the of the second alteration of the voice larynx. the arytenoid. catarrhal sores. as to these sign of coughing. 'of a sensation of burning or soreness alone refer to the functional aggravated by speaking or as the generalcondition far down covering of be the seat In addition Sensation in these parts tends ex- magnitude. which of the chronic membrane very between has Lewin hoarseness is one the repeatedly officers who among shouting the word of command. in most of bronchi. which in the throat. larynx does true arytenoid cartilagesand to be ascertained the from to a cause but is treat in a There the false vocal chords.which is formed know. finally like a reed-pipe. disease The severe is is untroubled. or swellingof the little beyond. indeed.and has nothing in common with the so-called lardaceous or amyloid degenerationof other organs. imthe and vocal greatlycontracts the larynx. hoarse. chords stiff movable. in the larynx.catarrhal fever is also absent throughout the whole course chieflythat form of it which " The the attack. cases.sometimes which often tissues. confined to the have the involve always not We dissection.and in the much been are the of of the organ. or ment ligaarytseno-epiglottic becomes of catarrh of some painful deglutition intensity. between the two forms. THE OF AFFECTIONS 4 longer call them mucous. results whose elevation or depth of pitchdepends upon the a tone of tension in which have stated above degree they are set. but pus corpuscles. surface of circumscribed interestingform we catarrh to the arytenoidcartilage. If. and the symptoms of derangements of the suffering organ. In the act of speech. Now. and the polypous growths of which a separate chapter. Its metamorphosis into a brawny fibrous mass. althoughit is not easy in all cases. The voice furnishes grows a teristic charac- deeper. all The vocal sounds. Apart whole find that ited there may be catarrhs.chronic laryngeal catarrh. to distinguish membrane the laryngealmucous anatomical The changes which of the laryngoscopeduring undergoes can be better ascertained by means We in abscesses. we that in catarrh of the larynx the mucous swells UD and membrane cracked. originateentirely with membranous reeds. particular the arytaeno-epiglottidian fold. the epiglottis. when . Acute catarrh of the larynxrarelybegins SYMPTOMS AND it does not spread into the with shivering cases. by post-mortem life than often no now of habit ul~ and tuberculous accompanies syphilitic cous of the sub-muleads to a thickeningand induration Derations.the region of the epiglottis. especially mere hypertrophy of the connective tissue.the lower vocal chords as to projectinto the organ as approach one another so closely vibrating If membranes. in of of first more titillation.and may . of other organs arises.therefore. COURSE.and renders ration takes place in a manner quite analogous to that in which induThe process is a of the stomach.limThus sections.

and the is hoarse voice vibration. mentary bark. seat of is also violent coughing-spells provoked organ to any When we catarrh. passage. of note a to which tension of the voice may their them The also vibration free patient into chords. and consequent elevation the titillation.in the inspiratory spasm coughing all of the exposure foreignbody. cracks.as with the true chords.the expectorationis scanty the " .so that the jugularsdistend and the face grows red. has the one produce vibratile nodes. press the " " thorax. less profusion. their that the utmost is insufficient to or from (justas grease). so spontaneously. of the chords. upon mocough then changes into a of the cough is cracked. in these paroxysms.and becomes CATARRH. rima and glottidis. the with air can pass but slowly wheezing sound. in normal the covers and this in irregularswelling. inspiraa expiratoryeffort consequent upon this is only capable of effecting momentary openings of the constricted hacks short of a rattling. a great of pitch in the tone. oough." This momentarilytouch mucus. frequenceof vibra- for instance. inadequate chords. Quite frequently. Frequently the hoarse voice of the suddenlybreaks the tumid to the muscles thus when latter.and thus to check the influx to it of blood from the bluish.or " extinct. such glottis. In other cases of long standing the tone harsh hoarse and and from of the thickening and unevenness grows the chords. when occurs undue the find that reflex as irritation " the laryngealmucous analogous fits of and unobservable by the most trifling causes.render brought into contact impossible.bathed in discord.pitchsuch is rendered the voice surface the uneven. the sound contact When catarrh is confined to the larynx. thrown into strong thickened chords are made to bulge upward and are The hoarse tension. of the glottis besets the muscles a that. increase in the In the healthylarynx we phenomena upon intrusion a of membrane severe become last allow of Extinction the see another. Sometimes.so tion.sonorous tion.from some powerful expiratoryeffort. thus producing the interrupted." or. sonorous which mucus is altered violin-string swellingand the as of the presence From deeper. or more bring them is as to produce a can tension same in involved become their vibrations result at the would as 5 secretion a muscles laryngeal frequenceof the to increase by also chords the to which the tension the vocal the If so is covered relaxed. appearance. The effect of vigorousexpirationthrough a narrow make in blowing upon wind instruments is to comas we or in straining. veins. while long-drawn. At increase so is noiseless then voice Thus false are a depend upon swellingof the false vocal chords. and. AND HYPEILEMIA movement through are excited by which the contracted the fit commences. the may bring of tone makes and with smeared relaxation of the chords can chords its tones when conditioo.there to cough.or even of the cough likewise deepens. and hoarseness. Besides burning.

its entire space forming but a narrow chasm.the pars respiratoria roomy the base of the bounded and arytenoid cartilage. a completely croup. and hoarse without wake suddenly in the feelingill.or At first it is either mucous LARYNX. by of swellingof its mucous impervious to air by reason part of posterior triangularspace.This cells. does commonly a deeper layersof the epithelial corpusclesfrom mucous tain con- and the submucous cases. or of the false ones. Not at all rarelywe has been coughing a littleduring child who a see been the day."is the sputum coctum expectoration. clutches anxiouslyat the throat .as to place the patientin danger of suffocation. As the the " become Even alone. especially of Longet.justas in coryza sure could not think to cut hot from absolute that a closure of one or other spasmodic closure of the of the glottishad nostrils .which every inin the that there so is no to the entrance hinderance A of air. not much is seldom simple acute In exceptionaloccurrence. yet the glottis another by the free chords swollen are generallyseparated from one spiration act with action of the posteriorcrico-arytenoid muscles. is a tolerably it. allied or we itself to . save or laryngealcatarrh of adults is of the the glottis.or and crudum sputum admixture moderate " ciliaryepithelium. there has been such serious swellingof the be drawn asunder cannot true chords. membrane *' swelled infiltrated. up. be compensated for by muscular action. the terrified child throws and barking. up symptoms of is troublesome nightwith great oppressionof breathing. of the older in There " of As does ancients. however. the muco-purulent.AFFECTIONS g " sputum. much vanish hours after few often sooner. This begins to abate. glance glottidis laryngoscopeis enough to convince any one that the rima so swellingof the mucous widely that a moderate gapes duringinspiration of air or membrane cannot materiallyobstruct the passage produce at the of intense cases dyspnoea. or of the cells from of young covering. In certain well-authenticated catarrhal laryngitis. the cough is hoarse which These attacks. Although simple laryngeal is smaller.the expectorationbecomes thicker which rather resemble rich hi young pus-cells. The inspiration and protracted himself about in bed. and from a narrowing of the glottis. disease form of glairy. rare is much often not physicians. progresses more tissue dyspnoea in the more follicles. which by muscular action. reputation panaceas One might suppose as in time. often confounded with called are or pseudocroup. the emetic judiciously-administered againstcroup. these that swellingof which we warm see might accidents the sudden it short their owe laid sponge upon the throat. if given arose an unusuallyaggravated but transient mucous membrane. or springs . usually " It is to these the that the milk. THE OF persons grown among children it is for the rare dyspnoea of latter the catarrh to be continuous. detached else it is clear absolutelywanting.

or soreness however. As the successive gayly.A hoarseness. tJie the chronic abates form with the a the vocal permanent deepening catarrh. These attacks take place almost solelyduring sleep.. Attacks justlyprized. termination. haps which tends. the result of repeated acute attacks. mornings evenings and fits of violent The he is troubled protracted coughing.when the cough abate. a membrane so quite inaudible.as it were.and. This chronic hoarseness.whenever the voice is raised.hoarseness brane proceeds from the intrusion of a fold of memthe posterioradjacent surfaces between of the chords. to above. of week. to also by a dryness of the rima glottidis. there is also a periodical described as symptomatic of acute attack seems to proceed rather from an .so that the glottiscannot contract properly.while a during slight perfectlywell. some crude. duration. a During sensitiveness disease other In termi the cases the what day the patientis someis that in the but and otherwise well. Hypertrophy of the in the and As. mucous chords. the of about several weeks. such "7 as shall describe we by- probable and-by as laryngismusstridulus.HYPEILEMIA the irritation mucous as reflex a AND CATARRH. mem- described in the of tone voice.is one cause Catarrh Chronic of sensitiveness the the sputa cocta.to recur that the dyspnoea is it is likely as he falls asleepagain. days. aphonia. by sputa until often of remain at last. " membrane mucous in chronic again. section.as to In many instances. seem above.coughed. laryngitis of of death.and sputa cocta generallyappear after a with exceptionof termination nating by recovery complaint lasts for at the end few the hoarseness. such as we laryngealcatarrh. symptom.and larynx. in the last and and In the fatal of cases Larynx.uncomplicated by any other the greatest of rarities.the upon disease In other subsides. and vomited awhile.besides spasmodic cough. A is the result. so laryngealcatarrh.after repeated relapses.produce it harsh render cases titillation. change weather. hoarse. and to often the the alluded remedies regards the course. in which the membrane mucous of the posteriorwall of the larynx close below the vocal chords is thickened and swollen. of the like these are action several repeatedfor children play about day cough. But there is another and more explanation. Hence as soon and peroccasioned by a collection of tenacious secretion in the glottis. for the At all events.so burning.the of the nights.although the laryngitis.pass almost off after the child has cried.save hoarse.the acute of appearance find we thickeningof continued alluded in even hardlyever larynx. this explanation likewise accounts glue it up. From irritation of the render the have the voice cracked mucous voice time to usually time.as brane.is the chief and often the sole symptom of chronic long-standingchronic accompanies acute slightaggravationor some thickens the vocal chords.

of their child is well is complicated with of salutation aftei .and grating. enough of the evidence the child may of paroxysm Thus it is that eight.the addition of a nocturnal physician himself* suffered To occur. In frequent there has been of error diagnosis.should phthisisbeing the lungs. mucous and expiration. syphilitic It is to deal have On The most induce course of cautious and DIAGNOSIS.are " that and nose the latter.the cough may be harsh. barking cough furnish disease. which from tarrh caeasilydistinguishable voice.cracked.with and the of only by means with which of positively above either so For call attention the present we to laryngitis. In oral nasal the cavities. fever.and with hoarseness mere of that enough otherwise. be well dyspnoea so often attacks of innocent a so frequent nor of the likelihood of such recoveries. the the of a cure chest. The point only. guttural. Here too. often to as of such admit cases distinction between treatingof croupous one Nasal The graver " the disease sneezing. in deeper. former. stridulous The addition of a whistling. chronic rare). Croup croupous most in the croup who the timbre dread mislead hear of children disease our determine can suspicionof is laryngitis of the and presence will " or Confusion of laryngealcatarrh awaken we described.even although have voice is is mothers. it does certainly proceed from not denotes membrane.emaciation.is changed itself is tone to apt more the " nasal speech modified. which the laity lay greater stress than the profession.AFFECTIONS g accumulation of in secretion after the expectorationof mucus. reasons hoarse.ten. is of the contracted resonance voice. The pointsof the two will be more diseases fullygiven while catarrh satisfaction founded a the laryngitisas of we laryngo-stenosis of hoarse. for OF the THE LARYNX.swellinginto a bark.2 to that the of pharynx.or larynx. chronic produce alteration of the larynx.and and other the the laryngoscopethat these three main night-sweats. oU passes small a quantityof peculiarlumpy yellowish alreadygiven. of pouches and Morgani. (catarrhal laryngeol latent disease usuallytedious. is almost as surelysymptomatic of the catarrhal is croupous of mothers raritywith at the which having given rise " pharyngitisof running nose simple catarrh to " the old custom true laryngealcroup. as inspiration swellingand hypertrophyof the mere the of presence complication a " tissue thickeningand induration of the submucous morbid the cavity of a growth encroaching upon laryngitis. or is neither anxious even we more.upon form the laryngitis.and relapse.or else repeated physicalexplorationof the Catarrh " forms association judicioustreatment nearlyalways a strong tendency there is also the hand. It is be can of only by effected.

j . hours) to with a . and the small every to like doses three plague him of patient with severe caramel. inadequate. If the remedies above mentioned must resort to the narcotics.duration. let the further irritation. incapableof children to the habituate to be is seldom disease relapseremains TREATMENT chronic foregoing sketch the is favorable recovery CATARRH. by If the " continued and singing. The assertion that he cannot on help gained by determination from deter you persistently tellinghim not to coughing should never the which.the common coughcatarrh. prognosis both from apparent AND has of the throat thick with reputationof the in cold their necks warmly clad . more a them When plete prognosis as to comdisease.urge the patient to cough. but.Wash- cold and river the sea bathing.sulphuret liquorice. night. They form prophylactics sufficiently . the patientmust be guard the affected larynxfrom in a uniform all loud Forbid thermometer. It Prophylaxis. gr. x at laryngealcough. we as precisely temperature. even though they have suffered by of ulcera- and resolution. The more direct. " catarrh discussed acute cases.and. regulated the this. aqua to prescribeten efficacious. but woollen shawls. be laid rules definite and their use.etc.we prove in treating True. than of antimony. but from keep air. 3ij. becomes The " uncomplicated. acute " in the In bad about the open weather.and inproper drops and more syrups grains of Dover's powder morphia (morphias.so much punctuallydo patientsobey.rather is than to shut not them enervate the increase to to cautiously up to liability littlechildren laryngitis . overheated be never Induration unfavorable.HYPER^MIA lion points between the larynx are distinctive The in growths or PROGNOSIS.yet talking or inclination much may to be his part. and a A should silk ribbon worn ing sympatheticprophylactic. or occasional laurocerasi. reasonable.the in . Even though not entirelysuccessful resist in temperature. Do its attacks upon every trifling in the house. of and chronic its symptoms. be Indication of action as to Cause. irritant upon some protectedfrom the the To patientbe kept be the direct membrane. it is 9 simple fatal.although a tendency to of this disease causes laryngitis The tends which systematicover-protection occasion. of its perpetuation. in chronic the submucous tissue is the hereafter. gtt. iet neck of advisable. although consequent upon cough.are active causes " " containingantimony are useless. be them water. the most must in prescribing rigid and down more to time.but among dubitably and boldness It is surelymore freedom. In violent paroxysms. catarrh the of cause mucous its further influence. above all.cannot of best commended. great caution in exhibitingthese agents is demanded with been used adults they certainlyhave not children.

mixed with For a drink.feet.by moans hyperaemia. blisters upon and waters less or either cording Acside severe. for.OF AFFECTIONS [Q LARYNX. The sulphuret of antimony is superfluous . found that greasy materials upon the hurtful. a it has Quite empirically. we may equal parts of hot milk.sinapismsrepeated from time to time. are diaphoresis in bed. Halloid (SSuerlinge.They are.or as measures overrated are cutaneous the by hydro- quite useful in the hands of pathists. objectionable. the of the entire body in cloths wrung out the application of a cold.stimulating compress of brief cold foot-baths. warm foot-baths.or throat is the cause hot best and simplestof diaphoretics The is indicated. to the in most use cases.have to the procedures. may The has the relied upon.wrapping the elderbloom-tea. or even mismanaged.either and of small efficacious mineral the over skin of alone the larynx pustules appear.and thus to reduce the mucous skin. powerful as that The stronger derivatives. sinapisms. with sulphuret For chronic laryngealcatarrh. nevertheless.the the throat catarrh has the with a solution extended for are and gargles. from indication. catarrh. In fact. skilled in then* employment. 01 velopment of which be carefully the chilling must prevented. itself. and acute be to haps. the reputationof specific.although the books give detailed direction for their bloodletting.in chronic laryngitis. Tincture of pimpinella.rubbed days. while An stronglysalted unsoaked set up disease act ones herring is a been derivative a tried. it is quitesufficient to produce a determination of cutaneous stimulants.but be is not much either give seltzer-water.and who are generallyenthusiastic persons in their favor. Whether they are more be doubted. astringent of nitrate of silver for the into the fauces from pencilling alum.or hyoscyamus. THE of catarrh. laryngeal well-known action may. may moderate in catarrhal inflammation. five with parts of for several to of the The oil of successive Tobold) the turpentine. in cold water. Plummer's pill(calomel. or in acute laryngealcatarrh. and the like. Enpoultices. be to are similar action a regarded of such merits to that of the above-mentioned local excitants. used ating the name of a specific. membrane mucous or pure are beneficially upon popular remedy. chillingof the skin. never requireseither local or general uncomplicatedby cedema glottidis. until vesicles establishment is arytenoidcartilages use is commonest more of the alkaline muriatic croton-oil. the calomel. per- quite as produced by a sinapismupon the skin of the throat. . to have of antimony). In where cases causal indications larynx.The latter ingredients might be of use in modereffectual than opiates the coughing fits.and warmth "When stocking.Instead of the more we as employ irritants. throat hot use in woollen a throat.the case usuallydoes well without any treatment which when whatever.and The stimulants. combined with belladonna.

and 117" In warm That the far the more real " of many course this Ems. by costume. depending upon very action the ashes addition conclusion of to the ashes of the the important role plays an rapid resolution other as fact that upon the justifies means more attributed waters. and a the upon it fails. it is best so-called drink of cases yet as mode permit him of the one let him may whey.while latter to be the in the added which from the rare cases. less tenacious that no advanced The of sodium) than (chloride becomes mucus been in are has in been these of cording Virchoufs.respectively. Several hypotheses have mineral richer in salt to indicate but it by or cure. springs themselves.that the springs of and Selters. use home. of Eilsen.at least. Obersaltzbrunnen. generallyby a if in his national an Swiss. without the on 90" do to Ems the be of cure. cannot laryngealcatarrh.of Langenbrlicken. so " much lauded more credit in the is given minus cheese. The cold sulphur springs. possible. pared well-preto warm that advantage over furnished whey. have often alleviated or cured chronic Ems.HYPERJEMIA has salts) unmistakable an from allow hiLi to or his milk. as they have. and. absolutely must be content with the empiricalfact.in the principality of Weilbach.too laryngeal catarrh. an dilute solutions of principalimportance waters. Grave objections repressedciliary may be brought against this explanationof the action of the saline waters. the to hardlyeffect can eliminated. is not well borne better.or or seltzer-water. with equal parts of hot of whey should have any customary addition of milk. at water.is merely milk. such patientto only when berg..and that seems salt.that or than been not milk and newspapers I allow It is by than more the only milk the somewhat patient. (such as those of of Nassau. Obersaltzbrunnen. The doubtful. and cheese has in which well and often to which bath-journals.accapable of exciting explanationof the epithelium. certainly formation of use of mucus. chronic to AND addition of warm them. is borne whey to the the mineral water instead. F. in the grand-dukedom of Ba- .or or will not means We temperature milk H placesas Ems. salt effects contained observation to which the of the the alkaline-muriati a process. order guished distin- Gleichen- otherwise. but in many cases curative.in beneficial action of the waters in question. which is not merely palliative. the Krahnchen of of F. unfortunately. In mineral salt to the a the amount of in of the that the catarrhal quarters (Sprengler)the alkaline carbonates of alkalies movements ciliary and we mucus are blood. cure.that their use reestablishes the extinguishedor vibrations. in the dukedom Schaumburg-Lippe. which. Obersaltzbrunnen."and. it is better to mix the imported Ems-water.to mineral waters as Kesselbrunnen or the spot. Appenzeller. For in which cases the send a influence CATARRH." at celebrated watering-places.they assert.is.

THE use warm Pyrenees. made with solution finds solution of nitrate of silver of (gr. instantaneous consists certainty. is employed. however. eight or diameter. alb. matter. For this purpose. in the these whereby In in and obstinate deserves The to those and to blow attempt the powder far introduced as to close his and lips.which acts with far as the whole almost Another the as the entrance both is often analogue in the the larynx. be inhaled to cough.we blow can into it of the of a small expressing the contents littlerod of whalebone. all the treatment LARYXX. and brilliant.and the upon causing the patient to inhalation [nebulizer]. inveterate local treatof chronic ment cases laryngitis. inclination medicated to draw a the mouth of one end. as in the .like milk.or whey. a curved to sacc. to untenable and vague into the powders or long quill. of have no regrettedthan the fact that we be exin which relief may pected. chronic of of operandi the modus of. An of adept in the use of the laryngoscopeenjoys the great advantage himself of his success being able to assure by direct ocular observation in passingthe sponge behind the epiglottis.Our waters practice. of the tube. we to yet as are in good reason. and the end fast to result of this mode The larynx. method generally-employed and recent inhale The the them apparatus of names Of apparatus. end the external are.mixed and repute. destination. and saturated | j) over " " " tube.xx of arg. nit.also. xx (gr. the to be extended an Obersaltzbrunnen. The most direct action consists condition purpose in of medicaments of a spray or a the small mist consequently bear slender stream convex disk. one. conjecturesas trial.which usually make we with Seltzer. the although. and of alb. A lines in possibleinto as reached has least.by aid of the laryngoscope.j ijto practiceby Trousseau frequentlyused calomel alumen. the the patient. other may of the part a we its clingingto remains a " glass tube.no doubt. pulverization. in this arg. tolerable in a to of treatment a striking in the ment treat- conjunctivitis. with laryngitis. 3 j ij). 3 j ij). hitherto there two are is driven the condition kinds.x ( 3 ss j sacc. of mucous liquidto be thus reduced these inhaled to of membrane in solution producing the of the larynx to the reduced employed for this nSphogene. If this procedure that ten a is laid within assume may ancient larynx is an should few end is is then blow into violent excite medicament. predetermine the cases which they do no good. to sacc.who else or deep inspiration. 3 ij).AFFECTIONS 12 den). a several inches in length. abo^e of the OF at greater part medicines most are (gr. procedure. The the velum palatiand pharynx. At present. nitrat " entrance of powder.and grainsof sulphur springs. far less criterion those Eaux-bonnes. inserted " of the efficient of catarrhal of use sponge. In forciblyagainst of spray.

sort. (tr. in few a since.a mask used. as well as the more simple I formerly used and at the cheaper hydroconion of JBergson. tough secretion. hi such of or salt for inhalation common longer standing.whether my " " inhalations of opii gr. (gr. The (morphiasacet. or else an appliancesuch as accompanies the apparatus which unable to state. particularly (Soolbadern).as to whether the liquidinhaled actually penetratesinto the air passages. This medicament.hyoscyami gr.a solution of | j). patients. in the great 3 : By exaggerated praise of real value has not only been of in solutions narcotic : to xx. either during the process or immediately after it. contraindicated. which -J thoughtfulmen.(ext. are of alum mark not pharyngeal or of the ify ver- sages. nevertheless. "eioi?i. instances. During inhalation order to avoid stainingthe patient's must face. f j).which clinique. the the chines. consistingchieflyin the exchange of the originalfor a small boiler of tinned brass. cheap instrument modifications. The fact is beyond all doubt. The atmosphere there is heavilycharged with a weak many well-known solution of chloride of sodium. laryngealca- often of nitrate cured. discovery often brought into positive bath. along and Reichenhall. " of be we the "j). The nephogene of Matthieu is thus formed.i x of which the alum (gr. decided. ss allayingthe impulse to cough. In the second and Schintzler. catarrh copiousand (gr. some very is Spray-bathsand inhalation-rooms have been established of late in the "brine-baths" at watering-places.argent.x secretion x " is more " j). air-pas- spillthe baby.tannin : j). I am experience.v (gr.Giron CATARRH. of silver the inhalation sensitive of astringents however.from own employ.which with modified so to substitute as of for the current steam compressed of Single.AND HYPER^EMIA of Sales.in muco-purulent.one inveterate therapeutics . In has been with scanty and tion recent catarrhs." not does failed to and now a new era tarrhs. 13 its modifications by Waldenburg.By the happy ingenuityof Single the apparatus of Jlergson macliine and " " has been air.small quantitiesof the liquidfor inhalation nebulized are by the action of a jet of compressed air. The most simple baths of brine-sprayare the promenades the salt-works of and galleries Kreutznach. ij iv " service in discredit its " estimation introduction of the treatment retarded " in of the the emptying of the inhalation after For have resisted perseveringinhalation but j : f j) are of who a various apparatus all modes of " of solution gr. Koesen. advantages over all other inhalation maalmost universally At my clinique. At Kreutznach and Reichenhall the .it is best to use a solu- has sal-ammoniac of In " j). Elmen. in treatment success However. : rial mate- any a by inhalation. made in use. " have diseases need treatment.for the nebulizes its various fragileretort of productionof steam. as to have supersededthem.ij x : the latter. nitrat.haemoptysishas set in. instruments The on Single'sprincipleare the only ones controversy.

and of the of excellent an the is also salt-works. allaying the cough. With similarlyinhaled.inhaling."that short narrowest Ems for remedy a richlysulphureted waters. " is rendered cough springs.ant preferred in these efficient et pot. air-passagesby gases. been the of the in At looser. emetic sleep to a above is useless. laryngealcatarrh. particularly articles. a teaspoonfulevery the good rule 3 to red. salted acute catarrh is to be profoundly. abode posing pro- it contains after.the this in brine brine patient during. the all.complain the same in favor simply nebulized the liquid. spray-bath.a brine-spray acts question. In The in mind. steam warm after the method appropriateclosets. ipec. The apply the skin grows and. prevent the glottidis. too This accumulation the throat. |j ss. in Rehme In LARYNX. and latter.it may moist relief. thus in the rima paroxysm to let the it and the recur.AFFECTIONS 14 is also nebulized brine Giron. j.especiallythose in the eyes.and Kreutznach. are an dyspnoea often hot m of exhibition administration of paroxysms dipped sponge calls for indication throat. (best according to Hufeland.besides brine boiling of spray still a the iodine the inhalation how. the symptomatic Besides of larynx in are fasting. above liquid. rad.though well.should many has also been bromine by has contract be relieved to spray.is pronounce the generated by and Whether. means of the the indeed. copious draughts surprisingefficacy. doses tart.a salt-spring.whereby. less salt than contains is there (Oeynhausen). aqua gr. Reichenhall. patients. expectorthe tions secre- . inhaled. to and not waken we a the similar to that of roe for herring taken a of in j. . will often and It is repeated. an to cases hot sulphate of copper. scillae. shake Should time. and inhalation of inhalation the obtained pain fact which disease. oxymel 3 iij." vapor for hall laryngitis. ten minutes). it to cause drying from up of time a to ate. and the attributable of of This as a analogues. As be done. Many whereby they hope process. borne inhalation further in chronic liquefactionof the to of disease. but. diet for chronic The the promptly relievingthe nocturnal To described. tartar and should be of is to given pulv. At the closets. emetic.the that " Galen even a the chial laryngeal or bron- regard that in recommended an of the at the have phur sul- recently be bered remem- Vesuvius near the word.is sense the to experience momentary time mucus in conjunctivitis by fact thermal the they might respirethe phthisical. THE OF the to sulphureted vapor it as rose. of indicated often emetic. child let it drink. ipecacuanha.and the Sales- of Ischl. water emetic.the frequentlyare and or leeches repeated applicationof until be must especiallygood repute.

consequent has these of late form respiratory passages which . After the second dentition. so of life.") is. Diphtheria. offspringof conspicuousveins (an ominous On the tuberculous age. when that malady solitary forms part of some pox. to it disease of childhood. but the upon by of the pressure a formation a of loss a of the blood-vessels substance of inflammation much in only in upon exudation in occurs the diphtheritic process fibrinous rapidly-coagulable forming. which the upon exudation fibrinous a of surface free inflammations Croupous " which epitheliumonly. No loss of membrane mucous and itself. croupous it is though the pharynx may be the seat of a most exquisitediphtheria.is almost exair-passages. a be by the swollen elements of the tissue. during childhood.CROUP. LARYNGITIS " BRANOUS MEM- CROUP. epidemic diphtheria. more subjectto it than girls. delicate. in of the most diseases of adults.that a transition from inflammation is observable. the disease is more that the period of greatest predisposition rare . and two been pears apit is instances of secondary croup.the also exerted within by merely stance. too.tender. a true the air-cells. general acute infectious disorder. If the croup-membrane thus epitheliumis quicklyreproduced. MEMBRANACEA. but it is an error to suppose full-blooded. Boys the seventh for croup lies between and the second year that vigare orous.results in membrane. and in the portion of the inflamed mucous so-called diphtheritic occasions eschar. CKUPOSA. well exudation.too. 15 CHAPTER CEOUP.smallor typhus. is one common those alveoli of croup is of far tion laryngealinflamma(Seechap.in fact. scar production of differs from surface The the no but membrane.as sloughing of the out involves the substance The in which formed remains. its sub- this interstitial as forms it is dispute). trachea disease of the and a larynx.for of the whom primary croup of the trachea and larynxscarcelyever occurs. in the croup.blooming children ill-nourished contrary.which. ANGINA " II. not but membrane. other upon mucous than membranes clusively and. croupous pneumonia. parent- sign for the even . upon separating.the rule.stillthe disposition a Although peculiarly is less during the period of suckling. Even to diphtheritic here. with pale skin and 'are especiallyliable.rarely affectingthe the lungs. On the other hand. mucous a inflammatorydisorders rapidlycoagulatesis thrown are mucous and (theessential dualityof which almost the croupous exclusively membranes of the Of cicatrix. mucous detached. it to retain the characteristics Croup upon of rarer occurrence of true the " croup. is also characterized exudation.scarlatina. ETIOLOGY. far and rare more and common.as measles.

THE OF AFFECTIONS 16 highly-contagious malady. mucous due the upon increases is deprived is swollen tissue.in who those the experiencethat. in inflammatory reddening croup.in a to enlarged lymphatics. It has been maintained a when the based exudation that it constituted hyperaemia. the fact that secondary croup of the the daily our hydrocephalus. however.and familyin quick succession. pale."occasions the disease. of its and epithelium. of disappearanceof observe we the of observed been may may that southerly. Very membrane cadaver is stillcovered frequentabsence of the of the croup-membrane. are epidemic croup combined facts have in unfrequently many It is this to be is certain another and appear in common several children often there would after the soon water.windy. or The such die of croup. to or tendency a more robust. shall hereafter we demonstrate larynx often accompanies diphtheria fauces.the mucous The which formerly the opinion prevailed.with children laity). partiallythrough ecchymosis. are survivors. with in the bodies not dation. great mortalitywhich desolates greater frequence than the members portion of quentlybegins very the head is croup Not times more the most children and intense disease with in life moist (see iinfre- not croup a families. whether with that as cases. not dering northerly. It face. but moist. acute LARYNX. A sharp northerly evil repute in this respect. of the some it somewhat make confusion by disease.bor- perniciousform in these epidemic diphtheria. with from equal or even croup to moist suffer hydrocephalus. commonly most seems It is croup-epidemics probable that the questionable. northeasterlywind stands in especially The be " or We shall treat hereafter relation of of the to the secondary croup tious infec- diseases. membrane submucous of the of peculiarform of have alreadyshown abundance mucous absence a membrane.and same of the of the which In pharynx. of croupous in most not to are cases laryngitis excitingcauses of the mucous the irritated condition branes. eruptions.pulmonary tuberculosis develops later the while. together relaxed. " The affected membrane mucous shows varying degree of reddening.It "Pulm.and. to the The with the We larynx seem always. than the on regions. memexplained. inflammation that the during life had been wherein after pallor. Even often the muscles too. ANATOMICAL APPEARANCES. there was no death. larynx which of the croup its attacked spread by contagion. damp places. Sometimes known as a cold. Tuberculosis").and in that the redness ishes diminpart through injection. eruptionon have been and epidemic in even protected more small one At appearance. nay.warmer. . and softer.of the hypersemic. exu- of .is principall y of elastic fibres in its tissues. place.

strong substance.and are expelled either in the form of continuous tubes and sheets.in and even subjectsin which. and pointsof adherent notice numerous red streaks. all the with have died persons who artificialdivision into true to an are physicianswho many autopsy. on have to do with exactlythe we coatingis found the upon we disease thick a body.although extremely frequent.the epithelium is soon reproduced. be free . young during the process of its excretion. mucous of the find the same has the consistence it. calling all others false croup. 8 . may which of the membrane small to mucous correspond bleeding spots areolar the whose exudation is situated. Upon clingmore firm. the generally be tougher and more may external tached deherent co- firmly. repeated. The frequent association of pharyngeal croup with croup of the larynx has a very importantbearing.of ejectedfrom section sometimes given rise to-daythere the in the found has croup. has not no membrane been In croup. ones and the In other cases. and there The to the softer from membrane.CROUP.the cause of death croup.until the disease hausts ex- patientsuccumbs. than is often in quently frewhich line more a we thickness. larynxto membrane. sometimes cream not either in the that in which as does it forms entirelylines the interior surface of the larynxas a continuous sheet. true false croup.is constant by no means or itself. If coagulatedor liquidform. mucous and the it thinner mucous pseudo-membranes surface with ease the . a fluid plasma first exudes. forming tubular and ramifyingclots . too.not only upon the diagnosisof the the physiological elucidation of its symptoms.but also upon do not acknowledge any case this comThe French true croup. and coagulateuntil after exudation. the pseudo-membranes persisting loosened exudation which graduallybecome by a serous proceedsfrom the mucous surface. Since attention been called to the subjectin Germany. where as plication has is absent . The membrane of croup of amorphous or consists microscopically in which cells have been numerous tangled enfinely-fibrillated fibrin. layer upoi After for a longer or shorter time. or Under favorable circumstances.and is prolonged into the trachea and even into the bronchi. in small flakes and patches. disease. but a lated coagu- Croupous tion exuda- . and thus membrane laryngealmucous a fresh membrane the process may until the be many returns succeeds times upon to the surface its normal of this condition.which clinghere a sometimes course. tough membrane. blood. sometimes it only presents isolated flakes and patches. and been of symptoms maintain has 11 that. it has been found that the coexistence of both forms of the malady. fall of the first one. upon larynx. compact.

Should A further If a swollen. not examine cases complain of the fauces forthwith. In many " instances feverish and cross ing prodromata give warn.and is no longer barking. soft note of which breaks into shrill.a persistent.inaudible voice. tendency toward the disease. hereafter. difficulty spotted here and there with small.oedema tarrh with we bronchial and aings LARYNX. cough and speak . accompanied by persistent profuseflow from the nose. and which larynx.white patches.and coughs Such suspicioustone. laryngeal tinguish thus early. They are absent.we may feel less concern has lost a who than for one already has suffered an attack.but other exhibits never of the individual. atelectasis. in very unexpectedly in all its many cases.hoarse. mucous the always find with pneumonia. which was becomes beginning.generally.the air in its exit stretches the them to bulge. THE OF AFFECTIONS L8 croup.except the child when.children la the bodies of croupous the hypersemiaof of the croup bronchi. an observant Even childhood. AND child is The of the attack.and them find we pointis found diagnostic child hoarse habitually grows cold.as the for an swollen vocal chords.however. in catarrh of the larynx. entirely their chords. is hoarse.and not the measure vesicular both such ditions con- laryngeal of consequences necessary ca uncommonly shown.from stretched. or prodromata may precede the attack itself by one two or days.soon harsh. At last the cough loses all sound. and may of copious secretion.which proceeds from nar . may be of little insignificant moment.and by a symptom.and of they indeed are the vocal must which owe be. in the middle Late in the evening. those of catarrh the muscles coats a a expiratoryeffort.and onlj rarelyseen is transitory symptom. is roused a upon chords. and of the relaxation by which are.that It will be intense bronchial membrane. we hear nothing.3 SYMPTOMS COURSE. being quiteas indicative of the approach of an of fatal disorders of the most of the onset of one as catarrh.already frequentlycoated by exudation. is equallycharacteristic of laryngealcatarrh. in swallowing. piercing discord.spots in are great a almost lungs. the disease settingin suddenly and of the night.chardyspnoea. however.or who These brother sister by this malady.hoarse. of interstitialemphysema. the signs of incipientcroup.and We Besides identical to the these of then a" symptoms. have before us firm. there croup. terrors. the deep.we while the same sneezing. The sharp in the cough. symptoms alone. physicianmay diswith the between child the although dd all In two. predisposition coughs with a bark upon taking in the and sign of . or show no harsh. thickening and palsyof which causes with sleepwith violent the child see his from them.and to the origin incipient exudation acteristic perilousdyspnoea. come short and instant into contact. if his brothers croup and sisters for him. This dyspnoea.however.

upheaval every pass is rima glottidis. nostrils contract. with form of impeded respiration. ac- the is not sign of which faction depends upon the rarethe thorax.In the first any other The efforts made is tremendously laborious.and other than in dyspnoea from hence. glottis. namely.We every inspiration see. confounded place.or if it be only fixed and hindered of of the muscles contractions inspiratory the of the is the ribs .if we with freedom.too. curve the the desperation entire into the arms being of its put to bed again. the diaphragm. there Besides this instinctive is another and laity. however. Every muscle. dilatingthe from to close. muscular rarefaction rapid however.in draw breath. When the air instead of projecting. expanding the chest. nostrils. is cartilagesbeing likewise drawn of normal only bear in mind the mechanism easy of comprehension. when of the air within dilated during stricture of the the epigastrium. duces upon the of no than that encountered in the air in downward. which. the levatores alae nasi During these laborious efforts at inspiration. causes obstacle to overcome). (pneumonia. and Now fram depictedin in the of the lung. the of the incurvation out of bed in to rarefaction of from moving diaphragm the inward. this. respiration.it order to He action.are exertions is far greater resisting power the lungs. croup. if once heard. where of occurrence there Is no and not easily requiresfurther explanation. where muscles the of nostrils would the ah* within the pecuh'arto the without (for. that with is stronglyand deeply depressed.and is forciblypushed upward. is known to the the the of "working dyspnoea of croup. throws be .CROUP. of the abdominal tendinous the its breath. to it arch of efforts to by up to be taken the do ribs so. t he of can effort.it yields. spite.is called into vehement his spinalcolumn.the be drawn it begs nurse its manner. sits up.are very evident. and evinced produce.for instance. so as more extends to dilate the thorax effectually by air In the of ribs. tend This nose). 19 which.which can aid membrane.This. desire which the diaphragm centre the draw to its fruitless child.will always be recognizedin future. beats about. which within even the rarefied. must The by feeble pressure If. talse the of rowing the and glottis. The greatestterror itself hither and thithei.however. nurse. of quent less fre- much course.The but slowly through the contracted markably rebreathing in protracted and tedious.however.is peculiar. respirationhave no abnormal It also gives rise to an exceedingly characteristic wheezing or sawing sound.but procauses contracting." and characteristic of tion. the xyphoid and costal in by the inspiration. for their cause then. by the child. or elasticity viscera. of necessity. the chest becomes pressure upon the thoracic surface diaphragm becoming far lighterthan that upon its abdominal surface. If the air can enter the air-passages tendinea its pars to descend.

it is not to be . glottis opposed.but infiltrated with we also serum. in young for an entirely different purpose). is distorted if to as all with bedewed and the obstacle to remove things. stretchingforspace. running antero-posteriorly. find the den.above child sick of croup a fact. or dysentery.has given rise to the or of the impressionthat.neithei either of mucous membrane pseudo-membrane nor considerable swelling. during life. by rarefyingthe air within the and " trachea.AFFECTIONS 20 clutches its at its throat. pale. spasmodic contraction of the laryngeal muscles to pathohas constricted the glottis.This view is contradictory logical look of and In not all only muscles is. Section of the covering is inflamed.pullsat breathing.that children often die of croup. Even a priori. the dyspnoea of this experiment bears so strong a resemblance arisingin consequence to croupous dyspnoea. In childhood. THE OF its tongue. or action. to the processus as the pars respiravocales. is stricken with palsy. evinced signsof the greatestdyspnoea. and bounded These by the membranous expansion of the vocal chords.from palsy of the intestinal muscles.is attended by such similar long-drawn whistling and other signs. must the anatomy of the larynx of a child makes it certain that a forced effort at inspiration unless it be held will contract close the glottis.known toria of Longet.relaxed muscular tissue.and Hothis condition kitansJcydeclares his opinion. do not find that triangular we open by muscular ward. glottisforming a small cleft. physiological inflammation severe the submucous covered by of and the inflamed mucous or serous cellular subserous membrane. has no the base of the arytenoidcartilage the extension. or serous mucous These. instead where their mucous of palsied. pale. membranes. tissues." That muscles in this condition reallydo lose then* contractile power. is shown costal by the paralyticbulging of the intermuscles action of the inin pleurisy. by the base of the arytenoid cartilage.sad The sweat and piteous. nay. animals (an operation originally practised par-vagum nerve. and by the inflamed other analogous observations. furnishes absolute proof that paralysis of the muscles of the larynx produces dyspnoea. In children.hi croupous inflammation. The face LARYNX. that the infiltrated. inspiratory strike the most the study of indifferent But beholder. be to contract must and close the cleft. after death. bounded and inward. The circumstance. who. and in the loss of peristaltic testine in peritonitis.that the similarity of the two ditions conefforts.in these cases. covered membrane. one to be held open muscular of the effect an by energetic inhalation action. sod- supposed that muscles in should be capable of a spasmodic contraction.render it highly improbable that many should the be laryngeal muscles spasmodicallycontracted.from a pathologicalpoint of view.but in whom. submucous tissue. membranes unless the the lying obliquely other.could be discovered.

free. in the latter.and fever great many cases.in the treat- laryngealmuscles. full. covers those takes of cases the French mind. geal in which cases muscles myself as often strengthenedmy of the muscles which actingnormally. and impeding most the muscles the know occlude the cedematous tration. Toward The forms larynx the the remove moderately increased will not any stinctivel impediment to its breathing. and mouth. through the trachea during inspiration. false membranes common is the body. child at its throat evince a frequence . and of pulse. body in morning.of are I have looked conviction of the as of the glottisforms I have theory. without muscular of need any cause Let aid. it is hoarse. we carefullynote expirationare in equal degree obstructed. In the clog the rima glottidis. it inflammation.that palsy of my correctness important element an convince to has materially laryngoscope.which crico-arytenoid posterior easilyparalzyed when them.or be laborious. case. remains. contains masses or is usuallyscanty.by of cause exit and utmost whether the palsy of main both it is of the to us inspirationand inspirationalone whether air for croup. exhibits depend may the course ture tempera- decided in the remissions of the abates. the of Thus. the general condition thin the day. the in able been in the dyspnoea of croup.and expirationfree. or glottis. but only the a elevated. . symptom the upon false The to clutchingof real pain in the of the Croup. hard. cripplingof of the dyspnoea.when drives follows freely. but expiration the vocal chords the air. as expired. It is difficult to of croup. must be croup-membrane can upon by far the most dangerous. of the The and cough. muscles. apart.) through becomes more morning the respiration cough is less frequent.CROUP. Upon rarefaction of the within the inflowingcurrent. when the larynThe wide gaping of the glottisduring inspiration.the tion. the which croup the open membrane mucous the part in bear us alone admit the more pharynx. the glottis applicationof powerful importance. As trachea. which might almost seem (Hence the homoeopathistspremise that their medicines their wonderful effect until after a lapseof several hours.rarely is generally The membrane. of coherent of shreds. In the beginning of the disease. that in rima are glottidis. the be seen pharynx.or the still appears not voice without almost suspicioustone The returns. and Intermissions.at first. infil- the of the entrance chief false membranes must dyspnoea. too. sound. juvenilelarynxwhich In any is we 21 cut may capable of being completely closed suction to the of ment whether be whether the former.which it inexpectoraperceives. which is easilyseen be to true why croup. the face is flushed. desire which whether say piping. forces the folds of the glottis nose together. the by ci the out air . undisturbed.

the flow exceptingwhen. and falls into a state of semi-somnolence. finally animals in which the par vagum have been (In young nerves observe preciselythese phenomena. a no half-slumber child grows The of .and the formidable. of the the A dis .the scene tire en- The the lipslose their pallid. and the continuance of fever.) These in the child's condition result of gradual bloodchanges a are ing poisoningby carbonic acid.until. the the from course exhibits becoming the remissions symptoms. pharynx. is by to gorgement en- (ashas been cyanoticfrom generallyassumed). the of course tends nocturnal continuous a in expected the fatal cases. we " of one The the main of sources above-described train of of the brain and nor is a child with croup in the danger symptoms its meninges ever from this disease.AFFECTIONS 22 recall to the mind to THE OF of the of terror scene LARYNX.and now . impeded respirationalone. of if only moderate. jugularsis arrested by compression of the contents child vith cr'Mip cannot be otherwise than pale at act due means no of blood of this the stage within thorax. cutaneous child lies exhausted gone. buttlingtoo great hopes upon these night may bring with it a repetition of the remissions. and appear.overcharge of the blood with this gas formcut. of coughing. the excite the croup Sometimes all. it involuntarily attempts glottiscloses .upon more coughing. and effect. eye. When.or draw Then a long breath. after the whistling sound in have the stimulants.bad coming greatest solicitude.the above The ware be- same The child. this dangerous.once more to in danger of suffocation. the child. respiration impeded in the highestdegree the moment condition a derstood they attempt to draw a deep breath easilyunafter the above explanation. the tion respira- inspiration symptoms dyspnoea.the malady too of rhythmicaltype throughout its more The beginning. springsup. the ceases child the of without the It to seems awakening from sleep.even presence nights following upon duration.the instances. (an and more death instead of but event and more in pseudo-membrane tolerable may days . in incomplete. life of the to the greatest danger But in common croup morning two three or terminate to croup). color. props itself up with its hands. Respirationalmost free as long as they breathe quickly. Quite frequentlyspontaneous vomiting sets in.anew breath. about hitherto has been which a it. more of symptoms remission in ensue abating. and sinks back again exhausted. and. while the flushed face emetics which insensible to becomes often of croup we seem grows remain administer sinapisms and other diminished. looks makes violent efforts to draw desperatelyaround it. previous night. In other run ably unfavor- changes. should the growing exacerbations which far are fails to more days.assumes gazing anxiously drowsy expression.

the glottis becomes so As that very littleair can enter into. The symptoms described acid.and 23 that upon to contract. at command. instances. In rare be suddenly and absolutelycut off by the fall the glottis. lungs by evacuation process of must oppositeeffect.4 Since within that of the interchange of less of the vesicles contain blood the of the of the lungs depends principally and the blood as air-vesicles. as those produced by the inhalation of carbonic exactlythe same In croup. as we are able by means than inhale it. an inspirationand expirationmeet affected. of all the auxiliaries on Now.as pallorcontinues the order.the access poisoning. and carbonic out the in in the of air contained renewal give gases cannot escape from it into the air of the vesicles are already overcharged with it. is somewhat differently circulation those glottisrarefies the constricted long a into external veins the from greatest power of with the equal obstruction.through of consequence of air to the of a by suffocation piece If the gradual always takes establishment place with of the symptoms in general paralysis.blood must each when one any draw tryingto the with cerebral veins have always When breath. sis place. never can Cyanosis take place in and within obstructed The suction with the air within this way. absorb carbonic unless oxygen.CKOUP. while which is atmosphere. the tendency the veins heart less and arteries grow of the contents the palsy of until. death the described. In fatal cases.or by false membrane and carried be the expirationcan only lungs.that the carbonic santly incesin the in the blood forms acid.the necessary consequence plexus of capillaries in croup and of the imperfectrenovation incompleterespiration acid which air in the vesicles is. expand .this will be drawn reach its highest pitch of intensity. the sets fuller and less. without.cyanoinspiration. blood less than pressure in. his thorax. acid and of more the air oxygen about it.indeed. membrane before and rapid death carbonic-acid lungs may of loosened may croup almost ensue.the improvement may take . take a turn for the better. as with the lung grows of suction of effort the power deep inspiratory stronger (sincethe draught increases as the lung expands).inspiration escape from.the influbreath with greater force ence can to expel our we blood of the forced from the discharge of the expirationover much occluded thorax outweighs takes the upon the does not than forced and then. thus and livid a the veins within thus and tinge is imparted to is subjectedto the thorax to vessels which the cause of a elastic the border As the lung being it to upon fuller. the carbonic acid created within the body itself poisons the other in the the poison is breathed with the case patient.the veins the pallidlips.

which of pseudo-membrane. I have a stated in the only opening which arises membrane. in their two of a increased The secretion of the promptly associates to me to glottis.""" of the croupous subsidence has been The free. seems With however.as the embarrassment In other than far less numerous is are instances.the voice louder. or a new of the laryngealmuscles.but succulence.till now and vomiting. an no an swellingand objectionsto make inflammation.it of vascular in consequence to the repeatedlyrecur inflammation as an exaggeration I shall improprietyof regarding other forms of of simplehyperaemia. that.characterized b) . and often tubular generallysupposed. is entirely due to these the frequence of which we can sary easilyshow to be a necescomplications. many The of the and oedema lungs. that the breathing. however. are coughing. retching. the must similar previous are capillaries Bohn bronchial and catarrh with laryngitis pension sus- ally habitu- Gerhardt invariably constricted of the genetic connection pneumonia and bronchitis. and the thorax When disease. That the danger from croupous or a consequence is considerably laryngitis heightened by the addition to it of bronchial catarrh is perfectlyadmissible real croup. comparatively ill success of tracheotomy. and atmosphere to penetrate air vesicles and membrane mucous and thus placed in a condition under a cupping-glass. narcotism disappearing. containinga lum THE OF more or cough becoming easier.large masses thrown after violent out casts of the bronchi.sudthe " much becomes danger. more in the process larynx. it is this quite text-book. and bronchial catarrh. the symptoms of of respiration subsides. if a reproduction of the exacerbation the glottis.after protractedcroup. symptoms of the against the opinions of rather as secondary croup which who consider authors do not derangement of secretion. death . somewhat result of the the alveoli into made are be inner wall expanded of the that to Hyperaemia and air subjected. which As is catarrhal inflammation of croupous in favor to the of the croupous complicate laryngeal croup otherwise. in many words of cases.however. dilate without to them. expectorationof quantitiesof tough of flakes of coaguless profuse admixture occasional place gradually with sputum.* mucous expanded.so denly extremely oppressed. bronchial The during croup portion of external and two in the air-vesicles diminution or allowing the alreadycontained rarefied. skin to which is bronchi result of the necessary the recentlyurged by upon argue are the are pressure circumstance valuable works processes.AFFECTIONS 24 LARYNX. in tainly always proceeds from bronchitis or broncno-pneumonia (JBohn)is cer" " " " *I catarrh have as The exaggeration.when its duration children perishfrom hyperaemia protracted. engorgement itself with regard that croup. oedema After child exudation of is safe do the not from once immediate occlude more inflammation again produce ".

croup croup child tonsils. the presence white a deposit indicates of But up. In the hands would settle the question.or membrane are coughed or of the fauces by no means the larynx. the during alone symptoms for account physicians. After tracheotomy. counter enexperienced practitioners may and between in distinguishing laryngeal croup the The cough. by virtue quite void of air in some places. never TREATMENT. capitalprophy- croup. that will croup these croup when times. are Among to exposure advisable to keep of the throat dried. with catarrh and 25 air enters the all other is murmur sounds feeble. after sunset. the oc- tasis tubal become portions of lung shrink. described hereafter when treatingof the the most complicatesmeasles.CROUP. spots of atelecof pneumonia may be made when out or large enough to cause cluded respiration. proof tain by cer- as claimed fauces the chords accepted that parents croup loosened been the of in treatment Inspection of of catarrh a have success belief the when laryngeal walls. in.be without is decided the child be afterward from of croup met.small pox. the aphonia. of their a croup. the be can the of seen of absence of non-existence of of doubt the laryngoscope no for is unsatisfactory. that the actic where As the sides of both It is also wind. diseases DIAGNOSIS. while the save few a rales. and keep doors provided in most and aorta the sternum. northerlyor northeasterly within of heart- the for protectionagainstlaryngeal catarrh.will themselves. nor it to too much while. B very there the real skin is causes instances. teach the mother by bright sunshine watch Pulsation Thus to sinks then diaphragm fall asunder. and even croupy [Even " difficulties choking. Auscultation with which owing to the difficulty the wheezing in the larynx drowns expert. infectious disorders. epidemic diphtheria. accustom clothing. obscure. an vesicular the must never has be certain as palate. is carefully to predisposition to the paying attention to predisposition cold washing Finally. and the dulness vena forward becomes Fever is had an " is rarely of alone.soft the upon bits their regarded be may .and had all arise and each may fact the of fever.the the ca laityit isal indications is considered cannot. be and other scarlatina. lungs. high grade. When deprived of their supply of air. perceptibleon but The as so elasticity. the bronchi being then free. a settled . Never becomes also cava measures edges of the lung abnormally wide. Meannot to let herself be deceived however. there weather-cock. alreadyrecommended because it has once shut up a child permanently in its chamber attack of croup.nor direction of the the to send child out the When wind. a the and rude child breast.] requires the Prophylaxisagainstcroupous laryngitis absent. or vomited for several and omitted.

if The the remove to treat courage apply itself.by means brill!ant they attain the most action LARYNX. If.it is well.and as even his reserve decision when first called hoarseness. In mere " skin.while awaiting the doctor. sicians. other- mucous produce may a complaint tween As. grave alone solicitation of the a thus croup simple a so hyperaemia active in success. however. depletionfrom iar too envelopment great number of restoringthe and same has the from pressed re- to the of restoration it may swell to surface of disorder to admit catarrh sufficed of chilling nutritive nature a blood the cure arise the one.especially habit one we child under the disease a get may year that one or we well two articles. tonsils. special the discovery. result of child becomes (often an of the " taking cold. croupous patches be the be to seems energy is demanded himself with the content utmost not such throat. and (perhapsfrom the astringentaction one instances.to give the child hot him warmly. and of hot. moist to apply a succession drinks. hoarse.the He been propagated from larynx.an incredible quantityof hot his is poured down preferredto elder-tea) child begins to sweat do they believe him safe. few leeches Let him into must the over rather stated that in many the inflammation fauces. from the (of which of the specialincidents with a be . and to see child a sufferingfrom nocturnal sudden dyspnoea. Bierni a in are forthwith inflammation has of management pseudo-membrane the measures. expectantly. and of the cases. phymany leeches for calling both or to homoeopaths croup of discoverable. This treatment be relied on. shall call for owe without upon the old. The hydropathicschool the of of that the surface.then. It has of epidemic croup.a barking cough. it is almost impossiblefor the laityto distinguishbethe two the physicianis often obliged to maladies. Granting.as practiceis false the remove membrane of the With of surest regard emetics. to especially country and on doubtful of very thoroughlycauterize the affected part.however. hi such emergencies. emetic in disease croup leeches the are exudation. Where n" is of of cases my membrane. is here until the foe teachers is the (which Not the a THE OF be the wise. imaginary one) driven from the field.and the is much the of to more caustic)is antiphlogistics." With true fanaticism. that of of the of part applicationof a efficacy. by similar results from claim body in wet cloths."by productionof diaphoresis. pharyngeal surface the visible upon the the physician.the is nol the mucous disease membrane the which.AFFECTIONS 26 fact that the croup the moment that milk sweet throat. the the the the applying had ever chieflyto Leeches emetics.and smallest trace the to moderate Hardly and one any to wait until It is even or child throat ones.to cover to the sponges throat. increasingthem leeches manubrium in number or .

and produces in them transuda tion. inflammation upon the hence identical. that impeded expiration glottisis becoming choked by false this stress lay great symptom upon symptoms. and is much small. if its circulation be interrupted. dissolved in two or ounces and let the child take a largeteaspoonfulof it every unti1 five minutes vomiting sets in.0 bleeding is hard to stanch. In treating croup. employ an expert to do it.would indication for emetics. We operate as a poison than when prescribeten fifteen grainsof sulphateof copper of water. Still less may we promise ourselves help from their diaphoreticeffect. the so emetic. should or apply the leeches ourselves. however.we must proceeds croup vigor a apply a applied over may be never with froir few the the In all case. in describing the should cause membrane. however.and. moreover. hurtful. With regard to the employment of emetics. the blood flows with greater force into the vessels of the neighboring tissues. They we in have deal to case). as it seems Beware. are strengthof to a are child.CROUP.as that sterni. with reason. if much the more peculiardyspnoea reason above have we described . we who leeches at enable whatever point contraindicated.which a him to he It will expectorate with to prevent the formation is dangerous most to exhaust requireat a later stage of the vigor. erroneous We such have shown that of part the danger swellingand infiltration. Among badly-nourishedchildren. leeches to the manubrium larynx. inflammatoryprocess is not interruptedby blood-letting. check can hemorrhage. it moderate the although may collateral hyperasmia in the vicinity of the inflamed spot . far the greater that of exceedinglydoubtful number Their recommendation view 27 of instances is.swelling. to sulphateof copper over tartar-emetic or ipecacuanha. to us infer that the We. of giving this remedy in doses too me. hence. where They are only indicated obstructing croup-membranes play a part in producing the dyspnoea. and when the child's effortsat coughing are We to expel them. insufficient have stated. accordingto in In croup. the age) are. puny. should out. Blood-lettinghas no of the the disease power exudation. As the formation of pseudo-membrane be place indicated.and oedema. The more complete the remission after the vomiting as an take the f"T more at the repeating a membrane the an thrown emetic. may may very earlyperiod.when blooming child (but only in such a ous. the revulsive action is through which they are supposed to exert an influence upon croup altogetherproblematic. more apt to used in full doses. abstraction of blood will allay A really inflammation.for it may then act with uncertainty. therefore.in great hyperaemia and they assistance directly are supported measure. if a stasis of the blood take place in the mucous membrane of the larynx. preference is given to given earlyin the disease.

experiencehas here more of pneumonia. it effect to the have can in an upon organ from indeed hend compre- by skin physiological separated it rightto respect than muscle. LARYXX. muscular immediatelycompressed by place. with dipped We entrance in a of the treatment small a the the of sponge of the tongue with glottis is the solution concentrated down press of a littleresorted practisedin France. (See treatment of the hydropaths in this matter. service more which.with whom a its lower fast to the sufficiently urge to the caustic uses originated. In families where they are laryngitis as the signs of croupous appear. ss to to reach rod This 3 of is ij). nitrate There lunar ourselves.as soon compresses. seems puerperalperitonitis. among made of the of larynx.and the of silver endeavor (3 inflamed applicationof membrane mucous curved end.AFFECTIONS 28 often do emetic is contraindicated. gr.) The fanaticism abstract reasoning.stib. flows curdled and cliildren they have when be expiratoryact see we remission. quicklychanged. aqua? . bluish the in armpits griping and much This vomit. authorityis inclined to credit the beneficial effect of this agent in its sponge which treatment of calomel takes . the sponge.as croup silver of personal experience. sulphate of copper a my of gram perience ex- small i .or of the be snould If there recur. rule is often with be membrane croup impediment. arrives in the larynx. by difficult and it be to as antiphlogistic may . and but too this local JBretonneau. and to no from free dosed incessantly ceased to milk. turn tition repeHow salts of different ! with mixed then* head away containingthe repulsivemedicine spoon the broken. and a now. while applying cold to an inflamed part. the whalebone. have already recommended We with membrane after has as much been child. who. has done more and harm than good. even lie bathed They push them the so the away their from and bowels.are loath to refrain from other hydropathic measures. It is doubtful if calomel have indeed or even a an antiphlogistic.while customary employment (tart. laid upon the throat of the child. shall have a far more this treatment. THE OF which gives distress.should no if the expelled. we afraid to use not happy result the prejudiceagainst it is not to be overcome. in which than in houses The The as to of cold employment first recommended act as direct a what in inflammation skin UTiwisch of internal organs.in most shun and the of from use too cases of a this quarter to half disease.if only a small one.cannot solution to nitrate touching of the pharyngeal mucous direct antiphlogistic. specificeffect upon although I cannot deny that very high croup. do they can fluid in vain no copper. nor that I two every leads doses tion contrac- me to of tartar-emetic myself make hours.whereby certainlya portion of the liquid. in the shape of cold applicationof cold deserves a full trial.

2 s. of in than The has and improving in treatment remedy the of the the latter and the I have disorders.however this treatment. and obviously based upon 3j. and the to seem may of open hours a the child of the means two every grow Should by them to intervals. sulp. this article in of applied. sulp. 3 i. pseudo-membranous put must the The act.if the at required. to self to which with of your own is cold a be never stated. aud woollen solution the must room course measures ten of without or the half compresses The next a less meanwhile.under stated above the conditions . Continue of nitrate of be change now cloth. do there not lose be no time . 2 3 i" 29 the It is better. deserves between infectious from after-bleeding have theoretical upon into use. or else it.to the entrance of the glottis. croup well temperature of calomel and a However danger.apply a solution of nitrate of silver.the physician the idea without his be misled by not immediate and that. during the next day. " hours). If the dyspnoea increase. are Give water. that so clyster. 3 i. do not until the Besides this. preventingfurther the state the Barthez.and bounds. there be no under remission.which those by croup. this improvement in same treatment the vessels .s. use they afford.and accompanies 3 i. effect. the coming night may again bring with it the greatest often The rendered moist cover the with use worse.which should the under in most is favorite a soda drug membrane. at intervals Do not forget.without suspending the cold applications.is also no simplic. a best the should above within kept first compresses confined. but of silver. blood. aqua?. of fl]. 3ss. longer night. if. (Cupri.administer room be one's relief the Leeches die. and respirationbe impeded.CROUP.The emetic is to be repeated.if the diaphragm may the one. recentlyattacked.during the night.). that. every and Rilliet as is almost now is large doses actual been administered experience the of Chlorate who make potash. potassium (IJ potas.) Sulptmret syrup in the fauces. of theria diph- larynx. of the of The obsolete. aquae. warm rather .the child active proposal of i distinguished much come " personalexperience treatingprimary laryngealcroup. remain not quit be. of three parts water. of i . called to the bedside of a child. cold.should twelve hours. of several hours. of one there the nor remission.that. soon should the bites on parents perceive be no exceptional conditions cases.with the earlymorning hours.save bowels bicarbonate secondary croup in true recommended primary interference. action When of distinction of acute laryngitis the never of hope of loosening the false coagulationof the exudation.in spiteof 2 such authorities. hence 3 i.in spiteof improvement.gr. to confine hesitate to free of grounds littlereliance.and hand. S. h. comes itp air grain often.aa eulogium has h.if the give an active emetic. vinegar. it must kept uniform. bed.

pulmonary pectorant ex- been treatingthe dyspnoea also to relieve the have earlier which. masses They emetic. and In benumbed. as The a child bear. however.over moderate not no importance. do not rate Although we skin. is of cold exudation hour every against croup. an feet. in. iv. operation." so tracheotomy. utmost always time hypersemia. or For acid. and to ought large doses.almost expelled. " hour. gr. begins to as of a soon the it to revive cause sometimes after stimulants. indeed.the oedema..the of to Ether x. and yet the as protracted.repeated bathing far warm of while. blood-poisoning by it. and often. s.the can be partly to the remedies $ means.sometimes where accelerate m.Bretonneau cation. to the of where the disease . child. making to A camphor employed effusion. for treatment tracheotomy. However means stimulus sensorium gallons of hour. principlesgiven above. our neglected has operation that injure not be never potash. gtt.at few when save in cool. but bad results. will death Even liver to once hope more bronchial and at LARYNX. paralyticsymptoms this water This service.m.the bath. the in we obtained of nioschi. and is and the high covered we the ministere ad- to the among dissatisfied are action plasterbe smeared with the promising more alreadydescribed. the hands of use less period. and a ($.after the when even should sulphur.immediately prior the order child the be the of calves of the worse great asphyxia by moment to the a by cough vigorously. Thus. of of have insuperableobjectionsare opposed applicationof sinapisms to recommended. slender hope complete relief.while fail to act . or half Sacch.their operationis often and are given and partlyas internally. painful. there marked but transient a this long prized as senega. proceed this. child. camphor div. acet.) forearms want that the to S. . or have itself. or powder. soles of legs and in water action derivative alb. the the due powerful remedy in skin the height. upon is also when take under- we prognosis. x 3iij. blister. the grow as the a Lose the upon purpose. emetics the favorite drowsy. poured from back much "flying blisters" of them should bath.ar^" larynx very or hot stimulants the from better of as neck irritants cutaneous 3 i. and the proceed use to cantharidin advises in oil. yet.such to be cold to xv. is treatment use head. THE chlorate soda. chest. vi.it the failed. upon a The other or a long delayed we rarely fail to improvement . for should quarter of every other to a in this for. nape. ch. or in is OF AFFECTIONS 30 hesitate of the with a blotting-paperbefore to flying solution appli . make we improving. gr.carbonate specific. Other are and less effective. of " the giving Schwefelleber. we may of of catarrh. " corroborate again growing effects of be based. water. for obtain Besides carbonic cold pouring charcoal vapor. with musk.

and immoderate and ever. occurs.through epidermic acute place takes of admixture from in membrane mucous LAEYNX. the In other substance the " Ulcers are second rare mucous numerous form of catarrhal the ulceration.as of the mucous lesser quantity a of elastic fibre. the 31 III.singers. THE OF which cell-formation. TJLCEES CATAEEHAL LARYNX. Where a plasterof cantharides has raised the the blister.enitself.the cell-formation irritating sore skin.the aryepiglottic ligament. the of surface When " the "*roaches upon it solution a the of this ulcer process upon epidermisin turbid of the of the tissue chronic catarrh. independently of tubercudisease of the larynx. a cells. producing in and membrane mucous the upon loss of substance stituting a superficial continuity. in place of the gland. similai it with is easilyunderstood. the anterior Special exciting causes mucous membrane certain posteriorwall of and posteriorends of the vocal chords. ulceratiou are When forced their .their contents discharged. exposed opening of the extends to the substance an salve. laryngealcatarrh. cutis the If. become formed are the upon face sur- deeply-situated more is intact. These of proliferation the the of substance a few days. namely. the particularly the larynx.and the epiglottisat the point correspondingto the processus vocalis of the arytenoidcartilage. in blister. larynx drinkers of ulceration. to the chronic laryngealcatarrh which almost lous always accompanies pulmonary consumption. This is a is still decided tendency greater in sore. Finally. their covering is finally loss of a round. especially affectingthe fauces preachers. however.and forming a superficial completely after the analogous with the anoint the ulcer of the catarrhal cutaneous membrane.TQE OF ULCERS OATARRHAL CHAPTER KTIOLOGY.The rich in mucous are particularly glands. seems toward to be one At the mechanical. so latter-named In all loud that their spots the talkingthe edges almost of cause vocal chords touch. causing its destruction. how the chronic in the follicular variety. another.in the vicinity scarcelyany trace of catarrhal disease could discovered. They enlargeconsiderare perforated. be render portions of the laryngeal liable to catarrhal ulceration. if we a very compare the skin. young cutis. crater-formed and. of The of the contents cells. of there spirits. there remains cases.inveterate smokers. in acute In follicular form. mucous glands which exist in the larynx the seat of a vast multiplication ably become of cells. conThe pathogeny simple catarrhal ulcer or catarrhal erosion. . surface with we blister.TilrJc has repeatedlynoticed rhal catarof which ulcers of the larynx.and the tissue placesfirst named it here contains membrane is loose.

forming an ex- an elastic fibres .running into aphonia." anterior had they the lower which membrane.) ulceration. They readilylead to less tendency to increase in width several of them of the gether. ulcer when a patientwith a harsh. and place beginning catarrhal erosions elongatedshape.that is to say.complains of a sensation of burning. tion addientirelyabsent. streaks objectivesigns.which raucous either rounded a THE LARYNX. the chords other destruction of catarrhal consumption " the cases only can is make be to seems the and membrane. the of swollen APPEARANCES.the of blood condition in the* sputa furnishes of the fauces and the gulletis of .AFFECTIONS 32 integument is during speaking. more surface the out of follicular larynx.no positiveinference can be this symptom tion. this in a But as painfuldeglutitionalso occurs of simple catarrh at this point. even than in depth. the of small of its existence. irregular mucous level of their upper membrane. io describes chords.of tarrhal ca- which.and retain their circular form. but these symptoms (although upon sometimes that the sufferer. todisease run and. or symptom is rarelyabsent. substance is so Lewin of tho vocal border. hardly ever is met with in persons with healthy lungs.and from time to time chronic hoarseness. even very extensive of painfuland difficult deglutition renders the to the other symptoms of presence an ulcer still more aryepiglotticligament. in a whisper)are often when The ulceration exists. of long standing. cartilage. if as appear The contour. or friction takes constant results in excoriation (Lewin. ANATOMICAL bave OF In " the ever. In author phthisical patientsthis has often so found catarrhal tion ulcera- in that where the vocal membrane portionof the laryngealmucous the arytenoidcartilages that he describes this laryngocover processes which scopicappearance. AND geal generalsymptoms of a chronic laryn" catarrh True. a by catarrh.during fold of minute vocal still oftener shaved only superficially considerable. or soreness speaking or coughing. to the objectivesigns of ulcera- admixture reliable token Among probable.according to the arrangement but they afterward tensive coalesce. of loss of substance and the extensive produce the ulcers originatingat the spread lengthways over The chords of both In many chords. mucous posteriorends the greater part the loss of been of one. severe case drawn from the most when and the the epiglottis. we are not suspect the may when modified materially existence of an accompanied by ulceration. barking cough.as almost pathognomonic of pulmonary consumption. show when of long standing. arytenoid cartilageis involved. howulcers.speaks so distressing without moving the vocal chords. Next alone. cases destruction ulcers upon we life. in order to avoid pain. exceptionally.as outer or of the shallow inserted a the under that off . SYMPTOMS The COUKSE.

however.especially when situated upon the epiglottis. AND VAEIOLOUS will local generallybe for treatment a IV. sore ulcers of the medicaments of over the are whole larynx applied mucous sufficient laryngoscopicdexterityto with a enable him to touch the ulcers with lunar caustic in substance.which When a measures. or will do well to adopt such concentrated solution of nitrate of silver. instead obtained of alum of inhalation or nitrate of silver in solution.which are formed the solitary glands and upon ot 4 by the similar the action of glands of Peyer. it is to be presumed that the disease has also invaded the larynx. however. a morbid process . under of a specialist. in: patientswith LARYNX. posterior pharyngeal wall studded with small round. yellowishsores. and ulceration. instead of that recommended in the last chapter. teachingof Rokitansky. and. The ulcers may be brought into view by means majorityof laryngeal of the laryngoscope. whether the dieteticand other internal treatment alreadydescribed is not to be often prone is not to which are so specialists neglected. and the true on aryepiglottic folds. TREATMENT. as in do not mucous membranes.but injuresthe credit of new has long resisted chronic ulcer of the larynx. mucous ULCEES THE OF LARYNX. of the with combined often larynx are OF ULCERS VAEIOLOUS AND THE teaches follicular of chronic 33 that follicular ulcers pharyngeal long-standinghoarseness If.it enforced patienthad relied solelyupon the lived imprudently or absurdly.TYPHOUS Experience great diagnosticimportance. Ifrom " the " typhus. " almost identical catarrh of other treatment where The ulceration of the larynxis simple laryngealcatarrh . we materiallymodify our ulceration It simple inflammation. of caustic at the hands recovers a regularcourse the of Ems-water use perhaps found that the cure.then. The partiality therapeutic only hurtful to the patient. practisinglocal treatment. be denied takes of catarrhal treatment place somewhat Whoever the has of catarrhal rapidlywhen more and solelyto directly cure the instead itself. other symptoms find a brane memlaryngealcatarrh. CHAPTER TYPHOUS membrane. While by cautery or inhalation. upon of the and false vocal chords." ETIOLOGY.we reddening of the mucous the and see soft palate. local treatment. supervenes upon with that of the that the cannot. and weeks after had careful and of absolute the nursing of silence. upon the the arytenoid cartilages. the belief has long dullary meprevailed that typhous ulceration of the larynx proceeded from with of the infiltration of the mucous subsequent larynx glands ulcers intestinal the therefore and was quite analogous to sloughing.especially surface.

Rokitansky himself. in the last edition of his of mode This " of the membrane mucous of the this view with of the ulcer typhous attributes Anatomy. consists of the mucous swollen which afterward usually extends as a as soft. however. the is followed of measles infection find ulcers typhus. and of the integument ical mechanand loins. The variolous ulcer non-umbilicated sore. according spreading over somewhat reddened.AFFECTIONS 34 LARYNX. soon to pustules are wanting. and.forming latter After the found thin film. besides the products entirelyforeign to abdominal medullary infiltration of the and of catarrhal.and when the membrane. matter larynx entirelyin ulcers typhous appear mony har- upon larynx. small-poxeruption.which readilyheals.and the its thus have pharynx. according most to its course without typhus. Rtihle. the while and laryngitis. indeed. but false The by the formation bursts.is membrane. far a a JRUkle. shallow.is certainlynot the origin.and a the the of lines. as inflammation ANATOMICAL substance APPEAKANCES. which runs intestinal glands). fauces.it only has the an membrane. even The irritation. secondary croup. or.flattened. as in the lower is also the case parts of the lungs. a " do to the origin in the from membranes mucous however. however. the of the transverse it extends others so it is as thema exan- of the mouth and eruptionof small-pox in the complicated by a diffuse croupous a is the involve the disposed to and to laryngealperichondritis. THE OF at all. by catarrhal. We larynx. few entire edges presents relaxed by posteriorwall lateral the on circumference to The " seat common muscle.source sole.is a propagation of membrane mucous with of this organ. not by diphtheriticprocesses. is at first the fall of the bifurcation of thp . . larynx exactly similar of the the While cases. epiglottis.nor even Pathological tion.and rule. of the edge penetrate deeply.the virus of small-pox. after long-standing disease ." that filtration diphtheriticin- to it is and. croupous of abdominal those to we in rare scarlatina poison of does larynx.As a some cases.which. more of a ulcer typhous bounded of In free and exposure loss of discolored larynx above epiglottis.however. which the there commences pustule.at points most or of the back exposed to pressure the portions of the most strikingobservation.excepting by propagation of diphtheritic in a majorityof cases. grows of which exudation croupous which. in which hyperamia from dependent gravitationis easilydeveloped. mucous Its most edges. croupous. is that of in exanthematic typhus (a disease whom.In thus lead may necrosis consequent to of the cartilage. localize itself in the inflammation the from of the pustularinflammation causes ulcer variolous The from has skin. if it occur of typhous laryngeal ulcerathe most frequent. rounded accompanies often somewhat The paler. rule.

is met not occur TREATMENT. cannot Never i n accident upon the dissecting-table.yet. by perichondritis laryngea.we Although typhous ulcer of of are not the mucous so danger the voice is not very much in ation relax- becomes great. there signs of typhous the causing the second so-called importanceof from the cases membrane their appearance almost without other life harsh. Gerby means this class of disorders is much more . neglect. severe did mouth necessarily give distinct a symptoms diseases two the eruptionupon furnish to skin and identical would the not with be pustulesin tinguishab disthe criterion. Either because occlude the muscles of croup)do that of the false membranes of passage the the or glottis.unless there of few a SYMPTOMS chords." ulcer of in these Although the the ulcers. typhus of it.and is often only discovered by recognized. and glottidis cedema third or laryngeal perichondritis.inaudible diagnosticatethe may occasion may of In stupor coughing. particular or by cedema glottidis. with the ception ex- occupies.that so the symptoms of larynx as are where cases fits of violent be even may larynx post mortem. part a " Our greatlyextended and Roth have if dence subsiuncom- V. see we laryngo-typhus this laryngealitself. membrane mucous is 35 normal. glottis(towhich here.is either slightor entirelyabsent.hoarse.SYPHILITIC of the condition trachea.it is only on genuine primary croup. fact fever. trifling COURSE.as they He half slumbering. Hence.like in this form of laryngitis. neen hardt the dyspnoea of occasions that dyspnoea. or all events. like the genuine. from week of the from them.do not usuallycombe Pain. and rough hoarse. causes or aphonia. AND Owing to the positionwhich it usually typhous ulcer of the larynx does not cause alteration of the voice. " coexistingswelling and relaxation of the vocal other sensation. Variolous those of ulcers and the not throat rise The laryngealcatarrh.therefore.the abrasions. DISEASE knowledge with OF of and modified shown that THE LARYNX. or disease though during even great. The and hoarseness secondary (variolous) croup. the vocal chords swellingof and " of disease symptoms no the examine to subjects. " Typhous and enough materiallyto cedema and palsy of the because ascribe we thick not are rare with variolous ulcers of usuallyheal of the olicated and need treatment no primary disease.nay. be recognized. CHAPTER SYPHILITIC ETIOLOGY. disease of the larynx lias syphilitic of laryngoscopy. plain sick. of the larynx existed.during life.and hacks. the At a the typhous ulcer is nol that. The cough is generally moderate entirelywanting.the THE OF DISEASE LARYNX.

in some lesions. They are with ulceration always. on These authors in any of declare the altogetheruncertain. they have of supposed. syphilitic analogouswith those laryngealcatarrh of is not The " anatomical merely those of of some " cold . By been hitherto had than common LARYNX. occur in most varied positionsin the fauces. ulcers. often are laryngitis. frequentlyob- more the whitish see chords. As a rule. ragged shapr. which they destroy more upon less completely. Simple syphilitic larynx. accompanying the condylomata in the cases reported by G-erhardt diagnosisof this form yellow coating upon Deighlx)ringparts are not ulcer to their base found in other the larynx.particularly and arytenoid cartilages the on terior posthe fold. syphilitic Condylomata They show The reddish flattened. like the latare probably due to the breakingdown of syphilitic tubercle.which are coexist with of the . Finally.or in the lower pail of the organ.existed Both. THE OF AFFECTIONS 30 hence the think is.condylomata.which mouth.besides shown the syphilis. be whole.its disappearanceupon mercurial primary syphilitic any a as treatment. yet the time of its occurrence. aryepiglottic ulcers Simple (secondary) syphilitic ulcers. its to dependence upon infection. complicated ulcers the of and the are. tertiary and simple ulcer as I base work of the destructive " these observers. condition both of the the of ulcers.and. surface epithelium.there the well-known extensive and profound tertiary ter. nor even of the frequently. and so-called preferto upon and grave outward no laryngoscopic large number of means laryngealdisease discovered examination. although they much are pharynx is the on and vocal the points..who unexpected APPEARANCES.evinced patientswho syphilitic the that. this class of of description my a disorders the secondary forms in the larynx with occur also " in signs of it. plaques muqueuses form their upon and we most wall of situation common the and projections. fre- tions affecsyphilitic that state " have alreadyknown catarrh. determined by fortuitous catarrhal inflammation. Such ulcers almost alwaysbegin the epiglottis.its duration. ANATOMICAL quence. ulcer.as and the luxuriant forms No rare. syphilitic lupus skin. thickening and condylomata of the in also at occur larynx. testify its to and specific nature.upon the epiglottis.and quite are simple syphilitic angina. Although syphilitic other laryngealcatarrhs by from distinguishable after palpableanatomical peculiarity. and patientsdated then: laryngealaffection from a of syphilisin this organ it probable that the localization degree. arisingfrom catarrh. true and false chords. or not unfrequently spreading thence throughout the entire larynx.these ulcers have a dentated.and of of some them looseningof the condylomata other the on served.

growths. condylomata of chords. primary syphilitic ulcer. and surround dency ten- a its papillaryand vances ad- bulbous deeply-retracted scars. The harsh cough.which exhibits neither The extensive encroaches characteristics of other Here. Its presence should syphilitic when.but hoarseness the that of have of modifying the symptoms as that of occurrence both of the voice the upon from opment devel- what we hoarseness. in an individual who.we may suspect simple laryngealcatarrh. condylomata. should or the aphonia. covered cicatrize to other at the at places.has and who has since had syphilis.has complain.or syphilitic larynx.without the throat. AND The " simplecatarrh and the earliest manifestations among If. and of the pable ca- of preventing vocal chords.should he acquire cough.needs no further explanation. as probably one ulceration seems to belong to a someSimple (secondary) what syphilitic later does with not coincide period. and should these symptoms persistin spite of appear. too. the vibrations of the chords.should begin to assignableexcitingcause. and syphilitic simple catarrhs. in almost all the cases reportedby Gerhardt and Roth. and series have sufferers mercury.DISEASE SYPHILITIC and smooth a base.should months who. so situated not to disturb as fact. of a feelingof ticklingin his voice become deep and hoarse.then of treatment and by with voiceless. there of organ the nor larynx. Thus.barking cough. with pro- . harsh. and the upon the of vibrations sonorous to the originof accumulations mucous the tone complete dependent upon a not are careful most graduallyincrease previouschapters about well the catarrh.therefore.barking a upon the condylomatain stated in the and some person. it appears. condylomata of the larynx have been dylomata accompanied by conother upon existence case parts.especially upon the mouth and of such our growth should awaken suspicionsas to their presence in the larynx. They form one of the later links in the and almost attack patientswho disorders.as its appearance ulceration of the fauces.as harsh. aphonia. are cough. then. are especiallycharacteristic.while their non-existence permits us to regard the of simple catarrh. They show a point first attacked. the of constitutional syphilis previously. diagnosis. As. laryngoscopyaffords and the profound surest forms means of of of years suffered resorted to the various here not first from simply methods hoarse of it. contracted a a management. SYMPTOMS the larynx are which COTJKSE. The that condylomata.the from are chain have the of for easiest to syphilitic a another. exclusively are throat. one or two years before. ulcerations (tertiary) form one that the upon recognize. be had of simple suspected primary arises a ease dis- cavityof the laryngealdisease.do not give rise to hoarseness. which with OF THE LARYNX 37 yellow coating.while the destruction The very voluminous the sore. secondary symptoms.

Thus. confidentlyawaiting her speedy dissopatientwere In this patient. We or always combined with a more the laborious. the region of the larynx of all patientssuffering to examine carefully the epiglotand to press with the fingerupon tis. without voice. THE utterlydeny laryngealconsumption. with profuse and often bloody sputum. in order suffered if it have to ascertain loss of substance. the of same " rules For the treatment apply which syphilis. the the sometimes which It is not the prognosisis latter. be made so ment improveby tracheotomy. any In gives almost positiveor negative result of this examination certain ground for diagnosisfor or againstthe malady. and bereft of all hope of imthe relatives of the TREATMENT. at least takes place. patientsdie. I have seen now an there is nothing.although a closer insightas to the extent of the process is only to be obtained by means fact. in some cases. terrible malady under which to recall to mind she lay utterly for weeks emaciated. in the " Prominent ULCERATION authors VI.with its stridor audible even of the larynx may graduallybecome development cicatrices and the cases. OF LARYNX.long-drawn breathing. In seem of prognosisis good. syphilitic for the general management the orifice.from last described to develop. the forms grave a very with symptoms of or later.save a a blooming female. almost complete recovery. in one far-advanced instance. tracheotomy is indi- sated. mark less intense dyspnoea. a partial unfavorable Most one.the laryngoscopicexamination. In extreme are of laid down contraction of disease of the larynx. from so in then- poisoningby carbonic dyspnoea suddenly rises to of the glottis.LARYNX. becomes respiration In other at of stricture of that vicinity. In condylomata and simple catarrh so good in the simple ulceration. with racking cough. although the respiration increasingmarasmus. sooner remain or even sufficient. CHAPTER TUBERCULAR ETIOLOGY. provement. slightstridor and a deficience the once in the soft palate. from laryngealstricture. The oedema of th narrowing contraction growths of exuberant and insufficient. the of occurrence This distance. a extreme. alarming pitch from an fact that the ulceration spreads graduallyinto the larynx from the root of the tongue and makes it a duty fauces. THE OF AFFECTIONS 38 are but these symptoms unfrequentlybloody expectoration. However. and ascribe larynx of a consumptive to corrosion the existence the ulcers of the so of often a berculous tu- found laryngeal mucous .and there begins its ravages upon the epiglottis.in which lution. acid sets in. so characteristic fuse and not larynx.

especiallyat the other covering of elevations of the covers not monly uncom- posteriorwall of the a arytenoidcartilages.in that form we sult regard as the reand (seechapter of inflammation experimenters have in succeeded now consumption). is one of the most common the of consumption of the lungs. and the confluence of irregularform. laryngealconsumption. bounded formation to the vocal worm-eaten "y. over views. upon inducing an Since numerous artificial generation by inoculation. results in small rounded at which is The cavities.very ulcers. laryngeal the the earlydisintegrationof of which membrane of the at the flattened The " nodules situated a upon a base pale. and the ulcers 39 sputa passing diametricallyopposite to study place in which very the as attributes these acrid the LARYNX. posteriorinsertion ulceration tongue epithelium. Not only does it accompany tuberculous form of pulmonary disease.the frequent association of a tuberculous origin laryngitiswith a pulmonary consumption of non-tuberculous such Plentiful for lation inocuwill not appear opportunity extraordinary. the whole often corroded. of consumption which if not oftener. caseous break soon form nor down appreciable tumors.by membrane larynx He the to liable to therefore. everted edges.and shallow into tubercles the that fact accident from become never Vir- recommends tuberculosis. the of by shallow sores. beand superficial. the with contact THE OF ULCERATION TUBERCULAR origin of ing. profoundpenetratingmore chords is destroyed. however.8 excessive of papillary growths with it is the seat Often. though rarelyarisingas Tuberculous an dependent in- tions complicaprimary malady. true tuberculous the non-recognition of it. and swollen. dull-grayhue are first observed They are spot just mentioned. the larynx. too. ules nodby hard. in the larynx of a phthisicalpatient. ANATOMICAL is that tuberculosis muscles transverse begins and epiglottis.finallyresult in a loss of substance shows various in the vicinityof the ulcers membrane degrees of redness and swelling. Small at part the of most frequent seat mucous larynx. Posteriorlythe chords. and. are without. The process. as extends it were.and spread to the root of the Sometimes of destruction .whose edges then seem and may soft involve the palate. for the mucous is afforded small breaches of continuitythrough the suffer many membrane must strain of coughing. spots.flabbyappearance. passing caseous APPEARANCES. The mucous ulcers. The growth and decay of new of several in the vicinityof those first formed.but it is seen quite as often. holds chow. Finally. and these are constantlyexposed to the contact of of the tubercle material. or else of either reddened these however.

The and suffice that than vulnerable produce to mucous in of it a jority ma- upon always growing larynx is more are not a upon toms symp- upon posteriorlaryngealwall. besides hoarseness or audible invoice themselves so " all these mucous very prominentlyinto membrane striking and notice that are more painful symptoms the phenomena force of tubercle . the seat of ulceration the assignablecause. patientsdepends instances.so and much the more inaudible. swelling the vocal the hoarseness does and obstinate persistent become. causes. The fits of coughing. THE OF AFFECTIONS 40 and goes. it is no longerpossibleto tightenthem. however. paroxysms unfrequentlyend in retching and vomiting. If. In other of cases. combined often is very ulceration reach the cartilages. skin. and thickeningof of shall we we hoarseness epiglottis.so and instances. too. result of immediate the the great upon the by why the secretion which lies hoarseness comes and persistent." AND with carious they become cartilages. another. brought on most distressing cant by the most insignifiand often inappreciable which of not choking.thus organ that necrosed. in seen. mucous least in most hoarseness. and is occasioned by the relaxation understand thus can a the supervenes but not have the vocal chords. in such thickness entire of posteriorsurface the upon ulcerations. the ulceration destroys their posterior attachment. syphilitic with In ulcer tuberculous a LARYJsK. often discharged are cartilages emphysema fistulasand producing laryngeal one. (There membrane. nor to throw them into sonorous vibration. just as.finally.the rare portionsof ossified ulceration has forming contrast a SYMPTOMS infer coexistence the cases. so. of tubercle of the of texture muscles of of tuberculous the hoarseness which the hoarseness lungs of the of tuberculosis wall perforatedthe When COURSE.To of the them. situated the ulcers diseased and slighterirritants far confidently in cases are an upon ation alterthe paralysisof hereafter. The voice is totally whispering extinguished.the latter. toms symp- prominent It is characterized by great irritability and violent reflex phenomena.If of its larynx cf the Tuberculosis the .at while of glottis.we may the larynx. cases. too. more The the nearer about in state a of alternate approaches to destruction every swollen membrane laryngealmucous the always seems parts congested.is as ulcer. brane mem- healthy a catarrhal a affection.In instances rare epiglottisperforatesits the the the of contour is still preserved. Nay. in which of hypersesthesia the disease the runs acute more a course. recur being.and sensitive.The We upon of larynx. speech becomes chords.)Here. chronic at of the time one when and ulcer without than at skin any become detumescence. tuberculous of this ossification of the long standing.

a They are all capable of being produced by other in every chronic degeneration. we are will not of the glottisis warrant able to show that diagnosisof the lungs. Hectic emaciation are the aid of capable of rendering the diagnosisalmost certain without of the laryngoscope we can easily physicalinvestigation.By means the view. The patient died in a few weeks. is the which to be afflicted. pointed jags of a dirty-whitish Of the wo. while solid food passes down more All of easily.' increasingstricture of after having been materially relieved by tracheotomy.shallow. We ulceration. expectoration diagnosis of b e since small but a (unless. The the night-sweats. portion shortness of breath. he believes himself with which he fears. pharynx almost always shows find its blood-vessels that chronic catarrh varicose.too. deglutition him to enjoy liquidfood without choking himself.too. At the autopsy found in the larynx the thickeningand induration there were of the tissue of chronic submucous previouslydescribed as a cause stricture.therefore. the besides symptoms I have seen intense and graduallyjustdescribed. can see a edge. In one case only of pulmonary tubercle.pieces cartilage ejected). the larynx. laryngeal affected. thrown into 4| the background. affection of may have been avail ourselves of the revelations of percussionand auscultation. being frequently often obscured by subjectivemanifestations fever and the only signs those of the larynx. and usually. the emaciation proceed equally from the coexisting tuberculosis of the lungs. At last it is often impossiblefor a great deal .and see small cles. ulcers into the a nd on epiglottis bring arytenoid cartilages posteriorwall of the larynxabove the transverse muscle. togetherwith tuberculous of the Examination exists there also.even feelingof crepitation perceptibleupon this manipulation is also felt in rare this organ in a healthy person.and at not once to institute plete. are of this organ. if of the not far very sufferer declares " advanced. vesi- erosions. indeed. that he THE OJP ULCERATION TUBERCULAR are LARYNX." and protests that the only evil ridicules the percussionand auscultation.lung. or The " consumption It is of the has larynx. they are but slightly pressure though we push the organ back against the spine. It is well. able the to kinds of physicalexamination chest.the hectic fever.with upper color (Tilrk).rounded phlyctaenae. larynx unless cases the closure however. a ag few . and is of no pressing upon diagnostic The of is useless as a means significance.In these tubercle of the these symptoms. The there. The sufferer hawks or small." for patientsto complain of burning or smarting in the sensitive to larynx. is difficult. of it springsfrom the larynx. fringe. least in form the of at a rule. nothing the matter with his chest. incom- to pronounce an an accurate opinion until we The fail us.

" which of annoying cough. " best can source a solution of nitrate of concentrated a let the and silver. suffers remain from in a atmosphere. and those of patient whose tuberculous hi a possible. first of all. any objectionto the which attaches this the to to nor patient hope prescription. and. although a LARYNX. accomplished by skilful and practisedhands. THE the main must laryngealcatarrh. nay. in the few effect. ulceration somewhat in the . oedema rare In the " the burdensome rob of the other patientrapidlysuccumbs. the this place.in consumption.to be swallowed make fasting. the roe of a herring. It has been customary to prefer the use of hy even a and oscyamus of the belladonna former Seldom As a matter remedies are of as are forbid him and. from of On of cures takes of tubercle cure diagnosis. the or are not indication to combat symptomatic indications are. to as cause in in treatment chronic The be. cough and attacks of choking. with waters. The insufflation of lunar caustic. more upon lungs. morning.to hot and drunk milk. this treatment may radical effect. The in the treatment of tubercle of the most importantmedicaments Little as they contribute to the healingof the larynxare the narcotics. course.OF AFFECTIONS 42 remedies in praisesof specific upon larynx are founded chiefly The of the hand. rare palliative over the have a entrance in have to which also pulmonary phthisisrecedes. symptoms of the disis indispensable.and moderate the be the as the Emser fasting Do the not some cough. mixed KrShnchen which the up. we must concede a certain preference tion. treat In very The rest for for may cases. all loud if opium seldom as trustworthyas from irritability heated to that of the uniform. exclusive application of nitrate of silver in soluto the direct and when or substance. the TBEATMENT. or from small a beyond authenticated be can number. compel cessive ex- formly uniWe abso- . Here.If the and pharynx be reddened . too.y patientgargle assiduouslywith alum. nevertheless their opium. sometimes stances inif repeatedlyapplied. cases. if its blood-vessels be varicose . is in guard against the too frequent hawking. larynx must moist bad especially preparations consequently. seem. effects. speaking. by moderating the cough. cases. actual Death some in condition of symptoms pretended of error doubt fully *Ji discussion which under of cases one. the with exhaustion.to the surface of the ulcer itself. which not unfrequently looked be result to of treatment recommended that most The sufferer of his as same malady the either the indication to meet the disease. we it with visible in it. shall we subject of tubercle of glottidisis suddenly set we laryngealtuberculosis. if phlyctsense in the itself the In this wa.swab ulcers be squeezing of a saturated sponge with a solution of nitrate of silver the glottis. their palliative ease action upon the burdensome ulcers.small ObersaltzbrUnnen equal parts of degree.

but great number (1854) and Lewin tissue. and carcinomata. mucous occurringas little bladders of the sist peduncles.IN GROWTHS of weeks' lute silence of speech. that pass described autopsiesare down in that.and the The latter as appears is cauliflower a have and follicles mucous become myxomata a whose serous or observed are vegetations. When duration.twenty-two to prone . They conpea. LARYNX. they are in the found commonly most LARYNX. three on the wall of the larynx . fibrous larynx are mors. and likewise common are usually multiple.with must seem rational as every act the air which from in as practice serviceable. large numbers. which laryngeal tumor growth. VII. eight on its in only two instances were pathologicalgrowths observed upon the hinder wall. lipomata. are Papillomata. when attached called fibrous polypi. tu- hemp-seed or bean . five on the false vocal chords .the is driven vocal it will be found to be are that. Very rarely lipomata rare haemorrhage. Fibrous generally spring from from the sub-mucous had ulceration and shape of globular or peduncutumors. particularlypolypi. either nodular. pathologicalrarities. without mouths are tents conoccluded. prone would would ulcers It is form. aryepiglotticligament. may tesselated is covered and and epithelium. epithelialcancer form. the in lated not than common more Of surface. tolerably for conducted polypi of at the present. and.which latelybeen From the "y to be care with supposed observed which that break soon and a used hitherto fact to most . it is hard- larynx have been . or texture lent succutissue. chords THE IX THE They attain the peduncle. twenty-one on the thirty-twoon the true.the most this circumstance alternate Such folding and position would a commencing tumors. by the fact that the latter point is subjectedto of the extension glottis. and whose colloid liquid. during the motions while be the more to therefore ulceration. medullary. and have growths seeks to exLewin plain frequent seat of ulceration. They consist of vascular by a connective whose be dry and dense. by layers of open. GROWTHS growths reflect we CHAPTER THE 43 subjected to friction this direction past them.tufted. do the membrane mucous Among Middeldorpf collected. the their itself. Cysts are more size of a pin's'head or perhaps a of the of strata seat the upon of rather cases of (1862)have epiglottis. or of a mulberry size of a proceed from the upper carcinomata. while the anterior arytenoidcartilages .which white transparent growths.nine on ventriculus Morgani. so tumors of instead the of larynx.

save in rare that a could surmise. or even them then* supposed laryngeal catarrh or from or Algiers.there to recover consumption. it would be cruel advanced with have pulmonary phthisis. in the overlooked polypous growths of of folds of growths or THE the other great part. Lewin.7 culties diffiin the larynx presents no To-day. in their desolate condition. Tilrk. be to no by laryngeal tion varying engorgement or depleThe size.when the in growing was of of considered the tumor.If.to effectually use cases. On cadaver. even a no to often turn to the specialists. became probability disease. a harsh supposed dependent upon though treatment. the trustworthy investigators. persistin spiteof sedulous signs of laryngeal stricture may exist.in the hands of a few subjectpatientsto it whc hoarseness and aphonia. and.AFFECTIONS y. but the majority detected by laryngoscopyhave not produced the symptoms certainly of the patientshad suffered hitherto described as pathognomonic.and which is not to so so With the aid specialists. the recognitionof a tumor of the polypi and excrescences so easilyand . made Certaintywas possible means become the to growth protruded. aphonia.we and other . It is not necessary to examine are sufferingfrom an acute laryngeal catarrh . and many merely from hoarseness.Bruns. of the excellent books be acquiredto the necessary skill may and by dint of assiduous practice. positivediagnosiswas impossible. the larynx come. tumor.that LA. which we the glottiscaused However. the it vary made the in greater.and of those on supervene dyspnoea underwent of the growth the larynx.and always a fatiguingone. Halbertsma.RYNX. sometimes we tumor began stricture to fluctuations took of closure which used larynx.repeated attacks could the even in of the course place. of Czermak. larynx. Until the introduction It is true. cough. enable us. to make all patientswho confirm our diagnosis. a reported as polypi.so as only in which where the patientscoughed or palpationor to inspection. It is justthis class of cases which shows what high time it is that the a of greater number laryngoscope. Most of cough. symptoms which we had simple catarrh.so however. from in have can tions observa- numerous that believe cannot we membrane mucous hand.by in those cases accessible to up fragments attribute only the the sudden change of periodicalreturn of cation suffo- to contraction of position of such or the choking-fits. hoarseness. OF insignificant mistaken been such for and of the laryngoscope.or troublesome to Cairo had in vain been sent to Obersaltzbriinnen. the growths within pathognomonic the diagnosis sure. who. as the procedure is very difficult to learn. as of symptoms laryngeal catarrh.so essential for the not as diagnosis of physiciansshould to disease this leave of the pay very more attention important art.Ems. with a certain degree of confidence.when. that instances. in doubtful of laryngoscopy.

or sensation if as accumulation an of mucus stickingin the larynx.first extirpateda laryngeal modem by other (EDEMA " or to whether size. " dyspnoea had energeticand frequent.but in only evinced with.particustridulous larly respiration.and throat without of his from the most brilh'ant advances both by Bruns laryngoscope.of necessity.or interferes with then. were entirely upon the cause growths Since the a growth.after what we have taught in the first chapter. In others when. brother.which of The it with aid of the the polypus incision.as colleagueBruns^ surgery.that our cases.even decide as to the existence that long-drawn. by the the goscope. attention. and my the to the often domain not. so that it would have been possibleto before the of these tumors in the larynx. rapid running. GLOTTIDIS. with the use of the VIII.and mounting stairs. formerlyregarded as pathognomonic were actuallypresent. On the of the vocal other hand.which hoarseness. neither harsh cough nor which there was The sole complaint of these patientswas. the like " after any alone which is however. (EDEMA ought ascertain neglect to to never whether be tumor a of the not 45 positively. is attached the latter .GLOTTIDIS.about in which the tumor It is only in the cases the physiologyof the voice. Czermak and Lewin called have it is frequentlyinspiraglottis tion below the be growth glottis expirationmay be embarrassed. has surgeons familiar CHAPTER ETIOLOGY.vihoarseness occasion that they. laryn- affection. under larynx comes 1861.effusion into subjacentregion by loose areolar takes place with extraordinary rapidity. and During of treatment of surgery. when the year laryngoscope. all tumors which do not imph'catethe functions Thus it depends chords cannot possiblygive rise to such symptoms. laborious. come bemovements increased. its upon laryngealstricture of symptoms of the of seat inflammation been forms one of the performed repeatedly. introduction of laryngoscopy. There was characteristic of stricture of the larynx. hinders the approximation of the vocal chords. have been It finally remains met to be told that contrary instances not no signs of laryngeal stricture. is easily of laryngeal tumors The great varietyin the symptoms comprehensible. of an ill-defined feelingof distress in the the throat.the operation.and the inspiratory bodilyexertion the more to newly-observed the of source of mjaiis in tumors the above if the while impeded. of a part where the skin tissue. bration. or aphonia. the besides signs the other symptoms of chronic laryngitis.

even or impossible. above over all. and lie so close together.8 prepuce inflammation extensive Finally. the connective If cut times some- into.yellowishmatter .etc.in general dropsy a in adults from life. diseases (withthe exceptionof variola) more mon comare in children.Let wounds when during inflamed swellingof the penis of that neighborhood. is the the aye about oedema the mind recall to us Virchow its LARYNX. the bands which stretch the aryabove (therefore arytenoid cartilages and in lesser degree from these downward.as syphilitic Laryngeal perichoncedematous to prone The of glottidis.serous the distended liquid.there tissue.which projectsinward. In rare instances. diseases. They may attain almost the of air egg. epiglottic tissue particularly superior vocal chords. The more at of the and muscles cartilages at alone.and.so the tissue pressure.is attached to tissue. the to more meshes at others a glottis. to the ligament). superventionof with to placeat the points above epiglottis projectsabove two the these. there is a loose submucous to epiglottis the from the swelling.or even may dritis often the of occasion danger these instances cases can be of The we added above-named than almost is observed have ANATOMICAL to do which but very few oedema exclusively among APPEARANCES. Upon the glottis epi- most close connective a its root. to roots persons. serum larynx. an the submucous facial erysipelas. just as an oedema gives rise to sudden oedema suddenly associates itself to a long-standingchancre. one a seem.rarely processes and sometimes chronic of the pustulouslaryngitis small-pox. the in acute morbid acute catarrh.at points. frequently and tuberculous ulceration. and backward to out the from takes swollen its base the lages arytenoidcartisize of a pigeon's becomes to the glottis pharynx. and In all is a partial festation maniglottidis and accompanying Bright'sdisease. the inflamed yielding point.that the entrance extremely difficult. is often of the rolls reach infiltration serous so tongue which great.sometimes flows from clear. as it would half merely of the larynx is diseased. which transuusuallyproduce the sudden serous excitingcauses known oedema dation into the submucous are times someas glottidis.at times.a turbid. tissue. called by of the fraenulum. besets a chancre oedema stasis through the capillary the much is. and more or less contracts the entrance pale in color. the post-horn-like This oedema.in rare cases. tissue of the throat.especially the does more membrane mucous lateral increased in the capillaries occurring in the The result of collateral oedema. a violent angina. region about a focus of inflammation. the swellings . THE OF AFFECTIONS "6 by transude. to the collateral oedema. and thus it happens that oedema glottidi? " grown The described the great loose pendulous and this affection. that .more larynx. only when singlepuffy swellingis to be found. These or of swellingsare less reddened.

explanationof the symptoms. save such as have alreadysuffered from tween chronic disease of the larynx. are swelled. forced. simultaneouslywith these as the air dyspnoea. passes over a harsh.although sometimes noisy. which is respiration. symptoms of oedema have described which we as belonging to croup. As soon symptoms. manage croup .the lighterand and evacuation and scarification. which.barking cough (symptoms which prove that the vocal chords. our changes which. arms of auxiliary planted.easy. are very similar to those glottidis. In the upper the submucous tissue is cous swelling is less visible.and by cooperation muscles is followed by an expiratorymovement. and in almost shaped tumor every if we introduce the fingerwith sufficient boldness.in membrane muscles degree closer knit. AND of symptoms an had as be wrinkled collapseof sometimes occur the post the post-mortem the with have death.or that the infiltrated laryngeal the chords to render tense). and the resonant. almost free." The then. a finger. chronic with There the is a into aphonia.after a physiological sequence.we diseases. in small before hours few similar mucous been correspond but membrane mucous A into folds. Moreover. the distinction beacute or the two diseases is facilitated by the great disproportion between and expiration in oedema inspiration glottidis. todescribes the inspiration Pitha as "protracted. is seen to be a natural conshall seldom the mistake two Nevertheless.we larynx. expirationas short.discolored. or layers. that among occurs individuals previouslyin good health. is neither of so in many 30 pronounced nor long duration. there arises the most frightful above the swellingsdescribed settle in the trachea becomes rarefied. muscles not in conare dition too. pearepiglottis cases. mortem. SYMPTOMS usual which. in seeing the swollen as a reddened. can long-drawn. when of bear we childhood " in oedema almost mind that croup almost glottidis always attacks as almost during exclusively adults exclusively . in croup. whizzing. (EDEMA and collapse. " acute (Edema or commences glottidis laryngealulcer. may feel the to two swellings.whistlingrespiration bring but littleair into the lungs. plastic sodden. no to appears membrane. for the exit of the air drives asunder the obstructingswellingsjustas the inspiration sucks them gether. COUESE. scarcelyperceptible. the foldingof has there when section the of itself covered and pale. a similarity which. with body audible at a distance. But. appearances anatomical under we and saw. Finally we may. We find the muthe laryngeal with flakes.and only practicable all the bent forward. thrown with the now 47 swelling.GLOTTIDIK. succeed behind the root of the tongue.and the laborious. inaudible. oedema glottidisscarcelyany.sharp. themselves the upper over aperture of the larynx.and which soon rapidly-increasing hoarseness.we instance. hissing. This inspiration.

although little suc- practice." here pediment in the throat.usually accompanied by increased dyspnoea is greatlyaugmented by this collection of bronchial secretion. is. tracheot- in its application . is usuallyassociated with a feeling of a foreign body or other in the throat Here it lodges. grows the sensorium and benumbed. blood of mass of drop a by such measures. therefore.are manifestations. value. Experience teaches that.LAHYNX. they spring up. re- repeat it. necessary is of far more bits of ice is sometimes once suffocation The witnessed seemed so audible." The ute.g minute to wliich.pelehas declared tliis itself. minim" " " " " " " " " " !" choking I'm these haste and Fear gestura and being .and after inspissation of the blood. We cannot as frightful mele. some theoretical be ascribed support for such cess treatment. There even largepathologicaleffusions have thus been absorbed. the are into in with sets with lous tremu- depictedin their entire sob and about. according to sufferers frightfully-terrified the pictureof Pitha.Only when hourly.during cholera. desperationare " in stupor. and final These words which. upon TREATMENT. irregular. THE OF APFECTIONS 4. rattlings a classical the out gasp it ! " the of symptoms the also. hypersemia arises. leeches in largenumbers to the throat. and glottidis. justas in the skin upon wliich a intense membrane cupping-glasshas been applied. blisters to the nape which the customary prescriptions are are usuallyapplied. they dash themselves until graduallythe countenance cool. hot footbaths. alreadycontains becomes rarified. groan the exlivid and tremities lead-colored. in croup. As but littleair passes the larynx. and. as soon malady and " of allayoedema the prepuce applied in vain in urgent diminish we may oedema by giving half and volume of the blood the croton-oil they generallyare the danger is not by efficient blood-letting. moist an to it in rdles become emetic is It is sometimes Local small ment I treatment and indicated. Blood-letting. but depend not upon impeded evacuation poisoningof the blood with carbonic acid (seeabove). of my ing slowly swallowUnder this treatr in colleagues.so upon the mucous The secretion. increases from ctyspncea." It is stranglingme. the which same chest oedema begin of the studied we be to lungs. the vessels greedilytake up liquidfrom the organs. or to defer whom omy.in order to decrease the in the vessels.but only like productiveof the best in sults. the to In cases is often this. emetics.after great haemorrhage. and that. can BO that loud such cases. hardly dared insufflation of pulverized nitrate of silver. of the neck.in severe cases. of the cerebral veins. through copioustransudation of serum into the intestine.the pulse small Then patientfalls the death heard. I can't stand tighterand tighter. The of remarkable recovery of imminent that we one effect of benefit. in spiteof the most that which the bronchi forcible inspiratory efforts. drastic cathartics.through profuseloss of its water.

the seat of suppuof suffering penetrationfrom without. ulceration of the laryngeal mucous are excitingcauses stead the above in membrane perichondrium. and its nuded. the When questionableservice.inmentioned. guarded with with a or finger-nail point. we pulsegrowing small and irregular. LARYNGEAL ETIOLOGY. Of course. however. and than preserved for months in cases where has occurred in tuberculosis of the larynx. and sometimes and typhus. of by means almost to plaster the adhesive the or unsuccessful. do not generallymean flammation inhowever. oedema glottidis IX. chieflyin persons or by the infection in subjects even at by syphilis. mucous membranes is one of the of the of ulcera- earlyeffects larynx. and without least. In other cases the previousinflammation with constitutions arises malady of the broken mucous down independently. The portionthus deand deprived of nourishment. who apparentlyare robust.or membrane. proceed forthwith to tracheotomyand insert a canula until the danger is successful like this.and is discharged. from its densityand impenetrability. If we should or effect. a as whole.either bistouri. of 49 poisoningarise.penetrating from without udation inward. In cases life has been in croup.so firm and resisting is tolerably cartilages The " the it long withstands any which process the finally perforated. Necrosis of the cartilage so great a detachment its nutrient from vessels.the the senses and must benumbed.and by between forms which the latter. undergoes very natural result of is the extensive separation. with perichondriumor fibrous tissue immediatelyin in texture. When membranes. and ulceration of portionsof the perichondrium. suspended. but refer rather to an affection in which an exand the cartilage the perichondrium.PERICHONDRITIS.septichaemia.the operation. the scarification be without should of carbonic-acid symptoms deavor en- swelling. the inflammation follows is called and the destruction of the larynxwhich inflammation. we By perichondritis laryngea.is to of effect scarification the be should the ice should we fails. of " " 5 . a rheumatic laryngealphthisis. is more past. which. CHAPTER PERICHONDRITIS. LARYNGEAL solution.sloughs off.becomes effusion between rative inflammation. catching cold is assignedas the cause is called a rheumatic . in the latter instance. ulcerative advances from is laid cartilage the tact con- that mucous bare. which an causes perichondrium sometimes Its and cartilage. mercury. the like . bits of cartilage have alreadystated that these necrosed generally connection We show traces tion of the with its nutrient vessels is of which ossification.

fall to pieces. but from this point spreads rapidlyto the coverings of the other cartilages. the more bined so. but. as the inflammation pain than occurs generallybegins at an insignificant point. ward afterthe perichondrium.but rather the reverse. and and larynx.the pus bursts through the perichonthere only a is and too. second aphonia. degenerate.hoarseness. and with it the entire left in arytenoidcartilage.or The by effusion of Many patientsperishin symptoms of the The pus submucous which has lated accumu- tissue. recovery being replacedby dense fibrous tissue. not unfrequentiy.bursts laryngeal stricture disappear. as the pain is comwith In the irrepressible cough. formed by soon.the painfulregion is also One eign quitelimited in extent.and drium.very distinct phases form perichondritis commendable its course. however. completelyconvalescent. In seen istic character- cough.the symptoms of a disease are SYMPTOMS AND rendered easier of comprehension by any not arbitraryand artificial ever.harsh stage. and is pushed further into the symptoms either the cavityof the matter this below some it.arising and tended disgradually.or suddenly.the lost cartilage COURSE. and of But. perichondrium. as unyieldingstructures.LARYNX. They become rough.the dense disease in ah1 inflammation is attended by greater in other affections of the larynx. might readilybe led to suppose that a forbody were lodged in the larynx . At last. Abscesses surface. through I have girlin the most frightfuldanger of suffocation relieved and rendered after expectorainstant. classificationaccordingto stages.discolored. As a rule. When. ting young quantitiesof a its stage. and. and the are perforated. the patientsusuallyperish in a .as the perichondrium becomes more more by the increasingvolume of pus. on larynx. the into runs the is fall into the larynx and external the to thus formed. ANATOMICAL it The " the latter and its sheath.by a the a submucous state third perforationand tissue. else the or At sinuses of times. stage is added.into the cases under the its confines. THE OF AFFECTIONS 50 order point of preferenceof this disof the cricoid cartilage is the perichondrium . an of intense dyspnoea and laryngealstricture set in. fragment by fragment. maceration.At first APPEARANCES. In its first stage the of symptoms are obscure. the study by stages is both in as divisions in natural and practical. then. even in such cases. place. pus. of fragments fragments of cartilageare and pus of the tissue submucous membrane mucous way between small abscess lage carti- pus forces the neck its are ternally dischargedex- has taken rare pharynx. thinned and softened. howinto or instances In the " laryngea. pus coughed up . after a time. Very the cartilages are floatingin a sack of pus.

disorders predisposed to excitement. of the sensory The excitability nerve-fibres. OF consequence The " MUSCLES THE OF has to the disease is not formed do of except in the sub- to perform the opening of any abscesses about and even at our disposal. suppuration. RYNGISMUS ETIOLOGY. it is attended." NERVOUS AFFECTIONS of Deranged sensibility the OF THE LARYNX. of the for the connection of account can we frequent spasm swelling of the thyglottiswith the most heterogeneous diseases cranio-tabes. hypersemia and hypertrophy mus.SPASM of state in marasmus. they are subjectare tion regarded as reflex phenomena. not Only by such a supposition organs.dyscrasiaor subject having tres nerve-cen- .and the TREATMENT. the after effusion nothing operationand the GLOTTIS. observed never as are independent diseases. mucous this tracheotomy. in hysterical persons. laryngealperichondritiscan. (anaesthesia) sensibility of globus hystericus and of spasmodic We certain count cases may to the first of these forms. NEUROSES. independent of the morbid condiwhose is increased. acting upon brain. [This " of the effected . continuance of 5} the malady. We shall treat hypercieach in of followingchapters. that the essential of this disorder is to be " of the constitutional of the anomalies. symptoms. CHAPTER SPASM OF MUSCLES THE OF ASTHMA LARYNGEUM THE GLOTTIS SPASMTJS " ASTHMA MILLARI ACUTTJM GLOTTIDIS " ASTHMA THYMICUM LA- STRIDT7LUS. persons cough. the latter sufferingfrom to be of the neuroses nesis and the function motor acinesis in the and / into spasm divisible into larynxare palsy. but muscles also nerves the seem disease citement spasmodic exis the glottis-muscles inspiratoryand expiratory depends mainly of whereby contraction of motor-nerves to take the part in the accompanied by general eclamptic spasms. the fever only a treatment generallyrecognizableuntil There tissue. they are only measures merely palliative. X.excessivelyexalted excitability their abnormally diminished and (hyperaesthesia). True. are Henoch often infers and sought in the medulla in the vagus and central alone.and the neck about are of by which of ETC. seeing that remains then THE of the treatment be course. teething.] stomach a or liver. a upon indeed which Hence seizures. of its sensory fibres bility sensicomplaint do not complain of abnormal but the coughing-fits to which in the larynx. larynx.hydrocephalus.

There have been solitary has produced death by protractedspasmodic but than breast. In minutes. of the with case laryngeum. with of the in vocal relaxed only hold those noo- larynx. the restlessness.and still remains strenuous even thymus gland. we he is completelyrestored.like the often-mentioned the forward At soft occiput degenerationof in paroxysms interruptionof pathognomonic of minutes. prolonged whistling. APPEARANCES.it seems affected are brought families almost many the motor of the attack. the spasm occurrence in the processes larynxapparentlysound find the is also the This phenomenon). cession suc- children among common more receive suffer hysterical persons but none children among children in all the and great cities. are matters all events.therefore. membrane laryngealasthma. and spasmodic spasm in wnich is the cough no the and or nor fast to it par vagum. There forgottenhis fright. as exist up and country be to who from the a seldom I have regarded Kopp does hyperaemia. of dangerous degree which in which instances seen the in Among of the spasm cases only exceptionally. Enlargement of ANATOMICAL many such adults. any diagnosis^ which respiration.the SYMPTOMS said an A COURSE. Enlargement of exudative (aswe in part of organic cause exist. inspiratorymuscles. Romberg considers congenitalpredisposition in beyond doubt. accompany of the child has the as croup.are autopsy course air attack glottis.of out thickened. the from must. in glottis. contracted. by the bottle. Occasionally sufferer may perish. as soon does spasm genera]convulsions hands occur. ex- By-and-bythe addition we If. noted intensityin hysterical persons.and exclusively Spasm of the glottisoccurs in the first year of life. In by the disease. sudden last for several teria hys- attained regarding the pathogeny)are after asthma mortem AND is neuroses.and the positionupright. few a the as the out ways al- not the livid countenance. as the laryngeal mucous chords part accidental. the fear. all confusion instances that of most which glottis. intervals of and the seizure. It is most frequentduring the period especially to of the first dentition. hoarseness. confine not Sometimes jramps oven at first is to neither are catarrh accompany of these parts alternate with the may the this. .is there the idea that asthma laryngeal becomes easy turnal In attacks many fibres of the to avoid of vocal is a dyspnoea which vagus the alone.OF AFFECTIONS 52 LARYNX. THE almost during childhood. The " marked is accompanied by the spiratorynoise. the contraction bent or by of hypertrophy.in- affection of the of it with and of chords nervous Angers toes. throat the glands of the the as not (arachitic of Elsdsser the of had spasm these in which closure " instances and glottis.or and found post and have bronchi. itself to the contractions feet. is the of is to bear of the violent again begins to penetrate into or completelyclosed. disease. nor. After healthy. and brain. if the interruptedone.or glottis. or emption.

the muscles are relaxed. outlastingthe endurance privationof oxygen.to of clyster plasterin the fit occurs. a teaspoonful everv aa fceniculi. THE place ETC. iij.and follow one another more There most are always apt to be accompanied by general convulsions. almost instead. 53 varying intervals. glotticpalsyby means cramp of local faradization of the laryngeal muscles. The " indication to as cannot cause be met. hysterical In first of all demands causal indication hysterical symptoms.In bad cases the fits week more or pass without may and it is these cases that closely. the effect psychological morbi equallydifficult Meantime disease. s. the paroxysm administer mustard We a instruct begins. and show children. the as should deavor enHowever. multiply.aqua specific. of causes nourishment the cause and the of spasm in at use the of the time attack be to changed. so the glotticspasm.the treatment undoubtedly of the treatment the actingsolelyby The is indicatio effects of the of mixed four to six times which this obscure in fulfilment. iv. m. two hours.the child pallidface assumes itself but sinks back and never once. as he is we may a " anable as to soon and have when as to a swallow. liq.. before we proceed to the of doubtful efficacy.OF SPASMS MUSCLES THE OF take described thus GLOTTIS. universally prized as a give mimos.rhubarb.This is what is meant employment of specifics when we prescribecalomel.which The paroxysms though have instances shown The remained child have a doubt no for months without observed in which been at a Finally. quent conseof the organism. a deathlyhue. laryngealasthma has In rare instances a again to recur. It is well to precordium it if valerian fail. syr. (Moschi gr. " j. oxysm parthe closure of the glottis. all of disorders and nutrition in to allay most digestion carefully show children who a tendency to this malady.are by psychical and I have cured both glottic measures. 3 as. and it produced.and If the of injections the parents it in fresh or to to take air.and other remedies in spasm of the glottis. is still to be feared. should fan camomile readiness. succin.in spiteof musk the medicine lauds and the for children fcetida aqua their first year.ammon. we glottisare obscure.even remains a great tendency to relapse..to the rub valerian tea. If. main small in spoonful the seizures asafcetida. a day. and terminates in suffocation. incomprehensibleaffection JRombergrrecommends a he orders which anti-hysterica with equal parts of simple syrup. .examine signs of the disease. lay it camomile upon or the child up its back. gum. like combated to be all other hysterical manifestations. simpl.. expires.a their repetition. Children fed by hand should be placed to the breast when they In older the milk. TREATMENT. recur. forth. 3j.) During the fit it is impossibleto give the patient medicine. paroxysm.

First be A formerly was and paresisoften ascribed while solelyto catarrh further play puberty. vocal of the of some found have we affected at power.upon the and understood. medulla. emulsio. TUB OF AFFECTIONS 54. is well begins. 3. The : complete of the in result want -openers. vocal chords Prior affection. of palsy of [OuR knowledge to this time.) two XI. j. premise that the vibratory and motor derangements of chords laxity amount other the laryngoscopic and these phenomena mere of a to due to the temperament nervous brain. m asafoetida. By means lung. cancroids of the oesophagus. the symptoms. or a acoustic. arsenic. which in slightcases 1. which fact of them that chords. ov. loss of all motor muscles or great diversityof both sides of the phenomena. We due voice . laryngeal mus- serious very hysteria. c. compression of a phthisical the apex about of the right by pleuriticadhesions of in such of pressure cases.or atropine. so or fatigue of is of in the a diphtheriaof the must vocal to a the function closers whether or paralysis to catching nervous the or woman chords for the be . thickening mediastinum. compression of the left recurrent nerve by thoracic aneurisms.substitute advisable to vitell. mental suffice in entirelywanting. or vagus the upon recurrent of Tumors imperfectly. clysterof a LARYNX. induce to an their aphonia. after the These age slightcold. both of palsy among apparatus then oedema the catarrh or pharynx. is the these among cold. as few a nervus these but ation degener- or glands. however. and latter with its cause or of might cles. or poisoning by lead. f ss S. due this of only forms the laryngoscopic era. . " i. organic disease membranes. It is of once. " clysters. of shock. 3 ss (Asafoetid. valerian. are the chief sources bronchial of the laryngoscope. upon or one whether only It fy to modimay ones be a may depends upon the glottisimportance to know 2. no. of of tone the muscles. for " iv. f. and slightor very vocal rarely. the to pressure were nerve. . combine Many circumstances degree. the with known. females may has the is often even any spinal cord. CHAPTER MUSCLES THE OF PALSY GLOTTIS THE OF DYSPHONIA " AND NIA APHO- PARALYTICA. larynx " in grave or both it be is affected.palsy of the that important part an that be a off-hand inflammatory an may cause disorders series a are of the coexist do ascertained not we the More alteration ascribed catarrh had dailyoccurrence. infus.

which the the a is extinct attempted phonation. simultaneouslycom- median voice of the and true is line. Sometimes the show the the form usual of the only alone openers symptomatic the palsy is apt well the as to keep hoarse. but in the deep inspirationthe chord. of the is gaping is voice of with alone else of extent line. the the closers. is Palsy of these muscles differingfrom laryngeus superior). possible. with middle its normal becomes It would . the he are close to the chords. Tttrck distinguishesseveral vus . Here. when calls one quite conceivable source latter chords. but vibration of closers.sometimes which the the instead but forward. showing glottis.however.the voice stops riina of forms gaping the can but that exists co- is found should muscles. out- move are other patient rests recurrents palsy the that so side tinues con- voice.or the to gape less rest at chords two or closing the chords the patient is the more gape the as that see we line. does Such verse trans- in the the the closers chord When the glottis- generally nerves. without the When be to a obstacle for to account finding any mechanical alone are affected. the makes Czermak respirationis In exertion. recognizablethrough of hampering or THE the 55 the laryngoscope of motions one both or chords. of voice utters laborious. widely. glottidis plainly absent.and are line. and ror mir- usuallyimplicated are on difficult when both not cases the recurrent the as becomes false the case When of motions. . the upon visible. that. totallyextinct. vibrations more hoarse. besides the muscles implicated.the a of the (Bose). the both then up only a alone seem palsy of of both (ner- sometimes solelyto ligamentous glottis.but deep notes. Palsy do if. and alone changed. especiallyduring nerves imperfect an When still are median it at all. though enfeebled the laborious. crico-arytenoid lateral are sometimes paralysis of the glottispalsied glottis does not opening of an equilateraltrianglewith its apex pointing perceive that upon corresponding cartilageof one we as that oblique arytenoidmuscles and other be to seems mind to cartilaginousglottis. discovered there that .but power long so it. lie immovable very is their is not one but. pressed.and openers instances rare is also pressure to be the solelyto to the due the near of of is confined affected. when of utterance patient is absolutelyvoiceless. the one sides. vocal has ing Breath- chords. ward. where chords or upon extinguished.PALSY Paralysisof when find we the chords arrest an MUSCLES THE OF is OF GLOTTIS. is not unimpeded.nothing remarkable glottis-closers seen sound. but touch not moderate. speaking becomes glottis-openers(musculi cricothyroides)often that from closure no the at either he is and the closes. and be derive they other in the that fact unilateral.

completely covering the true chords. THE OF AFFECTIONS 56 lie close during the acts of straining or coughing the false chords together.we by means glottis-closers of the larynx above that during the act of coughing the closure is the true and false chords not prevented (phonic palsy) . while ordinary palsy of the glottis-closers When the is not usually accompanied by palsy of the false chords. not cure always a speedy one . and defy treatment then. generally favororganic disease. Some benefit has been obtained treatment. important part. met hours some ( Gerhardt. to prescribe tonics in hystericalcases. extirpatedby the knife. expectorates be may a and the when he swallows. arsenic. The patient cannot for this purpose closure of the a cough.or appropriatelycombated. The prognosis of palsy unless the of the vocal chords is able. because momentary larynx is required (respiratory hence he ty. under the influence of some of mental disturbance. either mechanical.we often meet which for months.and the like. besides . Quinine or " a more of the the so-called " gymnastical effort often-repeated to utter treatment the sounds of the larynx.LARYNX.suddenly get also presents the during sleep. alone of the mirror are can see affected. or upon pressure which the function of the cerebral paralyses destroy apparatus of voice. plays that cases of any Local by In removal exceptional cases main A tumor object of treatment. but also cqughing. mental of the voice. and. furnish the iodine by or in the use pine treat to use intermittent be may to . and however. so also of closure a the larynx it. become impracticable.not only phonation.by cause may be resolved may arsenic be may poisoningby lead. above J3ose has shown that there of unilateral also. that. affection incurable depend upon a those central tumor." of the several . glandular degeneration. It may further coexistingcatarrh. the anterior ends of which are glottis moreover overlapped by the prominent pad of the epiis of the rima there the closure glottidis.diphtheria. antihysterics in be of atro- advisable anaemia. Levison). or the means is. and holding the breath. difficulwith palsy) .the or Intermittingpalsy of which the usually well.hysteria. hawking. over-use the is True. under peculiarity psychical excitement voice not for a while. particlesof food drink or easilyfall into air-passages. particularlyin the with capriciousand obstinate cases hysterical. TREATMENT. medicinal. all which cases Nearly recover proceed from catching cold. unfrequently returns the glottis-muscleshas voice sonorous lost was also been for daily in with.especiallyin cases palsy of these muscles paralysisof the recurrent. shock. but when both are affected. or electric. in Aphonia hystericalpersons that.

In the more the aryepiglotticfolds.by is sometimes limited to of variable a very aid of the OF P. where but one muscle is afdirect faradization is applied to it according to the precise and use that a of Ziemssen. THE laryngoscope. aphonia. place. 57 simple rubbing sound a (Bruns" without the upon of the thyroid cartilage. only effect of electrization be severe false that the and recognized by cases chords swollen by we find oedematous is often its redness the thickened tarrh ca- tis. sometimes small patient and EDITION REVISED AFFECTIONS " its after plete is incom- obtained. 1880. Mackenzie) then set upon the In neck without. ( Ger- effect good hardt). by help of the laryngoscope . the of the and sure larynx. transient. perhaps may be explained by the hypothesis that. All this affords the failed. and perhaps so much OF 3. epiglotand of a infiltra- . or. diffused.and lastingeffect ADDITIONS TO SECTION first the it is is 1.] THE I.the negative while duced in- the applied directlyto are difficult and constant is obtained success is in the some ally usu- astonishingresults) most both electrodes more electricity (which the treatment the In when sometimes employed. continued region. It has also been proposed provoke to reflex contractions of the muscles and other by insufflation of alum powders. or horns THE the by EDITION tones.the patient meanwhile making in spiratory which movements deep sonorous (Ollivier). and by the In a few breathing of stimulatingvapors. rapid sides usually tried electrode of being speciallyconstructed chords lages or arytenoid cartia applied to the fected. electrode intra-laryngeal is instruction At cases. has is treatment happiest and In current the may latter be wherein method.ADDITIONS and vowels Rossbach). and of and organs even REVISED in different diphthongs pharyngeal the of TO the mere OF the by chords with from pressure 1880. we can see circumscribed." During life. It may intensity. in hysterical especially by direct cases the neous percuta- within the faradization place. in these long-standingpalsies upper of the luxation a glottis-closers. I LARYNX. and the deep-red hue. exceptional cases good results have followed of hypodermic injections strychnine.which so becomes afterward that the outward reduced under electric current the of the above pressure have may cartilages takes mentioned. larynx (M.

aggravated by coughing or talking. hyperaemia.and emphysematous. injunction against hawking chronic catarrhs are timely in these cases. though full of blood. The and the portant exhibit imdeeper air-passages lungs themselves alterations. with are the inspirationduring upon parts of these but the the are the normal ab- condensed. which do not expand respiratorymovement On the other hand. which shows The character.AFFECTIONS 58 tion the impede to as OF of passage LARYNX. varying from often and chief The the sole catarrh of the ness. Very commonly the croupous coagula are prolonged into the larger or into the smaller even bronchi.and sometimes vena cava This studded of the with lung spots of lobular pneumonia.by panting. a constantlytrying to disagreeable his An such is most to neighbors. rather portions their air-vesicles are . to deranged vibration. which. however.strident respiraa clear mucus. which expectoration has no is sometimes of chronic of the form than of special characteristics catarrh continual larynx over-secretion There of is peculiar a .is is nearly always a hoarse. The immediate permanent It is jointlydue to debilityand is complex. it is nearly always in the lower and back parts of the lung. P. on only comes of this to complete and cause aphonia. aemia and result of bronchial catarrh. piration lungs. THE air larynx (oedema the through ylottidis). Very severe complicated of of the obstruction by signs larynx. by viscid mucus.and to respirationafter the obstruction at the larynx has been obviated by Other tracheotomy. 3." 18. According to BarteU. and dyspnoea. 2. hoarseness fatigue of the vocal muscles. of dilated the or upper compelled are wall the chest. P. which during resfront forcibly-distended bloodless. the afflux of place with each of state hyper- This air within blood into is a the the forced respiration. slighthoarsewhich after long-continued talkingor singing. his habit " " tion. 8. complained of." of chronic symptom change in the voice. are even burst of to move pale and and Now croup. is not uniform. There then barking cough. in consequence branches of the twigs of are rarefied which gorged undue in with condition an takes found are of a blood. consists in larynx Pain and now a and tickling. the The lungs abnormally chest. paroxysmal a no further which aly anom- the keeps tient pamost throat. forming solid plugs in the thus settingup fresh hindrance latter. to clogging of the chords mechanical to other or impediment to their movements. are shrunken and void of air.

which has is nearly all (JBoeckel. 4. disease. state in. and lungs considered. Of cases sixty-two recover well. the the less fatal even the per treated be to life course. mouth. of jStrass- cent. When result. state after of the regard to Gferhardt. the mouth hoarse lower sound recess hoarse. the note so tolerably natural still tumor . seems of stage drowsy. catarrhal better upon. a uttered but hangs and perhaps beneath very is made may the face the when is When pale emetic an midst livid. when so the to polypus in the found is seated the breath to drawing a deep utter a simple note. is contributes fever When rare. of 50 forty-one croup years Of recovery. of hope of first two the blood tracheotomy is somewhat relied success operated . of the of in the poisoning the has still a P. the adenomata with common of out than rounded is inclined upon of 39." At toms symp- weeks. than statistics of loss otherwise. further a rarely for more OF explanation of the asphyxia in the conditions above the described." Bartels almost found back at their fatal the to sees Sometimes part. pneumonia 5. According when seventeen seen last chance sores._p. deaths been unusual very air P. cracked and widely parts the to first. be as as sue tis- large as miliarytubercles. affords gland acinus. Sporadic In remission or and all the above carbonic-acid child the act. must set senses of these bottom and epidemic croup. voice edges of the papillomata.a : (here of is patient close attentively into three as the sound the ynx) lar- (the . 7. where exclusivelyin the front of the lungs and the the and EDITION open listen divided somewhat chord in the the is characteristic vocal When chords. an operationgives very slender given case. the 6. second. the percentage other 59 23. 25. tracheotomy disagree seriously.varying cases tomico-patholog ana- longer period. the the lungs continue within performed. the degree and persistence fever.ADDITIONS TO REVISED THE P.Rindfleisch has he a benumbed. or to ceases of recovery. and when five but 44. the disorders much a from the to genuine is croup of has burg). operationalone an for But from Bartels upon. alone treatment hot or patient recovers." Recovery 1880. of the connective cell-masses of the to we be got bronchi. when one intact. perhaps piping.

P. THE OF AFFECTIONS (JO trembling third. . from kidneys. like) was a . serous catarrh light the cases depending dropsy general a of set 46. is oedema transudation. of traced else or or a had which other regions to a its of paralytic the in origin requiring one itself shown of body condition case a (a that of in a heart the vessels or of the cedema place the dency ten- impulse with of with tumor.rolled has tumor the (while sound between up chords) the lies tumor LARYNX. local to glotoedema place. sympathetic. or hydrsemia company shifted the accompaniments the -inflammatory non fitfully the merely impediment In of one disease upon has mechanical development. the on natural a hoarse surface upper the of chord). 8. upon to its for tidis." another In of or scarlatina. scar.

especially during to according causes. hear it recourse. the the bronchi excessive In the that this upon forward first place. the although PASS AIR- AGES AND BRONCHIA/ MEMBRANE. catarrh to difficulty. general and a of have children period is called a tooth-diarrhoea. particular same is larynx." is where liabilityin slight certain in or simply other no strong the "a increased an "augmented conditions and tendency in catarrh particular. affections. bronchi the An an certain childhood. remia gives catarrh as rise the stated of nutritive catarrh be hypersemia and if that. predisposition chronic a diminishes catarrh large contingent flabby individuals becoming to show in . again. in to and . developing vulnerability hypothetical persons the of membrane mucous susceptibility of explanation exposure. tooth-cough." mem- bring membrane catarrh intestinal of period change to us ual individ- mucous we of permits mucous daily which as either to to the of catarrh from skin account predisposing the of to to however. assumption is Experience. general pre- . Predisposition variable is as readily. OP THE MUCOUS ETIOLOGY. the a old most hospitals unmistakable age. from " bronchial the of predisposition with or catarrh to peculiarity. and Secondly this senile furnishing : badly-fed." In more middle age marked. said of have for in of branes. there dentition. among inflammation hyperknown regarded as identical considered meaning." hand. already series a words that considerable every functional and included the inflammatory be must generally not are disorders. " have terms synonymous. SECTION DISEASES OF AND TRACHEA THE CflAPTEK DYPER^EMIA CATARRH AND I. temperature. plaint. frequent and it i? com infirmaries.II. "We " BRONCHI. at suffer to as and hear the the We causes.

of the proceed must to this affection liability causes it may : " walls. The the attraction.seen catarrh and in have the nutritive condition would result general. and the bronchial valve. . increased susceptibility. or by defective resisting the of the power inure vascular Lastly: to exciting readily.with be one follows intercostal aorta. stance sub- in contraction the left auricle.impeding of the left auricle be small insufficience of the to is less catarrh.we instead mucous of the pulmonary substance is ascribable effect will are right. chronic from to a dition. AND TRACHEA also often disease such hence be suffered .and. or vena less or into the bronchial veins consequent lesion which mind the more systolicregurgitation tents impeded outflow to the con- and if the the to those among pulmonary vein. An augmented tendency to hy- transudation those heading.so that engorgement which correspondingbronchi. cava.which act the individual. and themselves The First old itself. it to be supposed exposure. disposition much are irritants. . Another within the hence.capillaryengorgement the due of the bronchial the pulmonary veins auricle. mitral. a part of left side affections catarrh of veins. Thirdly: show the poor to they run. for if the circulation of the lung-tissue then the task of the smaller bronchial veins in returningblood to the the pulmonary veins will be increased. to disposition than predispositiondepends. Ubi irritatio ibi affluxus" still holds good . of the To most understand the blood of the the catarrh of to the veoli) al- only not of the bronchial heart the and inevitable physiological this condition. probably. of firmer persons This fibre. are transmit arteries.and hyperoemia of . although the afflux is only produced by dilatation of the vessels leadingto the point of irritation.upon capacityfor withstanding noxious of the walls of the resistingpower catarrh of feebler or or to the action exposed liable to bronchial more BRONCHI. flows from that into chronic bronchial the arise. both outflow : veins.DISEASES (52 THE OF when to catarrh. to saying. the immediate lungs (thatis.and should rickets. plicated com- above-mentioned rangement ar- of the vessels be deranged. according to For the bronchial be not bronchial tendency of from impeded an arteries which evacuation spring from blood whence into portionof only a portion of their proceeds by the vena azygos of the blood the lung of the and in from mitral of cases ventricle of the into is of one cardiac most constant symptoms keep must membrane The in flows fact that with the as but . who to proneness a of the trifling even well-nourished and and yieldingnature capillaries. weak be it may attributed of the tissues through which peraemia and to increased The in scrofula catarrh. con- bronchial placed under from disease this bronchial tarrh ca- of the parenchyma this if it does not give rise inclination. who lungs augments disease bronchial severe. influences . becomes all the more intense the bronchial veins be compressed by inflammatoryfoci or arises in if any of by growths.

we canfor the phenomenon. It is .which be looked has absorbed as upon the result of a morbid state of deleterious material. and who follow all. However.as bakers.in consequence by liquidin of excrement tines. blood in the 63 great branches of the obstacle. epidemics arise. time with the to upon operation skin of unknown or atmospheric time. chillingof the external skin. As we have observed. suffices to bring In bleak. bronchial from catarrh of a person after suffering seating himself in a draught of air while perspiringfreely.in unusuallysevere membrane.from the cutia the the and contraction haps of anserina. resultingin congestionof the brain or lungs." So in the cold stage of intermittingfever the circulation rial mateencounters a the the obstruction of periphery (throughout body). The process cannot be ascribed since a mere to a to collateral fluxion. Irritants which act directlyupon the mucous membrane.which to it in the symptoms can we produce at will by the exhibition of an inorganicmaterial (iodideof potassium)in large As doses.stone-cutters. or severe. Fifthly. not accompanied by an exanthema unfrequently arises during the employment of this agent. which thehypersemiaand often catarrh of the bronchial complicateintermittingfever.damp localities. vapors. almost account satisfactorily dailyobserved.and more especiallyif the aortic stream the point of originof the bronchial arteries. mucous which constitutional very or telluric extensive disturbance.is very distressing during the attack. change of temperature or exposure to a degree of cold by no means current of air.Secondly. spasmodic peripheralarteries. although we cannot explain what we there is something analogous see principles. in certain patients.and cous mu- of the cough which. the itself be impeded below of the blood is augmented in the other arteries which not are pressure throughout compressed or otherwise constricted. Thirdly. is well known.and smallFourthly Here the stands it must blood. As an instance of this process collateral fluxion ") we find sometimes (which Virchow aptly terms of compression of the abdominal aorta that.It forms a symptom of typhoid fever.or by accumulations or gas in the inteswithin from takes augmented pressure place in the bronchial and carotid arteries.from catarrh occurs.often of the skin. upon physiological of poisoning. Perencounter aorta an " " this is the of reason membrane. a very violent bronchial catarrh. If the ACUTE BRONCHIAL current of the CATARRH. suffer above certain trades.Under influences.and hyper^emiaensues of their capillary the range system.measles.and the action upon it of a sudden not change of temperature. too cold or too hot air. on on particularly such excitingcauses that bronchial catarrh is endemic. are so numerous pox. the sea-side. the attack. no other irritant having come cf which into we are either operation meantime Sixthly.occasion in it hyperasmia Those catarrh. millers. the peritonaeum. from constantly this disorder.with the nature some unacquainted.and. such as dust.

so the membrane those The third and the or of bronchitis mucous danger membrane from the more of access fourth is dry. periods. Since that time in 1800 and 1835. the subject. as symptomatology. to lay up for a week or however. Finally." APPEAKANOES. he is content in observe must that. ANATOMICAL trachea mottled.when catarrhs non-epidemicbronchial canal has gradumalady. containingbut few occasioned submucous impede of the ecchymosis.particularly partlyfrom use. especially an and the from of the diffuse.sometimes a arises the mucous calibre smaller a catarrh cadaver.now copiously and freelypoured out.Owing to the bronchi mucous in infiltration within membrane into them. This condition of pressure of the oedema the the tumefaction into is of the calibre of the important fact trast between blood of tubes. is opaque. AND it bears similarity. causes which people usuallycontent are respect. very mature cells of few that in and covered this participates.and takes influenza. epi- an "grippe.Such certain a the be exanthemata like that of the acute infection an TRACHEA THE OP DISEASES 64: cause demic. partlyfrom and through extension of the local affection into the pulmonary alveoli. from east to west. attacked at least one half disease was for children of its population. particularly regards the the symptoms first the the is reduced. Somewhat active development of cells usuallytakes the an place upon the surface. The relaxed. cells.its attack " influenza.we very No catarrh unless unknown. ten themselves.the one has easily. the vicious custom ally physiciansand people. acute redness. two with air scanty.in custom catarrhal from a mere suffering For himself to keep his bed. and.yellowishappearance.doubtful if of this which complaint.or the disorder. the membrane in the comof the intestinal mucous plaint. more productof which.of callingall the of the repeatedreappearance this in the part This (gastrischeGrippe). or seriously ill.to BRONCHI. unusual showing obstinacy. especially the intensity of the fever. both crept into among generaldisturbance.and tears magnitude. participation there have been and from other complications.using bad has. travelling through Europe. disease or detached at the young This con adults.appeared in the year 1732." the exciting explanation with cases. many " of tage.and a a later epithelium.transparent secretion. advan- days.that tinal intes- consider willingto accept the we the gastricinfluenza one an violent with when term fever is one of associated they have must taken cold somewhere. in the difference of the At in which to by the capillaries. With repeatedepidemicsof influenza. readily does prevent in childhood mented aug- tissue younger much tenacious. clouded look." or influenza. The a dangerous one. imparts to it a turbid. when mingled with the secretion.partly and for old persons.sometimes the other to injection. due being membrane mucous leaves bronchi and the In " ciliated .

And. treatingof diseases of the lung. power the relaxation of of the bronchial bronchi. sodden bronchial muscles is lost. chronic bronchial associates itself.its tissue puffed and uneven.containinggreat of young with divided nuclei. it in the of the catarrh with follicular catarrhal the finest the and mucous air. sparinglycoated latter form. this of the mucous membrane and of the fibrous thickening. completely fillsthe frequentlymixed diffuse and that the secretion bers num- substance. with which from escape in in- because corresponding manner.exhibitinga largercalibre than the they spring. at the same dilated. bronchial Chronic catarrh usuallypresents to view a intense more Its vessels are membrane.and coat as are. more but. while in frothy. one of the as that. bronchial which is usually connected dilatation.glairy. is a considerable gape changes In so we have described the larynx seldom appears claims Reinhard^ however. the lungs evince mucus. a aa accommodate the have erable consid- very opened thorax. constantlyto bronchi.consequent upon wall. while in others granulatedcells.the elasticity the swollen. disposition no degree.the cavityof of point thorax have has be obstructed attained the a sufficed to in them. tenacious. membrane itself coherent and is hypermucous bands and muscular layerbeneath trophied. lungs without compression of the air contained spiratoryexpansion of the chest has ceased with death.upon widely.but bronchi obstructed This able to diminish been not has appearance it is have in The allowed not in nothing the air to with common the lungs the the alveoli. to bronchial small dilatation bronchi which from Saccular may become of section.even with while common there lies upon the membrane mucous profuse layer of yellowishpuriform secretion. in a their of of tion contraction. simultaneouslywith so. contraction CATARRH.as is also sequelaeof chronic bronchial catarrh. of this disease cases many branches in its structure again to be considered emphysema. frequentlyconfounded. was not or to collapse.and surrounded believes that the generation by tubercular deof disintegration . is called dry very copious upon a in which the The by portant im- surrounding pulmonary parenchyma. dirtyreddening of the mucous time. if the if the the thorax. when lung substance. ulceration which membrane submucous (catarrhsec).and the fibrous longitudinal brownish the or membrane mucous still more are As.the lungs bulge forciblyout of the impressionthat the chest to convey almost 65 emphysema. finer little or obstruction or bronchi the fact. is often the largerit is occurring in have of noticed swellingof often the mucous bronchi.a diffuse dilatadeprived great measure. so too small.and smaller is of In it is The tissues the former bronchi.BRONCHIAL ACUTE opening Upon occluded by Indeed. The less easilytorn. in many catarrh. This diffuse cases. semi-transparent great.

however. The mother. Not uncommonly. Hence the sensation of ticklingafter inhaling acrid and the of feeling soreness vapor. AND TRACHEA THE OF DISEASES 66 of rarely distinction It often inflammatoryfever.and in exceedingly sensitive children. distressingfrontal headache.even of the trachea and to the a case applying position embarrassing.as of the the wall him share with as CATARRH ACUTE L SYMPTOMS the of TRACHEA THE catarrh confined this is shivering. More the of and larynx.with every slightalteration happens that throughout the whole if the patient of temperature. and per minute. leeches to the harmlessness a the head. without actual increase of any temperature. persons. sensation of the " upon an sensation thermometer soreness temporalarteries. shivering-fits During the inthe a the from this.often "most the and is sternum to and unduly sensitive. fever. nasal the of sinus. burning in the chest. hear fever gastro-catarrhal-rheumatic spoken of. greater its extent. with a perhaps even and to a singlerigor.has may case find his been obvious.which seldom exceeds the number In children. and frontal BRONCHI. increased of catarrhal and patientexperiencesa indication Added of the onset between constituting of pain in the catarrhal rheumatic the joints.until may Should the " " a profuse flow from the nose. attack.who. be kid in a fresh bed. added to these symptoms. the more much frequentlydoes it begin with greater mucous conjunctiva." coated. repeatedsneezing. be an excitement the cause transmitted of this to the phenomenon skin through is supposed central .and especially tervals continue to recur. of the bystanders. the integument of the "ever. convulsions take place. and in very rare instances. In running its course to beginning of severity it is accompanied by perverted sensations cases along of the air-passages course and under the sternum. iay before. be temporarilyalarmed by these manifestations.there to of an pressure. pulmonary tuberculous the BRONCHI. so The rarelyit spreads into the smaller bronchi. delirium sometimes is irritable subjects. and even may the physician.allaysthe or sommencing disease of the brain.now has become Catarrh In such that the the of dread doctor. largerbronchi is not always attended by from without end it.and. It is very indicative does not bear any of weakness of catarrhal fever that the intense feeling elevation of temperature and frequenceof the proportionto the trifling beats of eighty to a hundred pulse. AND is often bronchi proceeds from this ulceration as soon has been destroyed. This chill. pulsationof come limbs. tissue OF COURSE.we even too.with a long face.a view which we fully bronchus regardsinfiltrated tuberculosis (orcheesy pneumonia). or upon changing the linen. of burning heat. in important point an sensitive is chilliness. and the tongue become appetitefail. LARGER AND catarrh of the trachea Acute " with combined that membrane.

mucous ganglia from the sensory nerves is that not of catarrh the The of as quite so distressing cough laryngeal is with which more membrane.humming chus). there has been when and with tolerable rapidity. favorably.and which we call vesicular respiration. of mucus forms within the bronchi. Auscultation. not only over the point but beyond. If an accumulation walls. there is but a slightoppression. or entirelywanting . The cough is loose.the of the greater bronchi air. 67- of the bronchial membrane.and catarrh of may graver hear vesicular breathing the largertubes is to be diagnosticatedwhen we chest of a person alone in the sufferingfrom cough and expectoration.audible to the ear applied to the thorax. any . we call largemoist *dles. the perverted sensation a sound reed " " * Noihnagd tracheal and bifurcation of as severe has proved. as the bubbles formed are are largerhere than they can be in the finer tubes.* mucous fullyprovided nerves. and. with terially profuse secretion. by experimenting bronchial of the a membrane mucous trachea character lesser susceptibility. in as causes upon animals. " " " When swollen at the membrane mucous circumscribed one point. has excited Other irritation found as of the that at the promptly and regjons evince a . often gives negative results air. or.to distinguishthem from the rales in the lesser bronchi.we air creates at the points of division of the finer bronchi. the cough.and the patients A chest that their is stuffed of considup. subnowadays called muco-purulenthomogeneous sputum.too.is incapableof maand injuriously diminishingthe largecalibre of these channels.a few efforts suffice to cough it up. sensory has a hoarse It never the larynx participates in the tone except when At first the sputa are disease." In the beginning the sputa are patientssay that the transparent and viscid . causing rattlingnoises.passingthrough it as is much through rhon(the sonorous pipe. coughing particularcoughing-fits may those originatingin the that . and finally of the chest having previouslyvanished. scanty.produces a buzzing. normal." even swelling say the most able magnitude.IlYPEILEMIA AND CATARRH.remain which hear everywhere the whispering sound the inflowing that is. in the mornings.of course.and its capacityfor the largerbronchi. at most.which we often hear called a its course as a rule runs slightcough by the laity. There is. The fever disappears.which. or bursts through it. and often with perceptiblevibration racic of the thoof origin. as the secretion only proceeds from the largerbronchi.All thought of the bronchi catarrh of the minuter be excluded.brings up sputa cocta. and be larynx. and Catarrh of the trachea greater bronchi. the air sets the liquidin motion. afterward becomes the expectoration more copious. at a later periodthey are turbid and yellowish. particularly sides. no real dyspnoea in catarrh of the trachea and largerbronchi . of the chest shows Percussion no change of sound during catarrh of The vibrations of the thorax. and in the airvesicles.so that bubbles and broken.

it clings to the frothy. bronchi. when bronchial tubes have no sensibility. AND TRACHEA THE OF DISEASES 68 signs of sympathy and reaction of the general system againstlocal disorder.the When in the Adult. there is none the exhibits felt in catarrh soreness. which obligesus the two in adults.at any time throughout the sertion complication.has difficulty bronchi of the secretion.is vated aggra- so of the muscular fibres.even catarrh of the finer bronchi is sometimes ical periodaccompanied by severe but this the existence of a indicates dyspnoea .it copious. however.which overstrained. Here.lightersecretion from the larger adhesiveness the expectoration Thus of with air and floats. impeded respiration.but especially upon by any movement to sits up instinctively. and. and it retains the shape of the tube from which by its tenacity. periodicity very which is causing spasm of the in the muscles nervous complication. any Instead." occurs BRONCHI. dyspnoea.coming on not loose. more or than a bronchi always accompanied by to more however.Air enough can Extensive catarrh less of the lesser In is this of suffocation are and terror and sensation always reach the air-vesicles. which is mixed acute forms from of the smaller catarrh bronchial frothy layer a upon the when air-passages. been pain. nor the of occurrence of pain. and sinks in it. distress scarcelyever observed.shows of acute a The largerbronchi. but. of that feelingof itchcatarrh is confined to these alone. somewhat or laborious. surface. the sick man as so coughing.driven from the pulmonary vesicles by the in clearingthe lesser spasmodic contractions of the chest. owing to its it came. SMALLER THE BRONCHI. than that previouslydescribed. After a while. too. forms to describe separately. It is true that. As it CATARRH or often disease extensive.the air. upon catarrh. smaller form of bronchi. becoming described more with air. As the sputum from the smaller tubes is unmixed than heavier is specifically water.by the existence attack. Indeed. filaments hanging it. This proof the muscles ceeds upon whose of the abdominal spasmodic. the jerkingcontractions is observable act when elsewhere coughing of have muscles This is effected. at first. bronchial The sound.with fine cast into water. relax the abdominal cough is of far more It is in long paroxysms.is than sonorous in not catarrh altered of the in this larger rhonchi.the sputum is usually " but scanty . the hence. rarelyamounts adults. it graduallychanges.alreadydescribed as catarrhal fever. of more the percussion.as above. ter violent characThe muscles. bronchi. sibilant rhonchi .however. pain is felt at the pointsof inthe chest and epigastric region. it is the mild and insignificant ent caused by this disease in adults.IL ACUTE A. from overstraining muscles."that is. during the fit.and the great danger and totallydiffersymptoms to which it gives rise during childhood. minuter The ing. .

the elevated evaporation from In almost the arise.and which. a for diagnosisand nosis. sets dry. the fever remains. the patient.which has gurgling (Jcocheri) still violent " fine. succumbs ple Here to a simof the malady. If catarrh of the finer bronchi develop in an old man. in a few days. threaten not may of elevated there is persons immediate greatly accelerated scanty of remnant tory inflammano disease. which but the peculiarcondition leads to the danger. In old or one. the organism. and the physiciandoes well in promising to the "that he can the patient if nervous in these cases save non-professional cases. and cough.according as they or coarse but bronchi). very noises . originatingusuallyin chronic disease. enfeebled which ed temperature.toward the end.BRONCHIAL ACUTE CATARRH.rattling heard.and symptoms attend condition nervous mon (a very comassumption of a assumes among and condition.rapidlyprogressed to a fatal termination. the combustion. and it is not the perniciousnature of the patient. the subcrepitantrdles are catarrh of the finer bronchi also usuallysubsides in from eight to adults. bronchial catarrh .both we and small. the expectoration. but slightdyspnoea disappear. person debilitated in very fever." not is with For hours disturbed. fourteen The days. as largebubbles free. tial When membrane. De- dryness of the tongue." during which the patient usuallylies unconscious. rattling sweat do becomes sensorium in arise in the occur coughing. is ' (typhoid)symptoms do the brain function of the overchargeof the blood dry. flows younger an the upon a accompanied by " the coma if it be or adynamic character. all acute diseases. the the skin. consumes the There or no life. indicates the approaching end.the latter which indicate term or symptom The be may which pulse The notice we the ominous lay great stress. with its constant tom sympof which cause consumption vital force which of yet is augmenttissue. secretion becomes thickening of the mucous more sounds. nothing specific They are wherever is cona febrile disorder suming repeatedin exactlythe same manner. can in the chest.especially Fever.irregular.rapidly exists in these in any of these symptoms. ceases. and. be heard larger bubbles.the ' pulse. becomes .previously chest greater or At (which smaller last the sound at even also of distance. The tongue bebody causing an increased nutrition surface. people). The older physiciansapplied the term to attacks "pneumonia notha" occurring in marasmic subjects.are produced. in .tracheal rales. progthe frequent. In cannot form in the small tubes. In other cases chronic catarrh the disease rarely is dangerous.its excrementitial temperature of the and days before the end being vitiated by comes products. or rdles. 69 tubes from parwheezing sounds are heard in the narrower whistling. a called the been " and death-rattle. is with which not after cease This it lirium involved.

irregular. and accompanying fever. of itself relaxes muscular element of the bronchi. the canals.the palsiedbronchi is often said) having lost all power to expel supervenes fills If.the tips of whose chamber. con- the symptoms of suffocative effusion arise. Let the adults is which bronchial febrile a mild be not Children. aggravate the peril and we the in (Edema (seecedema of the lung). of course. these muscles accumulates.it we does husband and blood-letting adequate to the the catarrh. which always accompanies imperfectoxygena- tion and same of a to that case this free finer and of symptoms air to it long the . but. secretion vided pro- secretion. Catarrh Acute nothing is is the basis of all the hitherto of disease forms described. entrance the inspiration. AND counted. depends materially upon the with others. wheezing noise which the air produces as it the constricted the much of ah* into the air-vesicles.devoid account of diseases of of While " danger. which catarrh in marasmic a B.but the feelingof oppressionarises. as the of (notthe their tents. too. them. periodof den- bronchitis provided that this capillary understood to mean a tially essenprocess differing called catarrh. is with remain It If that. and while still far from the bed. more desperationwhich we child. but do we tling.DISEASES 70 of the skin by profuse perspiration the fibre . canals. apparentlyslightand further it descends hinderance It is not adults and into the is there set up limited in this in experience that nameless smaller against the dread repressed liberation the violent described have bronchi are of carbonic same presented by closed or a bronchial by The acid. Sometimes the disease with commences the of the greater bronchi.so the enter and efforts at in catarrh which slightfeelingof indisposition disorder. in complaint. In becomes death-sweat.which. too. are BRONCHI. whistling of from not proceed the strengthof emetics.and The the nearly aD. " with skin the paralyzed. contracted danger.the are palsied lung bronchi. narrowed as soon is driven the child and strenuous restlessness. the muscular palsiedlung. bronchial catarrh of old only perilousto the of one physical. be scarcelyto and small.its task of one we inhaling a As exertion proper through expiration.which their contraction.especially during be may expressionshall the a tition. A chronic bronchial catarrh.which from a first consider us Bronchi Smaller people on of children great number and of perniciousof most than more subject. are croup. muscles TRACHEA THE OF thus pneumjonianotha. as not supply of from beset often may tinctly dis- we tube. same and inspiration both accompanies easilydistinguishedfrom hear many. are the discharge of covered relaxed.must.which finally have depictedabove.it is childhood from causes purely the form that intense to which catarrh of fall victims. the whis- hear croup.too. as shown above.

and even bluish.during its illness.which muscles. rarefied being upon little too the function respiratory imperfectinspiration of supra attention else appreciated. and exhaustion adequate sufficient into the that further from manifestations of carbonic-acid poisoning arise.during the coughcough.the reddened stupor. got too confounding the permanent inspiratory " this appearance is due. with vesicto which ular expansionof the air-vesicles." high a It often thorax. 7.but is swallowed up any secretion. bringing and which.that breast. of cough.we expel our force than is draw it to exin. able breath with to are since. The previouslyfull skin countenance cool.such as they would inspiration. as dailyexperience teaches. or. even then. either physician). expansion of the inspiratory explanationupon We are a The should vesicles takes tempted to assume that the have in which manner superficial glance at mere hitherto place seems the the so nent perma- difficult of mechanism obstruction been of in the ration. air enough this. The first threateningof to the pay attention the hypochondria If. remain instead of we may feel sure see.should could be overcome . the countenance which seldom are exceedinglyviolent and distressing. of a avoid of recognize. becomes pulse now small.can no obstructed obstruction has creased in- so become totallyimpervious to air. and it is curious often such that two different with confounded one conditions another. fault of the the if the child.CAPILLARY As BRONCHITIS.1 of the thorax pressed. Excepting during the paroxysms the face remains normal.the contents the outflow of the jugularsrestrained in this as in every other becomes red. of long prominent. at each that the in. the vesicles remain In this case emphysema.the pale. lower ribs the jugular drawn are inward. as the physiologists greater required bronchi.however.and the air in reach air the A much of the than enfeeblement the regions.if we epigastriumand reaches the that inspiration. But. permanently in a attain normally at the height of state of expansion. as the disease goes on (oftenthrough air-vesicles.and that of the We must the attracts physician. respifiner by the action of the inspiratory be still more readilyconquered by forced expiration .we that difficult to As following points: regionssink epigastric and is not danger mother tion por- sooner has child.In emphysema they are abnormally distended. ing-fits. that the symptom hitherto importance. the tubes of many fresh have well-known the of its muscular air because the through the strength effort. can (asno new inspiration is being imperfectlyperformed.or and infra of the clavicular in this movement respiratory the vesicles. the color of by the child. make and inabilityto longer draw a bronchi the hot and supply of else or air-vesicles. comglottisis closed. the terror turns into picturechanges. is not ejected.and is the prominence falsely interpreted. quite as the as vesicles is and it).

or. from principally protection against chillingduring washing The symptoms disease The of described complaint and is children New-born " and very ficient inef- bathing.it. contented over babe. of the veins which condition the and which is really discharge always find arteries and which we mortem. rales). they do not notice that it only breathes The superficially.too call we it is overborne fine wide-spread by the whistling bles bubof minute rattle. otherwise appear well. often Catarrh catarrh contract the New-born. have perhaps coughed a little.the extensive and intense J'ingin the of condition the forced of the action in view keep we BRONCHI. the eyes dull. assumes different a In aspect forced exert well as The considerable a air-vesicles the upon former Even closes their outlets." children have sneezed cases a few times. a matter pressure this very as pressure.and. As long as . it have of the to those hardly any resemblance above. The explanation of the"e symptoms is easy. as when of such the volume by we press of the abdominal the upon the removed the from the phragm dia- acts bronchial body. contracted the upon cleared be cannot to diminish pressure expiration. friction-sound above which all. an acute cyanosis is diagnosticated. we lung by squeezing it. (subcrepitant ^Bronchial C. pressure unable are I have been led that.we in too enters the vesicular murmur. effected by meai\s of the muscles of patientsevery expirationis forcibly alone the abdomen. togetherwith the whole body. although the malady is exactly the same. or.and expiration upward by energeticcontraction thus inspiratory pressure. physician is not called in. if he comes.the press if But.wherein an engorgement the hue to the of their post as vascular imparts owing regarded bluish to beginning of contents into the is confounded the lips of the that contraction and capillaries with dying. bronchitis. Afterward we hear small whispering it exists hear the that disseminated notliingbut quantity. face becomes over change comes pale. almost always mistaken sicians. Where sounds. he finds no occasion to take of the breathing. an treme exunhappy conception. but a great account the child.in this class of by frequent observation simple explanation. tJowly give to the upon rise to thorax. changes to an ashy hue .etc. The temperature of the surface is lowered.usuallywith The suddenness.and often inclined to sleep. AND expirationis greater than of pressure TRACHEA THE OF DISEASES 72 tubes. in conseof which the child is fortunate In such in dying so soon. this to If laythe we sibilant ear Air rhonchus. The parents rejoice their quiet. of of the respiratory passages. and unequal . by unphysiologicalphy" quence organic affection of the heart. and This lungs. the sibilant rhonchus being audible at the time. the nose and peaked. the muscles.the arms grows legs hang down inertly.

and subsequent by now skin. and both arise poisoning cough as often as an older one a cough is involuntary. III.unless remains extensivelyprevalent disease. The carbonic-acid the symptoms of palsy poisoning vanishes. until.is a consequence If we succeed in making the baby cry or vomit. and the carbonic-acid of bronchial catarrh.into reach the as from tions. mucous above anatomical less as changes given development. confined not air-passages pervious. however. II. observed It may recur. are easilyclosed.although somewhat summer.the illness is indeed trifling. would of the Nor does the child portion only of in order to made part is voluntarily Experience has not yet taught the of for do. the .which has habitually spring and falL every At die disease almost first. obstructed child this art. the other remove impediments to respiration.the the arteries.Chap. 73 largerbronchi exist. to make powerful efforts to overcome which otherwise would There is no rhonchus sibilans. are occurring without collapseof the lung.and seizure.in The children may the ordinarysymptoms more possiblea concealed. blood with again the into color it normal to If the of death the autopsy often since atelectasis. the lung. The as yet undeveloped child is unable the obstruction. bronchi involved become often air-vesicles the find symptoms. described unexpectedly and suddenly the symptoms so collapsed. the affection is not ally usu- membrane.and with vigor. attempted. occur.finally. These. have we ascribed only slightlymodified are portions of solitary to form. in inmoderated perennial.By-and-by the catarrh spreads to the finer bronchial tubes. of cease. trachea. poisoning. to afford a " catarrh OF and diagnosticmark. The a heart the veins from streams time the as but the greater or in The chronic seat of the bronchial degree catarrhal of bronchitis. led. disease the of justas capable well as as latter. the in see (Atelectasis.BRONCHIAL snuffles " CATARRH NEW-BORN CHILDREN. very small by nature.) The tubes we children. ramifica- always develops from a frequentlyrelapsingand recurred protractedcatarrh. anew heart empty and warmth return CHRONIC The symptoms an acute BRONCHIAL conducted examination accurate second perishin without care or accompanied the of bronchi of bronchitis not having which belonging to acute chial bron- CATARRH. as catarrh. catarrh the into apt very the cause extensive is not an are to render been contracts is reestablished. and thus bringcan ing about fresh air enters more once energeticrespiratory movements. a carbonic-acid the as soon In the bodies which to bronchial minuter of such the lung. and Circulation to the attacks science. in the be be during life. during symptoms the become patientsremain exempt.

even remain themselves show of great on stomach An alae nasi.obh'ged night in as induced an chair. spasmodicallygrasped by nose the head the patient with unfrequentlythe veins. mucous chronic bronchia swollen in such particularly cases. dominal abby the contracted out muscles. of bronchial distended. cough- retching or vomiting.the and red about the kC drips.occasions copious and more catarrh. during long-protracted the jugularveins catarrh. dry atmosphere. the interruptionto the current becomes darkto swell greatly. Like other hypertrophiedmuscles. . AND arises from that lies upon the secretion tenacious gray TRACHEA T1IE form of the disease membrane. eyes and split.and thick blue attack of sels ves- ing.instead of lettingthem slightly in chronic head are the in in more the to than thickened hurtful particularly seems This and cords. drawn were shorter in like up toward and thicker.and In attack acute cold. and . expansion of the hypertrophied.cyanosisappears. it is the protractedand tormenting coughing-spells(due to which is the toughness of tubes) which are the these of them jugularscauses bluish. During of the coughing.the marked moderate im- latter in the sterno- the which stand the out upon scaleni.OF DISEASES 74 The tensity.those of the tion contracconstantlyin a condition of moderate catarrh.distended by constant there is no where emphysema. the (justas locksmiths or blacksmiths and the arms flexed. and When. which in order mucous catarrh. while liquidyellow secretion. and carry the their chest more of bronchial becomes much After to miserable most pass even the the chest dyspnoea and of inspiratorymuscles bronchial by these convex irritation sets walk such to air.the countenance chief the paroxysms in the smaller its situation secretion. continuous hypertrophyis most and by it.frequentlyterminates of the contents cheek the in being pressed seems if as both coughing-fits. but of much the and entrance short a entire as in aggravated. Laennec).the muscles. arm- possible. Not hands. and severe Sometimes." to bronchial sufferingto the patient. in in a invalids. become it habitually hang loosely). an often as offers in this disease common more we The are chest neck not is as seems warranted complicationof emphysema of the lungs from although the complicationis common enough. and violence. the is of source weep.since in this the acute thus swollen. and varicose.the dyspnoea chronic a upon membrane greater impediment happens. cleido-mastoid neck the of consequence humid of name they often remain for weeks constantlyto sit upright.the diagnosticatingthe these symptoms exacerbations alone.with more In the former variety (catarrhsec of comparatively slight trouble. in which a violent distress most BRONCHI. the receives affection to aid exertion become of like strong . Permanent is much dyspnoea catarrh. condition. respiratory apparatus so the muscles is asthma.

by copious secretion. in quantity. less mixed In this form with the air. considerablyreduced. they ere age succumb to they malady.Thus. proverbial. yet cough a very has great become few does it and.and hence more ration. swellingof the mucous the bronchioles. or blenorrhcea. it usually diminishes profuse. seat of bronchorrhcea being in the largertubes. patientsever endanger life. narrow the the upon of act through treatingof emphysema.there any whose of As complication. and its tendency being in water. membrane has . occluded.we sonorous (subcrepitant rales). sema. generaldropsy." with is presented by the secretion.when catarrh the both cyanosis and dropsy jugularsbecome unloaded. subsides. Their can for. easy of expectothe cough is not so persistentand distressingas in the " dry the more catarrh. In winter it is cells. in summer The secretion being less adhesive.CHRONIC not unfrequentlythere is .full pound or more of young is coughed up in the course of a day. masses. of to ourselves catarrh patients. capacityof recover indeed. vanish as be no can the attack doubt and itself.and often bronchorrhcea. bronchial is in coherent malady. body shall show we of causes by that expiration.do sputum not sink of this yellowish secretion. not calibre a exit of the considerable and the flow is the symptoms bronchial muscles pressure is exerted blood of vesicles thither the the main blood within the of rest no means the bronchial that cyanosis and thorax.more vesicular the of and murmur frequent small.moist there of the account never the if percussion-sound. tween increasingthe difference bethe respiratory the air-vesicles. is retarded.is one often hear other cases in the on of the most may when many sibilant be normal again. die of the in chronic but itself. or chronic more called catarrh. very The attain At the time same sometimes as ip happens. always is from the to is occurrence during the air from one reallydue were tubes the Hereafter. these patientsmay from is due sequelae. as tubes is slow.) of the (See article character catarrh on from mucous attended that of the which.and but difficult to account the . to very intercurrent tough. Alteration catarrh.or. In other cases pulmonary substance which result emphysema and interstitial pneumonia. thus Few ever of its it exist the then: calibre is rales bronchioles closed not disease rhonchus. rather to Sometimes produce a diffuse dilatation of the finer bronchi. Upon rarelythe bronchial sharper. emphy- to auscultation. diminished." The common dyspnoea. more or " catarrh sec.BRONCHIAL in dropsy that disease.where but has and the pneumonia notha.the respirationis feeble are from secondary disorders A its respiration.if we only prove to their abdominal contract the that f5 CATARRH. generallyis slighter. It is only when . too. scanty bronchial this old man's other different less or varietyof rhonchus.

these During so activity.too. the patient to imagine that the expectorationhas become tight.while it very sacculated than often becomes bronchus the contents in the diffuse putrid. the copiouspuriform sputa hitherto ejectedbecome unusuallyliquid. as long as the bronchi retain their normal membrane seldom calibre.forthwith the recipe of a pose diving into their arsenal of expectorants. AND TRACHEA that one of amount there swelling of is much the cous mu- membranes. of the bronchiectasis. Sometimes. upon increase of the dyspnoea. undoubtedly. here and there. the doctors who.and must be loosened. sometimes we bronchitis. in all are modified by diffuse complication recognize this certainty. and the cough (which little effect in clearingthe minuter to have appears contraction of the bronchial muscles also plays a part in ex bronchi). that palsy of these muscles.which then depends chronic the upon the upon BRONCHI. that besides the ciliary motion seem plausibility. causes " of secretion. cause intercurrent chronic The borne.in hear the of chronic rhonchi. however. nor in the even dilatation of the of majority of bronchi pituitarycatarrh. not. exacerbations the that This the secretion cell-production goes of the surface mucous with on is reduced less in quantity.the secretion of their mucous undergoes to as to us with putrefactive decomposition. if the of the cup. more cavity. patientsnot unfrequentlyattain phthisispituitosus. or coarser. is one so pectoration. ca . bronchorrhoea cases.far of and a contents of a frequently. if both sputa and stench ."a view in which. commost heterogeneous substances.then. which.the tendency of the is to frequentlydie of acute through the persistenceand cases. ere of the bronchi. Upon auscultation. and the more there breath increased an of the patient begin solid components form a of the to emit sputa sink a to penetrating the greenish-yellowsediment. Experience has taught that. of the main of dilatation in the tubes. While abundance enable disorders of the much so The than of haustion ex- discharge. The a tuberculous sacculated fact that frequently putrefy. also favors stagnation. production of emphysema bronchorrhcea general characteristics age blennorrhcea patients more The wonderfully well advanced an to prone is finer rdles. If.indeed. sometimes coarse This this form the disease. develops from the dry catarrh is more lungs.is the ectasis bronchi- matter for our future consideration.with arrest participate. That the secretion should also formed show in tubes which have become larged endiffusely tendency to putrescence would with some to indicate.ises and consequent putrescence of the secretion which they contain.76 an DISEASES attack acute OF THE supervenes dyspnoea. being no bottom longer . the peculiarnature of the sputa warrants our forming a diagnosis at least of its probable existence. upon whole.

as differential be means has of established been form one by the proved by Traube. 77 suspensionby the decomposed mucus. which. other or tufts in the observed are in that of bronchial the (of whose which find very uncommonly.of itself. speak of while detailingthe course bronchial catarrh 1. diagnosis. DIAGNOSIS. evil odor. of the character sputa of gangrene dilatation of of shall treat diagnosiswe fine of needles.which already have had occasion to and progress of the disease.to prove. microscopic examination great confidence. upon and of young. discussed of shall we catarrh and vantage greater ad- to inflammation merely acute of the indicate a few we important diagnosticpoints. which employment of ether. never presence of the changes the physicalsigns which sound of indicate . curiouslyenough. lungs. of an exudation.BRONCHIAL DILATATION. and the adjacent parenchyma of the shah1 find that this of the lungs. we of a bronchiectasis infer the existence of particularly may held in The of this sputum.we treatingof gangrene effect upon lung. common the of putrefactive contents a prejudicial very the wall of the tube. 2. well-preserved fattymetamorphosis.etc. bronchial that the catarrh.complications always exist. of its moment cells. find in the sputum a few inspissated we whitish. we delicately-shaped objects in the cheesy masses. The only painfulsensation proper to it is a feelingof and burning in the chest. character.or extensive even with pneumonia. Simple acute is never accompanied by darting pain in the side.easily-liquefying more Absolutelycertain sputa. a soft.an lain long it to consist which appearance Not stagnant. if. with is found elsewhere. is often less offensive in the vessel than at the with shows ejection. When other pain? arise.and sensibility soreness at the points of inser tion of the muscles abdominal upon the thorax. bronchial of the swellingof voice the catarrh and mucous of the brane mem- chords. bronchial bronchial excitingcauses. Acute so percussion. fat-crystals rine (marga- be dilatation. which has lost its tenacity. of any development throughout an entire pulmonary lobe. part and stearine).cheesyplugs.where of state a in the bronchial be can symptoms the present.in part of masses some pus cells have cells in of detritus.are between is easy.without the existence decomposition of the In putrescence of the catarrh the of contents " The In bronchial other of the distinction larynx cough always indicates has extended The of the after substance bronchi by any instances. too. some takes on a similar This distinction have of the lung.finally. and the cannot hereafter). of one its most about the even bronchus..which.as well as however. bronchiectasis. vocal has instances. between studied For is simple acute that acute pulmonary parenchyma we tubes Hoarseness and latter. the to the pointsof disease In secretion often it results in the common. indeed.

cold baths. catarrh. old threatens life.are as Indication as one to case Cause. symptoms of the chronic form. the yet.but. there is no immediate danger. as " in the This other.with asthma.78 DISEASES condensation from the rigor. the most intense restlessimmense all other and an purulent expectoration.and especiallyto bronchial catarrh. catarrhal but bronchial that acute of pain a the of parenchyma the 'disease as attacks but AND TRACHEA diagnosis. " of the the much bronchi. cannot be met excitingagents . symptoms. and as others cannot regard will the to in the causalis. chilliness. The violent most ness.especially accompanied by fever. The gravest symptoms are those indicative of impeded oxygenation in the air-vesicles.so scarcely ever the In adults.1 tuberculous phthisisand pituitary the age simple recognized. Upon this " " been said as habituation to commendable of children with full and head we the form the capillary countenance refer to what has prophylaxis against laryngealcatarrh. or. child. As long as the pulse remains ruddy.above ah1. younger patient.the other the causes of the of indicatio ful instances. consideration As some be while. becomes i f a again dangerous disorder.and rachitis. without bloody sputa. poisoningby carbonic and acute token of more threatened until such far less of are acid. Never arise.retarded dentition.which . There are with fonpigeon-breasted. when side.and flabby skin.in reflection many to known cases. nervous shall and explain the scanty mode secretion of and guishing distin- great dys- give the diagnosticpointsbetween phthisis.had patientbeen more accuratelyauscultated. cold washing. In their pncea.enlargedepiphyses.care- best results.it perilousis the disease. if should been the catarrh progresses. notha. by This applies. Cautious change of temperature. many open tanclle.in is rewarded of both the allayed. lest and exclude lung find an asthenic fever we Hence. big-headed children. (typhoidin- bring to lighta pneumonia winch would the singlerigor been properly considered shall appropriate chapterswe chronic from bronchial PROGNOSIS.to the general tendency to catarrh. and apparentlywith singlerigor. without the in begin may with shows tendency the be not attack have hasty too " as now we should autopsy catarrh a violent itself to peated re- with commenced in a diagnosticating " influenza nervous say fluenza). symptoms than the first significance forgetthat life is not really This best safeguardagainstover-active treatment bronchitis. cough. catarrh are unknown. demands predisposingand of the excitingcause.we pneumonia have BRONCHI. none the of THE OF The danger of bronchitis depends almost entirely upon In the the the smaller earlylife.engendered by scrofula. It is true 3. TREATMENT Prophylaxis.excepting among where it persons.

tuber- results sit all wine. who voluminous of the abdomen. the more so.the case any of catarrh result of pressure fecal matter teaspoonfulof whatever upon the to be inal abdom- by gas. Karlsbad. exercise. set him and milk people little . circulation of the bronchi. subsides. may by shall never collateral accumulated easy.sometimes admit impede the venous the catarrh insumcience of the of palliation. where charge retardingthe action of the heart. to like cases the upon but upon them. breast remains Again. such confine well as as him cause Finally. against their bones. high livers. When depends upon is uncertain. with but assimilation proportionbetween proper class of freelyof if common very bronchial room. haemorrhoids. alkaline the cough alone. assim- institute of symptoms vanced ad- in one It are pigeon- haemorrhoids to him such a done under- childhood. but self him- only in beneficial effect.time is afforded to the auricle to disthe engorgement into the ventricle." much material. having striking effected by tapping. A permit fluxion. mechanical obstacles at the mitral valve.giving mind recall to to have we children The useless are prescribecod-liver we often well-selected a upon meat. The arteries. among who drink of age. him a upon betake cases. or and catarrh. but so particularly life. caused bronchial catarrh collateral fluxion collateral fluxion of a to to which the into dropsicaleffusion it lung the upon in chial bronthe tapping .and consuming years 79 here diet.perhaps even the complete subsidence of a bronchial which few days before was the patient's a most catarrh. Let senega.forbid to take to culous.compresses cases a the of After the tion ameliorawitnessed once portion lung.requiresquinine.flapslike catarrh.the serious a " a them salt and recover. In chalybeates have other excitingcauses. milk. the found oil and the malady to paunch. aggravated by aorta is still more demand aorta. by the hyperaemia is due to its contraction.and bronchial from suffer children such brilliant.the action of digitalis In the latter case. or . not catarrh of the bronchi.let sparingvegetablediet.but its effect is very evident mitral. but illness months be to but nothing great tendency a to chronic to his person a evince be for baths. if derivatives and Expectorants CATARRH. as the diaphragm which in these is pushed upward into the chest. of and Kissengen. its entire contents of the which pulmonary vein has given rise. ous grievwe affliction.and the corpulenceand the Among or the of about chronic and affections follyto were taking Seltzer-water rather patientof this of fifty ilating day. a place we the consumption and set spirituousliquors. who who often supposed are breeches loose pair of a BRONCHIAL OF TREATMENT class a nutriment. the removal of which the pulvisliquiritiae compositus. Marienbad. produced by the pressure Bronchial abdominal catarrh. sulphuretof antimony and a .and with it the by the malarious fever.

during that " climate. Experience in his temperature procedure all the more. soon climate.where severe of abode. as bronchial Chronic a evident becomes error have arisen anew the under fluence in- circumstances winter permit." a rule. AND TRACHEA THE OF months or ter.. patientavoid into season.and readilytaken.is If the a be cause direct irritant to which a in certain dailyexposed are be cannot met. who nothing for blood-lettingin catarrh it is in these might to the send must we of the situation be In TREATING IN while pituitosus.send him.and bleed danger it.than before. chronic if the patientssubjectthemselves We should bear this knowledge air. after sufferingan chronic acute attack. lest the a be cannot cause Even " patients promenade to coasts.and bronchitis capillary alone.instead so let In the mighty hyperaemia. these as trades his patientkeep the establish and uniform a the mucous branes mem- avocations.a change is. INDICATION of in the been able to draw air . Their to the air. in which convenient for the "pine-needle-bath As institutions.or suitable more who for the catarrhus suffer from the upon the the school blood.dry to the action in mind.the causal or cation indi- usuallyin position to not these noxious catarrh As agents.from membrane.the this fact in poisoningby of wooded make little of Bouillaud. membrane many doing.DISEASES 80 taken evening so as to produce a sufficient dailyalvine remedy much praisedby the patient. make BRONCHI. during a cold winchamber. Wies- some some highly-oxygenatedatmosphere of the pineestablished have long been accommodations woods.of the into and be we dyspnoea.often indulge in the idle hope that the disease just passed away the chronic criticalinfluence upon has had some evil.Baden-Baden. and morning evacuation. the sightof the bronchial danger from and from bear us the dint of DISEASE.and that they now demands less. by enhance subside. as patientswith intercurrent catarrh of the bronchi. of Let the cold advise the residence in the milder themselves they expose as which catarrhs. bronchial have explainedabove.and much cough this to recourse our less much are the about oppressed chest. or epidemic catarrh. we not child the induced have at swellingof that the merely these cases. we is bated undoubtedly exacerof very cold. During spring and autumn baden. claim Let organs. catarrh dry salt-works. mucous the mind. and conscientiously for weeks room know we patientsare and to avoid give up their occupations. of we bonic-acid car- The swelling although hitherto. of respiratory to catarrh. will the efforts. THE infantile severe so-called misled of the mucous strenuous disease. ob- bleeders or remember of childhood of should may pcund of also us vast forms bleeding.hign dry placesare Soden. require. peculiarly-sheltered place. etc.that bronchial averting the of two arises majorityof viated.

enough through its narrowed yet He bleeding his strengthmay be inadequate to the exertion. Incomprehensible as the beneficial effect of this drug upon either of these disorders be. which.Copious be the most sure means. forms ounces clever ones. Kermes mineral. dissolved in six which come prescriptions and even that physicians. and particularly cause. 7 to in how produce to the vessels of other arise from catarrh is established by mucous membranes can fortunate cuttingshort succeed we derivative a the beneficial action whether bed-coveringseem warm as the the cases. either because into very extensive use they excite the action of the skin. other effect than Whether the irritate the to determination membrane.with one grain of tartar emetic. than of anti-catarrhal virtue. ascribed less of an antiphlogistic have come in bronchial catarrh.TREATMENT BRONCHIAL OF CATARRH. also reckoned is extensively chial an antiphlogistic.we a matter The in even a even may of indifference and the skin act to or effect upon recent of irritability the and in few hours. used. and liquorice The mistura solvens. Certain salts. Perhaps from where action might be expected in oases monials some slightpalliative abnormal the mucus continues to retain an viscidity. and. diminished sweating. has child a had few a hours opportunityof after such " " antiphlogisticneutral who has bleeding. laborious. to declare third of all that it take even I When devoutly order dose. SI bronchi to support life. experience. both in the broncatarrh of teethingchildren and the catarrh of the intestine which develops about this period.tartar emetic. the other on aspect of hand. liant brilbe by profuse catarrh. tations po- It is . long the respiration. where The treatment by diaphoresisis highlyto be recommended cold is the assignable when the catarrh is recent. the nutritive condition of the mucous Among these are certain antimonial preparations. It seems diaphoresis. golden sulphuretof antimony.muriate of ammonia.which consists of muriate of ammonia monial aa ( 3 j). if a observinghow undepletedpowers of nature are able to sustain a will readilyabstain in these is still sufficient. give small doses of from the sixth to the quarter of a there has been to which grain.I shop. mucous their happy influences.or one or two drachms of antiwine. yet experience has may have any hesitation in making use affirmed it so fullythat we of cannot We the remedy. The after the from cases section. vene- salts of potash and soda are as little as depletion employed in catarrhal inflammation by the lancet.or because they are supposed to directlymodify membrane of the bronchi.three or four times a day. and nauseous a a sider con- table- it them- hardly have can any membrane and to embarrass gastricmucous the and antithe sal-ammoniae the digestion. apothecary's into the very this hesitate almost of water. spoonfulevery two hours of the seives upon occasion. above all. Calomel. the altered seen once and.

measures. In cases up upon of a class of all events. 100" they the while Fahrenheit. nay. warm is rachitic nor into produced by the in chronic principles. began to flow more satisfied at their improved condition. half an have for kept patients temperature a in hot enveloped them the severe. however. put a pitch-plaster upon his chest We must be in the too employment of not. however. results of such fear as in treatingthis distressing diaphoresis malady. a or. assumed yet as the veterate in- an chronic of cases grave is ening is threat- bronchitis not to at my clinique. skin diaphoretic result.particularly like those bed have as consequence ones. spiritus miridereri. The introduction advance in of the our mode inhalingapparatus of has treatingbronchial of resulted catarrh.and a in protractedcatarrh of the bronchi.yet such of pupilsas have witnessed my with to into a the procedures described to resort often to forced mocks all remedial of which by means local derivation. the skin no the retained from applications. generallytoward the perspiration first week. sort of local diaphoresis. ire best omitted. Rash as it may seem to persons unfamiliar with this mode plunge a patient. which Allied to treatment whose will be above the of treatment. in a We erable considrefer . is scrofulous no of salt baths amount of use brine. at the dies reme- chest. particularly adapted to it has in whom him cover stronger fluxion the by an is then there protractedacute a energeticdiaphoresis.anti- flores so-called other and the least.in which long as not only greatly. it effect. sambuci. Soon. eight or ten dyspnoea had abated in the most and the cyanosis had disappeared. as readilyand freely. blankets.they symptoms.but to become the to in a the to and Perhaps catarrh.doubtful. strikingmanner. of all cases patientsin character. the integument experience speaks strongly. but the end of the during the sweating. as first. hasty blisters and of sinapisms.I bronchial by at time a and then one to two produced in a bath of most hours longer. remained from dyspnoea was very in the bath.to monial wine.if the say AND TRACHEA THE OF DISEASES 82 of at least blankets. whether or we cover whether as are very converted soon similar of Kreutznach.panting with dyspnoea and blue hot bath.determination such indicated. warm of the a by where treatment whom heat than contain as This chronic. strikingresults. catarrh.the use indicated of which is not by the catarrh itself.and were willingto they became the After baths the continue treatment. there is by general diaphoresis. I of means hour But. but only by certain While fever exists. cold these up.even baths and clothes latter process taint. have the extra and in inveterate even body itself. him wrap we of patientin a good closelyin cold wet the up diaphoreticsactuallydo be to seems BRONCHI. is set favor more successful than cyanosis. make the patient wear flannel . patient suffered At Upon former.

The followingare the most ed important symptoms. or. The cough will then be less frequent. laginous sweet. spite the illustrious names which labels the to their efficacy. when incessant coughing torments the patient. Of these waters. glasses fasting the let them be taken in morning. the course of the day instead of the customary ptisane.a mixture containingopium or morphine. As we have in administration seen.give ten grainsof Dover's powders in the evening . means there is an accumulation when of sputa in the bronchi. which tend to bring about resolution of the catarrh. day. which must be treatin accordance with the pathologico-anatomical phase of the disease : 1. mucidecoctions and syrups are here both inefficient and injurious to also and in of the digestion. SYMPTOMATIC the turpentine.too. is here as urgently to be mended recomEms.appear in greater quantity. which they occasion.as is somewhat to we lay down believe that indefinite.we also one combat these paroxysms.having more accumulation.it will ramifications coarser said article inhaled the unless S3 CATARRH. INDICATIONS. membrane have no physbeneficial action upon the irritable mucous we iological let five six be drunk in or explanation. cannot category. now endeavor expectorants. which "has loosened theii at . but the individual evil. the abatement of narcotics under of the these circumstances. too.BRONCHIAL ACUTE the reader what to has already been larjngealdiseases. not the cause. through the administer.its expulsionmay be hindered by so many be causes.that such oil of as of the rules for the exhibition acceptationof " We not shall of the so-called this word as to find local treatment the be of its way a volatile beyond of ture. of whose blennorrhcea. are the result. that the various remedies. the follyof resorting in every bronchial catarrh.which may all be placed in the same useful in aidingthe expulsion.when expectorated. from the friction of the the irritated mucous air upon membrane. If rest be turbed dis- night.they are of the causes of its aggravationand persistence. the as are cough-bonbons caramels. hypersemia and a favorable termination of the disease are announced by an increase in the amount and by a more of liquid secretion cells. or. the employment of the alkaline muriatic mineral waters of Selters. Although these by incessant and most distressing are coughing-fits only a result of catarrh. time for and the secretion from the bronchi. We have to do with catarrhs in which there has long existed an of the mucous excessive irritability membrane. as to them or in a bronchial is to be decried. Be bold.then.so that the patients are apt to praisethe powder. in acute catarrh. will. na- the bronchi. yet. not only moderate we The tend to cut short the generalcourse of the disease. however. Obersaltzbrlinnen. of the improvement be hence the formation best of will cocta promoted by any sputa .On on testify the other hand.If. Then. while promenading . copiousproductionof young These symptoms. so that the patientsare tormented cough.

state a BRONCHI.ammon. this circumstance.I moist walls remedies class ? like. iodide efficacy.their is in and all. sem. many abuse bronchi. liquiritiae " ij. ammonia." as so cutaneous strong. " ij. fceniculi. liq.is those patients.con- in out these cases.indicates sibillant AND TRACHEA THE OF contain semina stellati. relaxed ease the namely. which remedies with the seed of verbasci. " vj.to be taken by teas the that blennorrhcea so-called very water relaxing muscles) imperfect cooperation of the bronchial of by coughing. bronchial having drunk are infusion an in the warmth muscles a of few elixir 3 use of suitable they give be to ij " pectoralis. and of senegae The ss. be to apt profuse. in such is often nauseants. Sometimes 3. ethereal oil.with more by relief following brilliant.) anisat. with prescribe infusion may Above dpses of tartar-emetic.carbonate the relaxed. best rhonchi. .aqua although their greater stimulant " vj. phillandrii aquatici. pim- senega. when lowed swal- prescribepectoral norrhcea sufferingfrom bronchial blenalmost always expectorate with cups of hot ptisane. indeed. (As already stated. they have hitherto irritants. and of in the it is said next both to therefore is class. secretion the of the are favorite consistingof sacc. large and soft such among in of recommend muscular their these as indicate in to the pinella.sinapisms. ordinarilyprescribed anisatus.or the expectorants " benzoin.sweet.and cases get rdles attributed useful prevails. taining ptisanes.h'q. potassium the part a muscles the that bronchial small in of disease form that and membrane the the The periodically-recurrentdyspnoea. having once patients require constant warning against overactive finer bronchi most first very extensive of the great irritability are Its effect is often cases.ammon. and dilated. malvae. adapted especially Sometimes 2.flores et herba plantswhich anis.84 DISEASES cough of the well. is to be are too.The latter arti- also contains to be ta chorrhcea.is question.. it may anisat.the are an " liquor ammonias fceniculi who The as a Besides demulcent pectoral tea : rad. appropriate important squills. mucilaginous. do good service spoonful. the ing (soothalthaea.the condition opposite an just such (owing to difficult to in drug. we chest. 3 Preposterous as oflficinalexpectorants.such as semina an anisi vulgaris.a mixture ?) articles its coat substance. in belongs among especialrepute facilitate the the in bron- expectorationand to . mucous taken. prescriptionis teaspoonfuL of hot to all classes of with ing caus- ipecac. of the narcotics application blisters to the dyspnoea there the hence.and to a of spasm. In these The muscular relaxation. spoken which resinous matter. semina cle. of the cases muscles.radix liquiritiae. Finally. rid the to ss A cases of expectorants or while the less virtue very learned after aromatic lies mainly flores of of this what some- bronchi half is being It paralyzed.

out of Unfortunately obstruction overcome renders be the emetics in the latter stage of the bronchi. as we alreadyexplained.acetate of strikingproof. persist with scarcelyany diminution. four times S.during retching. alb. Peruvian balsam.The resins and balsams.is expelledin violent already commencing. or fail at least of out altogetherwhere us finest bronchial tubes. ^ ss. et tart. This state has been called the sputa. the rdles. shortened. A very favorite prescriptionis the mixture " B Myrrhapulv.3j. the excite bronchial muscles to the the pulse to rise and energeticcontraction. and the we this it is bronchitis so capillary dangerous. Aqua Ferri carb. of of the become which secretion.which.inIn of subsidingfor a time.recommended the same serviceable in diminishing mucous ground.the abdominal be energetically ed. ratanhia. bronchi. a tablespooiifiil a day. Let no time be lost.and the bronchial palsy the lung takes active no muscles the puffs. 3j. xxv. If. myrrh. M. capillary our task erate mod- to to exhaust the for this purpose. Potas. indicated. the threatens recommended means the folise uvse ursi. immediately after the act of coughing. an tively emergency. emetic part either the secretion them. ammo- Griffiths . Sacc. and the thorax powerfullycontracthave air. sulph.are either lead. of doubtful inert or efficacy.BRONCHIAL ACUTE stimulants The restrain the secretion. crystal. such an should emetic is imperathe expectorants fail. balsam copaibae. 85 CATARRH. lime-water.tannin. compressionof the air-vesicles thus produced Even is accompanied by by which they are equallyfirm compression of stillmore firmlyclosed.justas they cause heart to beat more vigorously. an 4. menth. palsyof the lung. In the treatment the A great par* it may symptoms bronchial redundant patient. gr.drives larger of have to which in poisoning. gum belong to this class." but incipient more " or expiration. are more upon of which then* efficience in treatment of gonorrhoea furnishes secretion. " viij. niac.. An aggravated by carbonic-acid is the surest expectorant.It may inspiration stead be detected when. On the other hand. often loosened and are enough firmly-adheringcroup membranes of twice the force expelled by the act of vomiting . of air to the alveoli. crisp. but an inspiration of that which accompanies this act is incapableof drivinga current of contained in and of forcingout the mucus air into the smallest bronchi them. lest the access being cut off by the accumulating secretion. But it may happen that the bronchial debilitated muscles become as no so longer to afford any assistance in and the cough alone is inadequate for the expulsionof expectoration.

times day.when act the in as either tar form entirelyimpregnated of turpentinein with is far gas mixed with its fumes . water until Thus we remedies half drachm a boil may they do with immediately.or is patient to inhale. or bottle of hot water. calculate upon a may and in this way. myrrhae. the removal of symptomatic indication requires. In the treatment which among folia cardui membrane mucous tonics which bitters and bronchorrhcea. Not " brcnchi of occurs. him scream of the laryngitisspreadsinto the of obstruction II. and to the benedicti. there appears primarilyin . Of course when to follow this treatment we we can applyit to only expect success the mucous membrane it is adapted . MEMBRANE.at least. vigorousrespiratory profoundly. manner pulmonary vesicles of Make the vesicles set in. in secretion means shall force the child to more sleeptoo much. is continued flammation ininto this. tite. and in especially the The harm. membrane. unfrequently.if symptoms MUCOUS terminal the Do not efforts.the lichen the upon of the and digestion. any CHAPTER trachea bear to influence an air-passagesrequiresa corresponding respiratory first of all. and a quarter of a of alone. which is then better have disease itself they scarcely not an know how obstacle the effort. into excreted bronchial the with contact these that desired be naturallyto It is AND TRACHEA THE OF DISEASES 86 an four hour. it does shall find that croupous we almost tubes. we shall remedies mended.where the cases to which In all other forms of bronchial is the seat of excessive purulent secretion. in young the to the branches emetic. is recomof the drug small portion. passing the glottis reaching the trachea We and BRONCHI. the feet. and his chest while upon the CROUPOUS and the the material influence.croupous . and of Upon the children. that is. a through a mouth-piece. by let him polygala amara.however. improve may given. Put him in a bath.direct that of the bladder administered more serviceable.for the cause they iii as come saccharum Here atmosphere the put may which applicationof The bronchi. mucous urethra.attached to the neck of the bottle. and secondlymeasures bath. their the accumulated which or also are have beneficially upon able who are stomach. regulate the body.taken dry. always Besides which bronchitis. catarrh islandicus.who do when emergency OF in like the bronchial a croupous although rarely. of bronchial cough.may act the 5. appe- nutrition disease. spirtcold water by brushing bronchi and catarrh are and too of soles of emlarrassed the unequal an in oxygenation hi INFLAMMATION ETIOLOGY.upon or the urine. AND TEACHEAL THE BRONClilAl.

greater tubular . rhonchus croup .are to be of spoken either its to as fourth order .is usuallychronic in its course. breathingmay become has been often-mentioned symptoms of insufficient respiration. The process sometimes spreads throughout other regions. the tubes as are in sibilans. is not completelyoccluded . and returns extent is as of the wanting soon as the bronchial as long as membrane the disease. generallyit is partial. as we time to time expectorated. or.consistingof tree-like. Croupous they form the whole over lung . of the a complete The " croupous months. corresponding to the murmur case. the respiratory my filled with exudation. From These have said. described. the by BRONCHI. convoluted masses not are entirelydecarbonized. great dyspnoea ensues.repeatedly-forkedcoagula. found. and then present regularly-formedcasts of the bronramifications.croupous is. ex- tree. years. of this disease inflammation membrane mucous that the are for years of bronchial extent extremely acute an of age. dyspnoea. take and death may placeunder the insufficient. tion inflamma- disease. as attacks The " in the feature constant a 87 predisposingor excitingcauses. generallycovered with a little blood. .after painful and spasmodic coughing. to be deed. young latter is of the bronchial which sputa number dailycoughed AND accurate any the laryngealcroup. bronchitis APPEARANCES.it This primary the during knowledge ANATOMICAL adolescence. In- larynx.and with condition same the In the of coagulated same the existingupon as The shall find pneumonia we pneumonic patients.OF CROUP of the third the bronchi disease. the coagula are bronchi cylindricalplugs. takes on exacerbations. already croupous bronchitis croupous of bronchi mucous branches up COURSE. but formed the larynx into the trachea plugs which fillup croupous In exudation it which upon of the nembrane the in but bronchitis smaller is seldom confined and to I know has almost the absence as from quite different while the drags on The save the a of the is of for the bronchi.in ceptions.and nothing certain relaxation and cate sleepinessindion incompletely. often commence are by fever. separately. hear exquisite we Upon auscultation. a as croup. who of the cast small fever. but of fifteen years girl.causes that of to this rule there . and patientsgenerallysuffer and a pale countenance even left bronchial progress in the some cases. followed and with a chill. These chial in water.and that the blood is from moderate respirationis carried From time to time.which. spread of SYMPTOMS well of bronchioles the we small a yet as tree-like ramified larynx in calibre of the canal not commencements membrane mucous tinct dis- a by preference persons have we extension and primary independent the bronchial this constitutes and. croupous of age AND TRACHEA and be must THE chronic one. the from process in described have tubes. become tangled disenejected.

is ascribable. lungs affords an draw accounting Essential according the muscular short.and unless. to is a the fibres of of proved now transition asthma between disease the of shortness the of of the comprehends of any nature so-called tomatic symp- bronchi.evincing acid. (3 The " becoming complicated at is even may yet be in dispute. now knowledge. par vagum of the prime cause Nevertheless. this tuberculosis.the mucus " great tendency to relapse. attacks be its action ASTHMA AND marked very CHAPTER [PATHOGENY In last the outset. error attains such PROGNOSIS.AND TRACHEA THE OF DISEASES 88 BRONCHI. we find by experiment to never NERVOSIJM.Moreover. the upon laryngealcroup.develop into a (Rindfleisch). heart. is impossible. in doubtful cases. Although the disease seldom magnitude the to vorable. disorder treatment management of iodide f elder). for the . brought about by means either through the or through the lungs directly. and alone of state the or sential es- capable the and The smallest to bronchi the tubes of bronchial possess of " in cles mus- especially an the point regular sphincter fibres. ETIOLOGY. As the mucus ploy emhave sufficient tenacityto retain its form. and lesion local . ASTHMA in which asthma. we may the test afforded by the different reactions of fibrin and muciii with applicationof the dilute acetic acid. that at distinct tractions con- of electricity.the fibrinous clot swelling up upon In well-marked cases shrinkingand becoming firmer. complete to prognosis endanger yet as recovery is unfaBronchial croup is an exceedingly obstinate disease. which of of one and by III. Drane " from the finer bronchi sometimes may coagulatedfibrin.aid down ss observed benefit any of accompany should resultingfrom all or paroxysmal origin. treatment ESSENTIAL it from is to be conducted potassium afforded that this so daily). often a TREATMENT. If the term " severe a principles brilliant imitated. consistingof of characteristic DIAGNOSIS. to distinction exists service dyspnoea. breath. of the bronchial mucous mem Croupous inflammation is easily by the expectoration distinguishedfrom catarrhal inflammation bronchial of the moulds tubes.we must asthma. we infundibula. as life. . our medium bronchi.regardlessof their palpable explanation of the for the (Thier- case in this disorder. independent which the the pronounced layer of of of present spasm I have symptoms. asthma. the doctrine of bronchial spasm as essential asthma bronchi contraction a bronchial smaller existence muscular transverse treat.which.indeed.

lesions by enlarged glands seem vagus of spasm the cases ASTHMA. dyspnoea. one these we find great a mass of to form containing is sputum catarrh. un- hand.mental agitation. and of the aroma known been asthma. of or views This quantitiesof fine finest do height of fluxionaryswelling tubes.peculiar form. of not may (JBiermer). and opaque. may a sign quite it that would catarrh the bronchitis the seem as were though . distinctlyvisible when crystalsof elongated. such as the irritation. the and vaso-motor mucous one the a but muscular depend upon spasm.such nervous peculiar expectorationhas a asthma. it without stopped largely to have with scanty. gives weight believes who that not of membrane who persons many become nostrils both influence. an with the to hesitate not intercurrent to also will have In many of bronchitis cases they catch cold. of these thus to give observation Further Another in the sputa explanation of of muscular teach must in the crystalsfound sputa been (as has ordinary bronchitis. to bring on The catarrh relationshipbetween tobacco. which truthfully maintained begin may from all of free nevertheless end with catarrh. and flocculi. There attack level of the fit of asthma a existence the bronchial the of of the to of as brain or it. do happens as from come delicate. although may begins the followed to that they of the mucous result of in the nasal perturbed in whom Leyden. cause those are . Indirect nervous evidence an of ipecac. Very rarely. bronchi.which grayish filaments In bronchi. viscid. and of of pressure More quently fre- reflex of certain flowers. octahedral These times.ESSENTIAL In most asthma lies in uterus. mucous On do the other explained. to six hundred crystalsare magnified three hundred the tips irritation upon chemical or supposed to set up a mechanical of the smaller presence or are and vagus. and also found rise to reflex is the the tial. essen- asserted)they been attempt- . so asthma it result of the be when the fit thus that. have and asthma still remains who know that they authorities many bronchial a due spasm membrane. usually trifling. . to sume as- catarrh it is very asthmatic that an attack. which secretion of the with in Weber or may attack asthma Halle. the remote some part of the body. paroxysmally rises whenever emphysema asthmatics are obscure as excitement.the action of as appears which of source are the the upon of asthma causes $9 glottis. the cause of asthma has of spasm us whether of asthmatics whether merely accidental. According up. ing more readily explained on the hypothesis of swellmembrane a as by dilatation of the blood-vessels be may smaller at asthma of symptoms preceded by the hypersemia newly-announced the the of is secretion by alliance This of membrane mucous be catarrh.

years. by Wintrich bronchial and the Bamberger.nor at to dispute. in attempting to obtained the negative results he relies upon of the bronchi by irritation of the trunk of the vagus produce spasm is balanced by the positiveresults had by other (which however ed and experimenters). and of dyspnoea). but not causing symptoms depression.which this the upon of tetanus. Generally of the disease. tendency to symptom the disease. healthy. also in asthmatic observable phragm depression of the diaBut. tonic cramp a port.has Asthmatic should as some able symptoms the more should dyspnoea be of pear ap- erable discov- autopsy. asthma. rejecting the theory of bronchial spasm. SYMPTOMS intervals " are asthma. there no (too fancifully. and that the contraction. in exemption. although which a attacks while. is met rather the that only not vesicles took pulmonary Nervous asthma but young. indeed always exists in asthma. attacks appears cause particularabode some they is inducing accidental in Men age. and suffer unless exempt never sufferers diverse most never the the then it sometimes families The and now of middle although In supposing that lungs. Should restless. so-called sult re- in is " due to an pulmonary flatulence of air which the lungs are made increased amount to retain by the The point made spastic contraction of the bronchi. the disease. Indeed. those some hysteria. sumes asby Wintrich. according to Jliermer. of others seen.] guard against a return APPEARANCES. AND diseases. In supof the diaphragm as its prime cause.the slumber yet unrecognized sensation of dyspncea gives paroxysm the as come on . often a retort beset spasm the the with Biermer of effect the this the a ascribed the to who by unless foresight fails utmost ANATOMICAL cadaver to that which without the the of for or a even As we to find of distinct of doubt. of some who only changes to asthma warrant be can a are for the in the in the uted attrib- diagnosis membrane mucous cause it is structural bronchial bronchial any COURSE. permanent cases.and the becomes during sleep.DISEASES 90 AND TRACHEA THE OF BRONCHI. who. that if asthma depend upon spasm be contracted and the diaphragm drawn lungs should by up. bronchial pure we are speciallocality. instances rarest live in a influences. is not the of the diaphragm tonic (which latter only occurs spasm of asphyxia. like other follow often one not is seldom another again to with alternate paroxysms its type nervous a regular one. of follow only but bronchi commonly than could in the part is more effected " " Bronchial typical course. in order other have in a tary heredi- is attack an cases) many We hear . with short pauses return for months. which rare women. and sometimes then subside.

in cases original neurosis. is often even so . sounds inspiratory undisturbed. with conies more panied accom- truly classical picture finds of a neuralgia of the frontal this the course the attack [One ends often increased the of of the would in think. with other braced. unequal. whistling. cannot to " the a The be be of organic there physema. mucous and is cheeks and a is small pulse of bronchial of neurosis " and bronchitis and and radial hands in distinguishing between difficulty onset murmur the occluded the secretion augmented DIAGNOSIS. so attacks that we of may cramp. some time. too. be hissing. an quarter either remissions.which parts by some often may back.NERVOUS to the has.because bronchitis." some latter As at comes puerile breathing. the eyes complexion is pale. hour. secretion ble. the distinctly . the muscles arms temperature of the attack. the of but the bedews and vain. pendent have which originallybeen quite indewe sometimes ascribed reflex bronchial prognosis as Although to its sudden asthma. yawning. of the membrane mucous there ought the dyspnoea of or mask emphysema asthma. finallyinduce may thus plete com- nerve. that a swelling hyperaemia bronchi. The in feels certain a the most 91 When frightful dreams. or perhaps suddenly. moreover. are widely opened . after lasting for several and action the the .causing about gradually.] to life is better the sufferer. Hissing. in but " expiration. And of tinues con- lachrymal secretion. or a cessation by eructations. brought into the upon the weak Such The vesicular even countenance an forehead hours with rushing forcibly for The of the in the one into the in case the disease. audi- are perceptibleto stands are yond be- alse nasi work ."great inspirationand upon embarrassment their describes the the point. noises are even deep a chest respiratory muscles. Asthma. rise breath. ASTHMA. cold sweat . terminates vagus a hypersemia and and mucous complete intermission. em- of So. violent.are contour air does sufferer desire it. as Homberg aptly but that both and the is thrown chest the . expand replaced bronchi and depressed. rarely coughing. with nervous with the asthma yet difficulties do arise. to the severe see catarrh.often as he than the may have ances appear- safely . with priori. while the the larynx and air-passagescontinue.purring patient himself. the air air-cells. irregular.the impulse of the . indicate. ceases brief symptom analogue in the distance.which awakes. draw to into penetrate sterno-cleido-mastoidei of the head not increases auxiliaries. and and a creased in- an which membrane. heart heard the he suddenly goes. nervous dyspnoea which attribute them PROGNOSIS. no from conjunctiva. not only louder Terror is depicted and are stronger. out to as is ceases.

we of the disease from all air. to the a or cup stand by Romberg. boldly. yet it as allaydanger as soon that signs of carbonic-acid poisoning develop. an relief which great . the causal indication. . remedies.undergone live that he will not attack. second. chronic uterine Where " itself cause indications for treatment The their preventionof the general. but abode long a inhalingcompressed experienceupon greater the after years in greater comfort attacks to arrest. strong cases impossibleto predetermine Among the justlystand of opium or of two the exhibition cup)."as the and jection in- experienceis . attain the first object. moderate a rarelythat institution purpose. ordered the experiment of fails. AND TRACHEA THE OF DISEASES 92 the through next.the great infor the efficacy of the inhalation fluence cause of which the inspiratory act has been periments proved by the exupon of Hoppe-Seyler. is hardly referred to in his writings upon this subject.in highest in repute. the of The more obstruction augmentation of pressure be compensated for by respiration upon may this that the gas respired. morphine may be made. dry.2 My others sense When between either which Mocha pieces of intermediate relief.or mitigate the paroxysms is the disease degree for. hence in widest it is during an this house. and. of the nature hysterical demands indication causal the asthma. It is remarkable (inmy opinion)principal of compressed air. In attack. of my the to meet all else the respiration of compressed been the be freed patientmust apartment suppliedwith pure. first. articles will afford it is a In some considerable solution of medicines in the of morphine may of small narrower be of the one they these of a fail results diagnosisis Where subcutaneous own or the word. most nervous recurrence. TREATMENT. of cause corresponding to measures being shorten. upon muscles a itself there lies disease in the remedy a to paralyzingeffect.as are also the spasmodically which the poisoningundoubtedly has of the entire body.before To unable are unknown. to efficacious of all dietetic is the word) of the his and tightclothing. has which an his undergo subjects to asthmatic easilyaccounted much so respire. (inthe remedies its value prove apparatus for many acquaintance. own The upon into take air.and medicinal their internal administration of recipeof recommended and these will renowned ounces water-ice. The with have observed well-contrived a constructed apparatus his in pressure of it is taken for the for measures sufferer a the blood gas within air is which we A Very vided pro- gentleman had asthma. and occur. to The coffee " ancient (two other dietetic of entirely . bronchial muscles are contracted relaxed. from sense attack.the The moment arises.warm opportunityto the patienthas good results a itselfare. the narcotics doses certain.fears an BRONCHI.

smoky. a instances. 15 every 30 " 93 so inflata. Such previous paroxysms. shorter and is to be regularthe more expected the such for the radical cases seizures we must so-called nervines.gr.) In instead itself. with combined friction upon as emetic. in repute for the preventionof new Among medicaments especially pure. stimulation. effect be on must and seem. The who feel as if in the legs. often mends a the pulsatilla extract to advantage with chest with turpen- warm the applicationof sinapismsto the wrists and calves of the hand and foot baths.only temporary relief.warm patients. long of the function are for the reduced the or and a their other remedies mode nutrition blind in of one the the pauses or more tween beIn occurrence. or sagethe use of the stramonium from cigarsof the shops.the the indication that of cure avoid the list of tin this is very nerves other class of of them empiricism.we should. he may and cause the attack instance. but. and paroxysms. a patient sleeps in a dark lightburning. obis so not.quinine stands Unfortunately. very unpleasantto many marked.caution tho patientto avoid exposure to any irritants which. accordingto his experience. as affords of no benefit which of proves great infusion an of the we nauseant v be may to of antimony. medicines modifies and indefinite from this are very have we intervals drug. and leave his It is desirable that all asthmatic open. Nor in treatment have of I observed reputed benefit derived from smoking a pipe containing mixed with tobacco fifteen grainsof stramonium-leaf.to say of the much twelve or leaves. beg incessantly that be done to something more agony alleviate their sufferings. localities. no comprehensive as possible. . few of chloroform in vapor rule. although the vapors thus generated are asthmatic and are patients. of death.such cutaneous emetic internal medication This we When use.in or ss. of the source of cause and exact as supposed the " should persons reside in a dry they dusty.if comes whenever atmosphere . The much when irregularin selection of to attacks. The experiment soaked in a saturated of burning saltpetre-paper solution (blotting-paper and then dried)may of saltpetre always be made.first of all. famed minutes). an threatens paroxysm exhibit may vi to " administer may doses.x asthma of lobelia tincture xxx " ASTHMA.NERVOUS not of the favor in (gtt. in fact In distressingheadache. prolong 3 to them. the of attacks severe ipecacuanha. from which the first. (We must scure. tine. In order to avert future attacks.so It is unsuitable to recourse and asthma. that should how matter odd the even the have always instructions nection although the conFor altogetherunintelligible. ipecac.or the nothing of that.and " have must be been between or close doors the attacks chamber.such most procedures result inhalation instances. tartrate (Koliler especiallyrecom* " j. windy and that they should not sleeptoo long.

oxid.gr.)are preferred to to doubt me hundred parts). than more any seventy-fiveparts liquid to opii (two parts). me effective. of capillarybronchitis emphysema. disease rule.castor. hundred while metallic epilepsy. iij in die.the displaced one respiratorymurmur 01 is inaudible.nitrat.the a zinci x. and It is colored SPASM " Aubreys of efficacy potassium. Vitus's iron. then rigid up to The expiratory attitude. Bamberger In of bronchial it has failed cases five of Its active cochineal. . the lung and the two intercostal the of depression of sound twelve or extends heart-shock and spaces. the . . becomes last overcharged with carbonic acid .gtt. (twenty-five of pot. solution. one v " of infus. are part MUSCLES. inches are too far percussiondownward. long.The thrice as or expiration being twice slow as inspiration epigastrium does not bulge. expiration shows ten abnormal a minute. camphor. dance.assafcetida. the in THE spasm expiratory abdominal ly fixed to asthma the with (each IV. severe force to as to not the hinderance The in which asthma and asthma of The alone. the the project. gr. instances in many with " In two of probably iodide and (carbonateof nervines ij iv .ext. TRACHEA THE spasm sibillant the of rhonchi volves respirationinforciblycontract patient must the diaphragm. it has proved without or -J. Fowler's valerian. the upper portion alone Percussion after extreme heaving moderately. the of the thorax shrinks the toward spine.and the even but this so faeces RESPIRATORY of the so dyspnoea. its muscles. rectified spiritand simple syrup (two seneg. " AND neglect this this account on nowever. disturbance of whereby Should the are the the attack cerebral the blood immediate effects of tonic spasm of from fails. also auscultation. argenti." gr. root). BRONCHI. v As etc. describe obscure muscles. iod. act utterly. the lower part .OF DISEASES 94 St. one or cardiac Upon two dulness clear The diaphragm.and incompleteness of respiration. or in My experience induces asthma. its viscera and that the urine forciblycompress face is blue. red with CHAPTER OF tincture specific parts). the breathing pass involuntarily. in die. consciousness circulation. belly hardens. purely nervous is the It consists Wintrich and is due dyspnoea bronchi. in die. of cases diaphragm form absent. The the above symptoms diaphragm.

scarlatinous. cyanosisbecomes cases. the extreme death cases severe 95 cool. but undependence of whooping-cough upon of the disease. these easily it wilJ . reported by JSamberger the patient derived chieflyfrom use of the cold douche.too. is of the Bamberger from spasm that muscles of forms some and inspiration. cough. ETIOLOGY. the frequent epidemic appearance the almost positiveprotection against its propagationby infection. is views. inhalation of chloroform.the . whooping-cough our catarrh a however.of which shall we that the sole result of the of whooping-cough is a local affection.in so very of this disease mucous respiratory in the different. of the fmasm of other opinion by its mode of originand by of peculiarhyperaesthesia fits the spasmodic cough. the shorter longer or a small. from distinguishable. in treat acute disorders. such as being unaccompanied by any cough or expectoration. as is not from are membrane.the dyspnoea ceases. however. however. of the may ceed pro- possibly.WHOOPING-COUGH.remind respects of the origin and small-pox. from to this COQUELUCHE. after pulse grows place during take may the skin seizure. traceable to action material and nature vary the originnot only as of of of that the their and that term. however. from essentially as denied to be whose epidemic contagiousdisorders. scarlet-fever. but possible. both membrane. the abatement. since have we since local disorder the of definite no all the of the infection are the ble proba- disease diseases. duration. which depend upon a air-passages. gradu- cyanosis fades. CHAPTEE WHOOPING-COUGH. typhous poisons involve the while entire system. usually the arises at the end of fit of bronchial a asthma.it regard this one mode . specificcause. is maladies. but question narrower tis must the of sense Inasmuch. The an doubtedly unknown. of other forms hereafter of the so-called infectious The circumstance. respiratorymucous of V. membrane. " According " catarrhs other asthenia of expiratorymuscles. the malady afforded in many us by a previous attack.and propagation of measles.3 knowledge regarding symptoms are Indeed. is produced by merely local. we in the infectious results effects as even these whooping- even specificpoison. morbid processes. STICK-HUSTEN. specific excitingcause and the rubeolar.and In nate fortu- more subsides spasm in ally. At well the same other distinguishing whooping-cough for reason a time. but he eventuallysuccumbed In the relief cases taneous subcuthe to disease. detail.and injectionof morphia.

any the secretions mainly in membrane. The and volatility of such its other fact that this as have occur upon contagion seems frequentlyduring winter weather. to whooping-coughalways diminishes Predisposition as age advances. grainsof salt. more In OF par intense hyperaes- who physicians. whooping-cough is a combined with opinionsof of the affection nervous the (namely.arise from reflex action majorityof violence. if it develop spontaneously. catarrh regard that it affection.a proof that the malady. are whooping-cough patients.or to lie The unknown.coughing-fits. causes of degree It is year.DISEASES 96 DC of it to treat of oppositionto the it either as TRACHEA THE as an affection membrane. else believe or vagum. Epidemics of whooping-cough and exalted diseased cough when we come Sporadic cases the The vagum.that views our AND whole. mucous is enhanced predisposition catarrh. . In etc. might easilyescape observation . usually and that from a singleindividual the disease may spread to a great number. from mucous respiratory Colds. a BRONCHI. with some contact or sharp-corneredforeignbody.and of of the diseased Predispositionto in die out succeed exhalations symptoms. periodsof complete exemption.a condition which is certainly suggestive is a catarrh the of of the typicalcourse spellsof tke utmost of the character. air-passages complicated by such a nervous based partlyupon the spasmodic character of the coughThese views are the fact that the coughing-fits and alternate with partlyupon ing-fits. any an important capable of ducing pro- accidental tation irri- the membrane cold or other cause. and sometimes most the measles. contagiousness of whooping-cough.as often furnish the exciting of an attack of whooping-cough as errors cause of diet. whooping-cough are exceptional.and membrane of the pronounced most in persons has But diseases. sugar. of the respiratory organs. the stand air-passages). great to say regarding the typicalcourse of whoopingmore many to of of specificcause attacks persons.but whose been such as exposed to irritation. are qualities whooping-cough is greatest attained their second still more so by by in the presence of its particularly children. nervous in coughingspasmodic perfecthealth.and catarrhal diarrhoeas give rise to cholera. but such fact in assuming the existence from we a surelyare not warranted mucous respiratory of a of the par neurosis of the aesthesia) and occurrence We shall have susceptibility (thehypermembrane accounts mucous fullyfor the ready violence of these reflexparoxysms of coughing1. but They often accompany and do not epidemics them. " and is extinguished almost without exceptionafter one attack of the disease. which provoked by slightcauses. preciselysimilar. approach of warm of scarlatina. discuss the spring." slightbut neglected catarrhs.in spiteof mucous respiratory of the thesia the on practical.

upon contrast SYMPTOMS m symptoms COURSE. are those. hydrocephalus.in whooping-cough. always. special " of been 97 the medulla neurilemma has been observations.and. are is doubt passages. upon but There of enlargedbronchial its membranes oblongata.beginswith violent catarrhal and great intolerance of light fever. by a distressing No one. may post-mortem However. the respiratory anatomical but to demonstrate undergoes some alteration.could ment predictthe approach of a whooping-cough at this stage of its developperiod of . nay. no membrane mucous the glands have or hyperaeraia the par vagum. wide-spread atelectasis. disappears moderate degree of existed behind. fails find to investigation derangement. The catarrhal stage.in spiteof its development into whooping-cough at a later period. AND whooping-cough : the " It is catarrhal customary to recognize three stages stage. it is often mistaken for an intercurrent accident. in many instances. either of numerous. which Such anatomical nerves or central but its existence in the cadaver the richness par that. far more of the rarely. in elastic fibres of any is a task of the which hyperaemia. we particular.to changes which observed.leaving no and infiltration swelling. so far from receivingrecognitionas the incipient the disease. but upon refer to we upon the appropriatechaptersfor further discussion these subjects.the convulsive stage. take may between the Owing great difficulty. trace readilyelude close observation. vastlymore organs.WHOOPING-COUGH. mucous have may after totally death. As this disorder.croup air-passages lesions these do As not depend or or lungs. In a few davs 8 .meningitis. in solitary. the A membrane mucous nothing conditions to the of of the also. affection of the an the post-mortem In few a been cases relaxed was vagum condition it has found of the medulla the to as par claimed press oblongataand and vagum that that swollen. membrane of say place in these largerairduring life.or or situated so Owing to the idea that whoopingattention has been paid to nerves.with reddening of the conjunctiva. however. The patientsneezes and is tormented cough. the best recent authorities still persistin consee founding above)which even with catarrhal emphysema. In find that permanent inspiratory inflation (alveolar ectasy. simple and find almost we uncomplicated. the whooping-cough itself. without knowledge of the prevalence of an epidemic.relaxation. nia pneumoin its several stages. incessantly. its complications. the after during life and the appearances death is no more puzzling in whooping-cough than it greater nor catarrhal is in other when complaints. which are gross. palpablelesions.in the cadaver of a whooping-cough patient. ANATOMICAL cough is APPEARANCES.very seldom ends fatally. the results of the complicationwhich has been the cause of death.and the stage of decline.

which in bad cases empties the stomach to as ear The whenever the forcible the child compression involuntaryevacuations others. they recover.being unable to force the open in turn. disfigure Haemorrhage from is caused by rupture of the membrana tympani. in throat each fit of day and night.viscid. whoop" alterby the crowing.togetherwith frequent still. clear. the latter finally becoming almost inaudible. the abates die fever BRONCHI. (produced as the air is slowly drawn of follows series Then a expiratorycoughs short. their to They clinganxiously nurses. however. of all its contents vomiting. Schneiderian of the the catarrh togetherwith side.rupture A fauces sensation or coughs.the deep red.may amount to twenty-fouror The children upward. or begin to cry. awhile they remain exhausted. recognize these precursors of an attack with dread. the often ears which conjunctiva. or is ejectedby vomiting. of faeces and prolapsusani of ticklingin not urine. is of the coughing.and ruptures infiltrated with blood the patient for days and weeks. thick suffocation. and obstinate more the at the But membrane.piping sound constricted into the glottis).although we observe may this is of rare. with certaintyeven and establishes the diagnosisalmost mouth fills the mucus cough the Soon. support for the head. of the or The (the air.spasmodic efforts at inspiration closure of the glottisduring forced impedes the of the jugulars. the number sertiort of abdominal of always is the only indication Sometimes abdomen. At produced. current producing acute cyanosis. and is removed intuitively by the mother. secretion is pathognomonic of whooping-cough in its second at this period. for more glottis Thus the nates act. however.adhesive.and sufferingfrom pain along the inthe muscles. coughing-fitbegins with a long-drawn. of takes becomes shed eyes tongue looks tears. than a moment at a time). until after lapseof some not at last (thoughoften minutes) the viscid " brought up. of the contents some elsewhere. From of the convulsive This fauces. seek a After the paroxysm. begin .though vigorouslyexpelled.long-drawn inspiratory until with the cough. photophobiasub- the conjunctivaand of the redness . the usuallyprecedes course of a Soon. copious stage.what is more As shown of the stomach. the as the big from of vessels so the to burst and nose occur in the their sockets from to be patientseems mouth swollen. persistent. AND TRACHEA THE OF DISEASES 93 each of end tenacious.rapidly-interrupted. else.causing the date point we panied accom- ning begin- whooping stage. of the larynx.becomes cough astonishingquantity of an paroxysm. Bleed- place.transparent a peculiar. it is peculiarcharacter a action muscles this glottis. or if about and seem and blue . the which. the becomes the verge on and . The patientgrows secretion is bluish. by violent spasmodic closure and reflex assumes the of . and. is succeeded and this.

whooping-cough If. influences. mucous much sooner of intermission new be weeks. laryngealrattle. or often deglutition. watch mother.or good appetite. Indeed. Although par-vagum cannot we external paroxysms although the the of acts speaking.ceases to occur. or opaque. too.crying. decrement^ catarrhal secretion larynx. although irritant of unwonted some violence if the The secretion the is a coughingactivity. Relapses are extraordinarily carefully protected from all pernicious membrane remains extremely sensitive for be not disease be extinct and the child be recovered.insignificant result of demonstrable the of symptoms alternations these is upon we an awakens ourselves that the fit is preceded by a slight it.as soon he begins to cough. and recalls to mind the old affection from which it has upon long been free. and cases so many the much convulsive as of the of irritation to the source new more The semblance new spellis a The attack. and chancing to spellof the apt to occur. vomiting. and tion secre- expected. apparentlyrhythmicalmarch violent it has been. The Here.yellow. the larynx irritants . mit ad- night. the altered secretion affords evidence that the hypersemiaand of the mucous membranes irritability nal are are no longer provoked by slightextersubsiding. provoked. in other or loses its liquid. coughing. The paroxysms sputa cruda become sputa cocta. It is difficult to assign a question observing u ntil the ourselves. to play.loud that give rise to the is neurosis a that the seizures. child's throat.we may satisfy and if we look into althoughperceptible.some once to accumulation the of which tough mucus pro ends it. and the becoming more easy of ejection.and discharged. very brief. The the ejectionof which secretion time elapsesbefore a fresh collection of it pro* that so stage having months. they are in always not provocation. istic made Physicalexamination during the interval affords no characterevidence.WHOOPING-COUGH.graduallysets in. Every slightcatarrh is attended by spasmodic stricture of the glottis. and auscultation reveals signs of . sleeping child a of that deny increase often theoryis based nerve. transparent quality.however.which forclosed the seizure.as irritability of the mucous The merly the fits themselves* shortened. are decreases. Percussion is normal. stage tenacious.until with eat to 99 a new fit that the interruptstheir comfort.yet this for reason has room not grown circumstance. excepting when. form. It whooping-cough laughing. the stadium The of decline. membranes reflex symptoms growing milder.becomes more the is the lasted next three of the membrane rapidlydoes more to paroxysm or criticum four sen is given Every coughing- disease. the encounter ancient child mucous months. we must frequency during the colder. the pharynx will be as and the /bund filled with eokes the duces a the and thus the coughing-fit.

feebler. This is continue.or in the effects of its intensity.instead who have suffered from undergoing resolution. are few weeks or suffering sequent from chronic catarrhal pneumonia. Under and aller. AND changes depend upon the complications. while the forced expiratoryefforts paroxysm.and is thus made to press the pulmonary tissue and the thoracic walls that the so heavilyupon latter are be brought to so high a degree of tension that they cannot set into vibration no by percussion.although the to inspiration. but it is with comparative raritythat the form of consumption of which they die is -the tuberculous form. the percussionsound catarrh.such in recovery event an a largemajorityof cannot cases. murmurs the vibration are distinctly audible. the latter sequel of whooping-cough chat assertion. During the according to Wintrich.sooner consumption of the lungs. In such cases. respiratory the During heard the during protracted. the So such great emphysema. the means recovery . and prejudiceshameful whom it betrays into a stupid laisser highlydangerous to the laity. synonymous. with cheesy metamorphosis. Upon auscultation. has complicatedthe original catarrhal pneumonia.and subdestruction of the inflamed lung-substance. When terminates almost i t is a case always in consequence fatally of which consist merely in abnormal extension of complications. which disease.and.is often to be is that acceptedwith tuberculosis There made. umbilical common. Other probably due to the fact that.and duller. four incomplete an week. doubt for as whooping-cough some terminates lung-substanceand of the owing to having the lives. before occur the for a physician. of no were breath that a result. no ear. some of of the " disorder. due to the development and subsequent destruction of miliarynodules in the the signs of phthisisappear.and into all sorts of heedlessness. a lungs. a to six weeks.100 DISEASES TRACHEA THE OF BRONCHI. sonorous interruptedexpiratoryact is communicated chest the of be can murmur likewise. many reserve. short disease. children. is shorter.during the act in question.the air within the lungs undergoes considerable compression.results in the condition above described much than tubercular form of phthisis more common phthisis.remain it. Most of the children. a number of their rest may long statement of leave the as was children or later.in whom months after their having whooping-cough. judicioustreatment systematicnursing. If any of the bronchi a .it is almost always possibleto bring the disease to a twentieth eighteenthor close in from In other in dilatation It is after cases.from whooping-cough perish. that malady inguinal hernia and of the attenuation hereafter to be described air-vesicles.so tubercles behind terms phthisisand quite allowable. Whooping-cough terminates in According to popular belief. which is still more what The by are no rare.

the peculiar infants at the breast. traces the air more collapse. of the disease. are The occurrence In error. become permanentlyoccluded becomes already contain touch. rare.if patientgrow sleepbe troubled. precisely " of cough it idle to talk of deem we " a differential diagnosisof the paroxysms. and very muscles of the glottic sometimes reflex symptoms absent. and long duration children. the no is established. if vessels of the its is signs are obvious so and easier of its initial unmistakable.its almost exclusive epidemic appearance will prevent its obstinacy. however.are not apt tear. though subjected to very severe pressure like meningitisand acute hydrocephalus are not to be induced by a hyperaamia.so they terminate. The cerebral symptoms arise scarcelyever from brain. moreover. The convulsions.the general the symptoms In all such appear. or an expectorationof copious tenacious epidemic of whooping-cough be One " die in affection a must may be be aware secretion borne in and the mind.or in coughing-fits those from of the this disease opinion.ere rarelychildren one can witness become a plectic. by As the undistinguishablefrom arisingfrom arterial anaemia. short of breath. which sometimes in appear whooping-cough hydrocephalus. among little children. the overlooked. The apoplexy. the If catarrh catarrhal pneumonia a air-cells.or normally nourished. cough and and.or susceptiblesubject(such as an hysterical woman) by the most its character irritation to physioindeed. unless the prevalenceof true nature of the PROGNOSIS. etc. catarrh laryngo-bronchial severe any are.caused DIAGNOSIS. as the cough owes logical trifling varieties those which in like the other occur processes.dry cough arise. complica- lose then* characteristic additional coughing-fits begin to short.or other febrile be repeatedlyand carefully must we burn.proceed either of the from temporary a brain. and atelectasis bronchioles into the the absorbed. if hands catarrhal of or bronchitis.. complication. nearlyah fatal cases show always awaken suspicionif which of We these can they walls the from spread is set up.their vesicles that alreadystated that catarrh. if the the of the It should if an features. for the search This partlybecause and symptoms. even to eases disfrom within . signs of capillary pneumonia. in my of cough produced by the entrance that which be provoked in may a tremely exan foreignbody into the larynx. palms health cases disturbed. by " obstruction venous cold.which take simple and transitory placeduring whooping-cough. Croup of the larynxor pulmonary vesicles is far and violence of of the acuteness partlyon account recognition.followed seizures. apo- paroxvsm .WHOOPING-COUGH. with or infiltration cedematous else they eclamptic are reflex action.of atelectasis.meningitis. that which vesicles in the to penetrate by 101 have tions. how whooping-cough fit. and which seldom endanger life.

TREATMENT from " " small. The occasioned that plications.an demands. I am in the habit of advisinga migration to some region free from the disorder. by deficient become oxygenation without treated month bronchial hi other succumb a but cyanosis.weak." acute bronchi their blood of cause but are as atelectasis. imperillinglife by atelectasis. and to treat the most and precautionwith which. danger arisingfrom these comby the sequelae. when. anxiety. The happy effects which whooping-cough patientsoften obtain by for by the exemption from change of abode are perhaps to be accounted continuous of the disease. without who Children not " because foramen well as ovales the from old encounter two or is as " yet unclosed.calmly await the advent of last. and separationof the sick from the well. moreover. in cholera-times. carefully not influence able which to tralize neu- excites the disease. Whenever epidemic prevails about the dwelling of a patient of mine. \ho at first are only too careless. to protect children with the utmost tude solicisimple catarrh with the same taking cold. Experience accordinglyteaches that the mothers. causalis remove but cannot the who be children their had met. Recogthat the in have catarrh ition to deal n a fact.in seasons every from care epidemic whooping-cough." sides two of because the greatest of the obstacles heart a mingling com- threatens to which with catarrhs.and while attacked The similar in indicatio nor it to frequentlyseen developed among manner. to the or repeated exposure excitingcause which extensive an they thus acquire. of irritant which can give rise to catarrh.and by As. and they which so their to often little or occluded.the facility danger. is augmented the predisposition by catarrh.particularly epidemic prevails. As whooping-cough scarcelyever it is and often as infectious. whooping-cough we of . we put patientsupon diarrhoea.it is well. remain relatives been as free from we prevalent epidemic less are who ing-cough. the disease is to subside. as they think. those scrofulous children to whom the disease would bring great danger. the twentieth week. prophylaxis except as an epidemic. avoidance of where circumstances placeswhere the permit. temporary The indicatio morbi calls for the same which we general treatment have recommended for other laryngealand bronchial catarrhs. During epidemics I have kept children continuouslyconfined that any slightunsuspicious cough arose.and at dreadfullyalarmed. from the moment in one room and kept up a uniform temperature day and night for several weeks in a have succession. curs ocProphylaxis. whoop- had been nursed.has alreadybeen of in detail. by-and-by grow further solicitude without or attention.DISEASES 102 AND TRACHEA THE OF BRONCHI.and look upon it as a dangerous rigiddiet for every trifling illness.

ministrati by the adrian. and of diminishing of abbreviatingthe paroxysms contribute frequency. where alongside of their nurse woollen a get into perspiration. against whoopingdried vaccine phosphorus. so the membrane. materiallytoward The longer and keeping more up violent the irritation of the last attack." and very already called attention sal-ammoniac. kept their the in ments apartSeltzer catarrh non-specificorigin. it of reputed specific. use need we catarrhs. (Seebelow.WHOOPING-COUGH" with. Oppolzer believes it possible and close in a few weeks. crusts. they should wTear Throughout the somewhat a the put in temperature be may have the disease so the The fact. arsenic. or cough and copper specific naturallydeduciblo dren physicians. and even cantharides. but means out throat.calls for of coughing.and hence " in decidedlyaverse are On whooping-cough.castor.and the water. but beneficial . upon patientsmay returningto their insist upon mixed from inhalation we the the of should we flannel next wear As . nay.Besides. and inveterate of which. the lie in a cradle. I continual but should they soon sock round open ere if it Treatment the the in many instances one. expects to cure aggravate preparationsof calculated .Very young in bed remain or mother. by carefully tinuously con- alreadyinsisted upon bring the malady to a I have to uniform maintaining a such statement a long since adopted perseveringlycarried it is recent. set hot had or the the in. belladonna. valesilver. either as and practice. though Al- sick-room. should from us useless and a 103 hazardous of treatment Unfortunately. in a yet a chest. It cannot be ignored that the coughing-fits establish their with season warm air . other of treatment it the to the other to their other ployment em- hand. a has although we have used acquired great reputation.then. pass for We even cannot zinc. mucous much the sooner may . complaint upon for the the from questionablevirtues of anti-catarrhal remedies. by sweating. in both recent efficacy attach we urgently. the great value to well-managed treatment catarrhs of other origin. possiblyprove may pulverizedmedicaments as be drink. and keep it in a slightbut most child to the exaggerated cool the or warm proceeded by of have evening with cold.first of all. search to hurtful again and again submitted exposure.treat other the of observations sufficient number to symptomatic indication. such from deter TREATMENT. children must not perspiration. of not year.) extensivelyin the treatment laid down treated be the is to principles Since. drug which of whooping-cough. I yet and strictly gratifyingresults. milk any skin. the doctor the b ecause catarrh. the antimonials.the principles knowledge are grosslyviolated by many remedies. give short. When bed.nitrate to other assafcetida. therapeusisof the expect great results not have We of medicaments. Chil- are of for this disorder for remedies ascribe in the specialcurative any minds influence of to some men.

the ejectionof the mucus since with the paroxysm usuallyterminates.and virtuous to some indignation. stop coughing.it is true. and for weeks be maintained dietetic must after apparent.and compel the it to resist objection here and there.a equallytender mother. statement a to even as this. is the more easilyexpelled. to withstand child may excited induce me emphaticallyto reiterate my counsel. the epiglotand as the secretion collected about tis. Reduction of whooping-cough.though if need warning. further diate imme- for this mental by the wife of a Prussian general. A portion only of the coughing is involaccumulation and By of exercise an inclination firmness. the viscidity of mucus. " of which in is mixture xij. of obstinate treatment that the sufficiently urge I cannot this purpose For the ligent intel- parents. that whooping- made an the Such rod.be directed to make the child cease this harsh demand to enforce and. if from coughing persevering. S. less numerous. if deprived of its tenacity. teaspoonful when shortening the fits of employed 3j. however.as soon on. when or the of children. but inapplicablewhere law is well known.a moderate reduce carbonates As the alkaline potash be promptly administered. even as soon as possible. if necessary. ($ Coccionelli simpl | j. " iij.bring on catarrh. even must ing the remain- be. if . The cough. admonishing. BRONCHI. and to the same causes completely to the irritation. ni. explainswhy exposure and will. often syrup. and. threatening. effect but surprising. gr.a become determined most cough tell to cough the have but woman.however. by enabling the disease the sooner palliative and duration of the of the number. carb. AND TRACHEA THE one and milder seizures OF not we rendering the in succeed can we only produce results which to cease but radical. as is bition prohiis as important for the cure paroxysms are talking in of loud hoarseness. benefit mother. have as no weeks. with tolerable harmony in approving this theory and practice concur There measure. as fine rales in the the child larynxabove perceivesa described of soda or of dose of carbonate give notice of its approach. judiciouspractitioners the parents are It is of course stupid or rude . that violent reflex symptoms the physiological are controllable by the will. a a much potas. is discharged. Perhaps the fact that adults are better able themselves do not abandon so to resist the inclination to cough. only curable was advice assertion the heard I have a given rise even this. the threatens).but rarelya catarrh of the intensity observable persistence This treatment fit to be coming in the is whooping-cough materiallyaided.and finally. untary. Notwithstanding personal experience and the approval of other it can. spontaneously. .DISEASES 104: the expect we next hence. severity. and child to much as by tire of never lapseof days . the mucous and sternness as wholesome as soon with severity. the aquae attack coughing is in whooping-cough dest. if.

that it renders find out " in the mucus Prescribed the or 105 probably produce given as a matter be not hours." two viscid of cochineal. being apt to action any the hyperaemia of cause in cases which remedy. to the its virtue hardly owes which TREATMENT. prove ineffective.in the condition of the pupil. Since.dissolved in point of older amygdalarum." glad to are milder of soda about only when when throat. every and actual suffocation of narcotics is indicated.or.to or we may the doses the give of aqua a few laudanum. an cannot we (belladonna included)has whatever narcotic of their approve the of hyperaesthesia especiallyintense admit and hence catarrhs. whoop- complicatedwith but air-passages. his nutritive from sleepless during the occur Belladonna enjoys this an advantage over opium. even as a specific.This of narWe have alreadyexpressed ourselves in favor of a bolder use cotics in treatment which we that catarrh a in use ing-cough." also been and prescribedto shorten the coughing-fits their number. it.-fa \ in die). by children. regard merely as of specific course they whoopingthe and lessening they act by mitigating cough briefer. frequenceof the which are perpetuating the irritation. and reduce there is scarcelyan article of this large class of drugs which has not recommended been in whooping-cough.we morphia (gr. and the case vaunted is especially with belladonna. loosens Narcotics the in the have Half like. we may For incipientnarcotism. value of chloral and of the bromides of potassium and ammoof . as cough.and latter way.but tumbler a the parents attacks a of the there a is a is approaching.the the with suffer.from to should brain. as paroxysms. water. To children. paroxysm and same routine. Bintz of muriate and others have derived decided benefit from the quinine if given in pretty large doses. graduallyincreasingthe dose up to half a grain.night and morning. say from to twenty grains daily. narcotics are not well borne as a generalrule. danger Should condition If againstthis disease.however.or until the pupilbegins to dilate. that. the child empty the its stomach begin nights. given above.we have index for regulationof the dose.we from the render any of restrict their those to use outweighs danger from the should treatment. exhibition of opium is less hazardous.according to the age of the patient.as use shorter. and he thought it useless to push the dose two and to the four years. Trousseau preferrednot to divide the daily dose.WHOOPING-COUGH" would occasionally. convulsions or administration disease vomiting constant signs of should paroxysm. drops of [ Von use one The much so lauded by liquid like some West. drunk and result This should mixture teaspoonfulevery collection they soon they say. whom prescribesmall may " children. the ages of between give the eighthof a grainof the drug.should seizures.but gave it all at once.

-0. enough. a are particular indication. of merely not testimony. until the come of If. the sedulously of must breath. a decarboniand repeat already explained why produce the desired effect. so much much the more so the an justly. been of of disease. source shall we Emetics. nitrate and By useful. are second after the child grow cough.00) the to seems now and from is there bromide of silver the of effect action beneficial gas-works the try check may of profuse secretion. BRONCHI. from in accumulating already pointed compressed-air important very In obstinate In flow.00). immediately the of show therefore.always whose is there and alum children membrane mucous found been attacks the moderated stages. in is. which of of steam.-0.1. later inhalation the prevent When collapse sium potas- the tubes. obstructions such cause bronchioles bronchi ample The minuter the catarrhal of depends the the the subject disorder that out being themselves. caustic emulsion " " fumes Another the important in part we day. impoverishment urgent and the of symptoms. any The the of approve without the etiology.. Finally. watch we should or the is there still remain there their smaller danger more air-vesicles.03. the emetics symptoms dally which but give recur. an cuss dis- to that very enfeebled become in danger obstruction practice its have inflammation lung every tion secre- We whooping-cough. (0. but of to we propagation treatment if cases. when furnish meat-diet. when of of 50. thorax. of stage. it whenever it is that of of administration child.] atelectasis. of part zation the of audible not blood set in. short throughout imperfect forthwith. the abandoned. of of inhalations use.06to 30. to bronchial a upon consequent its of highly thought cannot into the and indication pneumonia. especiallyin the blood the free and general third exhaustion administration preparations the is indicated. in inhalation of that the narrower respiration do the their rdles the the them.02 to have has little even the touching treatment. obstruction. apparatus. the most wine. chest. can hyoscyamus persistence tannin of possible. eggs. As local a with larynx lunar atomizer. AND TRACHEA THE their to as efficacy.DISEASES 106 nium has also OF been conflicting reports with but tested. the have the (0. unfortunately and do if signs of also emetic We have not always this of play although third or is common bronchi. ferruginous . shortened and means sometimes extract.

yet mistakes the regards significanceof the disease. followed in feeble constitutions if a the ineffectual. 20. patient alter for the worse suspicionof phthisiswould of the cough a warmth the to air . hyd.0. a suspicion of the existence of grave thoracic disease.ADDITIONS TO ADDITIONS TO SECTION II. catarrh which precedes phthisisregarded even by physicians chronic for the see the as ailment insignificant an . besides the tracheal pain a pain in the side. Although the by often are whether made. real disease.0. given in 1.. such as is a part of almost every disease of the lungs or pleura. . especially . P. " S.3..cort.and of many other disorders. however.might readily arise.a young the though hour. there . and often do we How overlooking the latter. should cold if Therefore.too." The Liebreicli then and LiebreicJi ones. a bronchial 107 OF AND 1880. 92. 95. trial. idea of Letztereich has characteristic pertussisin lately found spore. one-half results several the is followed one reports by quiet large dose. respiratorydisturbance the few a and even very frequent his recommendation. 2. livingcontagion a and aspect From of in that gramme. it upon used summer too fever prove wholly negative. muscular TKACHEA 1. this disease symptoms a of their fauces. half aa a states subsidence solution 3. an $.of consumption for instance. there to proper as attack other some OF existence presence the EDITION REVISED THE DISEASES " the REVISED THE should happens. rabbits and the the of the patient. 78. or perhaps to some or neuralgic complication.." of OF EDITION THE of often If. is to be Chloral the to or tractable in- P.50 in advises aurant. physicalexplorationwere Chloral pulse if. as to be an independent affection or symptomatic of disorder. as catarrh. due perhaps to be from mild rheumatic coughing. catarrh is easilyrecognized so of and cough expectoration." have be of in then. by smaller be should be repeated dest. more and much in consists error graver mistaking a subordinate secondary bronchitis. for appears dis- asthma nervous servers ob- aqua3 dose. soreness A common 1880. if it do of shunning ! yield not respirationshurried a be it appears that in sleep. in claims that which. to dates the the glairy sputa have by implantationof from induced time of all the this sputum upon of Linnaeus. hydrate deserves be warranted. first dose may minutes. P. chloral. BRONCHI.

lar lung. A vesicles the second form Virchow and the of notice calls disease heart of multiplied. themselves of Under with lung hypertrophy. mitral the the enlarge/ of is said other said are induration. one of the of capillaries multiplied. grown side right thickened are and ume vol- increased an the describes. capillary hsemorrhages to brownish and ing. or " number greater their OP LUNQ THE may certain be suspected diagnosis. THE cases of use third the describes vicarious a in to shall we lungs Rokitansky of tissue. intense occur thicker Skoda in of expense lung tissues haematin form consists hypertrophy in the the as coloring from the the of and transformed in walls to been tissue lung. tissue. more of then: and larger. must of smaller. instead rarefied. then- voluminous. are valve. admits of admitting of of the of the the in the sues. so of at has to their and simultaneous dilated.but in of the of of the vesicles has closer We air-vesicles.III. pulmonary true as this t"j appear is expression. pigmentary chronic severe form This the vesicles the hypertrophy pulmonary it in when lung. being enlargement an which in customary a treat - LUNG. be and wasted title of emphysema. SECTION DISEASES OF OF PARENCHYMA THE CHAPTER I. which the the hypersemia that. fully upon more lungs the hypertrophied. tisceeds prothe stitial inter- air-vesicles. and too. the of ment of increase as tissue. while walls the Here destroyed. lung any granules. the Here. particularly in valvuof not the notice The the which engorgement. resist- more is due epithelium ever be and hypertrophy neither totally browner. seem tissue the specks in This resulting from microscope tissues Either during and darker is it the and form life. HYPERTROPHY IN by the far enlarged. more of development atrophied chapter. to exist . color under demonstration blackish and numerous pigment ments ele- blackish in we the vesicles the resistant.

or atrophy the chest is actually contracted. and. are extensivelycovered over by the lung. occurs and in old age.and to the absence respiratory . Now.or senile emto the disease physema. and in these cases and sometimes of the aira wasting of their septa. in senile atrophy He in contact with a large part of the thoracic wall. that attenuation. it is heavilyloaded with ment. In senile atrophy. distinction practical a This between tant importhe two affections. however. coarse a dry relaxed. so that.and mean atrophy of the lung we gradualwasting of the vesicular walls.while in emin the stricter sense which difference. expiratorycollapse. in true emphysema. the volume of the lung is diminished.and his a state of manent per- is shortened by compressed by laterally of inspiration pable incaare man stoopingattitude. while in true emphysema the thorax is either in a state of chronic in senile enlargement. This state of the lungs and chest explainswhy old men become short of breath.and the atrophiedmuscles For a similar reason of dilating it effectively.which results from imperfect nutrition of the lung. form.and why The shortness they are so apt to look blue about the lipsand cheeks.why their blood is imperfectly decarbonized. We most monary commonly see this wasting of the pul- BY tissue organs. The thorax of absorptionof the intervertebral else it is in old an substance. more are Through body.bloodless. The the entire lung forms network. finally. This deposit of pigment is of blood. it is increased.or else in a condition of permanent inflation.OF ATROPHY THE OF THE 109 II. EMPHYSEMA SENILE. which.thinning. pigand is sometimes uniformly black. The size of the lung manifestly depends upon the capacityof the chest. it is when Sometimes by general marasmus. and large gaps vesicles coalesce. the heart and liver. tissue feels soft as down to the touch . sooner and accompanied by atrophy of completelythan more the atrophyof involution of the other the rest of lung the the symptoms decided. great many. depends upon the difference in the condition of the thorax.several.but is due to pigmentary metaresult of extravasation not morphosis a of obliterated of the contents These nutritive capillaries. inspiration effected by the wasted of that muscles.so that the title of senile emphysema is not altogetherinappropriate in question.in an aggravated case. like those to be derangements of the pulmonary tissue are essentially described in the next chapter. of breath of and the venous state of the blood are due to the diminution of in the number to a decrease breathing-surface by loss of cell-walls. of the furnishes word.as characteristic of vesicular emphysema of the lung. physema. LUNG. CHAPTER ATROPHY LUNG. is to the incomplete manner in which capillaries.

Finally. The ETIOLOGY. accordingto a fourth view. ration.emaciated.has no analogue elsewhere.thus causing venous engorgement of the aortic circulation. they termi- is out of the question. because occur is imperfectly pulmonary capillaries. III. like lungs. cyanoticsymptoms the right heart. Four principal the subject. and difference is the their and percussion-sound heart that of the and the harsher walls THE LUNG. of the forced vesicular walls. of the lung. the former.emphysema is the result of oedema of the " " excessive mechanical distention but inspiration.namely a rigidenlargement of the thorax. contracted so bronchioles much Treatment of is between senile atrophy of the Upon the capacityof the which nate.thoracic the easilythrown full. The elasticity expiration. but no tive consequently adhere to the classification into vicarious and substanair-cells is emphysema.DISEASES HO THE OF PARENCHYMA OF THE LUNG.the dulness The the over the greater the auscultation. opinionsof authorities as to the mode of originof vesicular emphysema of the lungs differ materially. but of is not duced pro- expiration.become. of the volume of the blood keep step with and generalreduction organs much the marked the symptoms. by by expiration theory the its is to not mechanical. . According to the first. lung CHAPTER ribs is remarkablyloud air-vesicles in vesicular flexible liver is increased.so more importantaid to described. constitutes the " primary disease. likewise. must the atrophyof the lungs. by forced and long-continuedinspiration theory of inspiAccording to the second. either a morbid enlargement emphysema of the lung is meant of the pulmonary vesicles. owing to obliteration of so many emptied.to which dilatation of the only secondary. such as the subcutaneous areolar tissue . BY " " " other organs. arisingmainly from the blending of several else or vesicles so as to form one great cyst emphysema vesiculare tissue interstitialconnective die escape of air into the subpleuraland The latter is analogous to emphysema of emphysema interlobulare.which of any strain or stretching.and singleone will account cases. above As thin.having fewer efferent channels. OF EMPHYSEMA are murmur. the more unequally atrophy of other According to this explanaticai. origin nutritive occurs dently independerangement of the lung-substance. and into vibration. but it arises from According third. a morbid condition. advanced by Freund. "We believe each view to be true in certain for all forms of the disease. have been theories advanced upon too protractedinflation of or emphysema arises through immoderate the air-cells.

so If. the size of the remain to fill it contribute vesicles which 111 cases and wasted.substance pulmonary the the chest capacityof If the capacityof in which shrink portions of without thorax. must act for them. become of the reduction all in arises. up the inspiratory that other free from ad so must are parts of the lung. the of or gorgement. by swelland imperfectly. that the air enters by accumulation with into the corresponding vesicles. are near regionsof the thorax. From the foregoing representationit is evident If vicarious inspiratory theory is a correct one.thus reducing the bulk of that form in must part of the lung to which they belong. other portionsof the lung. a during inspiratorydilatation atmospheric pressure then. followed by chronic Finally. the distention. thoracic anterior such wall.and apices spinalcolumn. extensive originaldisease.vicarious the chest. and are to undergo an cessive exand bronchi the abnormal is often lung. dilate cells will not accessible and the remaining hence these them. depend sponding corre- its wall. part in occupying the space created in the chest by its inspiratory the anterior and Hence. and united. expand for them distension. part of the lung narrowed of mucus. the Where yielding vesicles at the the Of lung place. especially thus made lower borders. and become abnormally distended.or else the remaining vesicles must emphysema arises where all of the vesicles do not participatealike in by inspiratory fiUingout the additional space formed in the thorax dilatation.expand equallywith situated to the diaphragm. and which those and the placed near to the adjacent movable parts of forward. although the portionof the thoracic wall adjacentto them movement scarcelytakes any part in the inspiratory the cells in the more movable of the chest. individual constant. by collapseof the must.the ward yield and be pushed downpulmonary pleura are firmly course. too.and cannot along the back-bone fullyperform the their apicesand expansion. emphysema Vicarious LUNG. of course. all the air-vesicles are inflated uniformly by If number. the of lungs. either a vacuum dilate.the normal Under have must rise air-cells in the serum.a part of the air-cells be filled up by exudation no air more and enter can and vicariously " of all persons the bodies the who died in the costal and pulmonary pleura give conditions. must costal and for this to take and displacement become impossible. such difficulty. or for c them. that during inspiration. Thus. " enough that the emphysema arise . hypostaticenlung spared portions of between rigid adhesions to vicarious emphysema. which catarrh. Secondly.first. Normally. will not do its share in filling expansion of the thorax. THE OF EMPHYSEMA then- upon portionof them perish. be so much of the If. vicarious calibre of the finer tubes catarrh emphysema. the abnormal an find vicarious we by undergo ones or chest. in " degree of of pneumonia emphysema So.in one smaller part of ing.

conceived it to be as follows : If. This is true . such obstacle may insuperable. broncapillary Secondly.or the to its gradual wasting emphysema enlargement of the independent disease the the the emphysemexplanation i? rupture elastic elements is.it is replied that the suppositionis erroneous that the auxiliaries to inspiration ceed exthose of expiration at all events. if the affection develop slowly. We must destruction decidedlyoppose the widely-spread as in a adherent of case the impressionthat other without over-distended of change (just permanently enlarged). stretchingof the vesicular protractedinflation and walls.a form of pulmonary cells arises. septa are PARENCHYMA THE OF LUNG.or of tedious catarrh. THE the intervosicular hypostaticengorgement. of the lung and of the thorax.so that the vesicles are which.but that it does distention of the not air-vesicles of account an for the abnormal emphysematous and lung. but elasticity Substantive wherein as is owing solelyto elasticity loss of The false. lost has lung atous simply lose cell-walls above the men tissue. that this hypothesis would be satisfactory if the enlargement of the no pulmonary vesicles were greater in emphysema than the enlargement spiratory which they normally undergo in healthylungs at the height of the inact. is unable likewise. becoming more have been to escape and more The act adds inspiratory more. emphysema.OF DISEASES during a pneumonia acutely On ruptured. who first pointed out the mode of originof substantive of catarrhal emphysema. is effected mainly through the elasticity and through the counter-pressureexerted by the intestines during inspiration. as regards forced expiration. next over-filled and distended. completely. Laennec. and means expiration.while it has of the air-vesicles. That texture caoutchouc-piperemains tioned.in many of vesicular is a elasticity. yet we that it is chiefly the larger have already shown which bronchi are emptied by a forced expiratoryeffort. excessive This argu- . especially very littleaction in promoting evacuation " if the bronchioles common occurrence be obstructed. which has fewer auxiliary which at hand. of permanent It is thus that vesicular ectasia for the account we of chitis.an bronchial tubes. glove or an above the that " likewise " of their over-stretched an is true. primary and more in consequence instances. such owing the to to the obstacle may powerful muscular passage be force of ah* arise surmounted by which in the smaller during inspiration. Thus a portionof the air prove while to is retained in the vesicles.growing thinner and thinner. or the other hand.the vesicular walls undergo a gradualatrophy.and becoming until at length several cells coalesce into one large cyst from perforated. of their septa. pleura. this act is effected. or owing to viscidity swellingof and of immoderate obstacle secretion.in consequence the of the bronchial mucous membrane. Two ally continu- main jections ob- advanced against this theory : First.it has been urged againstthe explanationof Laennec.

the in vesicular icalls. it would originof emphysema the seem is the fact is that the correct . after expiration.while.the direction of which is obliquely current upward.grow thin. sound.In straining. such of the glottis.and in whom the pecto- absent. perand then several vesicles blend into one largercyst. of is rare. wind-instruof the glottis. forced into the upper was prominence ol part of the lung as to cause the upper and intercostal spaces . from immodinspiratoryexpansion and stretchingof the vesicular walls. emphysema reallycommences. The result is the expulsion of a strong of air from the lower bronchi. This account of the originof substantive erate emphysema. indeed. In severe in as occur paroxysms is vigorously the thorax whooping-cough and chronic bronchial catarrh.)But. though in a lesser degree.in patientswith thin fat.and process occurs. It is easy to unhow the the arise in of emphysema may lungs as a part upper forcible expiration with simultaneous result of often-repeated contraction of coughing.both in coughing and so straining. of the under observation.at the same time. in liftingheavy weights. and.upon pressure lobes of the lung. if the air be prevented from escapingthrough the larynx.and but littlesubcutaneous been have The of emphysema. in other severe bodilyexertions.often per- Permanent removal (These are the cases emphysema authors. but cases. ought to have prevented the confusion inspiratoryectasis and emphysema ectasis inspiratory obstacles of the may subside 113 which of exists the between lung.is not instances in to all cases. by the air thus compressed. striction contracted. bronchi.in a compressed state. I pectoralismajor were much air have been able to see that.must direction is obliquely downward. completely .the ah* is compressed within the thorax.the escape of air is impeded by conand in playing upon ments.whose By the centrifugal the vesicles of the exerted. muscles. too. and there are a good many applicable which must derstand we give credit to the expiratory theory. in patientswho not posed exoccurrence and to any certain. the latter upper become distended far as it is possiblefor them to yield. a of the Hence. if permanent vesicular be inspiratory inflation kept up for any great length the and continuous strain expansion produce structural of time. and I have often noticed pointed out the same phenomena.become forated. I have whom ralis minor does of had so subside. and upon the adjacent thoracic wall. the same So. be driven into the upper a portionof it. and with a groaning or panting and only allowed to escape at intervals.EMPHYSEMA ineiit manent OF THE LUNG. third of the largerportionof above 9 in causes a small theories hitherto number of the the mentioned. In all these acts contraction of the chest is effected by vigorous upheaval of the diaphragm. and. In a vigoras ous to of so-called recovery man. changes They atrophy. however.

like a distention that place sometimes whooping-cough. frequently-recurring coughing-fits.UNG.chronic catarrh of the lesser bronchi. appearance of the from to the which. the when tarrh caportion of emphysematous patients. whooping-cough dry bronchial catarrh . to disturbance. ease. same however. consequent emphysema. toward Predisposition emphysema is sometimes congenital. lifting wind-instruments. in the a chest together. . the and similar procedures. inflammation wasting of adhesions.perhaps. wasting. developed a emphysema years arises from over-distention and Interstitial emphysema an rupture the interlobular and air-vesicles the of interstices. coughing. according to the theory and shall show rare exceptional. and causes are catarrhs to as in consequence which scrofulous of and the quent fre- rachitic The it appears extensive those especially well " inflammation pleura. rigid dilatation of the thorax as a primary disexpansion. that. " The almost universal statement. causes. and to Bolm Gerhardt. without any had few later. corporeal some cases exciting and of unknown. but may septa are not always due to a mechanical according proceed OF PARENCHYMA THE OF DISEASES 114 Perhaps us.calibre. according bronchitis.though of interstitial emphysema after croup probably attributable is.as middle however. characteristic of emphysema disorder nutritive occur and-by. so the of of of that the and of the malad} excitingcauses of the the lung. It often during childhood as a result of whooping-cough (whichis almost appears disease a exclusively and children tedious are furnishes " From are chronic above contraction playing upon burdens. pleura adjacent to into the the air interstitial of and connective with escape sub-pleural and the and arise from the I cannot.one . heavy the In severe exertions. and often causes partialcollapseof the lung. process. is certainly The of of of occurrence rigid dilatation of large majorityof instances. deny having met which seemed to support the theory of Freund with a few cases cases dilatation the chest had marked of occurred in which a rigid during the treme exsign of emphysema. sometimes of of air-cells large number takes created space somewhat cases where taking part in occupation of the chest The frequent. prevalent.with with main the age).perforation. then. but in which period of puberty.gradual atrophy causing permanent inspiratory and the cell-walls.most in lent vio- very prevented from are by inflation inexplicable. As we byFreund.and nutritive from to THE and final disappearanceof which. " excessive This tissue. is most sec that bronchial liable. ANATOMICAL APPEAKANCES. constantlycomplicateslaryngeal croup. period of advanced life. most of cases from other inherited at causes known present un- belong emphysema to this class. the vesicular L.strain.

EMPHYSEMA the opening npon THE LUNG. and there physema. the bronchi and thus prevent further escape of air from the vesicles. although it is not due to the latter disease but to its complications. is constant and peculiar to this affection. there is a wide-spreadobstruction of the smaller bronchi.in- counteract marked. exterior that is in the autopsy.were of the chest.emphysematous also very which understand lungs.when only met with opened.they have lost a considerable part of their elasset so up that the reason is evident why lungs thus diseased remain .more extent.during the last breath escape of the dying patient. emphysema is very frequently complicatedwith capillary which is the chief cause of obstruction of the minuter bronchi bronchitis.whereby the of air from the chest is prevented. to elasticity tying from walls of the would some be the the stomach after oesophagus collapse still. soon collapse. is not the effect of emphysema is in cases where. A very emphysematous lung suffices to Although the opening the forcible in the chest and.and may vesicular the favors we of permanent occurrence small obstruction hinder evacuation in the of the bronchi complicating contraction no (whichwould removed inflated.contracts escape occlusion nor likewise prevent retraction lungs. and vesicles. have tion dissecout with- by posure ex- atmosphericpressure immediately escape air would collapselike into those open where thoroughly to erroneous extent. flate pylorus.and the thorax lapses. healthylung. Besides. of the elasticity inspiratory expansion. the respiratory muscles relax. did the resistance by the weight of the bronchial wall.the emphysematous lungs bulge forciblyout it. tubes. em- thus those of an empty heavilyand narrow.while. colTrue. all their walls would their outlets In order allow remains vesicles. only a portion we and not blowing. besides the emphysema.about their upon the the of the rest of the air which of the to from propagated. and certain a thorax the bronchioles of healthylung. a of the the egress. the bronchi.upon it not when larger than healthylungs.is incorrect.and more comprehend been this act from to why merely exposed. sack. because cease oppose the its further body. A this fact: If we simple experiment will demonstrate a remove stomach and oesophagus from them. and of the retention of air in the vesicles . we surface. the remain ideas then When.or of OF least at inexact. upon a of one lungs).when the is opened. add.we must of the thorax. The vesicular walls of an emphysematous lung are thinner and slighterthan those of a ticity. thickly-walled Owing to their weight.when an protrusionof emphysematous lungs through is by no of constant in emmeans occurrence physema. Even is of air-cells.or condition.and thorax. yet incompleteretraction of the lung. and. that walls. the by reducing diminishing their expulsivepower. This active projectionof the the lungs from alone. chest. after air will escape heavy This of the air-cells.

Such removed from the chest. diaphragm. did they when it was and of there also be should This mortem. increase the by-and-by.is found in result of the an size would however.we may of wide-spread especially substantive the dimensions of the lungs had during life. actually. circumscribed the In increase in the the varying in that size from and inflated.as like chest been of the removed about find groups that of a from crease in- the indurated or of tender vesicles. of the cavityof the chest. and in part from an a peculiardirection of the ribs. we of a hemp-seed to traversed exposed post capacityof the thorax. of circumscribed lung. which. lungs vicarious atrophied parts of size.when re- . the affection is limited and lower to the anterior edge of the lungs. THE when exposed to the atmospheric pressure.DISEASES 116 OF PARENCHYMA THE OF LtJNG.and thoracic the the depressionscrowd together. puffed up and inflated. This will be readilyunderstood. after the explanationof its pathogeny given On above.when which of the seat the disease is a cellular dilatation result is not does portions If constantly not at all retract into the of appear marked assumes course cavity. If an to contract emphysematous lung were in why.while the collapsedregion is created of whole organ. the of lower If inflated. and may even bulbous or pedunculated. network. They tightly pea. any of the at the the hand. it persistseven body. has arisen acutely. frequentlyat most When the The seat the apex vicarious by lungs. abnormally large. almost by deep the shape bous pediclesof the bulprojectionsand lobes the and interior.the hard cords by so closure edges. the disappear if cases m been of and elongationof the costal cartilages.that inflated emphysematous lung exist alongsideof collapsedand shrunken parts. Where the vesicular distention strain. retain the about when volume same the further understand closed. Since emphysematous lungs. it depressionsand rigid bands. emphysema A portions of lungs. in the apices. conand correspond with that of the The emphysematous parts are prominent.when volume the after emphysema. cut were have delicate a shall show we normal a emphysema parenchyma. this into. as in in their depression of the from arisingin part increase an is laid open chest are vicarious the of remnant a is emphysema lungs. or chronicallyas in pleuraladhesion.during a pneumonia or hypostatic engorgement. where other bronchi. always intervesicular septa.often present a very irregular tour. and it a lobes proceeds from is distributed it is forced more characteristic stricted con- ticularly par- protractedinspiratory or of expirationand of the lung and less this out evenlythrough- variety. as they do not more than contract. the substantive emphysema arise from its seat is always in the upper glottis. do healthylungs. the anterior regions.and often occupiesthe apicesand other characteristic of this varietyis.

the emphysematous the remarkably tissue is Interlobular pleura. infundibulum one size of a vesicles find. The inflated tissues of acute emphysema are of a strikingly to the .and a the thorax.moved from the chest. walls atrophy infundibulum one with blend .full small pressure. usuallymuch enlarged. An emphysematous lung feels remarkably soft to the touch. in last described. perceptible. the seat also in the of emphysema ward. but directions.creakingsound is barely pillowfilled with down. in diaphragm there editions of this work walls anterior the intensity.a dull. or pea vesicles of cases. the heart.beneath froth. varying in size and of to closer examination shape. This disemphysema. both conditions same THE OF EMPHYSEMA a horizontal more are direction. vesicular mark dry. the lung often covers to the seventh rib . by fact alone if lifted as of furnishingan easy means interlobular placement. At the first.by wasting of in the worst interveningwalls .a into a coarse network. greatlyenof irregular in specimen especially) large cysts. hematine of superficial glance. previous with statements erroneous many In regard positionof the heart in emphysema. Single lobules of minute vesicles. capil- larged.the produce cases. forms the latter to however.like islands. of certain French authors. cannot only in and emphysema be may bloodless a of narrow assertion air is not the all lobuli.which bubbles causes of distinction displacedby between are This lines which often the seem that. primary ectasis of their upper portionsbe lies in source entire If the vicarious arises without which varietywhose lungs of the maintenance emphysema the obtain. the severer solitary ridges. as of of in number. in chronic and pale hue bright-red of Even to bands. by produced uniformly in enclosed. Upon cases. stages of the disease.in that form with mechanical origin.in vesicular emphysema. border enclosed in the but air-cell?. are pulmonary pushed far downthe pericardium completely.like a Upon cuttingit. until at last. we of the septa. large part of the pulmonary tissue is converted of the capillaries As many perishwith the septa. emphysema The regard to the extent of the malady natural shape of the lungs.the a sometimes acute melanin into conversion there and here dark.traversingmost we the between the as are laries.they are exceedingly black irregularly-formed spots. but those of its reduced are is limited the to to the the afterward dition con- septa vesicles neighbors. of much LUNG. In mild defind perforations chronic emphysema. with rule. contained a (of a in the dried of the and former be to seen are bean. and be cysts. the the These the air- thus boundaries suffices to refute air.that to the varietyof contrast to the and of lungs or left The rightreaches down the lies upon maintain their normal contour.a few delicate grees vestigesof the lacerated interalveolar septa. .

On the other hand. lungs respiratory if contract do not or fectly imperthey expand properlyduring inspiration. producing emphysema of the suband thence to that beneath cellular tissue.it exists only between cysts by which the pleura is extensivelyseparatedfrom the lung. tion as is eliminated by a due from the system.is more imbibition the attenuation important factor persons suffer.and the of capillaries of the septa. rarelythere are larger lung. and it happens that the pleura itself at last gives way.so the of carbonic acid and the alveolar septa. within neither formed the carbonic acid the and can body be renewed. a largenumber diminished. to a upon nutritive a derangement sub nent promi- most less advanced or more the another. AND withered of portionsof vicinity and has during life. OF PARENCHYMA THE OF is LUNG.so are for interchangeof gases. the been.as one of those and emphysema wasting to common of either form. the fore. The is materially more pointsof contact breathing-surface the conditions much the more favorable the air finds with the blood. vicarious " shrunken and and pathological more lung. is. distinguishedfrom one a In another life.caeteris paribus. the smaller this surface With the much is. Circumscribed. THE intervesicular connective no in the tissue More the lobules. of many the destruction and enlargement of the air-cells. air-cells the within the is air not sufficiently during expiration. The slowly a more expanded to find in the acute an The symptoms stantive emphysema are characteristics intervesicular the symptoms has more the surelymay anterior been expect we lower and monary pul- autopsy. have also perished.cannot anatomical be in nized recog- clinical than interest.so much vicarious emphysema at the borders died. allowing scarcelyever the pleura penetrates that the air beneath its cavity.DISEASES 118 There in their interstices.there- emphysem- air contained performance of in the oxygena- and If the thorax surface. vicarious extensive of the the thorax forcibly the of distinct more more death-agony. the emphysema. the air-vesicles is as of oxygen A in the sufficient essential to of the the carried pulmonary normal of the tion elimina- The loss of tissue which dyspncea from renovation on.or air to enter along the roots of the lungs into the areolar tissue of the mediastinum. By-and-by we shall brieflyadduce vicarious differential diagnosisbetween the two instances many during forms the and be cannot points upon substantive which we base emphysema.nor can the latter obtain the oxygen required . SYMPTOMS COURSE. and the atous first incompletely. cutaneous the skin. extent the of blood. the hypostasishave of extensive has person similar very depend septa.

that it is dependent simply ation attenuupon That parenchyma. on the one hand. proceed with now much decreased of of it unlikelythat seems lung state. greater flexibility during expirationby means than the draught of by the spring of the ribs. 119 rassed respiratory expansion and contraction of the lungs are embarmaintained in emphysematous persons. these expiratorystate. Hence. has been by most authors. since.particularly a displace- otherwise. not suction the perforationof the intercostal pleuralcavity.is suspended upon physema.the suction. inaccurate motions respiratory lung. pleuralcavity. in spiteof emof the the thorax and in spiteof the decreased elasticity lung. afford remarkable the any that sistance rewe made by emphysematous of neighboring parts.inthe be it should embarrassed cannot thereby . which I have spaces. have connected of the ficiently pulmonary tissue.* expansion. they have not sufunderstood that the loss of the elasticity of the lung is due to certain changes in its structure. an"' that be of It is very chest.which is overcome be quiteenough to this caused normal under It conditions. but. The ribs.by which possiblybe impeded by affected that by this to us mentioned false and are it behooves hardly be the tissue . elasticity other obstacles. air into enlarge. and loss of the elastic other circulated many hand. it is drawn is contracted the aid from no more From inward by this a pressure the of their thorax.among should this pulmonary elasticity. Experiments. more tory enlargement of the of that the alone thorax.an emphysematous lung cannot is still able to return lungs to to its to the contraction mention see lungs * made. is to in order made the ribs and of during inspirationby neutralize is action the upon bodies of not elastic lung contributed muscular adults. and how of the lung can interfere with expiratorycontraction resiliency the thorax.as it needs accomplishthis. as.have to overcome lungs.the thorax does could their the need sternum chest-walls the after There the from return to weight muscular be the decide to the elastic when than ease much question whether.in . how. suspended.if an establishment of the the traction of the tion positionof expira- procedures. of pathologies. this be spiration Hence. In the first place. on contrary. diminished. against their In children it is not elastic in most this may improbable lung. they have the of the on notions to the as decreased in which mode of the elasticity influence closely. the . greater such be to the and at least shown after entrance of that.THE OF EMPHYSEMA LUNG.seem piratory ex- the to inspiratory expansion of the thorax. The inspiratory muscles. so It need elements study inspirathe lung is the expansion of the diminished of the cannot effected.moi cover.which it produces upon the the entrance of air into the inner wall of the thorax.when look at the thorax we harder proper.and the collapseof the lung. and the fact with the loss of elasticity they.have the fail to inspiratoryto their the spring of and action.

it is to be did it reallydislocate the heart and and downward.a third structural cause thorax from in is to be alteration air-cells. If an emphysematous lung did indeed the liver. of the diaphragm considerablyimpede the return tissues. bellyhave been opened. erroneous alreadyinsisted. preserves position remains walls the free exercise the as thorax after all the and upon sink until its upper it is clear that the loss of persons. the from has emphysema diaphragm. surface where all pressure upon viscera is out the It does suction then.the permanently is To the may of most the renovation as designate. the expansion of inspiratory wall inner during expiration.does indeed condition factor of the in emphysematous patientsthe permanent more completelyprevent its the important muscle of respiration. may expiratorystate.the which the lung suffers by emphysematous attenuation elasticity.even closed. may the which of it the with sometimes phragm dia- question.however. and we said.and returning to monly com- pressed com- its normal . relaxed removed. to its Thus the dyspnoea of emphysematous inflatedcondition^ or. emphysema will demonstration This of contraction thorax the diaphragm.* have we which and air-cells. nay.OF PARENCHYMA THE OF DISEASES 120 ^(JNG. mainly depend . THE by the lungs. are that relaxation of its inspiration upon partlythrough the upward pressure of position. In many the the in many minute of expiration it. upon expansion and contraction of the chest. Hence not the of relax lung . emphysematous lung an and assumptions. resultingfrom is confined the of the tion obstruc- cells. condition that with emphysema the upon obstacle to its contraction an oppose also act outward suppositionof The the would this pressure that presumed of air. partially by the traction of the elastic lung upon it confusion to part whose show to serve either the impeding in influence in have we physiological. partlyto against its anatomical and pathological. the of movements easilybe can of permanent as inspiratoryexpansion proper.in differently very ribs. added. as more depressedstate of the diaphragm. but important most abdominal of ing dur- inspiratory abdominal plays the very the of respect. the from described upon part this in The The those In process. as long the this in it cadaver. because tory expira- this its during expiration.and cooperationis lost of no descends still ascends diaphragm the movements respiratory force of cases pregnancy.and of the of centrifugalpressure neighboring parts is due.or of depressionof the diaphragm and inward exercise a pressure liver.which hinder the the all.returns to latter the that proved occurring after repeated on distinctness affected.and air in the vesicles. however. the abdominal part of or of the viscera the thorax surface is the its upper does not until cease viscera. cases. the during expiration. which muscles. if not inspiratoryexpansion bronchi. * In of the of second great permanently these. heart of the merit chest.

True. the deformity of 121 costal to which cartilages. and others whose bellies. of other arterial walls.or degenerationof at least depends that suppose may this forced accidental effect the the mentioned alteration ribs also and above expanded develop in them are of the or very goes be the be costal to seem It would one. do not take place at all where the emphysema late in after the cartilages have become life. emphysema is shown. and they normallyattain. the alteration is confined ribs.which the from or inspiration. of the part played by this rigid thoracic other ways. to the upper Finally. first called attention Freund sists each cartilagegains in volume in all in a hypertrophy. rigid character. ever can and ribs and bony which ectasis. dilatation in our not appear The in In such patients I have importance cases many of serving unfrequentlyobthey lie upon their not whose patients.costal hypertrophy and rigid dilatation of the chest. When emphysema arises forced with closure of the expiration. brittle. not num By elongationof the costal cartilages. however.and in consequence the structural changes of this irritation. of the traction assuming few very turned are rigiddilatation of the thorax. emphysema. expiratorystate. the at cases of pushed forward. inspiratory h ave become the thorax not cancartilages rigid.from this inspiratory the largestdegree of inspiratory expansion which the its to return of the as manner hypertrophiedcostal the ends upward long axes in the same inspiration by the In the from bodies. This deformityconin his valuable work. particularly inflammatory inflammation. dyspnoea decreases when and the thorax .OF EMPHYSEMA complicated with THE LUNG. same costal the change majority of instances.assuming a remarkably firm. it would before an Freund secondary. wind-instruthrough playing upon and strained. the is of to be rather changes in the costal cartilages.by which directions simultaneously. ing dur- axes cartilageto somewhat seem which distention repeated injuryfrom from their that Freund lung lungs also cause hypertrophyand degenerationof its analogy to hypertrophy. As. only is the ster- is lung farther driven but the ribs moved are much may thorax exceed aptly calls far too " in a this sort In A alterations the structural I beh'eve of that the geneticconnection evils of the origin. violent coughing. from glottis. probable. it is not appear about arises which condition the only a twisted muscles. thereby compress are greatlyrelieved by exerting a lateral pressure upon the of the chest." primary disease. and to alteration From to their upon of inherited cases principally most. we cartilagesis result of a straining.as complication. When forced expirationwith constriction of the glottisis its cause. .as a rule. among does ossified.and does outward. until frequentlybeen able sufferings lower to part observe. If forced have inspiration produced the emphysema. ments. the alteration of the costal cartilageis general. structural related processes upon to said.

of this due decarbonization to imperfect are class. and often chronic in its alveoli.dyspnoea. we might suppose.that in that portionof the lung spared by the emphysema usuallyits lower part the pressure is increased. first place. greater or less violence and frequence in all and described emphysematous persons. the veins of the its auricle. and the expiratorygulliesin the liver. and force to open the neck scalini with the thorax .OF DISEASES 122 OF PARENCHYMA THE LUNG. the apathy. The aspect of entire the patient betrays obstruction oppression.in order the better to compress the thorax during expiduring life.first accuby Liebermeister. is to lie down. by an aggravated catarrh. indicaa long . the benumbed. should of eye small and surchargeof the heart-beat of the The when fatigued. the increase pression ex- and manifestations those to of acute Before the days of Laennec^ such poisoning by this perniciousgas.and emphysema.Frequently. the the lower in all of part energeticcontraction of stances in the ininspiration. as respiration extreme pitch. and rightventricle. oedema of capilNow. the harder and broader air.and chiefly costal cartilages ossified and their jointsatrophied.it constitutes third a be in the When autopsy.and the upper part of the they contracted the triangularis rately transversus abdominis. " aortic circulation would and would dropsy however.the the irregular. are the of the forms sterno-cleidomastoidei stand out like hard the flabbiness. the number laries which remain not sufficient the of the receive contents to being that the right ventricle. sterni. that is usuallv observed cyanosis No for tion. the pulse ashy and cool . numerous rightside of tomical ana- heart is diminished. in the loss of the the by the emphysematous produced of With the the tients pa- disappearance the capillaries.and of blood it becomes the seat of intense hypersemia. patients muscular The tion. upon structural with is associated factor seen of dyspnoea change of the emphysematous persons. the channels from hence. which with recur attacks. used generallyto be considered as asthma. THE ration. be " overloaded with extensive very accompany of any of these symptoms blood. that. to these cords.the dyspnoea rises to an Patients fearingto choke if they pass entire nights in their arm-chairs. blood becomes complexion with sensorium extremities acid carbonic muddy. perceive and tarded re- hinderances constant the bronchi fourth one contracted a are added.could descnbed the thorax rigiddilatation of lung. which we relaxation. They alae nasi from play . respiraall their summon every in which the their out becomes of want of the oxygenation of the When blood. and that chronic catarrh takes place in its bronchi. nervous The are derangements of circulation which in the changes pulmonary parenchyma present a second of the mteralveolar number of efferent It follows series of septa and symptoms.

is easj? . cava ascending vena blood is impeded. the cure a signs attain (blindpiles). gastricand catarrh.and the blueness is never so pronounced as in emphysematous have congenitalheart-disease of the right as persons.lime. hypertrophy of " ventricle right heart. does of the is never the cyanosisattain such severity. lips. chap. transitory derangement of the aortic system in emphysema.which met with in valvular disease of the left ventricle. counterpoises compensates mitraJL of the In the namely.from subside cyanosisset in. cheeks. or in such side. and which of the cerebral veins evacuation of the course blood of cheeks complain of are venous The insufficience." the latter tremely exstages of emphysema the cyanosis often becomes The intense. upon to 123 LUNG.just as appetitewhich and troubles.to regard the cough " a the the as the their extends veins. alas nasi (See it. literally In no other disease excepting in cases of disorder and it are mostly congenital.and tongue of the patientare blue. THE OF EMPHYSEMA the as catarrh the disturbance depends upon proof that the circulatory The causes same operate aggravationof the catarrh. the patientsgenerally blue True. the symptoms and oedema bronchial the aggravationof time.which hitherto has received too little attention. which improves. and of rests becomes All headache.the obstructed dizziness pitch when the outflow portalsystem to the intestinal and often enlarge into almost have the the for all-hopeful misled by a the it. a proportionas the circulation becomes complicationdevelops in the rightside of the heart.mitral up and by column the face and blue. upon cyanotic. lipsswell engorgement critical haemorrhoidal the from of engorgement same centre. orifices of the right heart. This fact. appear- liver swells because of all their root varicose makes patient. grow about the lips and cheeks. They main and gastriccatarrh.. of its muscular jugular metamorphosis up the which into ventricular and throb. with vibration. impulse. ca- a the avert cyanosisand dropsy of appearance in valvular in tarding re- often disease embarrassed.as every thrown the the of fche valves systoleof the right during tricuspidare addition The of shared is ventricle. and time if. so long tarrh. ears.the Symptoms patient coughs. the gastric latter circumstance loss of of their source the ance. in the latter.and flow. stomach The manner.which has the opposite pediment imthe for which and circulatory effect.) become The of symptoms are they attends to call their stomach-cough. the of cavae derangement about the vena does not take place in emphysema until this compensation begins to fail heart-wall by fatty through a gradual degeneration of the thickened Then the veins swell fibre. The varices the found the intestinal always greeted with joy by now In In have also set in.but the general color of the countenance remains pale.giving the patient highest the in veins its through rise to of the rectum believe that is they trouble.

or which tion LUNG.it the is the greater circular which smaller contains little too blood. upon of emphysematous patientsis crasis prevents hyperinosisand increase why the venous poor in fibrin. the of the renal arteries and glomeruliof the malchieflyupon the filling secreted urine is concentrated.in the form of a brickdust-like sediment. All other symptoms attributed The cough is a symptom disappearsaltogetherduring the as give any usual.while the quantityof blood in the system is abnormally small.DISEASES 124: of pulmonary the surcharged with blood. the quantityof increase. with readiness. equal to that opposed to resistance a empties fibrin in blood also to the extends veins is filled to vein vessel which other any of the subclavian the When duct. It is one and to the premature which contribute to the general emaciation causes for of emphysematous persons account marasmus . its existence to of .and pighiancapsules.upon the it may also formation of uric acid of oxygen being ficient insuf- salts. compli- bronchitis. of the urates is not due to concentration Precipitation to nor a depend at the upon to as increase their of expense to BO relative in absolute the urea. all cases chronic while does belong to its cations. and.a pallidcomplexion. moreover. perhaps.as the amount small produces a diminution to be ceases afflux of of insufficient for. THE OF PARENCHYMA THE OF their orifices overloaded. precipitate of the urine alone. fixed In basis by no means emphysema of the summer." prejudicenutriof several both of the blood and of the entire organism. see.we subclavian.symptoms of the heart dropsicalsymptoms. which requirea great deal of water for their solution. great of the the the flow distention. when be physically cannot ever proved. tion Restricted of fibrin. is and contracted.and in conmany the ventricles are usually malformation of the rightheart where circulation aortic where is have ill developed. why Now.too. afflux of chyle must. in emphysema have of the pulmonary capillaries genital perished.thick. obstructive This of lymph the and chyle must of current encounter if lymph be the source simply physicalgrounds. left heart of the In valvular affections explanation. but only to such a lower degree as to give uric acid. it may in the serum of the blood. for the small extent.and the emphysema often tinues con- physicalexamination recognitionof emphysema.and finally of the urine depends urine. The scantily dark . venous pensated properly com- into the left side pulse. On the other hand.but the the scanty supply oxydize the nitrogenousproducts of the transmutation of tissue produce urea.which dency the lack of albumen produces a ten" to the As establishment the as soon of circulatory derangement add of the left heart distinct of to those in blood Incomplete filling engorgement. thoracic engorgement the into the blood. the urates.

chest man in full time We the holding the of this condition alteration of the a considerable of the extent. clear and of the originof real manner The deformity of in which the chest is not produced by the emphysema of the lung. The sole reason is the in emphysematous persons mentioned above. cavitywith yielding walls. become rounded and approximate to the spherical form.to which within the is But augmented.is fixed. but differently shaped is inspiration thorax.upon which we have founded of the chest.and of the pressure abdominal air contained the in the muscles lung is the upon viscera of the stronglycompressed.are increased. is not the In the cases observed in emphysema. ribs are abnormally crooked. Individuals enough after cases.produce while strongest possibleexpiratoryeffort. cording Ac- retain simple physical laws. not LUNG. the to THE formation in very intense negative result even toose. for both emphysema the same and deformity arise from The causes. has emphysema thorax will In some 125 the of thorax. abdominal muscles join in the rounding out of the middle and this explainswhy the emphysematous thorax is more indeed. the thorax is more It is able remarkor spherical barrel-shaped.in upper which find the lower portiondilated. by making to for a short pand temporarilyex- can the from thorax of so-called the nose and mouth. often strange seem effect no proper. as long as the costal cartilages the thorax.we spheroidal. etc. the emphysematous thorax. playingupon windthese the diaphragm is forcibly acts By instruments. may. but we . abnormities. find this rounding of the middle and portions of the chest. By very deep inspirations. Instead a of circle .like any other pliability. particularly and the " a greatlyfrom that having shown our expansion or indeed.called par excellence emphysematous a healthy atous emphysem- latter in ourselves time.and bulged outward upper . presentinga views erroneous absolutely emphysematous thorax it is as produced is have the to as mode while the prevailed. the the shape of that broken the sternum forms a segment of line. wherever to then: must the pressure of the it from upon thorax. simple as possible.may emphysema. a part attached. emphysematous thorax is only seen in that species of the disease which arises from constricted forced when as expirationwith glottis.OF EMPHYSEMA with regard Inspection.and upper barrel-shapedthan are cannot the the lower as for the at the same permanence hypertrophy But this and deformity thorax." and in its upper the depth. in which only one emphysema in forced of do not we develops consequence long-continued inspiration.it portions. the lower takes no part . costal cartilages chest. long.the thorax with suffer the upon give a contraction shows idea of the characteristic peculiarform a In this the middle of circumference erably consid- portion.coughing.so-called paralyticthorax the This disease. driven by up belly.

upon But it is not it rests. Finally. it and the thoracic wall.but its base too. upon in furthest of its abnormal cases point upon which depressionof the heart becomes more Percussion physema sound the to be thoracic than at least. neither of the is due of the which extends adjoiningribs. or augmented. the apex lies). which.displacedtoward the middle line of with Bamberger^ that such displacement is agree even proved by facts nor possible.we epigastrium. of the apex I still This better. I have recentlysatisfied myself that this tumor rarelyconsists of the apex of the lung.which the to concussion lower has part been is can synchronous of the sternum usuallyascribed to of the heart. but hypertrophyof to and it is found the in all right heart. as.and of the and the shock the but body.upon inspection.) Even when emphysematous patient has bethe considerablyenlarged. if the resistance even the capacityof of the . makes tumors are jugular veins again when it ceases. obliquepositionof and its apex lies farther out. only the apex of the heart.has been driven into the space between depends upon neck by the the chest formed In the diaphragm. especially of the right heart without emphysema.with cases Inspection. a heart-shock is perceptibleat cases and outward point farther downward than is normal. affords is of a an almost considerable unusuallyloud wall be certain However. which rests upon the diathe very part of it which descends the and. these sinus of the empty themselves and cough the of it were. which disappearsimmediately upon the cessation of the coughing-fit. augmented contractility contribute inspiration may but it no of dilatation. indeed. permanent inspiratory a hypertrophiedmuscles this to of perpetual condition the disease LUNG.126 OF DISEASES and in of the OF PARENCHYMA THE The condition. phragm. in some doubt gree de- mainly often referred to. Hence. a tumor thorax at the side of the neck. further reveals that. dis- of hypertrophy. extent. which. as great majorityof enlargements enormous fill up costal of the pressure smalL too by which violent of the THE during the cases. with the very the first rib and the pleura. however. That the apex is displaceddownward.the shock of its apex is imperceptible. concussion perceivea strong with the pulse. depression(farther.which considerable complicatesthat ease.and.' em expect the full in all cases. is simply owing which to the depressionof the diaphragm. basis for we diagnosiswhere must not though the vital of th.in many projectsthrough the upper aperture of the every violent cough. as a natural consequence in the diaphragm emphysema.upon palpation. besides the concussion of the epigastrium. lung having become interposed between feeble Sometimes. so cartilages of emphysema. horizontal. (See Hypertrophy of the heart of an come Heart. This concussion physically epigastrium is not directlydependent upon emphysema.

prevents regularvibrations.which. emphysema and heart the has must we ist. in that. pointswhere nothing vesicular where catarrh.particularly in the neighborhood of the sternum.as moment every occurrence lung. which catarrh. at the utmost. Upon the left. is generallyremarkably murmur loud and can hissing. is so completely covered by the lung feeble between discriminate those accompanying bronchial vesicular breathing is feeble percussiveresonance. no . againstthe wall of the the right lung pushes back of the liver considerably the border . cases dulness we auscultation.the this over at here lies passes point the into dull percussive-soundof the liver. correspondingto the lower limit of the right lung.the walls of which are tightlystretched by inflation. this proves but generallyremains disease vibrations. is only so or the the emphysema. While under consequence necessary tension occurrence of the symptom in same cluster of inflated cysts.however. compression of the air. or take can LUNG.unless there be complications percussion become loses its elasticity. reaches to the sixth rib at the rightmammillary line. This assertion. characteristic only It is the of extent the intense very of regular full.fursound that the diaphragm is depressed. and in a manner strikat the anterior wall of the chesi .and conditions. the respiration is loud and hissing. emphysema.which is augmented the the vibrations of by walls. In well-marked fourth normally at upon of the lung the it most extreme that the cardiac In to the often spreads downward. which of the the tympanitic. If we make percussion the a bladder.as a rule.for of the have we normal percussion-ring.it is said that the in strikingcontrast to inaudible. the of the minuter the to be are As a the phenomena proper of placed to the account rule. freelyfrom the bronchi the respiratory into the dilated cells. and hear clear percussion-soundalmost sometimes far down we as as the the dulness lower edge of the arch of the ribs. duced prowhich the heart commences percussionover costal cartilage. as of emphysema. The a of the is by percussion. level disappeared. of producing any does the sound tympanitic.OF EMPHYSEMA no lungs be increased. In severe chest.nglyin contrast with this. where At usually.indeed.to prevent abnormal in even sufficient. a the precisely lungs. The the pulmonary tissue entirely through which tympaniticring is a result of regularvibrations. has become alveolar walls lungs.capable active very THE Neither place.besides bronchi. air passes is the intense far rect cor- usuallya complicationscoex and At catarrh fine moist rdles.however. It is very commonly found that we only hear rhonchi and rdles in the lower lobes of the lungs . upon jpon sound is not diminished or the a of emphysematous The is seen.clear nished disease. hear or. there the but these rhonchi breathing. 127 vibrations. points. very there is emphysema of the left and in to the sixth costal cartilage. loud very full resonance.

are to be in treatingof degenerationof the heart . or a if the person who played well. is usual hi emphysema. even the lower to upper there is no regionsof the lung sometimes murmurs valvular disease. I fullycorroborate though the remarkably feeble at the level of the third and fourth ribs. The recommend where heart. should we it.or if the who boasts of having postilion. Many emphysematous with their troubles grow the asthmatic attacks reach persons their increasingin even years. the violence and advanced an age. is. infer. though al- dyspnoea augmenting. amination.not only in the dyspnoea. Of malady). which by Seitz^of Giessen.to the descent of the secretion from by gravitation (a theory which has much to in the audible the it). we dence.as we Death the patientsdo not considerable one. Cases of dyspnoea and cyanosis.with intercurrent an other distinction of small extent considerable be easilyto cannot be diagnosticated which lead to violent severity.where is covered by the lungs. in childhood. frequency. by physical ex- give rise to those symptoms.or that the disease depends upon a primary find emphysema in structural wasting. The organ explanationis manifest.spared by the atrophy.a emphysematous. is healthy portion of the lung. if pleurisy. of the accompanying catarrh.but in the cyanosisand cured. and while. For the differential diagnosisbetween the at. shall pneumo-thorax and emphysema we conditions between which speak hereafter.DISEASES 128 This the of ascribed OF PARENCHYMA THE OF THE LUNG. and of the of the remission the decrease dyspnoea.as far as it depends upon these complications. least " historyof furnish pneumonia or the case the and substantive physicalsigns " in some physema. em- cases emphysema have developed after a violent cough have particularly preceded If the ground. never are If the have repeatedlyexplained.and continue The disease may commence throughout considered life.with a certain degree of confimay that a partial wasting of the lung or adhesion of the pleura has occasioned vicarious emphysema in the anterior and lower a part of the lung.are from the The the symptoms rarelydie patientsvery of of an attack. The ferers suf- this is because they feel better in summer. takes place (if finally dropsy of very meanwhile succumb marasmus or asthmatic of to general dropsy. DIAGNOSIS. and vicarious no of breath is of affirm that the shortness patientsdistinctly earlier date than the cough. but I may say that the observation of Seitz. On the other hand. " Emphysema with certainty. able to keep up the note for a long of having been have arisen after whooping-cough.are very audible at the epigastrium. shortness of breath has been a musician or . had attributed which we to the collateral oedema circumstance. in some degree. The part which chronic catarrh plays. distinguished. that the heart-sounds.

the bronchial catarrh. the indicatio morbi.especially at its apex. Emphysema complicated chest former. the presumption substantive emphysema. which almost always accompanies emphysema. but The of iodide use againstthat serious complication.stimulants to the chest. etc. it cannot be denied that emphysema sets up a culosis. of potassium is especiallyefficacious in these cases.especiallythe thermal vapor. and quite as false in principle. whole.EMPHYSEMA or a tedious catarrh that warranted like manner. solicidescigoing under- cheesy metamorphosis. a accompanied by here we OF cough. tion proposed modes of medicado not deserve the equallynaive.so as to set bounds. In raw of the emphysema. persons sometimes able to tell precisely what degree of cold is hurtful to them. of the bronchial catarrh.first of all.in the hope that frequentrepetition of the process might effect gradual decrease in their size. tude. the barrel-shaped for the latter form more the " " "y pneumonia (a somewhat lest the pneumonic cate. causal indication requiresjudicious The of treatment TREATMENT. are often signallybenefitheir action is all due to their timely application for a while. at least. the cial springsof Ems. but down.upon PROGNOSIS. immunity against tuberthe bloodor venous crasis. when the temperature is low.warm or mineral alkaline muriatic springs. favorable. totally upon These. By others. make emphysemObservant atous patientsare keep constantlyin their chamber. for brevity's . and " unable to fulfil the indications many other " for the disease itself. to brace the relaxed pulmonary tissue and make " the alveoli smaller. The habitual shortness next symptomatic indication is to moderate of breath of the patient and 10 the attacks of severe dyspnoea. violent to deal with have 129 LUNG. absolute if not certain degree of protection.) Prognosis shown above. The requiresproper treatment symptomatic indication. tonics are recommended. Indeed. after then A fatal termination is rare. THE a thorax of the state permanent inspiratory argues is In for the of emphysema. nutritive alterations as cures and we are whjch the disease depends are irreparable. and greatlyadds to the distress of the patient. (See Croupous Pneumonia. togetherwith the our should after cell-wall. The prognosisas to life is.the dry catarrh. is altogether as to complete recovery as unfavorable.whooping-cough. the periodical The administration has been advised. though a cure to the progress weather. be impossible." depending either upon the upon lessness of the lung. To meet and forbids their going out. Habitual wearing of baths of water flannel next the skin. and of the disease only occurs long duration.. of emetics to compress object was the lung the distended vesicles through the pressure exerted upon by active vomiting and retching. and afterward break should occurrence) unusual exudation be not excite reabsorbed.and in winter. radical The least confidence of emphysema. and other similar treatment.

which benzoin.HI. two of the Where heart. symptoms promoted by depletion. keep pulvis open daily. both upon the avidityfor air and the wood region.'" strict observe a patientsmust eat little before diet. and thus bleeding poisoning would only be narcotics.the patient.just as in dropsy from 3j to water dropsy. J vj. a attack. and | (3 i to For " are ss the other " head-symptoms" brain. air-vesicles OF COLLAPSE " There decreases THE IV. a tablespoonful q. is mild and the efficient cathartic.and when three hours)in an every the carbonic-acid attacks large doses three of spasm. camphor.as " valvular does carb. proposed by Waters ( " j of turpentine the use fail. The of more are appropriate) of port hours). (Acet scilla3 " j . pot. liquoritiae During compos. especially opium. AIR-CELLS " COMPRESSION are and conditions their walls APNEUMATOSIS OF under THE which finallycome " ATELECTA- LUNGS. though merely transitory. squillssometimes service.when by means dropsy arises from failure of the heart for the circulatory rangement deto compensate of the lungs.) CHAPTER DIMINISHED CAPACITY SIS ETIOLOGY. The alreadystated from the explanation of views our the of main element the have We benefit derived *". inspiration To is easy. Later in the disease. S.is excellent. purpose.130 DISEASES sake. oppressionof the allaythe persistent the patientfor the summer to the pine- there is a heavy fall of to places where particularly phere benefit which The they derive in this highly-oxygenatedatmosFrom is always warmly extolled experiments made by them. excellent. improvement blunted mistaking the the attacks. saturationem. musk. every disease digitalis fails. wine " these aromatic water.too.it OF asthma.the effect of this unforsomewhat costlyremedy. tunately apparatus for inhalation of compressed air. s.whenever a bronchitis. ad. the This . unless suitable remedies (besidesthe the stimulants. hours.Many patients machine. very the iss every these in bronchial by of engorgement venous The used and sensibility be must emphysematous asthma. the into capacityof contact. called chest.I have repeatedlyproduced excellent results capillary upon of vigorous diaphoresis. with although only general health of emphysematous patients.avoid food likelyto induce flatulence. going to and For latter the the bowels the bed. has it depends already been stated. Aquae destillat. The with called for caution emetics. In order desirable is very PARENCHYMA THE to to send THE OF LUNG. avert beware of for the effects of asthmatic the in of compressed air. and dew. "feel the like men" while of in the new palliative.it may be relieved for a time by the use of digitalis (an infusion 3ss " vj).

the diaphragm is cavity. particularly cry. may It is then called congenitalatelectasis. In other external pressure.curvature of the effusions driven not from voluminous thorax.muco-puruupon lent plug.which Alter is normal atelectasis is most those who world in have of state a found frequently born been apparent prematurely. together.depressed spots here contrast more against the surrounding emphysematous lung. and lead.which the has stopped up the bronchus leading to it.firm. they with thus acute the of is tracting con- the chronic bronchial or in In adults which catarrh. or collapseof instances the air is expelled from the vesicles by the lung. suffer from very commonly either congenitalor contracted a catarrh. 131 persistin portionsof during foetal life. when in In in the lung. from effusions in the pericardium. When atelectasis is of long standing. instances occludingsome have difficult of inflation. blue. more These inflate spots At them.by which upward.arrested of a possible to blood. the air is absorbed. Compression lung takes place in conseof liquidor of the presence air. present cut first they rigid. and catarrh. are more subsequently induced not are during atelectasis. to in be fast glued acquired or tasis atelec- merly Rokitansky forThe called it catarrhal pneumonia.other changes take placein the collapsed portion of the lung. and first hours other first hours to who after tedious not as which in feeble one children. at a later period. In other the lung after birth. cases which then collapse. into the come thereby caused to make deep inspirations of their life.do smooth surface be afterward readilyinflated.contain The grown congenital rarelythe parenchyma. so air to the vesicles to which of children. APPEAKANCES. This is called acquired atelectasis.COLLAPSE OF THE LUNG.and it is no longer always may areolar of the those a atelectasis walls seem parenchyma justdescribed. that rise to atelectasis given bronchi. we a usuallycome thick. If we cut into the atelectatic spot. of the bronchi are somewhat is of small and air seem immediately children. or frequent occurrence easilyobstructed.or death which do though air-vesicles. complicationof It would filled with become is always connected acquiredatelectasis. then speak of compression of the lung. labor. more found to be depressed somewhat surrounding parts. in the the In or of to have seems life. blood. ConWe genital state. the essentially are of into.and finally. which belong to that very frequent sequel of this are same as . crackle.as it is a the of their quent peculiarlyfre- symptoms of the quence typhus (typhoid?).from aneurisms.more rarelyof a tumor in the pleuralsac.and.from a number of the vesicles. after birth. by impeding ply supof the Collapse lung. are abounding they become " The alterations less to half or below dark-blue view a scribed circum- the whole the level of color. spots the of the abdominal the in ANATOMICAL lobe development spine.

softly and of very life. cyanosis. but expel and the blood.and kidneys. but merely whines the and becomes it even nose cold. Finally grows it usuallyperishesin the first few days and the lips livid or lead-color. and cannot freely.more symptoms of rarely. dry. too alone. into often converted a mass. We cases.and warranted without appear in resonance in and extensive the course of of symptoms closure poisoning from of the collapse not of sufficient of ficient insufof many air-vesicles.cool.moist. the sions. AND those essentially are ization of the lung is The " congenitalatelectasis breathing and often been have of symptoms of insufficient blood. as rarelyare very large. resembling a In the highestgrade of all. pale. spinalcolumn. of compression produce compression. The child breathes quickly.that breathing and the littlebronchial these we find only deadened tubes. In like manner plied little receives the blood. in lobes side of the to of the sequence con- lungs. When collapseof the lung bronchitis of little children.is remarkably drowsy. uncompressed capillaries by and those diseases which magnitude frequentlyarises collapseof presents a symmetricaldulness of the all the if we an diagnosticating acquiredatelectasis. is not entirely compression the of forms has pressure not sufficed to vesicles and left the air has blood-vessels the overcome red.liver.which is supbrain. bronchitis. of the chest.PARENCHYMA THE OF DISEASES 132 disease. does not cry as it and suck whimpers. commonly with convulin demonstratingby percussion succeed can fourth with the thoracic the wall. condition of the parenchyma.subsequent distention of the veins of the greater circulation. comare accompanied by derangement of the circulation similar to have described that which we as attending emphysema. leathery. It is but that seldom that solidified lung we third and much less lies in contact with week. full the bronchi. gray.it cannot. If. the vessels also are compressed. in accompanies capillary many with have seen. distention. which.not until the and general paralysis. however. pressed. THE in fully enlarge more creased Compression of the lung of slightergrade presents an inChapter X. hypertrophy of the rightheart.catarrhal pneumonia. The symptoms also are where the pulmonary vessels of imperfect respiration.then. should. be diagnosticated points of atelectasis the latter disease.the collapsedspots are the percussion-sound dull. tough leaden. It most of very exhibit may carbonic-acid should symptoms are children .and a condensed In the more intense void of air. condensed The SYMPTOMS COURSE. peaked. capillary a It is difficult to discriminate on between both each the lower in symptoms make measles. and of incomplete decarbon- described.the lung appears bloodless. OF which upon shall we LUNG.venous engorgement of the the left heart. extent over a wide Generally speaking. hence we call it carnified. piece of muscle. in treatingof certainty. blood. gray. dilatation. densityand consistence.

oxymel ipecac and they do etc. In pulse becomes severe compression of the lung.the complexion pale. child shows soles of their Finally. of wine not of be newly-bornchildren not the accord. force them if to cry periodically even sleeptoo long and continuously.the urine scanty.the the thoracic the space.Should from be .if we reflect that bones deformed by rachitis after the retarded in their growth. nourishment of a few to become its nurse . suf- of the uncompressed portion.see that milk the and.apply a then. This fact is easilyaccounted for.do cry of their they do spoon. perhaps. irregularity from dyspnoea or of cyanosisuntil the period of puberty.catarrh. let it sleepin a being if the they cradle. give them made to should an cry there emetic of the still remain respiration fect. have been the and these deformity of not.and an for the dimensions of formed body and of the mass of blood belonging to it. have become They seem we very short of this respiratory and of breath. of accumulation any that care that their mouths properly.and usuallydie earlyin consequence come circulatory derangement. hyperaemia. If from the drops not cool. of a the disease. the sufferers usually die of dropsy. considerably venesection.but rather receive best. to one lung alone. imperfrom the time time in child to a warm bath. Compression of a large section of a lung has an important influence she the upon the blood the from in that threatens from rightheart is lung the In The lower the the same deformed and the lung the of parts may even lung be thus when narrowed pressed com- call for part a mand de- arisingof and produce danger persons. of the the remainder TREATMENT.and oedema breathe It is a curious fact that humpbacked without can persons of the and show do not evince no circulation.OF COLLAPSE THE LUNG. even are originaldisease has become of spmptoms Where extinct. in the sure presoften greatest danger peritoneum.have caused may rest of the body any in the grow mal nor- chest of the insufficient for those vertebrae crookedness if the development arise between child. difficulty. and mucus bronchi. of principalseat the manner. Deand complexion with which persons then acquirethe appearance familiar in the emphysematous.the uncompressed lung. the of oedema effusions upper be in the increased. though sufficient for the lungs of adult.is and chest .a disproporwhich. but in the room tion must thorax of its establishment parts at the time loss of the being retarded.give a tendency in the arms feet. occasionally. by blood of the distribution their of fer spot compressed.and be Take " freed in the mucus squills. by brushing the own take the mother's breast.placing Do not let such children cold douche to the breast with a clyster-pipe. which Should in the is contracted thorax directed (collateral fluxion) may lobes tapping. 133 small.etc. the hypersemia way If all uncompressed parts. although it is exceptionalfor them also to beconsumptive.

or Caution OF THE PARENCHYMA and method OF LUNG. THE ETIOLOGY. When the action out withby symptoms of pulmonary hyperaemia.air will reenter the collapsedvesicles.. which delirious persons. if most recom* to the succeed we in overcoming the obstruction. use great mental give rise to dangerous hyperaemia of the lung. the latter that both I. and intrusted morning. organs Fhe in the rude a nurse. and the like. as overgrown of stimulants. retarded efflux from the contents we are interested. But even cardiac erythism. rage. CHAPTER HYPER^EMIA LUNG THE OF V. violent bodily efforts. PULMONARY " kinds active " of name the more of " the disease.when capillary treatment mended for obstruction of the finer bronchial In twigs. " " words two proposed the (Wallung). in whose capillaries. an the sole In most cause to of of the death. in cases. heart. of Compression of the lung requires mainly a judicioustreatment the principal of the more ing threatendisease. or patientswith delirium tremens. Such a case lung and pulmonary their the symptoms greater or are difficult of planation.is observed " often We see of the heart is increased. ment. as to their bed. ex- systemiccirculation . are found lips. OF LUNG. the of blood" "rush stagnationof since desirable. Fluxion. persons young the moderate in whom the most subjects.and symptomatic treatment of the derangement circulation. unfortunately. Fluxion. uncommonly not are THE rewarded by prising sur- success. accelerated afflux .with considerable 1. with bloody foam upon intense hypersemia of autopsy.as it is upon especially function and nutrition determination of of blood organs to the depend.and where there is no overspecialpredisposition. etc. cases. having been accompanied brutallystrapped iead the next reveals. lungs. or For the the " be must (EDEMA regarded Virchow first. use produce palpitation of the increase in the force of its impulse.. The of has been as acquiredatelectasis is the same the latter disease has led bronchitis. indeed. exciteimmoderate of spirits.These names " blood has of as active and passivedo which physiological processes give rise to quite not the two an increased. particularly at narrow-chested. scandalous as as they are of frequentrecurrence. "fluxion" passive form are and HYPOSTASIS lung of the Hyperaemia " "".upon oedema.DISEASES mother.slightbodily efforts..while he calls the (Blutstockung). correspond to forms passive. depends more upon stagnationupon an impeded. trifling causes. may There are togetherwith increased and accelerated action of the heart. the period of puberty.

and of the poor success of tracheotomy. alveoli glassor or have alreadystated produces determination the boot diminished with have Junod to pressure occluded seen. fuller the 135 produce hyperaemia. pneu- effusion. of the are glottis main reason of causes which that blood a rarefaction to the fluxion lungs. time. hyperaemia.and. pleuritic Finally. and be upon is closed condition lung produced by direct irritation. passive hypercemia. Stagnation of the blood. where the latter are or compressed or develop in portions of the lung where course.the inhalacold upon air mingled with matter.etc.the are veins. yet which little noticed. The the action transitory of hot very Here to fluxion exposed to cold for laid upon tuberculosis 3. and efflux from exists in the in whether lungs. The fluxion. less resistance the skin quite similar. it must is free in to impediment.as alreadyalluded stasis in oppose too. which would otherwise In the most simple manner be and unintelligible. compression.when for the consecutive of the The air in the cuppingsuspended a air-cells of its a child chest. tion relaxa- to the actingupon causes.or 2.justas to the the skin. of the capillaries it expands subjected. the of the and arteries.as is proved by from sequelto physiological is a the and it is appreciabledilatation of the surrounding unobstructed vessels. as if a hot poulticeor in the same connective which and way.occur and abnormal it in pressure is thus to the relaxed.but far too treatingof emphysema and pulmonary tion in all cases of obstruction of the pulmonary circulaits capillaries.A a skin. Such collateral fluxion ligationof an arterial trunk. diseases of the lung.as bronchial we catarrh and in croup.is. from we .occurs from a a to The softeningof of the lungs. tion the pulmonary tissue.or comprehension. giving rise to and circulation. it accounts for the action of venesection in monia.especially and may traced to be tissue. fluxions. neoplasticgrowths of the to is unknown chronic The it. seems of of condition of the increase alone attempt not normal degree chest of fluxion instances do the the natural even heart-action increased we pulmonary artery when "y the creased the afflux is in- another Whether The lessened. be the of any acquaintedwith sufficiently not tension is the is accelerated in proportionas capillaries circulation is quickened without any actual blood quantityof of distended more much so not the . the of of the to ble capawe are pulmonary in the blood us. walls their of organs. capillary of the been of air.produce reddens if it sinapism had the accompany mation for- tubercles. to the symptomatology of most quite indispensable it explainssymptoms. A have we manner short relaxation third form of same destroyed.we 4. are easier irritating bedded imthe tissue in which the capillaries are walls. The less full their walls. THE OF HYFEILEMJ.so much does of the heart action augmented mere LUNG. pulmonary oedema which TI. of the circulation as say.

THE form.or pyaemia. or the formation of bed-sores. When the heart's action weakened. the have obstruction become. such as typhus. at the While with contracts evidences see to the of the evacuation such energy. Stagnation. Enfeebled forms hyperaemia of intense valvular disease be Both valve. and its the and cavities. walls is equal to that of. are the from of but fevers. though evince greater a the fluxion in current venous LUNG. while the blood degree of the arteries into from Hence of see we than capillaries the to their in which cases walls the with capillaries blood to them. takes place in abnormally are continue arteries OF PARENCHYMA the mechanical illogically separate the THE OF DISEASES 136 when does. hypertrophiedlung depends of the indurated dilated 2.we soon hyperaemiabegins to form impediment the body. effect an gorgement en- is of the obstacle its yet when of gravitation.are constantly accompanied by of the pulmonary capillaries. supply from the from the chief of the mitral whether the hence the of in the the the heart We of cause Whether blood which are know upon have we the evacuation of be results in heart impeded heart imperfectevacuation efflux of blood diminished is obstructed. proportion Here the as flow out- thus asthenic frequent. From mitral of the sufficience the accompanied by that the brown rupture of found the to be auricle the the capillaries. A healthy he in bed for months without the development of this form person may of hyperaemia (hypostasis) in the capillaries of the back.in which incomplete.or the different phases of pulmonary hypostasiswhich the almost constant are accompaniment of a typhus of long duration. We have learned that swellingand succulence of the mucous brane.or the systoleinto the the pulmonary vein. action of opening lung. memand constant increase result of and more alteration of hyperaemia of a mucous the follicular membrane are secretion. and blind until the until the ruptured.or most occurs typically the of engorgement comes be- pulmonary capillaries. even convey walls their then even all unduly difficulty. . the artery.) that stagnationresults in a far greater dilatation than tension filled and from flows since scantilyfilled themsdves. as there is much which capillaries.pulmonary veins Here the stretched.puerperal fever. most color left auriculo-ventricular the of contraction in veins. gravityfurnishes a new in dependent portionsof capillaries is easilyovercome when the heart action and is depressed. " 1. either auricle. dependent places. (Blood continues to flow capillary the capillaries after the heart has ceased to contract. retarded. similar the processes . as the blood continues them to enter appendicesto the arteries.and capillaries of of in* must the arteries is not contractions disease and regurgitatedduring impede the emptying of process give rise to overcharge of the capillaries. of it were. walls.or tension of the capillary delicate membrane no can longer support such a pressure.

relaxed. Here. pass through the now porous this condition hypostaticpneumonia. lung.it must which membrane have no mucous secretion from the vesicles. e. thus scarcelygives any the lung is of appearance solidified. the in bronchi.foamy liquidis contained in the bronchi.and to the tissue of the lung. If not recent. interstitialtissue and the alveolar walls condensed swollen that the much so are parenchyma The cellular indication of its structure. If cedema collapsewhen have we developed open the in the chest. While. all in THE OF HYPERJ2MIA of cases severe and moist more LUNG. the term or If the in cells differs structureless cell-wall is that the and air-cells. a bloody. from properly.being liquidand serous. as in other whenever is of pulmonary vesicles. takes placesimply the wall of the fibrin. The blood tissue is succulent. lung. ered cov- dropsicalcrasis their hyperaemia it which has has but of the consequence of of the capillaries upon pulmonary under slightpressure. " When the hyperaemia is moderate. of the contents organs. 137 hyperaemia.crackles but little. the of the (Edema effusion an with is combined lung. too.i. over When the parenchyma and of longer duration greater intensity. little albumen in solution. there is a double reason we engorgement understand serum free a interstitial where cases all cases.which is poured into the bronchial secretion. very filters out developed.but all portionsof the serum In of this form of dilute albumen the blood.y into and bear we that be evident merely by imperfectpavement epithelium.and has nothing in common with mation inflam- proper. presents a certain similarity spleen. . in other organs.the transudation. in that in this that the into surface such fullyin treatingof Bright'sdisease.however. be very different from bronchial mucus. of a solution not merely a transudation of place. succulent. and its vessels are filledto bursting.and is therefore said to be splenified. proper. but the secretion. a process which from stagnationof the blood. ANATOMICAL APPEARANCES. however.and hence it is easy to become form the capillaries extremelyoverfilled. bloated. the walls is takes undergo an excessive pressure. vesicles. bluish red or blackish red.take the placein swell the walls alveoli become up. does is tense to the touch.or of increased their walls. it seems swollen. applied to oedema term infiltration of the lung finer pressure into capillaries and the whenever a If oedema As vascular tissue of the serum subjectmore cedema. blood in in the upon the into serum only used effusion an hyperaemia.it is called hypostatic for the have learned. arise from a hypostatichyperaemia. is not.but. The looks dark.even and we call vessels.dark red in color. mind that there more or. We of the shah1 consider this hypostatichyperaemia. flowing freely the cut surface . and at all in the none the must but are few follicles even mucous is oedema the tissues.

the this " chest a fulness " .dry cough is added is sometimes as we are violent which must heart. other or one side. complain of shortness palpitation.the circulation is no blood of the change have us. hyperaemia of the lungs.amounting to splenificacomplete cedema.DISEASES 138 OF PARENCHYMA THE OF LUNG.or a more or less the blood.sometimes enormous color.at of of the the surface with mixed with generaldropsy. no or There is abnormities.sometimes here the apt that " forerunner habitual of narrow- have which state is respiration Those air. AND lungs presents we coagula of fibrin. intense conditions same the from cut we bubbles. set facilitate and promote capacityof the air-vesicle.the parenchyma has and the lung retains the impression of the finger lost its elasticity.with scattered streaks of shows no Physical examination pain in the chest. if it be one of hyperaemia." we of An so obstacle much chest" as as may often The and well spoken. in the pathogeny. uniformlyoccupying the posterior cases . they very correctly they experience in to short. over Here the serum of hypostasiswe hyperaamia. after longer duration. of blood to the consumption. has find tion. moderate The symptoms. A " the so-called hypostatic degree of fluxion to the dilated capillaries present a greater and with this acceleration accelerated. inhale The lungs cannot of whom youths and girls.flows been tains liquidhardly con- largerbronchi. though perhaps not to believe.except a expelled all the air from the less with or air-cells have few any more liquidis full of air. In ously copi- entirelyfilled up cases.and not In other air.while the other lung may this side alone. in the lung brisk. .frothy. however. bubbles. if the indistinct granularaspect.mixed red a still contain and serum spots.mentioned excessive action of the be regarded as consequent upon life with unexpected sudthreatens and aiises rapidly.it may a This cut. chested call the " sensation A stricture.the hypostasisis often confined to continuallyupon be very extensive. capillary the swellingof the cell-walls from and augmented transudation may diminish the thus up.nay.and may of the air-vesicles at the condensed be healthy. If the contents portions be evacuated of the parenchyma cannot completely by pressure. appear If the patienthave lain portion of the lungs next the vertebrae.in their attacks of breath. an quitepale.if the If quantityof liquid.but. the vesicles. tense inbe consequent upon an distinctly.if the liquidwhich flows out section shows an clouded be little by before pneumonia SYMPTOMS to the surface the COTTKSE.If the cedema longerand more lung is colored red. air. the the enlargement of the dense fluxion is more net considerable. THE pit on pressure .the cedematous it does the not of symptoms into the cedematous others clear. We to determination blood. When. far more condition rarelya frothyexpectoration.as more grows both cumstances cir- oxygenation.

and which most generallyproduce pulmonary and the be of in the chapter. coughing-fits. pneumothorax. circulation is im- their supply of air. into their anastomoses as so capillaries the mucous membrane and contraction of extend not to produce the tube. and mucous accompanied by violent of the cancer tuberculosis.OF HYPERJEMIA den such Hence ness. announce tating The symptoms of acute fluxion. to be scarcely cases shortness The schlagfluss). more an itself acute The changes the scene. surcharge of the blood 139 pulmonary apoplexy (JJungenof breath quicklyincreases to a serious extent The hurried and counted.the muscles of acid stilland drowsy.. the called are breathing grows feelingof fulness and compression causes of choking . THE of this with with the form fear mouth with arteries. serous Coarse. of the the Here a large part of dyspnoea depends upon the overfilling in the portionsof the lung unand affected swelling of the vesicles. the threateningsuffocative effusion. the be unabated. radial pulse and makes hyperaemia.are Collateral more blood If the is reduced. interpreting when Passive hyperaemia (Blut-stauung). every cough fills the bloody expectoration.the of serum. the symptoms. or. The hyperasmia to which lung. etc. examina- post-mortem this form of hyperaemia. and collateral oedema. contents. in the descripa grand tion lungs and which of shall present we pneumonia.cannot restless patientbecomes rid the tubes of their bronchi.frothy. LUNG. by venesection. The heart beats the betray the carotids The filled vesicles. The felt tension follows which oedema. If shall not we we when arose the obtain better peded. death of air . capillaries Without this complication. to speak bronchial haemorrhage. audible even the approaching end.soon can carbonic a visibly.palsiedwith the in the trachea. usuallysuffer from a very distressingshortness of breath.if to examine fail to find patientsdie in the first stages of air has penetratedinto the pleural die of the records evidence of collateral of hyperaemia and tions. of the mitral. The no a copious.give rise.brought on by the inhalation of irriof irritation of the larynx modified by the coexistence gases. are bronchial and are membrane. the other muscles. if they Patients with insulncience and contraction even although it have from no is but bronchial the alveolar tumefaction of little appreciatedin the engorgement does and when catarrh. face paler. and admit tion sensa- face is reddened.the collateral fluxion completelydisappears^ although the chief When or shortlyafter pneumonia or pleuritis. pleuritis. by the inflammation. even unaccompanied by than fluxion to the lung. creates greater dyspnoea pulmonary oedema. compressed the lung. moist rdles. This is easilyaccounted for. . feature lessened dyspnoea often continues disease vesicles could pressure next forms condition such no unaffected the treated to the fluxion properly. aggravated by the slightestmovement nevertheless . they sac.

the we arise when In other vesicles Bronchial are seldom the cases hear serous we filled up breathingis only to Breathing takes place when the such moist no heard takes of the of the vesicles sound respiratory by cedema. one.scanty nputum of pneumonia. the inadequate and final death of the patient.we engorgement of the lung with hypostasisor with its sequelae. take place more respiration. liquidtransparent. It would be the symptoms cedema the of occurs this normal and alveolar hyperaemia one of its most necessary the and hyperaemiaand as grade of of the unnatural result artificial to make of cedema.the asthenic fever.in the of typhus or the heart.from becomes from swelling so severe dyspnoea. should sputa be ejectedmore less or have to do with an obstructive tinged with blood. occurrence rdle. has taken place. which is formed in viscid fluid. do noi .that is to say.profuse. the become now sion Effu- A inadequate. Almost where universally has has produced death.as from cedema. incom- should of the parenchyma of percussion indicate a condensation the lung.whether should become respiration it be of symptom a shallow and plete. that is. the PARENCHYMA OF LUNG. of of course an pyaemia. can * membrane mucous Bronchial which bronchi. the symptoms of pulmonary apoplexy and suffocative have described. respiration. be easily sounds rattling transudation hear A and in vesicles. important symptoms. The characteristic sputa second point for diagnosis. circular in the former of cause to in retarded dyspnoea and added THE OF we in the latter but Intense dyspnce aprevails. Such liquidsecretion is seldom or never cous discharged from the bronchial muand the of membrane. is very properlyregarded as of serious omen. great number of those have who disease of the heart. graduallyin congestionand acute of disease cases If. a rdle dry may be distinguishedfrom moist rattle which a a one. of the heart die of acute passive for the sudden oedema. Auscultation also give a gives information as to the of oedema. expectoration mixed with less if it or sputum. In other cases the symptoms of effusion of serum into the pulmonary vesicles.which never walls alone. without discoverable cause increase in the impediment to the circulation. their walls . serum been found in the air- vesicles.DISEASES 140 when tion is a reflect that we much as double all which effusion. supplant the viscid.* serum.are often suddenly and unexpectedly constant shortness into the air-vesicles now of breath exists of disease beside swellingof has merely impeded hitherto. In the secretion place through the medium bronchial as occur those fillsup the spots at which enter. If a a distinction between hyperaemia be intense.filled rare with where no in air instances. THE the passivecongestion(Blut-stauung) in fluxion as it is that accelerated. near the spinalcolumn.from of a thin liquid.in the We infer that first place. more blood.

all the air have been distinctly become the lung have of the air-cells by the oedema. It may. if the apt also. if we keep in Hyperaemia view the symptoms just described.occurring in the course may fluxion lead of a pneumonia and tion obstruc- worst quences. jontain any iensed spot.moist rattles. finally. cedema of the lung. change from supervened upon undergoes that oedema indicates ilone. conse- life of the frequentlybetween most bedside and to the unfrequentlythreaten not occurs two the at the the collateral and pleurisy.are easilydistinguishedfrom other diseases of the lung. sound. which mistakes to study)to make a distinction passive hyperaemia. If these upon for grounds effusions cedema their as the in the of cavities furnishes serous panies dyspnoea which accoma tympanitic sputa.in cases patientdelirious. serous percussion. general dropsy. " air. respiration(of the treatingof pneumonia). and are but lightlystretched over is sometimes tympanitic.finally. The confusion fluxion. sound The no has the percussionwhen upon hyperaemia hyperaemia. If.which Percussion.between and active between in the appear may . and driven out sound air. and patient. of venesection to prescribewine.upon the diminution patient. sequelae. camphor. and In treatingof croupous fullyinto detail pneumonia we shall go more the subjectof pulmonary fluxion and engorgement. of lung which dropsicalswelling of the cedema of we warranted are in ing regard- cause. conmoie . and instead commencing paralysis musk. upon pulmonary of the of interpretation Should symptoms.as with and appear this with to do form. through oedema. PROGNOSIS. of passivepulmonary so frequentlynotice the occurrence give rise.to think of passivehyperaemia are the of the heart. filled up requisitefor bronchial fullywhile at the same time. the condition. that we pulse be small.and the of the pulse. however. placesfor flat. symptoms of upon tion the utmost importance in that disease. the by the secretion.and demanding especialconsidera- and from of obstruction in its treatment. supervene. upon dry tongue. upon the delirium. the heart-action and asthenic fever enfeebled to which passive hyperaemia. THE OF HYPEILEMIA ticity lost their elas- alveolar walls have their contents. is almost and of bronchi. be very difficult (easy as the DIAGNOSIS. matter " of the confusion and. its With arises of condensation every dull percussionbecomes the lung.sometimes 141 LUNG.the of void other in the characteristic or with cellular tissue and subcutaneous the best these or dull we form to that regard.and of recent pneumonia.but are not The prognosis of hyperaemia where. which It is easy originof to see which always wanting in lead that we of cedema the shall pulmonary to the latter speak oedema. moreover.the appearance in manifestations have hypostasis.however. We the final exhaustion of the hyperaemia and cedema of the lung.

valve. Prognosis of of the course of description the to the disease. and. heart of the the disease.in above recommended The the the whey or grape brilliant from service cure. of to be ed. are As " lung. in venesection better order from Wiirtemberg to prevent large a excessive vineyards of the grape-cure. above grape lake of Geneva. order often coincides with the lungs all. incipient In the collateral form the of I have grapes. stage of home and comforts in quiet On the other hand.and and other and moderate forbid Strictly drink or In like it is taken. With regard action In the to is demanded very home. water. purge set so main be cannot mitral the more like manner as urgently are hi fine sweet indicatio fluxion grapes. present my seen car a severe . action the allowed be to the bodily exertion. and do not let the patientinhale very cold air. Acidulated to be recomdrinks.if they dc excitingcauses. spirits.at violent increased to the demanded.arisingfrom inapplicableto to the lis causa- In obstruction of use becomes cause indicatio In disease met. on the cure all. of cases to phthisis. these cures which instances under discussion. and as. lemonade. retard- course stimulants in heart.* do not hastens end of which are merely purge.and less serious the adventitious from the various forms are which of causes amenable more derived from tions. productionsin the lung. Meran. Let dusty placesbe avoided. and other placeswith a mild clime. heart of the of use to cool tea.so food The do until the heart's action palliative a weaker asthenic * try the pulmonary hypersemia causalis contraction as of treatment the indicatio opening to may them remove tuberculosis. strongly as to be in after eating three from morbi. obstruc- than to treatment usuallydifficult are be can LUNG.the cases. somewhat inexorablyforbid dancing manner Shield exercise. in the incorrectlybe regarded indicated. time same fore be- patient.1 TREATMENT is Indicatio " of frequent cause a fluxion is often the to such condition of forerunner all food order coffee. in youthfulsubjects. heart. are generallyof character. the and riding. regimen and treatment the of palpitation habitual causalis. are milk and whey treatment is especially The suitable for such of Dttrkheim. become has in of the is digitalis lung.DISEASES 142 OF PARENCHYMA THE proceed Fluxions. all hot and smoky rooms Besides these the lung is psychicalexcitement. to which the grow four time bold the in pounds the of an ing nourish- and positionof patientswith to time. enjoiningregular from all possible.where sweet grapes. It the cultivated. " " advanced in an patients.accompanied by hyperaemiaof the lung. and all to be protected from injury. its lung depends essentially upon not THE OF allay. a settling diarrhoea most not the of of the much fever. suitable a tuberculosis.as far as precautionarymeasures. cream-of-tartar mended.the threateninghypostasisto be changed of the blood.

too. during the even freely. by increasingthe danger disease main occur is also lung deeply. the the of arteries the hyperaemicparts transudation the less full. like that of emphysematous of the disease.the bloody foam The and here is forces two upon fulness : the first. cases. how- to the cases importance to restrict blood-letting oi the most urgent necessity. in by far the greater more cases. the danger look rather so case. If. become contractions. Venesection. too. Persons with disease of the heart do not bear repeatedvenesection well . their blood. of pneumonia. it threatens Collateral fluxion.immediate of the the led without with small the be if.or recent more reduced.is reasons. unfavorable an astrayby pulse. and of oedema danger threaten to life may in the demand a the relief consequent upon expectationwhich has been entertained.the pressure. and ceases or has venesection let blood itselfbe threatened pay open us which of serum.OF HYPEfLEMlA as of the the volume blood has (asit depends in the arteries able patientsoften become operation. it as a reason new is collateral surelycan fluxion rely we success.when requires venesection. let as to pneumothorax. but . recent if the for bleeding. called pulmolike these. result The threateninglife. the more say. As SOOD the pressure diminishes lessened. the original mass of liquidfrom the tissues and from the intestines . life. too..however. the cardiac LUNG. are capillaries had alreadyset in. reestablished by absorption is soon readers it thinner . Since. threatening. in that rapidity.also. the more easy The of intense serous. iiac action THE expectoratingvanishes. was here. the the heart). we effect exhaustion from these and often moist dyspnoea. by diminishing the volume of the blood.second. audithen imminent. which have been In cases nary the danger arises with such lightning apoplexy (Jjungenschlagfluss)^ they were physicianusuallyarrives too late. blood. and for the same in fibrin and albumen. so upon much the much upon the ment impoverish- strikinginstantaneous that is to necessity.does or see patientbreathe the the yet flowing from number of the so results. and has great tendency to form serous poor transudations.a etc. course the and recognition.while the blood is freelyand more vein. from life may be rescued the greatest danger by aid of the physician. after long duration persons.in the become sputa regard to no not . the of not the of blood. In the other forms of hyperaemia of the lung which we have de- . of disease course diminution of the venesection In these of the volume usuallysatisfies ever. but the tendency to of the lung is aggravated in and even to cedema dropsicaltransudation it is of the utmost this way.however. more of energy the cavities of of to breathe which 143 astonishing.the force of the heart be diminished. unless life or pleuritis.thereby. or rdle become is ble. upon Should symptoms heart.

no causes limits. HEMORRHAGES In mucous the FROM majorityof membrane is almost alluded cases is the THE in which source of the RESPIRATORY blood is coughed bleeding. of the treatment to. camphor.and to intense heart. is scribed. emetic of sulphateof copper if the patientcough.strong leads at last also fever.an " emetic may main be disease. In these cases be.as they most As danger.a haemorrhage of the pulmonary tissue cona nd which destruction.but. up. the of far most cause frequent haemoptysisand pneumorrhagia. procedures just spoken of.but here. dischargeof sputa be arrested. the latter class of in almost scene cases are all tedious by and far the ing exhaust- fierywines. cedema of the lung alreadyexplained. diseases. an . organs.venesection PARENCHYMA TEE OF DISEASES 144 THE LUNG. by fined Hcemorrhagic infarction.with tartar. and though oedema every thing may the of the as our depressed heart.but only when to aid been has not lead the to in extinguished. the bronchial bronchial rhage haemor- always the attendant or forerunner of disease of the lung. which?from its great exucollateral fluxion in the course dation.as a very efficient mode of treatingcedema of the lung. as a symptom (Edema the " gr. Especiallyis this the case how great it hyperaemia occurring in asthenic fevers. give an even hope of saving life ipecacuanha. for reasons may lacks and the the cough palsiedbronchial muscles as as soon energy. 2. discussed been to enfeebled contractions above.no matter threaten life. of general dropsy. are much more frequentlyindicated for hyperaemia of the lung than is blood-letting. Traube recommends the use of acetate of the application and of a very large blister to j every hour chest. monary Pulwithin narrow 3. of distinguishingbetween The and approaching heart-palsy difficulty of pneumonia. requirethe employment of emetics. musk.as ORGANS. Blood-lettingweakens energy of the heart with and the augments close the frequent. Under the head of haemorrhage from the respiratory ingly. in the circumstances indicated.emetic.demands of the lung. has of the soups.OF absolutelyhurtful.too. accordshall discuss : 1. Bronchial we haemorrhage (broncho-haemorrahie). abundant haemorrhage of the pulmonary apoplexy proper. contents Should expelling the serous should the rdles in the chest be increased. and from alone can this means the the pulmonary veins. have we preferredto treat of this subjectsimultaneouslywith that ol haemorrhage from the pulmonary substance. supporting by energy depends upon blood flow away its cavities be emptied. addition In cease the or the of the bronchi.

we as yet have is usually limited to absolutelyno explanationof the disorder. are an caused tissue.and sad this not results.often does not assume always persists. the bronchial erosions seldom of the ulceration or the of larger blood-vessels extremely rare. and rupture of in tba result of perverted in the first occur of violent irritation of cases disorder circulatory the air- attendingorganic disease the first of these heart. Haemorrhage from cavities and bleeding arisingfrom the opening aneurism into the air-passages to be treated of hereafter. In such cases. that nearly state of the haemorrhages are mainly owing to a morbid walls to a haemorrhagic diathesis * of the bronchial mucous of the vessels. in fact. apparentlyin bloomhealth. and which " " followed * cular We by such employ walls. vas- the a* . and struction by rupture of some causingdeof an apoplectic of the lung. indiathesis. of OHAPTEE VI. to the due they are been too importance.to be ejectedthence by haemoptysisor bronchorrhagiaproper.so that his vascular system is considerably depleted. are air-passages. too.and of vigorousconstitution. are sloughing to and membrane mucous the of Wounds " HAEMORRHAGE. great practical The The fact.which latter condition. haemorrhages Capillary of traumatic origin. until after the patient has lost a good deal of blood.or due As a rule. BRONCHIAL 145 of its large vessels. with the formation cavity.but by the bronchorrhagiaare not fact. A bronchial haemorrhage to a haemorrhagic tendency to abundant with 1. and do not is of depend upon over-filling all bronchial vascular membrane only " " that attacks of truth of this is shown haemoptysis and hyperaemia.or else by a morbid The nutrition. delicacyof their walls.a tion.in which bronchi.in bronchial of causes. haemorrhages which capillary trifling proceeds from stage of acute passages. caused capillaries. general term a morbid merely condition to of latter may nutritive to thus sometimes so modify the and impair their resisting power. BRONCHIAL ETIOLOGY. of the a tenderness although walls we of the admit that of the blood-vessels haemorrhagic diathesis. Is met in rare stances.haemorrhage either by over-disten- membrane. has little appreciatedhitherto.HAEMORRHAGE.not usually that the spitting of blood almost preceded by bronchial acter obstinate charan and.which the capillaries of the bronchial mucous is often membranes. 11 to signifya state lead morbid blood the to . accordingto the above definition ing occurringunexpectedly in young persons.proceed from the the catarrh. while in of of the most of blood are large quantities poured into the haemoirhages.

to a kindred of the nutritive principle. delicate health. centres by compression of vessels. Such an hypothesis. redden nose and the ples.coalescent masses of tubercle and of inflammation. rapidlygrown corresponding development of the various organs of the body.and why haemorrhage scarcely seat occurs brain.and having patients frequentlyhave Such constitution. cause become tissues excessive distention more easy of and attenuation of their walls. the tendency to bleed when the lungs become does not cease ever into the in the the organs.have often bled at the suffered from rickets.and cause beequallyliable to tuberculosis. having been immoderately expended during the maladies of childhood. Epi aimatos katharsis biased the judgment of physicians as ano.between in young of LUNG. Much OF fifteen and weakness from have nose. give rise to fluxionaryand obstructive hyper is favored. has proved normal insufficient to maintain nutrition of the capillary walls. haemoptysisas a sure Many physicians sign of in- . unusuallydelicate seems blue veins and bronchi THE OF find similar frequentlywe more haemorrhage from of PARENCHYMA THE One be may might and transparent. aemia.or great loss of blood. having lost then. traced almost the over be their cheeks ridge of the tempted attribute to easily. or scrofula.parents by consumption. tem- the remarkable quence fre- haemorrhage in persons of this type to a deficience of vital material. They in infancy. and their skin even long bones are thin. which. marked been orphans an early age.justas we the accustomed ascribe of to are occurrence spontaneous bleeding after of bronchial severe tedious illness. their chest narrow. exhaustion does not in the nose. and suppuration. in partlybecause depositof tubercle and chronic inflammation the pulmonary tissues and the bronchial membranes to mucous which imbedded in the relaxed are relaxed. any Then* of the twenty-fiveyears.by which rupture of the capillaries and a belief in of Laennec views Prejudicein favor of the narrow the ancient emeto phthoe Jcai toil Hippocratic theorem. or into other of patientsof this class. source of however. The haemorrhage in all stages of these diseases arises frequenceof abundant partlybecause individuals who are liable to such bronchial bleeding are and to consumption of the lungs.whereby they come be- rupture.so that the capillaries their undue suffer (now no longer capableof resisting dilatation) and affected. explainwhy afterward haemorrhage should first be bronchi.DISEASES 14:6 2. Finally. have seriously puou bronchial the relation between and to pulmonary tuberculosis. have without and time acquiring at the same tall. is a great predisposition 3.and by the rapidityof the growth. tendency to profuse capillary the ages people. bleeding and have do given not rise to hesitate to extravagant accept a and brisk erroneous ideas. There to capillary haemorrhage from the bronchi in persons sufferingfrom tuberculosis and consumption.

form in the manifested are attacked is patient ranted. although arisen.or individuals of lungs who that they tiate substan- repeatedlyfailed of any have other died to tive destruc- suddenly of pneumorrhagia. when.until he the individual In of with tubercles in which manner a occurrence the of disease of the objective. while in enjoyment of apparent health. to which.and by no means the tubecuular the of of commencement seat deposit. Such the patient.at bleeding. i s because based the erroneous though logical. of the theories most modern question. or cipient. there cases As consumption tubercular consumption. According to Laennetfs physiciansadhere without view. or other the sign of pulmonary disorder. dyspnoea. we may has formed either simultaneously deposit with the the Such of or to prior occurrence bleeding. are exceptional.they confidentlyassume caused in the either symptoms. regain their health and indeed completely. rule.as where no precede discoverable the disease of initial mediately signsof consumption follow imattack of haemoptysisis also stronglyin contradiction an upon of Xaennec. is shown. moreover. by the that tokens no of the great majority of very disease has in which cases may bleeding has of its Cases the deposit undoubtedly lungs. sumption signs of con- earnestly protest against this opinion. That bronchial haemorrhage is by no means so rare an event. a first attack of haemoptysis preceded by either cough. altogetherunwar- suddenly by instances. collate the reports scattered through our literature and However. the lungs are free. I must in tuberculosis.however. erably by the tolgrave in which numerous cases or more persons. between such connection haemorrhage and the consumption must be denied absolutely.should age. ourselves I have pulmonary tubercle. of haemoptysis. fallacious.so that we do not often have an opportunityof examining their condition^ostfmortem.and been established of even HAEMORRHAGE. hypothupon upon that the confidently a tubercular . present have fraught latent so that or tubercle. of the correctness find post-mortem traces in the disorder shall we above of assure remarks.as and occur. subjectiveor after the the presence by lungs. haemorrhage. inflammatory processes and the process to the danger affected. Hence. often traces live to of That the advanced an tuberculosis extinct bronchial lung." argument. where there is no disease of the lungs. soon no lungs. nevertheless.BRONCHIAL. if we their compare the been not statements. It is true that such subjectsrarelydie of haemorrhage. after sufferingone attacks of pneumorrhagia. where the first symptoms of consumption follow is but close one kind the a present of " " assume haemoptysis or pneumorrhagia. in the and after death in their lungs. bronchial haemorrhage can never all genetic produce a depositof tubercle. by fit of haemorrhage.

and to the of which of of a form a bronchial of rhage haemor- contrary notwithstanding. anatomical and pathological processes These with common very such tissue pulmonary inflamed that effect is quite bronchi. Here both events spring from 2. is retained thrombus .that consequence both undergo a caseous metamorphosis.and by consumption. lungs always THE have perrallying. the course of a monia pneu- often rapidlygrows worse immediately afterward. health. a which. Bronchial oftener than is generallybelieved.I may observe that the bronchial haemorrhages which occur in established an and destruction The fact is that of case of the the serious consumption tissues. cause. and from tubercular of posit. thought accelerated the to the haemorrhage. haemorrhage occurs my in persons who who become never are consumptive not at the time of the bleeding. although. Finally. no and effect between the haemorrhage and the pulmonary disease. it being a common (but one which is rarelythe true one) that fresh tubercles have formed.coagulated blood surrounding parts vein but sense. common consumption bleeding may 3. rhage opinions regarding the relations between bronchial haemorand the pulmonary consumption differ in some respects from this subject.and of occurrence event. by others to have As are some.or in great as within coagulum tissues. Laennec bronchial a air-vesicles upon a of exuberant little thought but is the immediate the midst its stricter in after observation and who. a "galloping consumption. interpreted supposition .and so.148 DISEASES esis that OF and Unbiassed has hi taught me tuberculosis and ways. and thus also hasten haemoptysis in that the disease have caused chronic cause pneumonia the fatal termination." that such patientsscarcelyever succumb to a pulmonary few a the OF careful in the warning and often by pneumorrhagia ished of consumption PARENCHYMA THE subsequent decay.who. however. Copious bronchial haemorrhage frequentlyprecedesconsumption. pneumonia arisingfrom A (See below.) a source result in may is. haemorrhage. haemoptysis. when diately it immeconsumption assumes agree closelywith the type which follows a bronchial haemorrhage in an individual previouslyvigorous fatal in the course and healthy. it has been falsely as a rule. months of a phthisisflorida. de- without patients.have been attacked without and is that as they usuallydie of. or consumption as yet When. Bronchial to precede the development the of patient coosump .and proves of a few months. is generally admitted by physicians. the both same to source " from and a on predisposition part of bleeding. its irritating vascular bronchitis various clot the upon The arises LUNG. relation of cause there being. views I propose in the to state them prevailing briefly upon followingparagraphs: 1.

the mucous cases. swollen. however.there is extreme Where The of all organs.re- tents again. Tiibingen. unless in blood-clots. haemorrhage.be also found in the bronchi. broken-down bleeding is former commonly is most inflammation ascribed rhage after the haemor- a state of a fatty I have published a case degeneration.bearing a of the veins.HEMORRHAGE. In has found where cases in death ceased. The " of admixture expectoration occurring " in small the quantitiesof form of and is a very common quite traversingthe mass of The largeramount expectorationof a somewhat symptom. into the airlungs. BRONCHIAL 149 and haemorrhage leadingto chronic inflammation destruction of the lung.* Sometimes stain. in the course of established 4.1864.at pointswhere the blood has descended If the bronchi less reddened. is prevented. is never or less amount chronic of be to of time some whatever trace no place and. in which coagula.and In other pressure. which either pure sometimes or mingled with bloody mucus streaks " " the inhalation jpon * " Upon sumption. indeed. membrane causing " the of of course examination of Upon post-mortem died of bleeding from the bronchi. It sometimes. and more vesicles.the entire condischarged. of air from the air-cells filled with their bloody contents. and anaemia death has been caused by haemorrhage.by may destructive found the where i-arely. in the most strikingmanner.denser. appearances my entire process. ANATOMICAL who is disease accelerate the fatal issue of the disease.escape remain inflated when the lungs remain the chest is opened. has dark- laxed.the air-passages are less extensively and completely filled up with masses of bleeds upon and takes inflammation. as of nature The mechanical a of source live ulcer-a- or lesion.from yet latent. When consumption." the of acrid vapors. either the lungs " signs are found which. as haemorrhage APPEARANCES.*were found in the to old thrombosis perfectresemblance bronchi. it chronic more clotted red have or blood. place during the the blood of effusion membrane mucous into its bleeding is to be found never the of uniform a it is tissues. been to have seem capillaries presentinga pale and bloodless appearance. exhibited the from in which the post-mortem clinique. or are heavier. SYMPTOMS blood in AND catarrhal COURSE. Haemorrhage from the bronchi occurs frequentlythan it precedesit. con . although consumption more tion bronchial 5. this else the greater taken has of the to tlie case in its different the or " stages. appears those the its cause. relation of bronchial Inaugural dissertation and or after other of Doctor harmless blood " follows irritation of severe pulmonary haemorrhage minute to pulmonary Biirger.

loose cough follows. its full reality. upon sweetish taste attempting to clear the throat. it from occur of course in tubercle bronchial consumption. or perhaps the next day in spiteof the most careful ! treatment Indeed. of in the foretell a occurrence haemorrhage patientsof the long may if they have often bled constitutional habit above described. and often." The individuals of the utmost even saying of effect.a sense cough. Such a discovery generally has a very depressing raisingblood.when we emof blood and of a the terms (haemoptysis) bursting spitting observant In such an blood-vessel cases physician (pneumorrhagia). be escapingand collecting largequantities often ejectedin a short time. years.or is with mixed Attacks of haemoptysis blood.DISEASES 150 OF THE OF PARENCHYMA THE LUNG.of a very different nature.seldom the heart.especially and then from of the have suffered now at the nose. obtains a respite last from his haemorrhage. a short. sometimes sooner may . and palpitation however. are rarelysolitary. whether haemorrhage is singularly whose attack lungs are exempt persons known disease. however. indeed." stands out here in Mephistopheles. Short gushes from the mouth.and almost fainting.the attacks are generallyrepeated for two or has grown three days. that the attack itself is preceded by warning symptoms or by sensations Far of constriction of the chest. more commonly the long-dreaded haemorrhage sets in suddenly. at times not The mucus continues for several hours. courage. Blood the bleeding may have been trifling.) The or vary from an ounce subside in course of half an hour. pauses blood seems between the coughing-fits. he perceives in his mouth. and. heart.Though yet we often find the patienttremulous. Soon after inclination of titillation induces to raising the first blood. upon is a quite peculiarjuice. rarelyimperilsthe patient's Very profuse haemorrhages. from the nose. obstructive hyperaemia.brigmVred blood chest. Coarse. and usuallyallude. is of still more " " " " " " " " " " " for mouths In such or even cases.but the blood is no longer pure. They almost always recur in course of a few hours. until at length the patient. may the and air-passages. often arise walls to resist the pressure of of the capillary from a morbid inability it is to these that we ploy their contents.pale.or or any othei . blood that he is finds that he expectorates pure or bloody mucus. in disease of frequentoccurrence and results seriously. in this manner.which pale and feeble. from life. The patientfeels as though a warm a strange oozing up from beneath the sternum liquidwere .or even who a week. of it are (The quantityof blood attack lost may two to a pound or more. It is but occasionally. to retain a bloody stain. moist rales and a gurgling sound are audible in the and frothy. and.full. intervene to during which more in the tubes. in most others.and.too.and oppression of breathing.the uniform.

and the respiratory flat and or indistinct. sound. BRONCHIAL Very rarelyis in should bear spiteof intense life mind directlyendangered. that. lancinating less severityin the sides or pains of more have frequentlyfound a slightdulness. inflamma- few days.I have usuallybeen able to discover.recover rapidly. friction a I Moreover. imprudent percussionand to expel the air inconsiderate into pass useless and it is both and the exception the vesicles else bronchial.during the few days less or immediatelyfollowing the bleeding. tendency dissolution. violent inflammatory condition ever In most " since my has attention been to the drawn of this consecutive occurrence pleuro-pneumonia. It is important that we that patientsnearly always survive the attack. should why they inflammation subject. If meable a bronchus. and increase in and the frequence of the pulse.inclinlonger bright red. common constant auscultation.have almost always succeeded.constitutional disturbance.its to pending signs of imand impeded haemorrhage. so less instances the pulse continue. with sub- had where considerable time in cases elapsed crepitantrdles. and the patient coughs. to bronchial from more moist coarse. I at least.so as to close it and render it impering but is no dark. and If blood considerable any the chest and syncope. form.in finding an elevation of temperature. and blood have lodged air. is resolution.by the patient.of frequent termination most other these constant. immediately after the occurrence symptoms. The . in prostration. expectoratinga respirationremains persistenceof the fever.or the of chest.which little books the hitherto piratory res- bronchial have attracted mentioned in The symptoms often this consecutive vanish in a tion. or more haemorrhage. 151 of in color to black. hurried. examination. grows the cases many bloody mucus. In comprehend why almost attention.for a while. and is generallyascribed. and and increased the completely convalescent. patient becomes of of the sequelaeof hardly anywhere are by far.of had distinct.after expectorating small masses clotted blood.and on The are arisen. of patients. continues in a mild The to rheumatism.two or three days after an haemoptysis.by careful of the bleeding. portion of the lung." by attentive observation.HAEMORRHAGE. I cannot organs. after a haemorrhage.too. Death respirationis somewhat of Physicalexamination of to few a agitatethe from patient by enough that point is death from with givesnegative results. in those who and soon even regain their health patients.we shall discover a more of the lungs and pleura. the percussion-soundover either feeble and murmur dull. In other obstruction than rdles . Even since the haemorrhage. elevation The of temperature generalhealth is also influenced by quence frethe pain in the chest.

DIAGNOSIS.the a cases mine) patient of are this feels able.and the it is of importance.the respiratory patient manifestlybe growing thinner and some shall have we PARENCHYMA THE a chronic pneumonia. on and under the effect of intense fever with evening examore more cerbations.in order that he be not deceived himself in the midst of the generalconsternation. stomach may particularly has taken of a haemorrhage which the source place years before upon . proceeding from orrhage haemfinally repeat that persons. I a former a have result tained.the pain. carefully large number of concerned since observations.we LUNG. gums. the patient have not and inform himself and palate. In the dissertation before all fit of strong very nevertheless. or if the patientlie upon his back during the bleeding. fever. rhage. Haemorrhage from the bronchi.of pulmonary are.the cough. after the a toration. bled at the nose on The between distinction haemoptysis and haemorrhage from the have if we to decide also have its difficulties.in the neighborhood of deadened and flat.is if the latter proceed from the with confounded particularly epistaxis. or later.even though it may not have been followed by from it entirely.that such then. nevertheless. or tuberculosis.or process phthisis . which murmur referred of by common may find dulness that lung. cases. has been the in the set up weeks. who have suffered a severe from the lungs. The pneumonia has resulted in wasting and contraction of the inflamed portion of the lung.while the respiratory percussionis somewhat is enfeebled. do not take a turn for the better . and the to. and is not to fear that reason to be the a abandoned. and although they may have recovered any ill effects.in danger of dying. Here the blood flowing into the pharynx reaches the larynx.and is then I may " frequentlycoughed and his relatives. " subside.the dyspnoea. the become if and profusenight-sweats more copious sputa . sooner of pulmonary consumption. preciselywhether the previousevening. profuse bronchial haemorthe contrary. detailed. administered. Physicalexamshows a depressed spot in the thorax. arise.DISEASES 152 OF If.all hope few OF murmur point in the chest. If and signs.besides muco-purulent sputum. ascer- is a very one. if the patient. posteriornares. terminated has in cheesy metconclude that the chronic pneumonia amorphosis and disintegration of the inflamed pulmonary tissue. miser- more destructive patientwill die of In many upon feeble.that he should deliberatelyinspect nose. the vinegar to the great physicianmakes have been terror of the patient his appearance. percussionat if indistinct. expec- kind as (one of which and. two assistant fail these THE though he had had a severe sickness. regulationdoses and Long hawked before of salt and up." His recovery is rapid and ination complete.not unfrequently. the if evidence of formation of caverns we physical purulent.

the of a has cavities The objection.and the clot. or erosion of largervessels. In treatingof haemorrhage of the it up. that they assume violent haemorrhage. hence. It is remains of food . usuallyacid. thirdly. distress have preceded the gush of blood or fully carefollowed been the bleeding have to whether as by black." people who have spit blood are prone to exaggeration. frothy. that the walls haemorrhage a of haemoptysis.violent haamatemesis ing.tar-like the whether few is it after the attack."instead " of . a has been artery of great we the blood tinged with mucus for have amine opportunityto exfrom the air-passages discharged. or be may is almost always attended by coughConversely. orrhage have now We to add a few words regardingthe distinction of haemthe bleeding arisingfrom a from of the bronchial capillaries a tissue of in the wound of with mixed It cavity. of the one admitted.whether they have coughed always able to tell. convinced any one appearance.it is highly improbable that there should cavities in the lungs of all perbe undiscovered sons the air who have suffered from from and severe profuse bleeding blood-vessel. the patients not are exactly.as it the not been patienthave the stools."while the actual lost has not been amount nearly so large.that from bronchial the haemorrhages from the nasal largean effusion of is untenable capillaries. often cannot since sibly pos- capillary profuseas bronchi of equal activity. first of all.and specifically light.that been which blood hand. is firm and heavy. very easilyyield so much are of the term so "bursting a Moreover.which servation.may blood warrant to applicationto it as fully to " blood . secondly. On air. but that all profuse bleeding. of blood small quantities getting into the larynx . by is which largervessels. days the other If.that we must examine not .with alkaline will be soft.if it forms one.or the vomiting by cardialgic accuratelyascertain whether cough .and talk of "gushes of blood. and been clot form.or whether a have cough Should reaction. be he never so healthy in have heretofore escaped obin his lungs. and afterward up. Besides.and a haemorrhage from the if it flow from a sufficiently large surface. excepting where is has which blood voided usuallybright red." and of coughing up blood by the pint. its reaction but contains air-bubbles. and merely remark. that we must.HJSMORRHAGE. flow they are who a had has that justnessof this view. springsfrom rupture.moreover. even eroded. So moderate degree. BRONCHIAL 153 cough often provokes retchingand thrown swallowed. vomited the blood or up the fullyupon the distinction between stomach. contains a bubbles vomited is stomach has of dark. 111 haemoptysis.the irritation of the blood the vomiting.proceeds generallyfrom the capillaries of the mucous membrane. many raisingblood. some traverse authors. we shall enlarge more two conditions.amounting to a pneumorrhagia. so mucous membrane endanger life. black.inquire followed by vomiting.

seem we obliterated become In THE large vessel .in the differhaemoptysis and haematemesis.or can can the The " serious irritants.and have the more same existed often holds prior the good to the immediately after it. they Now.that kind this Burger's we good health . RokitansJcy. If excessive Indicatio hyperaemia of the membrane chial bronchial mucous play a material part in the originof a bronhaemorrhage. The prognosis. would be be of of But not them the most runs in almost case. and partakesin consequence for any inclined readilyas they their belief. at all of the in LUNG.Such comparison with the This bright-redblood .the less apparent the cause the graver of the haemorrhage.however. are direct from come venous every the blood laid have become however.or if it be attributable solelyto increased lateral pressure the mdicatio the from w alls causalis iu capillary within. pneumor- lungs and large quantitiesof in inferring that justified are a branch of blood the pulmonary strikingexample A ruptured. or dark air- made public (see accidents. as to complete reThe is exceedingly bad.as regards immediate danger to life. entire of in the body. become of the set is much menses of may it.as a rule. provided allayed. perforated by erosion. ejected. may. ential remarkably bright-redcolor. Suppressed menstruation these causes only be counted among that the be be patientsmay anomalies. in frequence of haemorrhages of bright-redblood. According to the classical picture of the pulmonary artery. covery. upon attack. has been caused The prognosisis better when rupture of the capillaries excessive action of the by excessive hyperaemia.) artery of is of in diagnosisbetween the lightcolor upon passages. or. character of the symptoms. is. prognosis.so that. pneumorrhagia does from PARENCHYMA THE in other who.and wlncn with attribute to Absence than and irritation thus or " . TREATMENT Causalis. either from a branch of the bronchial artery or vein. flows when eroded become occurred a from rupture.latent than that proof from the it cavities large blood and lost in has the of various forms of and darkest only not of times. are extraordinarily rare. from the bronchial brane memcan mucous only come my treatise).the branches a soon OF extraordinaryif haemorrhage from much more frequent occurrence recognizableones. much as their to such blood-spitting when the physician satisfied. to be respects. not branch of the pulmonary artery. and small.due to direct injuries.DISEASES 154 but passages. rhagia. of the disease haemorrhoidal " has may the cause which bleeding ceased during up repressed haemorrhoids extreme reserve. very to were OF pulmonary PROGNOSIS. however. other heart. on the whole. Some- consumption. slighterthe provocation. favorable. has been and clinique.or blood It is which only blood of suffer the but haemoptysis.great stress is a (Seeabove. at all events. have in spite of the alarming as we shown. so much is the omen. events.

all conversation. should agents attack.in the first place. We should. here of his bleeding to death.there lung. we certainly in deceiving the patient. a morbi.to an open air . that in our chief is the the power source not the mind tient pa- those have to restrict must haemorrhage. wall.nourish- in the . the combat At all events. demand little to but pallidsufferers waxy. inasmuch The indicatio him from further always repeated several times. forbid all hot drinks. vessels Let spiteof the alarming hyperaemia of that it is not " the epistaxis. to master the as blood-lettingto is from do 155 venesection. rationally specific possible. whom easiness painful unber of no a success slightimportance. generallybe haemorrhagicdiathesis by causalis cannot indicatio to Indeed. to represent the haemorrhage as a salutary even process. warranted are Indeed. Coughing in haemoptysis is quite as hurtful as is snuf" * I here lirectlyupon call to mind the effect of conjurationand haemorrhage. recommended. state haemoptysishas set in. ened patients threatany with this them with their nutritive peculiar care condition.* leave his patientin a state of With littletact.by affecting and to make lightof the affair. or preparationsof Driburg or Imnau. but us bleeding.unexciting.seek to calm the spirits which most althese attacks are as are always much excited . we bronchial reason and often we cases. are is have enjoinavoidance milder of who or affection. above all things.and make the patientstoutly resist the provocation to cough. it is scarcely after means.and cold. the relieved. and the neglectof the that these blunder.demands of the patient.at the same deny the possibility absolutely come. by straightwayinforming should time. It does lancet will stay in its our the most call to nostrils is moderate.and action In bleeding. moderate food regulatethe action and et venere. we while. should carefully in baccho excess Where there is corpusclesin the blood. be pressure in order tampon. but has lateral pressure the though cease. it is well to save him that there is more blood to agitation.the employment of Pyrmont-water. in . assigna to empty.which are we we from cases persistentand a with haemorrhage.the exhibition of iron. Take care that the chamlet all food terdict Inbe eaten be cool .BRONCHIAL only in such cases. unable in admit.the physicianmay a he has found in the most comfort and peace of mind. cautious regimen. prohibitall excitement. and. such HAEMORRHAGE. a decided of want measures a from We of the bowels red gross alreadysuffered ah1 hurtful should bodily exercise order of mental which could to be serve pre- injure ing simple.whose capillary walls. . for the and delicacy of thinness bronchial bleeding. be almost long as case dead Since of the met are forced to the heart's where.to effect any rapid change in the abnormal of the capillary in dealing with It is preferable. penance on the and spirits. cases.

occasion scorbutic of the bad state nutritive state of the a blood.Finally. there come five to ten fingerssets rectif. spirit.salt. been arrested. various drugs are only to be made use of in very dangei- These severe them the is $." recommends particularly moptysis. piper.come and the common acids.mixed in a sufficient quantityof water.156 DISEASES OF flingand wiping the the clothing which patientto means form cold of of which. these is acetate of lead.* this. half-sitting posture the combating bleeding is the in the In in nose OF PARENCHYMA a assume of in the THE time cold. Wunderlich in doses in the in aa we should not directlyto of four course or serviceable * Fill tin or well^"queezedwet are The greatly to tion sensa- obstinate be copper compress.of which give ten drops every two A series of other haemostatic hours. a immemorial. much lay it These the upon compresses a . when taken in excess.the a in very use tum. confine the in bed. 3 ijevery two to four " j . S. clys- always been the resting reputationof arwithout to explain our haemorrhage being able. haemorrhage. cornu- numb said to have five minutes. Sulphuric.and which bladders soor of ice. Balsam cases. be his tion solu- a mended recom- The most in means. all and. and ous secale cornutum. cough. this recommendation.. compresses. number the little a of substances piecesof ice.much A in. curiouslyenough.until formula. exhibition a oleum copaiv. or we apply may addition small doses LUNG. of medicines. we may make the patientswallow two one or spoonfulsof finely-powdered.or cold in the vinegar have form has give of ters. not firm con- employed freely. HI. secundum. must capillaries. follow remedies edged not of such are these. salt.let him swallow ice-water .aquae menth.and The We bleeding is the cause most cold.which. the as the of secale pricklingand impotent all forgethow bleeding of the nose.inhalations 3 ss with " vj) has of been against haemoptysis. are therefore as efficacy less highly esteemed. powerful apply this severe. rhatany. warming-pan the we these ha" stypticsare to apply able are Latterly. more in moreover. how Under all before this act.by this experience does My own moisture preferred to the heavy should narcotics restless the patient. of iron (3j to sesquichloride exceedingly alarming haemorrhages are The where.and which. be. dry still salt. the portionsof chest. and of from " hours. very of frozen shape to press THE remove epistaxis. bleeding point.spirit. remedies two : they head. others. then freezes.which generallyacknowlthe acids. of which the Among English physicians maintain " simile aut nullum balsam terebinthinae. and upon compresses.for violent more with of ice. syrup balsam. so water. other grains.is vim internal that.are more preferable. Next copaivae.or phosphoric acids.a lead However this and to hemorrhage. especially the elixir acidum we Halleri.physiologically. of use when small to from Besides added. ether nitrici 3 ss . being less innocent.

taken ing separate chapters. the interior of the HaBmonhagischen Infarctes.or entwined.notwithstand- satisfied that in THE their essential essay of my the variations in to demand me TO I seat.The abrupt boundary of a is caused from by the fact that the bleeding only comes pertainingto a singletwig of the pulmonary artery.and Dissertation why voc . are originof of metastatic suppuration. so-called the metastatic complete identityin in their extent seemed to they originate.3 or powder 3iore at CHAPTER PULMONARY HAEMORRHAGE IN INFARCTION editions former of which haemorrhagic infarction. above and OF METASTASIS from occurs infarction drachm LACERATION" " text-book my a be VII. WITHOUT HAEMORRHAGIC 157 limit capillary of a the capillaries range of the haemorrhagic large branch of the than one extensive which forms about pulmonary artery are far more a smaller twig.tt^MORRHAGIC OF INFARCTION THE LUNG. section sharply-defined cavityof the lies in their interstices air-cells a disease anatomical and difference. the lesions.and the But from my and former in the from opinion of Rokiespecially owing to an dissertation views were erroneous that the modes of that a of Doctor of which (neither seat external ence differ- in which manner of . Tubingen. are ulceration. tansky. haemorcapillary of infarctions which the lung.and during the day an emulsion. Let a Dover's night. infarction consists in a tion infarcsanious limits of singlelobule. different pulmonary heart. and. The capillary system of an artery depends upon its size . boldly should we order opium. and heart-disease. and is effused.since. hence are CHYMA PARENLUNGS.with half half a grain of morphine.and ramify toward roots of the lung in company the surface. identical. of real no thrombosis treated have by Gferhardt. lung are Inaugural large.constantlygrowing smaller by repeated subdivision until each ultimate is plainwhy twig terminates in a singlelobule. from an excellent series of observations Hopf? that I have become constant)constitute to bounded a by the partlywithin of small the vein. As the main trunks of the pulmonary artery enter the with the great bronchi.the reason the infarctions * Di Zur occurringin Diagnose Flopf. des 1865. or and THE of the the all. it. ETIOLOGY. Haemorrhagic " confined often in of laudanum. bronchi. a vesicles and between the The terminal rhage.and publishedin the magnitude haemorrhagicinfarction from own.and partly fibres of elastic tissue by which the not produce laceration haemorrhagicinfarction The arise within the blood haemorrhage does of the lung-substance.

muscle.elder-pith. beyond the pointsobstructed. liver. superficial within THE and some remote swept into the in impacted admit of at the has of the current of the haemorrhagic of the long arises. and by introducing particlesof fibrin. This obstructed.of the dependence of of embolism of clots.or the with rightheart impacted until it cases to pass into the intestines.he proved by dissection of bodies.158 DISEASES OF peripheralinfarctions the a whose clot -which by its calibre in the demonstrated the LCNG. in the small very easily is it is ones some* difficult times That the whence that it detached it has until. branch some of the roots tion pulmonary artery.it is the portalvein.as constantlygrowing larger. pulmonary recognized been infarction its place of region branch some its passage.in the which diseased had been metastases as found. pneumonia. of current the the veins heart. doctrines revolutions . the become to narrow conditions from comes become it has artery too hag obstructingcoagulum lodgment. we find in it a range PAKENCH1MA preserve lobuli. remained to understand by emboli from suppurating or obstacle have undergone septicaemia that is. which under formed not lobular haemorrhagicinfarctions. Where find infarctions in .finally. but that haemorrhagicinfarction upon many tissue into the It is easy caused circulation from from its are " and pyaemia of " has unshaken. it unhindered latter whose of sanious of organ. which dischargefrom portal vein within for emboli blood. upon Of the late. or thromboses disintegrating sanious point of originby the its way When surfaces.causing metastases from when is detached into the diameter the enter the arteries of the exceptions to this rule through rule for emboli. credit of this valuable That discoveryis due to Virchow.or from particles originwas traceable to some region of suppurativeor sanious liberation thrombosis the surface. of particles of the introduction or of why metastatic infarctions of the lungs are of peripheralveins. or the and which to occlude which is not occur.kidneys. which undoubtedly had proceeded from a of a superficial whose disputabl invein. the jugularveins of dogs.and similar Upon to the embolus an the of ulcerations ramificain that left side of the brain. THE size and the cuneiform shape of is more less or but largervessels. originatefrom in lungs or the spleen. the like into these foreign produced artery. and small abscesses. blood. but as both OF of an arterial branch Upon careful examination hsemorrhagic infarction has formed. arrested come the the as meets which nor is less than portalvein we sometimes no it travels its own. and pulmonary body. demonstrated by dissection that bodies blocked branches up of the The investigator. fibrinous plug. It passes and on into the arrives at or heart of the grounds. spots so long known that the arteries leading to the affected occluded points were by an embolus"a. Conversely.

which trabeculae. As very while the latter are generallysituated near of the thromboses from minute particlesalso may be washed away likewise the rightheart. and that pulmonary of the in disease lung. erally genWe ease simple explanationof why the infarctions of heart-disthan extensive metastatic of why more are as well as infarctions. course of disease cases opinion. in the interior of the lung. tangled usuallyexist firmlyen- of the one particleof by it. being adherent that the so skull.a process which. did capillaryhaemorrhage I that of the mitral them compressed them. especially of course arise in diseases like the greater circulation.although I could the minute. smaller peripheralones of an obstruction The to be explained by which process still remains afferent arterial branch produces capillaryhaemorrhage in the region thus about find a very the obstructed vessel.INFARCTION HAEMORRHAGIC arteries whose organs embolus the that liver in thrombosis the of to tables the of the in heart. ignore that the extreme produce metastatic in from the right auricle. the former are the periphery. to often so have not heart.and which clots of the this results of the clot be branch of the torn cardiac from the thromboses aortic off and pulmonary haemorrhagic infarction from gishness slug- ensues.it seems probable been diploe*have the skull.and the has valve. a detached come emboli of which the heart. larger by accretion of fibrin.where LUNG. which that the been arterial contents in the but is facilitated. the right side infarction.tion peripheralvein).is simply due to the of the veins of this region. coagula into of entrance of reached. has their interstices outflow organ been them explanationgenerallyhas and a hsemorrhagic infarctions the In first penetrated.which.without grown of walls of the gaping 159 infarc(forinstance.seems . as has been proved by Rokitansky emboli The Gerhardt.haemorrhagic embolism.but from from come in the during its that.especially the clots in the arteries so blood of produced my of the from leadingto of the blood infarction and convinced now am also arises from heart do not washed away artery The by fibrinous in consequence If those a of the current coagula thus larger than the into the vesicles -of the This separate and block which which circulation. near often found its roots. besides the largerinfarctions at the also occur in heart-disease.in disease of the heart. roots.the coagulated. are circulation.we see how. at the first glance.4 The of the haemorrhagicinfarctions after injuries it has occurrence common very first has at through the system of THE have not another of capillaries the passing through could embolus an OF are blood. of blood escape the been tion the infarc- restriction of sections abruptly-defined of the artery in disease the obstructed becomes long to which circulation. the But and prevented capillaries was for the the stagnation formerly obstruction I ascribed at all account not of existence known.are prevented from collapsing.

and anatomical in arrested. different simple or what condition prevailswhen forming a mere blood-clot fermenting upon call we depends of the bleeding believes effect their suppurative pneumonia more . and comes collateral route. which vascular the upon Cohnheim of nature which we yet ignorant. e.or bloody sweating or exudation. regurgitateuntil arrested by counter-pressure s Anschopneighboring veins (Cohnheim? of of the due to giving way pung}. Signs haemorrhage now appear. caused below above circulation of state most circulatorydisturbance the THE OF [The of elucidation.. they also arise from diapedecapillaries. small or arises at metastatic somewhat degree matter upon of the the the abscess. of stage the and First. however. ed sis. but withholding of disturbance a chemical a alone and The visible. the does not culation interrupted cirtrict dis- obstructed the walls. brain. plug artery has The such do terminal their lobules If arteries. embolus is harmless is withdrawn the by on pends de- breaking are capillaries carried a channels. case duces proscess abbut resisting power . until at capillariesfirst becoming covered to in the " " last the naked to even cause of think to the be vascular the exercise induces are as A a some baneful of that blood new the from of integrity. capillarytwig one mainder. both The stagnation. where is but there be in pressure backs it is into the the through the of the then plug artery. it by blood again reaches recent region beyond the into up LUNG. re- above be the terminal a either death or the several by interlobular lateral vessels. there vessels.as " the circulation. the surfaces of the overloadwith red blood-disks.the hsemorrhagic infiltration.kidney.which the off any embolisms way numerous). much very and blood is led in the whether upon then In harmless. become extravasations dilatation distention and small eye the a adjacent tissues. easy upon by PARENCHYMA THE OF the a flux re- into even capillaries. the the of the embolus. at be the tissues which then " because there Cohnheim if. of extent of ing be- plug.through the continues blood of up that the connection efferent arterioles .especially the anastomosis embolism by plug is then it should servations preciseob- vessel. the bloodblood from the neighboring veins the obstructed is district .DISEASES 160 by DO means Cohnheim. but. region below the plug.before in the no imperfectly kept no into other new only it. and retina possess also in some degree the lungs. contains mechanical seat of instead embolus. (when not the If. and upon such a infarction. too from same and the obstructed with anastomoses capillaries. so vessels there are spleen. the If it arterial anastomosis obstructed artery supply suffer does.and The dimensions its virulence In organisms.as periphery. i. according to Cohnheim.

accumulation into the them.or near is usuallyat the middle the roots of the lungs .if the time. bronchioles bron- new extravasated formidable process is end.and We " we a rule. an OF such LUNG. locality impedes a This that the patientsurvive the attack for any absorbed. vary are of air. and the coloring the fibrin having undergone fattydegeneration.so a The blood in size from blackish-red that they can that of or be a hazel-nut blackish to that of a hen's egg. the is rarelyfind the blood liquidin stance circumcoagulated."] an APPEARANCES.can be INFARCTION should we that made In out.and of the medium-sized and part through fatty degeneration of some branches rupture. blood reaches also the thus this rises mouths Coagulation and a Thence. of the lower lobes. granulated aspect. more show? rarelyat the surface. of recent is easy infarctions . tioned. rhagic infarction it. as alreadymenfrom collateral fluxion.completelyinelastic." a the jRindfleisch. as for. Still later. the into way abnormal sure pres- the other in the the hand. the fatty of the blood matter decomposed."the says neighboring bronchus then existingin it is drawn with the of circulation. fillingit finally takes brought lesser blood Upon the it is sucked blood all " into last vesicle. lected in the tissue outside of the capillaries.and has turned into pigment.ELEMORRHAGIC Furthermore. may the this o f is usuallyfull of sharply-defined lung vicinity spot blood and cedematous Its seat. and color. from the brownish-black off be In with the mediate immass scraped scalpel. felt from without like hard knots. coarse. which infarctions in disease of the heart generoccur Haemorrhagic ally length of is retained.and they have no muscles nor ciliary epithelium. it is not indeed nor the cases THE 161 in other any infarction hsemor- every for source probably comes the preslarger vessels. part of the haematin and the only remaining trace of the infarction induration is a blackish surface in the presents lung. Microscopicexamination the capillaries which also col to be distended are by blood-corpuscles. by aspiration. and pulmonary artery.it is reflect that. by by thelium. place. arisingin part from sure of obstructive in hypersemia in the lesser circulation. ANATOMICAL dissection force its to as to the bores of occurrence corresponding lobule. an In the 12 rare instances in which an abscess forms it may be- .if to account dischargeof the blood. through rupture of smaller of remark that embolus.it looks palerand yellowish. but forced expiration the in vesicles can only empty part. They void Their of cut which a irregular. the bronchial action of the and that of the ciliated epimuscles. being partially fibrin is absorbed. while the coagulableportion liquidpart is easily from bronchi the expelled by coughing. On of of the the very chus. Where the infarction is of long standing.

SYMPTOMS in spite of of the account Ik many separatelyof the symptoms diseased heart. of metastatic When of the middle which consists decay of the contain any the extravasated blood the pleuralsui " and the yellow When former situated like see can disintegration thickening. Upon pouring water the lung floatingin pus. forms two perfectcertainty.and a cough In many instances there are with a peculiarsputum tinged with blood. tion situacuneiform alluded to the small volume. obstruction. dyspnoea. its contents thicken may LUNG. result of a be Chapter XII.we hollow. ease infarctions are metastatic entirelysimilar to those which arise from disdescribed in The the heart. which friability. gradually until at the even cavities of the vestigesof spreads part . THE OF PARENCHYMA THE into reous calca- cheesy or a mass. sudden a normally. difficult. adherent. since difference cases in with can of infarction metastatic sets We " haemorrhagicinfarction arisingfrom of of COURSE. AND we a can ence that its exist- other infer the of disease case the cases formation of the heart. and rounded-nodular which its cut over depositsform faces to become forming a filled with fibrin. as will haemorrhagicinfarction.but scarcelya pleura. be proof is one shah1 treat the . the branch. the appearances. discoloration also microscope cause it lies the infarction. debris of same disintegrationgenerallycommence and diseased gives the terminates infarction abscess. have already In explainingthe pathogeny of metastatic we infarction.and of those The their the anatomical varies identity.must the of a extremely .haemorrhagicinfarction which haemorrhagicinfarctions more ease. latter.and pulmonary peripheryof the abscess. from of respects many with symptoms.either lung. carried the or of on of entrance bronchus.OF 162 DISEASES come and incapsulated.either of have access blood of an equal and in blood. the of Gangrene lung. cause unequivocalsymptoms.which beneath prominence not immediately under the upon mass.which the signsof a circumscribed are frequentlyfollowed by those of pneumonia or of pleurisy.which may threaten suffocation. not uncondensation of the lung.consistence. metastatic in form. dis- them.and it generallyassumes.yellow croupous pneumonia substance. molecular of first does at The is left of trace a or the in surface. It is manifest branches of the pulmonary artery will that the stoppage of one or more produce extreme dyspnoea. furuncle a " (RoJci- tansky).and superficial In color. As the process of respirationcan only be are.or of an air into arterial part of air in the the the vesicles and arrest.when both the are capillaries properlyrenewed. in the which diseases of the of chronic disease well-marked such of appearance and in demonstrated characteristic or in on heart. the shape. In or quite impossible.

hence all immediately are symptoms. cardiac thromboses so These of the which pulmonary proceed be regarded to are are.that they produce be own very coexists with those washed away from no characteristic nomena phe- there are where no hence. physicalsigns. The picture of a the latter group well marked.a sudden widening Gerhardt of rare. a are. most My of cessation This existed. may condensation of a persistfor a week or even fortnight. which one alluded above which branches more infarction. Although sounds such audible are they limited a over region of the The diagnosismay confirmed.and had sound previously is not only is generallyvery significant.and where unchanged. frequentlycause be few a Besides the the tokens indirect as of the irregularity the sudden attention work of one of adventitious an subsidence but of full to . as we find that haemorrhagic infarctions often produce inflammation of the surrounding pulmonary and still more inflammation of the pleura. in thrombosis attack hitherto stoppage upon artery. tissue. Circumscribed the pulmonary tissue can farction only be detected when the hsemorrhagicinis of comparativelylarge size.HAEMORRHAGIC INFARCTION OF THE LUNG.whenever unequivocal signs of disorder of the circulation and of haemorrhage of the lungs suddenly arise in the course capillary . deep in mind that the air-vesicles is not moreover. diagnosticimportance from my hasmorrhagic infarction becomes experience. great variety of seated bear within causes the the characteristic always that violent fits of ID disease lung. 163 ture respiration. and.from the strong admixwhich of blood to pneuthey contain.morbid a of the a sudden dulness.and of sudden was are cases. we may still confidentlydiagnosticatehaemorrhagic infarction.and that infarctions.The sputa. when. but they are less tough and almost always darker . meaning of this symptom by the but I can fullyconfirm both the its full sign and But above. murmur.there occur. the of of extensive or by development pneumonic infiltration. days bloody expecdyspnoea toration.and has extended to the surface of the lung. described or right heart. described.cause of no the observed expectorationof in haemorrhagio dyspnoea may arise from a heart. longer time upon expectoration than this of secretion is continued for a much is the The former expectorationof pneumonia. Finally.it is easy to under- .and crepitation upon bronchial and chest.bear a certain resemblance monic sputa. infarction.and first called to the of the occurrence and of haemorrhagic pulse. inflammatory effusions into the pleuralsac. embarrassingeffect the moreover. cardiac which loud. The sound percussionthen becomes dull. disease of the heart. even signs of cardiac thrombosis.if the blood we from and. other many the strikingoccurrence. after the symptoms dependent from cases emboli may of symptoms break off. where the cardiac dulness the pulse remains tinues conregular.and small.

DISEASES 164: stand the why OF THE PARENCHYMA disease. while result in the the of the of side there cases are It lung. very exceptional. Finally. in appears arteries of .at the autopsy is even septicaemia during some sup infarction is based.purulent like.does are be quiteindistinguishable. the very pain.*5 We In most cough.or produce bronchial breathing upon in the affected region. and It would disappearing from thus seem the list of to secondary inflammatory as though pyaemia.but violent fever. intense pyaemia. difficulty may est and dropsical. point expectorate thin.the former infarction sensorium is blunted have are which ed thus picion sus- dissection prepared " where of find to their existence ulceration almost and. heart. latent metastatio mind The the toms symp- intense branches in where infarction. the even decomposing. skull affectingthe diploe we our fidence diagnosiswith conmay pronounce I that this like cases are repeat. breath.we h'quidproducts of into elude patientis is otherwise haemorrhagic infarctions has the THE cases. does many sometimes instance. Dyspnoea of slighterdegree is not noticed In like manner by the patientin his stupefiedcondition. therefore. septicaemia. danger of by side of septicaemia.and be audible in the if the originalmalady be one frequentlyproductive of metastatic infarction in the lung for instance. as generally the sputum patient neither coughs nor expectorates.why their are in the pain process. besides. " " * According decomposed are recent in the some to parts of the body. introduction into the blood not only of absorption of liquid inflammatory products which observations.notwithstanding infarctions metastatic their superficial occasion position. It is only in very rare that patients comcases plain the and of piercingpain in some of ohest.and of of cases diseased The been not pass rise to the " as accidental with infarctions. pyaemia and where cases not the symptoms inflammation asthenic of of disease fever. during life. gives rise not in distant been to liquids. in of diagnosis. persons of complain symptoms of the of or emboli and membranes. intensityof diagnosisof obstructed. scarcelyever circumscribed dulness percussion.and why show breast. the the dyspnoea. for " OF in the lungs. rigors. a sputa. was infarctions the by of disease who even In the fever.an injuryof the as. large arterial exist in metastatic nearlyalways give see to find metastatic the always latter why most patientswith extremely depressed.nor or nation incli- any neither subjectivenor objective the rule.These for.if we only call to easilyaccounted which upon lung the died purativeor ulcerative which. .where as. are reddish-brown region of friction-sound If. to and alreadyextremely short should the metastatic they detection discoveries inflammation circulation metastatic neither present the small* not suspected. but.which. the characteristic is almost always absent. serous LUNG wretchedly ill. lung occlud' small. may maintain its cesses prohaa placw .which diseases.

the extremities. is ever missible. in other than it cases. cases atheromatous of the its aneurisdegeneration pulmonary artery causes mal final rupture dilatation and more sions. the beware affection only can proceeds from ease dis- attributingthe dyspnoea that are aware pulmonary hyperaemia. injuryof into the the " Violent thorax. chief real is ansemia of the skin. or of blood sudden death . A taining cavityis found in the lung. and of hastening a fatal issue.faster and rapidly-fatal followingserious haemoptysis. so that we knowledge of the mode of repair of an apoplecticcentre.and to collateral oedema of the rest of the lung.are concussions the causes of pulmonary apoplexy. portions of its the to this cause.too. SYMPTOMS. of the thorax.the applicationof cold at a and later The period.becomes stimulation applicationof sinapisms and warm of blood is rarelyso abundant expectoration and the to The the haemostatic of remedies inflammation of the demand local may recommended in baths as a to of the patient. stronger. suffocation can be from effusion expectorated. but.or. treatment our which to usually is cool. conand and surrounded liquid coagulatedblood.APOPLEXY. has given rise to of sundry arterial branches obstruction collateral hyperaemia. be of treatment a the of The " haemorrhagic infarction When symptoms. we must the aggravation of an of treatment 165 or and when cause the that cautious As until confine must we warmer. especially rupture of the which arteries.and an abnormal cavityis established. dyspnoea is plainlydue in great measure either by cupping or venesection. haemorrhages are almost always fatal. a general rule. contu. lung or pleura. other phlogistic anti- measures.which often sets in depletion. We heart. to call for exhibition previouschapter.until the pulse. PULMONARY TREATMENT. bronchi. and grows of to lung. PARENCHY- LUNG.which usuallyis feeble. by tatters of If the apoplexy have its seat on pulmonary substance. is often torn. and blood is poured into its Such have little sac. wounds. WITH LACERATION APOPLEXY ETIOLOGY. In this form " of OP THE OP THE MA.the pleura. commonly. " the periphery. An injudicious venesection might have the effect of increasinga collapseof the lung the alreadypresent. It is only erosion or laceration of the largervessels. It is only when in the lung. Capillaryhaemorrhage scarcelyever destroys the tissues of the lung. adblood-letting. or ANATOMICAL both the lacerated APPEARANCES. pulmonary haemorrhage the tissues are destroyedby extravasated blood. CHAPTER PULMONARY HAEMORRHAGE VIII. In rare produces destruction of this kind.

dis- secondary pneumonia^ independently. cells (pus-corpuscles). in contradistinction pneumonia. and of its distinctness pneumonia. LUNGS. the vesicular walls become dation. completelyrestored after expulsionof the exu- In croupous Sometimes pneumonia crasia. varieties which separate disease. exanthematic may trom a under occurs have (aswe This typhus. Catarrhal pneumonia.may be the symptoms of this exceedinglyrare of no treatment. CROUPOUS ETIOLOGY. etc. too. course is latter form subject. the regard to been chronic in usuallyacute.this human the With " refer to what has concerning croupous disease .the free coagulable exudation no of inflammation these varieties process a is formed. of .a fibrinous. the free surface of the air-vesicles. inflammatoryproducts are thrown out essential the lung itself sufferingno of nutrition. THE OF INFLAMMATION attacks the that which identical with larynx in laryngealcroup. As tissue. involved membrane mucous in : a the of intimatelyrelated to that producing an alreadydescribed as catarrhal bronchitis and laryngitis. also. haemorrhage.is susceptible from internal lungs may properlybe regarded as pneumonia.and constitute It is primary pneumonia.which we arise may influence learned)attacks often than typhus more be distinguishedby the the other the it does name more oall of form other of the an acute in air-passages pneumonia.which. 3. being absolutelydeadly. in which the air-cells are Croupom process of three kinds of the Inflammation 1. it has the to other IX. 2. Interstitial walls of the been also called chronic whose varieties.and active generation of young in which but upon a the tissue of surface. which is an inflammation the interlobular connective and air-vesicles. is thrown out involving upon and their epithelium.justas catarrh measles.PARENCHYMA THE OF DISEASES 106 THE OF LUNG. PNEUMONIA. is always a CHAPTER we both In said in pathogeny of croupous the second chapter of the inflammation. acute dys- which infectious companies ac- orders. disease. Here. disturbance involving the pneumonia. diphthe- from dation exurapidly-coagulable pneumonia. first section ria. includingthe newly-formed cells. augmented secretion.

no all however. and effected an are.therefore. acute and other acute erysipelas. producing and afterward inflamed. air.foreign bodies.the inhalation late. in the and air-passages of the thorax. This prevalenceof acute inflammatory disease through the operation of unknown atmospheric and telluric agencies is generallyspoken of as of occurrence the prevalence under the conditions northeast the precisely irritants hot very a be as counted conditions is the about severe found are morbid growth regard to The cold severe more exposed himself the upper extend with effect of cold a somewhat root.Nor attack the parts haemorrhagicinfarction. more have already pneumonia often complicatesdiseases which and constitutional impoverishment of the blood. females 167 pneumonia croupous subject to peculiarly are robust primary to extreme and breast.may bronchus. from however. into of or the entered in the elevated to as localities of very cold or the of often found to out of fifty. the secondary form. however. exhaustion. Males periodsof infants at the attacked are quently fre- more vigorous. commencing usually " spreading thence other pneumonia preceded by an exposure the patient has repeatedly that to which than as impunity.been Direct at pneumonia a in greater frequence of have. as belonging to liability down life. broken-down who exists at all however. are disease. individuals diseases. attacking their same victims without matism.CROUPOUS chronic some upon The in the than old age. of to of We influence. disease.or a double the to process pneumonia. cold.it has is difficult to decide vidual in indi- been Croupous pneumonia almost always portionof the lung. actingupon the lungs. among because supervene sons per- by convalescents subjects. indeed. At times are exciting causes generallyunknown. of cases malady. although scarcelyany of these among croupous a and wind.wounds the excitingcauses. PNEUMONIA.which to the It is rare. feeble and . but exempt means from this first years of childhood. inveterate succumb to intercurrent pneumonia. reverse. grave from pneumonia. Very the of many inmates of sufferers hospitals. articular rheu- obvious any the prevailat provocative. and lobes.full-blooded The latter. which stopped up observe particularly pneumonia regarded as untrustworthy. inflammatorydisorders of very time.with emaciation . pneumonia Its becomes frequentoccurrence. alreadyhave repeatedlysuffered liable to be attacked than the perhaps. while croup. Opinions. . to regard m*ong. ANATOMICAL attacks it arises statistical statements northerlyand have one the influence whether instances to the to exist in form With epidemic during protractedwinters Sometimes.6 extensive Sometimes the a attack of case disease around APPEARANCES. inflammatory epidemic an entire to the lung lower is lung.are divided producing pneumonia. fractures of the ribs. finally disease. not. the may It is .

are scrapingwith The where distinct is most the The friable.and to depositshere is secreted in the lung. is the We disease. a considerable resemblance thus the generally-adopted of red hepatizationhas and name liver. granulatedaspect of of the redness condensed viewed air-vesicles the small. with of engorgement Upon pressure. the rigidity. 3d. together and there of the black pigment which bronchi and vessels. individuals pulmonary parenchyma section. lung has become is firm now remarkably heavy. phous fibrin which of new active formation cells. tion an has taken The place in the extremities of the bronchi.instead of a uniform red. the more. Besides the amor the microscope reveals a very fills the air-vesicles.partially emulsion. lung. air has disappearedfrom the air-vesicles.especially where they plugs so The mentioned)can often the but scalpel. nature. often lost its elasticity. arisen. their contents from converted liquefied. filled by small. marbled.the and THE stage of purulent infiltration. are of appearance its cut by oblique light. An albuminous become the walls of the vesicles. the friability. partially above when the pneumonic exudation is less fibrinous and less coagu- . owing to spots of lighter color. and into an are eliminated. impart to it walls of the air-cells.or a or gray respects the fades from and more while yellowishappearance. in the stage of the fibrin and the young cells entangled in it undergo fatty hepatization. here distinguishthree hepatization .7 Sometimes. OF in cachectic and lower attacked. and the latter are to which of blood imparts a reddish A similar exudaadmixture color. of the interior of the bisected with the whiteness the section. does not crackle. granules (which are merely the fibrinous no longer be extracted from the lung by adhere the firmlyto the cut-surface. presents a variegated.the stage of In the crackle In the a and lobes upper of extern generallythe until anatomical blood the mode are involved later a firs! period of stages in pneumonia: (engouement] . texture cessation The continues lung of the assumes in other the redness hyperaemia. the becoming not first stage the brown. bathes tenacious and the It is heavier much.1C8 DISEASES OF THE curious that in old persons sion as usuallydifferent.and this large. less so in children. same. transudes serum metamorphosis and disintegration. the second LUNG.the be to PARENCHYMA liquid.but is very tender and when is granulated.which probably spring from the epithelium of the vesicular walls." to " Afterward granite-like appearance. Should resolution set in. either from haematin.firm plugs of coagulated fibrin. to the surface touch. by absorpfinally tion. the stage firmer.of of the a dish red- pitsupon lung does not viscid strikingly cut. 2d. and inflamed brownish stage. 1st. of disintegration pulmonary the the substance remaining rigidand granular (yellowhepatization). sinks in water. deviation There is from the a slight by expectoration.has is dark the surface the of portion reddish or red.

Gangrene of the lung is a still rarer sequelto pneumonia.The exudation even may become gangrenous then changes into a grayish ichorous liquid. arteries.form and they are solitary abscess huge either they may open pneumonia is set up capsulatedin a firm communication a from time to the interior surface. ated evacu- replacedby fresh matter generated by cavitybe closed. diphtheritic and infiltrated. by whose means in the stage of red hepatization. surface. or phthisis. after disappearance of the organic substance. therefore. The purulent contents 1. of the pressure sometimes of of inflammation tissue of the proper increase may tissues . in the with Should from the other cases. end Should the occupy they in the form. and in that into the passes of in other cases.by which cicatricial time.and take The place. great number. and in the secondary When persons.in In lung is infiltrated with exist in of process fibrinous so coalesce. a tissue.and be converted into a cheesy paste. but them size greater part of fatally through ulcerous into the pleural sac. while the The granulated appearance assumes as softer. a is most old of smoother. 160 is lost. its comes be- monary pulpus.and are easilytorn by the pressure of the finger. pus itself in the lung.the cut-surface is its bathes matter reddish-gray ceedingly expressedin largequantities. the monia pneu- mation cell-forpurulent infiltration.) 2. else. and more chial when especially they form in the bronThe lung nutrition of the lung is carried on.The tissues are extender.the pus may become thickened. do to part absorbed. interstitial abscess becoming contents are is in- smooth. The minuter of the lung. however.and the pulmonary down tissue breaks into a blackish pulp. may idea the debris and parts adjacent. here have we in are The abscess. fibrin undergoes disintegration stage. (See Chapter XII.its the are the bronchi inner remain. that of third A grayishyellow.- of the continual lung. is unaltered structure . nature. which collections of pus These The the form excludes essentially When tissue. purely croupous a In this way tion.its is The [able. or is cut common prominence. . may cretion.and become sequelaeof pneumonia rarer be may fattydegenerationand undergo may be may abscesses instances. This without pneumonia of typhus. melting that a finally These rarer reactive the wall a infiltra. sloughs from small . complete recovery may Here. pale gray. change into a mortar-like or chalky conwhich lies imbedded in an indurated firm scar. Formation with which destruction has more of of inflamed the of Sometimes substance.or. CROUPOUS liepatizedportion then distinct granulation.PNEUMONIA. the pulmonary tissue itself is still intact. ejectedin part. several the of down abscesses filled with cavities. It appears when the blood has been of to cut occur only supply completely off from the inflamed portionof the lung by the formation of largecoagulain the pulmonary arteries. too.

subjectof secondary treatingof typhus. the and mentioned Of this shall we treat in more XI.8 walls long standing.cheesy substance. etc.as it is impossibleto draw up a disorder without making a detailed analysisof the symptoms AND this of the The the periphery of disease commencement upon " which of We it shall discuss the depends. and exceedinglystriking. the the stasis of the of the lungs. prove their is completed. due to participation interstitialtissue in the process.firm. cells which the supply of THE of croupous often second and the OF which lung hypergemia. showing minute arborescent injectionand ecchymosis. Lumps where the heart. The as termination it is still too the ff. and arise of upon sort of identity those of tubercular lation.pulmonary stated . the attacked is not actual before inflammation fact. in when disease. appreciablyelevated. giving place the cold is a mere known. or even As well heat. of the is stagnationof brain. This sequel is vesicular Chapter That is the the termination rare of the the latter process similar a of the to the take less or cheesyinfiltration(or. they are firmlyentangled amid the valves . It is then clouded and opaque.in Hereafter this the by applying a of the the when detail in disease the fibrinous sion effu- fattydegeneration.its is less full. flabby.is finally tedious pneumonia.is overflowing capillaries ished. granu- imputationto with ourselves express a titleto both.in many oedema of is of common. to be lung.the on vesicles insufficient. and jugularveins. subjectivesymptom. blood exists in the liver and kidney.170 DISEASES 3. the rightside of the heart. liquefaction firm. in almost all cases. supply being abnormally dimin- left heart. fillthe into shall we OF pneumonia of by the begin to dry up converted are stage effused serum fattymasses and third or PARENCHYMA tuberculous called.yellow..as cases. is for several rigorwhich may last for half an hour. from which of blood the outflow Generally. extends has been to the impeded by with blood the . portionof the of intense seat is. is before of sensation to a hours. SYMPTOMS pneumonia pictureof in COURSE. vessels is not of curdled the in the fibrin exist in trabeculse long. cause the by Wherever the flammatio in- pleura also becomes implicated. subsequent changes occurring in shall lung.and covered with a thin layerof fibrin. and the temperature is during the algid stage. THE is more infiltration) vesicles more again refer of inexpedience of the as a infiltration of caseous 4. polypous coagula may be and drawn under out arteries. In like manner.in The condition for the the of lung the same sinuses blood The major part of that which is in the great is coagulatedinto firm yellow masses. in of death. primary pneumonia.tough. but liquid. before permittingthe products of Cirrhosis the walls LUNG. and of all the reasons. or induration.even announced by a .

appetiteentirelygone . either neously simulta- immediately afterward. by increasingthe rate must consumptionof the tissues.and is red . This the counting instead occur The of the duration of of temperature. and of a distressing of the limbs.even the disease. betray themselves by remain latent. We assume may of nutrition commence inflammatorydisturbances the diminished greater quantity. by increase of thirst. This has as all febrile in or unchanged. a elevation of a which the first on rises to 103" heit Fahren- 105" or day.they used formerly to be attributed by many to the even accumulation and to far so gone of fibrin to ascribe as a declare that the disorder the blood Some have (hyperinosis). do we chills of equal violence .convulsions often chill. at least. fully. of nutritive general health of earlier are derangement which the lung same thing in febrile catarrhs do in such not that cases the quite as soon.but disturbance not of transformation the position com- interchange of terials ma- febrile account sufficiently take in placein for febrile fever. yet we may often observe the and other inflammatory fevers.or demonstrate of the elevated nutrition fever and than the the the be increased and in of the fever.but that of derangement causingpain. The countenance the patientcomplains of pain in the back and loins.a accompaniment breathing of adults to be it augmented in see minute.and are w hether fibrin the blood the of diseases.or twenty breaths a pneumonia to forty and even fiftybreaths. occasionally tongue is vomiting. first of these is shortness pneumonia. we rate constant of twelve.PNEUMONIA. symptoms of with The of for or functional the chill or a We need while of the they dyspnoea. less pronounced that every fever.and perversionsof affections symptoms. The is and the there coated. CROUPOUS both rigor is important in 1ft diagnosticand hi a prognostic In no other fever affections. products of blood temperature constitutional " that with mingled Although occurrence or quantity remain blood. is accompanied by tion accelera- pulse. (rarely higher). latter disorders the paroxysms are repeated. in calculate. appear in the In other lung instances. whether quantity. There is great prostration and muscular soreness debility. As these symptoms often precede the local manifestations two by one and even days. after the elimination only disappeared in of the superfluousfibrin from the blood. excepting intermittent point of view. therebyalter the are crasis and these more and the its All Assuming of the normal breath. however.which disturbance symptoms blood suffered. the function. and in the and encounter septicaemia. In children.while the rigor which ushers in pneumonia is almost always the only one throughout the It is from this chill that we entire course of the illness.and find it to attain a still . more appertain to the fever. criticalsignificance to pneumonia (Dietl).cough.sixteen.

It is apt to be completelyceases. into the swellingof causes capacity.more oxygen the in out organism.to the fever. the of of these itself with patientsendeavor of the distinction aware hardly ever painful distortions make for It to. therefore of air. doing.therefore. at least. etc. which 3d. so that coughing.and a and is part of goes completely. 4th. the patientsassignthe seat the obstacles cases. countenance the in it . short sentence. associates soon very side. lung. to of an to be or even exceedinglytransitory character. but the to combustion the of in point at other the pleura the to thorax. of the commencement one disease. altogetherwanting in the pneumonia of old persons if the and very feeble subjects. and the alae nasi dilated.and with a certain degree inspiration with every contracted of caution and anxiety.and matter. respiration pneumonia as to be absent in but in all. It is time. a tionately short.causing the nostrils to As the of act " of breath shortness renovated the in is inflamed breathing-surface. rarelycontinues of the other intercostal by which inflammation. furnishes ground pneumonia. or and more a is. be importance to a to repress while child.the breathingis enunciation THE The greater frequencein children.the dyspnoea ceases it is felt at cases such expiration. do as suffering. bronchitis and cases pain above It is at first short. particularly of the upper of the inflammation be the apex of the lung or seat one lobes. fever. else.since. speech is interrupted. 5th.in and carbonic more see that.ringing. as accompanies coughing or sneezing. is also pressure The in all its violence symptoms to the thorax upon character of the stabbing.although all almost consequent augmented acid the and the assimilation which destructive diminution uninflamed vesicular walls the breathe not the in blood which to the air-vesicles oedema pain which the does need increased collateral with lung . to who part of the exudation to slowness the due.dyspnosa. 2d. the aggravates not pneumonic forcible every In the stillcontinue. muscles. We given is of in then- decrease on symptom a In most instances. remote doubtful solelydue in contact comes of the participation and especially Every deep inspiration. is pioporlength of each respiration fresh inspiration is required a superficial.with presently Pain few is constant so of the with pain the the whether the in of the described side. It is of Cough in the alluded and is pneumonia The observation a of manner between of the facts.and absent. on even It abatement clusion ex- causes during fever. Its any length of for at the and ment move- pain is usually intensityvaries. diminishes all to inflamed patientas piercing or burdensome most It " above patient.DISEASES 172 OF of LUM*. by of air . deep breath deeply . the harsh. 1st.the levatores alae nasi are work. they while dread to cough. the afterward and the stitch " accelerated is sumed con- shall lung points. during the OF PARENCHYMA THE even is executed rapidly. excepting old men. In almost all so ." The breath.

acid. not gled. that is to Thomas^ is remittent or of be and remissions daily fluctuation in its exacerbations may considerable. pathognomonic a cases. spillingits contents. an exception is the hepatization the exudation is often a non-hsemorrhagicone. it almost always during the period of engorgement.PNEUMONIA CROUPOUS of peculiarsputum. brick-red. This sputum correspondsessentially in the air-cells have fluid which. which mucin.immediately upon not contain they Their mucus.but continued of Leipsic. say. the mature constitutional the leaves symptoms to increase. slight. begins be to to the earlyperiod. or else they may be The not exceeding 0. sometimes few pigment cells from and of young small number a cells. appears Like that liquid. immediately before the crisis.8" to 107.4 F.75" F. 173 the malady.. These are fibrin- found are in the of the casts While. amounting to 0. or On two before the other the occurrence of the hand.7" F.which always correspondsto the The without inverted is with amount light red.and sputa. forms of old people alone to these. upon the entrance lumps stage. it may rise as high as 105.when of the doubt as to of pneumonia fever and until of the chest physicalexamination its nature.the pneumonic sputa are so tough and adhesive the mouth. a day increases. but yellow. minuter a the to careful researches fever. and contains that it is difficult with away latter the blood which bronchial be often can the mencement com- attack. temperature is at its lowest usuallybeginning in during the earlymorning hours. to 1. to 0.the fever subremittent. attainingits height usuallyin the afternoon.80" F. be recogand by the employment of a low magnifying power nized may ous as repeatedlybifurcated and ramifying coagula.all a these symptoms disease. pulmonary be may day further as rule. albumen. and them from to remove they are usually that cloth. but. rusty. in bad cases.besides a blood-corpuscles. second no addition coagulatesupon shows examination the coagulates upon mucus plugs from pneumonia Chemical vesicles. red. which cloud of the upon vesicles the are its second into surface addition of of dilute acetic diluted the of the nitric existence of and of acid.as pneumonic exudation The of their contents. usuallyshows great numbers Microscopicexamination easilyrecognizableby their form and color. the exacerbation of the forenoon. as we viscid adhesive seen. and extravasation monia pneurupture of capillaries In this rule.apparentlystructureless. which of being disentanare susceptible expectoration. a They cling so firmlyto the receptacle. of the wiped At its establishment.5 F. is more intimatelymixed than it ever color. The forms a fibrinous of the expelled. ejectedat an is almost by always attended blood. of blood the commingled. most the cases. small. the sion remis- fever sub- . continue According is never bronchi.or reddish of intact brown. the course In when.

In other. extensive and action.reaches sometimes sides.and other diseases.and probablyin weakness of the inverse is because imperfectlyfilled. if the patientbo . in may ninety and between usuallyranges in frequence majorityof contractions. the the lack of The left ventricle it is obstructed.that too little blood enters the left heart.the appearance liquidmay be of diagnosticvalue hi doubtful cases. which of the pulmonary pneumonia. is also dependent upon the disturbance and upon circulation.and from the frequence of herpesduring pneumonia.causing a feeble pulse- expelledfrom the pulse. impediment to the outflow of blood from the right and from the veins of the aortic circulation . and. circulation the supply of arises In an from (partly inflammatory stasis. often acceptable explanation of the reddening of the cheek. cannot circulation in the uninflamed of the capillary portionof the lung. In many stances in- herpeticeruptiondevelops upon the second or third day upon the lips. pulse.) most and in hepatization.but deficit in a small and blood to the the to soft. by which left ventricle.by which the invasion of pneumonia is accompanied. the and power. The headache. attain a frehundred and fifty and thirty. by dreams . blueness The of the lips and is observed in severe cheeks. it is not in the aortic system. where it often progresses. but we have no ventricle. of a hundred or or a While. continues with throughout the attack. more rarelyupon the nose. THE height greater than a viously pre- any attained. the malady of the attack.the temperature OF PARENCHYMA THE OF DISEASES 174 LUNG. this is due some high temperature (which its feeble strokes scarcely of the renders the pneumonia. Under and small a the cases. which occurs at the side upon which the pneumonia exists. It is generallycombined ubiially the sleepis ti oubled or sleeplessness. is very In soft. The extravasation. depressionof to blood.while the right consequence overloaded. resistance opposed by the aorta to the outflow these circumstances (upon the principlethat the tends always the a quence high. conspicuous in yellow purulentinfiltration. proportion to the resistheart. and its great rarityin abdominal a of vesicles filled with a cleai typhus. blood is heart's little blood but temperature small becomes the proportion to wave.whose The severe the at cases. an cardiac causes pulse afflux of obstacle effect ance). severity average twenty beats a minute. The is. cheeks. the and in cases.or eyelids. and to the overcome is in hundred a of pneumonia that so produce asthenia). but little blood flows beginning of hepatizationdepends upon blood of the inflamed part is from it. more. heart and the veins of the aortic system are (Upon cutting the into a piece redness of the in The lack of and gray hepatized lung.it usuallyis large and outset as full. partlyowing to pressure of the exudation upon acceleration which be fullycompensated for by the capillaries).

stools dry are fever.The urine is scanty and concentrated. However.by of beware must accounted for by are stools. The tongue. the urea structive increased in quantity. thisthe liver is theory of the originof icterus is only to be admitted when quently. and the We fever subsides. fregreatlyswelled and the patientis extremelycyanotic. cease as soon the as of grave inferringthe existence of these signs alone. cerebral disease from the presence there is no Even where complicating gastricdisorder.and is analogous to the with cause.in consequence the dryness of evaporation of the tissues become Obstruction leads to of blood slightjaundicewhich this obstruction icterus which disease flow perceptibleenlargement a oases. and we are why no such want is usually quiteat a loss to understand coated felt by the patient. creased in- which unfrequeiitly Perhaps.and to the due mainly are 175 be slightdelirium.as well the aggravated thirst (see catarrh pf the oral mucous as membrane).and shows a tendency to dryness. system and for the a compensating supply of The would assimilation increased an also the result of are complaint.the appetite usuallyis lost. the biliaryducts. pneumonic process and the fever which attends it exercise an the fever While importantinfluence upon the constitution of the urine. and its specific gravityis high.and appetiteis constipated. hepatic veins former the is diminished. there an symptoms is apt to fever. account which of febrile destructive priori^ that the augmented means symptoms other every difficult to most during fever. in some is dependent during pneumonia the liver. Far more of jaundice during pneumonia depend upon the symptoms a catarrh " of the dissolution " biliaryducts. is considerably Among the solid constituents of the urine. same the from occurs liver not organ. As is well known. distention of the retention and thus cause latter. its tendency to dryness. for. irritable temperament. a disintegration into of the blood is converted free coloring-matter duodenum of the and and of the " corpuscles.its color is some what dark. the thirst is considerablyaugmented.CROUPOUS at all of These PNEUMONIA. would the occasion One demand nourishment takes of the the on loss of a suppose. which high temperature place is body part of the replacethe waste. then* secretion dryer and to to may are tolerable frequence intertwined result in with compression of in the the absorptionof bile. satisfactorily of liquid from the skin. or else it arises from of the bloodblood that is to say.the tongue is lightlycoated with white. of that circulation in from appears. by which outside biliarycoloring-matter of the liver. the ultimate products of deThe assimilation of nitrogenoustissues are eliminated under the form . the upon the of of the the As heart. These and almost in occur the maintained. is reduced in the urine lasts the proportionof water by the insensible perspiration.

so distinct in healthy urine. of entirely twenty-four hours. in which. with violent the productionof urea.by the absolute or relative augmentation in susceptible Patients suffering from pneumonia.which solution in urates formation in the water of the healthy person a and meat forty grammes was pupils.and for the account few of no doubt.the amount is it contains.DISEASES 1YG of in febrile disease elevation of the The depends abnormal an upon THE OF PARENCHYMA THE uric acid. of the can sick time. chlorides in the secretion of alkaline quantities transmutation cannot warranted be in upon pneumonia patient a of their attributed supposing .from upon that this me the in grammes than more. previouslyacidulated. While the of the urine urea inorganic salts which diminished. passed man. and the at is increased of quantity. and urea OF LUXG. as a complete disappearancein the diet of the portionof from The patient: alkaline the of sodium the chlorides blood concentration and product of pneumonia we are depends.small in even found this containingsalt. be good health. solelyto that produced by destructive assimilation with the pneumonic exudation. than to ing hold- excessive an the . becomes within urea of precipitation phenomenon I have eggs. the nitrogenouselements participate.the augmentation of urea. food in chloride the diminution urine. reduced incapableof By gently warming the cloudiness of and redissolyed.and ere his muscles are The increased tion restored to their originalvolume. morbidly-active of course. is scarcely.eliminate absolutely be excrete fifteen to turbid becomes but it appears to proportionof the urates at a low of in is due thus always The urine rather but from monly com- very its urates to the temperature. temperature of the generationof heat bod y from a combustion of the constituents of the tissues. If The the are its a greater part of of use might but add we as.if at all.who cooling. especiallyits alkaline chlorides.even urine.without fever. salts themselves. the is the creted ex- dimr . height of the disease they may disappear comhi drops of a solution of nitrate of silver to the precipitate of the urine. pletely.of But the patient not much only grows thin because longer duration. of the urine. diet of alkaline starvinganimals. chlorides tissues.A short fever reduces than the weight of the patient far more does a fast. of chloride of some silver. while one of my whose diet was and preciselythat thirteen not the urine the urine be dissipated. destructive assimila- nitrogenous constituents of the body during fever is also of direct proof.and a considerable period of time elapsesere a confrom fever regainshis former strength.if almost pneumonia patientsto known non-nitrogenous. the of much quite as diet their in urea consists food whose does their though fever. in overheatinghis body. same urine. but the muscles his fat is consumed undergo a marked valescent atrophy.observable.

in cause other In circulation venous of intense evidence of the of the albuminuria source of heart-disease tion is obstruc- kidney. 177 of biliary well as the appearance as chlorides. of my book pneumonia a in fifth. The the at ment commenceskin. If. affording moist. in decline takes . is only to be ascribed to such a when it is accompanied by cyanosis. seventh. appearance in severe pendent in the urine. and which consists in and is a a apparently result of excessive elevation of the temperature intense the fever. the odd ones. The presence of albumen urine of pneumonia. upon warranted Meanwhile I have I have by great positive- the third the results of become with a either day.in calculating the initiatory chill began. is emulgent known. however. The more the more be found in the urine of pneumonia probably will albumen although there may be scarcely patients.which not unfrequentlyoccurs pneumonia. or febrile crasis.of which of the engorgement venous the greater tion. of the attack. any sign of venous ment engorgeof the systemic circulation. Its presence is sometimes by upon As well albuminuria of the veins. but the crisis occurs period of pneumonia even cases. notice of the hour accurate at which that the crisis of able.but not in parallel former Its transition rare asserted almost constantlyarrived instances. which no doubt. of the the chief most its cases kidneys. of obdoctrine . This parenchymatous degenerationof the kidney.is unten have pronounced ir authorities who spite of the high modern the duration of the disease its correctness. in our speak more fully swellingand opacityand molecular destruction of the renal epithelium.so much body. usually dry bathed becomes in sweat. is and after often two a day or parched. occurs in a great varietyof febrile disorders. the stadium have been describing ing Hitherto we inerementi. in many Monday at noon. quite as followingSunday .however. culminates.the formof the the disease. it will be seen place quite as often upon For instance. is deoccasioned other causes.are simply due to the improper quality conveyed The albumen of to the kidneys for the productionof urea. without. and enlargement of the liver. circula- is in the source shall we of parenchymatous degeneration second volume. a pneumonia.which. stage of is stage of decline.CROUPOUS PNEUMONIA. with its consequent albuminuria.and even any material relief to the patient. other any In editions ness the that the crisis of this assertion be to placewith a decrement^ suddenness or out with- disorder. into the stadium takes gradual. engorgement the lower animals in be produced artificially by ligationof these may of the nution The veins. pigment in the of matter the urine.and I large number satisfied that the ancient on believed servations. pneumonia always occurred on the odd days.or.in favor of we and that the take of that in which the critical the days as upon begins by a chill on course of 13 of the fever the commenced.

DISEASES

178
often

during

The

the

(hence during the

continue

day, which
middle, of

of the

with

constant

generallyarrives
the

first week
the

patient,from

strikingchange

takes

place,often

of the

the

frequence
patientfeels easier

the

THE

sixth

LUNG.

day)

in the

as

noon
after-

pulse

and

increasingintensityuntil

or

toward

of the

within

often

a

free.

; and

hours.

the

the intense

dition
constitutional
con-

a
solicitude,

The

rapidly,the

In

while

earnest

an

few

sink

end, less commonly

thirst,and

awaken

to

the

disease

dyspnoea,the

disorder, is beginning
and

OF

day.

symptoms

the critical

PARENCHYMA

THE

the forenoon

seventh

or

about

OF

temperature

dyspnoea abates,

of

twenty-four hours
is often
convalescence
fullyestablished. The patientsleeps,calls for
this time the
food, and merely complains of extreme
debility.-From
of
steadily. The temperature not
patientsprogresses
recovery
many
more

course

standard, and I repeatedly have
unfrequently falls below the normal
the pulse sink to fortybeats a minute, although the patient had
seen
not taken
a
grain of digitalis.The blood disappearsfrom the expectoration,
with
sometimes
suddenness.
The
gradually,sometimes
sputa
somewhat

become

compelled to

are

we

copious,but generallyto

more

that

suppose

absorbed,and

that

and

transparence

of the

greater parts of the

littleof it is expectorated.

but

be

must

the

slighta degree that

so

exudation
The

disappear with the blood
yellowness depends upon

sputum

city
tena-

it

;

The
an
yellowish sputa cocta.
show
less trace
admixture
of young
of fatty
more
or
cells,which
cells filled
slightlygranular pus-corpuscles,
metamorphosis. Besides
becomes

"

and
collections
fat granule-cells,
of granules and
of
oil-globules,
free oil-molecules,
and black pigment-cellsin greater or less numbers,
found in the expectoration. Although reabsorptioncommences
are
very
with

after exudation

soon

elapsesbefore
infiltration has
exudation
conditions
of

a

is

complete, yet

auscultation

and

a

percussion

disappeared. Yet,
are

as

in their

enclosed

for their

reabsorptionare
effusion with but
pleuritic

considerable

the
own

one

show

time

ally
usu-

that the pneumonic

smallest

of pneuparticles
monic
of capillaries,
the

net-work
favorable

more

period of

than

surface
capillary

for the

absorption
opposed to it.

of the vast majority of
subjectspreviouslyhealthy,the course
Indeed, with the exception of the
pneumonias is as above described.
In

infectious

diseases,there

are

few

maladies

whose

average

course

is

so

should
That we
have perceived
remarkably uniform.
not, until recently,
in which
its evidentlycyclical
character,is owing to the active manner
used
came
bewe
formerlyto attack the disease whereby its typicalcourse
bear
in mind
that not very long ago
it
deranged, One must
letting,
bloodwould have been thought a crime to treat a pneumonia without
and even
without repeated venesection.9
In

some

cases

the crisis does

not

occur

at the

end

of the firstweek.

PNEUMONIA.

CROUPOUS

or

is but

there

second

into the

continues

again,and

remission,after

short

a

179

which

the
The

week.

disease

pneumonic
high, and is

spread,the temperature remains
prostrationnow
Signs of extreme
higher than ever.
also
the elevation of the temperature, partially
to
continues

to

excessive

infiltration
sometimes

it,due

set
to

vrorse

grows

in part

exhaustion

duced
pro-

to the

and
calorification,

profuseness
by
I have
of the exudation, which
repeatedlyestimated at three pounds
and healthylung. The
after comparison of the weights of the diseased
an
assumes
asthenic,
fever, formerly of "inflammatory" type, now
The
pulse grows extremely frequent,
nervous
(typhoid)character.
and

continuous

"

"

soft ; the

small,and

; the

blunted

are

tongue

dry and incrusted ;
unfrequentlyvoids his urine

becomes

patientnot

all the
and

senses

faeces in

in the bed ; some
patientslie in a stupor from which they
voluntarily,
that it is
so
can
scarcelybe roused ; others,again,are wildly delirious,
such cases, especially
In many
possibleto restrain them in bed.
scarcely
been
if the patienthave
not
a
depleted by blood-letting,
change for

the

better

and

'again the

of almost

still take

may

transition

toward

place
from

condition

a

end

the

the

second

week,

apparentlydesperate,to

then

complete convalescence,
may

of

occur

in the

of

course

a

one

few

hours.

crisis at the

The

stage

of

the fever

end

of the

hepatizationpasses
continues

fails to

first week
into

on

into the second

that

week

also,when the
and
purulent infiltration,
equal or even
aggravated

of

with

occur

is dry
intensity.Here, too, the pulse is usuallysmall,and the mouth
and sticky. The
ture,
patientsare somnolent,or else delirious ; the temperaand
there
is
sometimes
in the.evening,
greatlyelevated,
especially
are

slightchills.

of
quantities
and

sputa,which

The

cells in

a

state

of

percussion alone

are

generallyprofuse,contain

fattydegeneration. It is clear
can
distinguishan extension of

that

great
cultation
aus-

the process

hepatizationfrom the transition into purulent infiltration.
the pneumonia attacks aged persons,
When
or
subjectsof depraved
though the malady be
constitution,
adynamic symptoms may arise,even
and
duration
of unusual
not
although purulent infiltration have not
of

ately
develop,so immediIndeed, so promptly do they sometimes
and the first onset
of the fever,that
after the chill,
do they appear
the signs of pulmonary disorder are
entirelyeclipsedby those of grave
have stated already,many
asthenic
fever.
As we
patientsof this kind
do they complain
have
no
sputa y nor
cough and no characteristic
is often
either of dyspnoea or
of pain. The frequency of respiration
die with the diagnosisof a
ascribed to the fever,and patientssometimes
catarrhal
a
fever,or a
typhoid gastricfever,"
typhoid influenza,"
occurred.

"

"

whose

autopsy

having

been

reveals

deceived

extensive

by

pneumonic

external appearances,

infiltration ; the
which

physician

reallybear

greatej

OF

DISEASES

180

resemblance

fever

healthy

and

gastric

or

the

of the

may

sputa

well

result in

extreme

the

create

malady

has

has

in

set

by

incrusted

the

have

thickly-coated
tonge, which

the

black

the

safeguardagainsterror

and

is apt to

very

of
a

bowels,and

afterward

often

abdomen

and

distended
if the

"

intestinal

catarrh

by the jaundiced hue of
is our
sole
Here, too, physical examination
"

The

tremens, and

the

when

the

beginning of
symptoms

monia
Pneu-

disclosures.

mortifyingpost-mortem
peculiarcharacteristics

intemperatehabits.
fit of delirium

the

choledochus

ductus

sclerotica.

assume

scabs, by
the

watery dischargesfrom

skin,and

to be

the

"

with

also involved

the

rare,

pain,cough,
depressingeffect
sity,
usuallyof great inten-

is

"

"

not

are

the

as

; but

fever,which

acute

and in other symptoms, which
prostration
terrifyingimpression upon the minds of the laitythat the
that a nervous
become
fever
typhoid" ("nervous"),or
The
and
disease
is further disguised,
the diagnosis rendered
an

doubly obscure,by
becomes

the

as

inasmuch

persons,

with

complicated

cases, which

at first absent

not

complicationas

soon

True, such

of old

are

is

pneumonia

catarrh.

pneumonia

characteristic

and

LUNG.

to

vigorous,where
intestinal

differ from

THE

pneumonia of vigorous adults,Mid hav
a
physicalexplorationof the chest.
also develop,sometimes, in subjectspreviously

make

ing neglectedto
Asthenic

than

typhus

to

OF

PARENCHYMA

THE

it attacks

attack

of

sons
per-

rather

seems

perverted cerebral

prominent that the pulmonary affection is liable to escape
The
notice.
patient can
hardlybe kept in bed ; he is exceedingly
does not complain,but declares that he is perfectly
well. He
loquacious,
action

is in

so

are

a

cheerful

most

humor,

and

his delirium

and

illusions

are

of that

He
pathognomonic of delirium tremens.
small animals,especially
mice and beetles,
pickswith great industry
all the manipulationsof
executes
at his bed-clothes,
or
persistance

peculiarkind
sees

and

which

his avocation

is almost

though a patientin this condition
have no cough, no expectoration,and complain of no pain,yet his chest
should
be explored with great care, especially
if he have fever.
Many
with a diagnosis 01' delirium
mens,
trea
patient has died in a strait-jacket
whose
real disease has been
pneumonia. At a later period the
pable,
fact that drinkers
are
scene
equallyincachanges. It is a well-known
or

and

an

in

pantomime.

still less

even

augmentation of
and

that

exercises

an

vigor of

the

a

fever

Even

capable,of bearing
their animal
of

very

heat

moderate

an

than

calorification

increase

of

aged

debilitated

or

intensityand

brief

exceedinglydepressing and exhaustinginfluence
heart,the action of the brain,and upon all other

sons,
per-

duration
upon

the

functions.

small and
weak,
pulse,originallyfull,
grows
excitement
and
demeanor
to
the extreme
a
bustling
give place
deep
skin
is
and
the
bathed
to
rapidly-increasing
somnolence,
apathy,
the cutaneous
of
iii sweat
(from incipientpalsy
muscles),gurgling
In

a

very

few

days

the

PNEUMONIA.

CROUPOUS

arise in

sounds
of
the

"

With

regard to

that recovery
sorbed

the

patient dies
of

rapid,where

the

the

stage
the

place from

exhausted

patientsare

with

termination

completion of
also take

may

(from commencing

the

is often

after

the

chest

and

bronchi)
lung.

the

as

the

by

18}

paralysisof

the symptoms

pneumonia,

of

have

we

the

muscles

oedema

of

alreadyseen

exudation

and
is reabliquefies,
ration
hepatization. Complete resto-

of

of

stage

weeks

of

purulentinfiltration,
only,
their
convalescence
is
fever,

extremelytedious.
Death, during the first and second stages of pneumonia, usuallyproceeds
from hyperaemia and
collateral oedema, by which
the uninflamed
rendered
air-vesicles are
incapable of carrying on respiration.Much
more
rarelyit depends upon the excessive extension of the pneumonic
The
intense dyspnoea,profusefrothy or liquidsputa,
infiltrationalone.
moist rdles in the uninflamed
parts of the lung, the sudden
sinking of
patient,the drowsiness, the vomiting,the coolness of the skin,arc
all signsof insufficient respiration,
and of imminent
danger of carbonicacid poisoning. Unless aid be at hand, the symptoms of palsy soon
vail,
preunder
and the patientsuccumbs
of the lung,
symptoms of oedema
palsy of the bronchi,and of suffocative effusion.
the

A

fatal

engorgement
rarer

the

issue,during
of

the

of

red

cerebral veins,with

Simple

occurrence.

stage

blueness

hepatization,
resultingfrom
is of far
consequent effusion,

of the

face need

lead

not

us

to fear

the headache
and the delirium sufficient
congestion; nor are even
such
warrant
ment
apprehension,neither do they requirethe active treat-

cerebral
to

demanded
imperatively
fall into
of
numbness

if
or
respiration,
of his limbs,or
threatened

the

which

somnolence

symptoms

of

The. third

and

by

that

by

cannot

condition.
be

If,however,

ascribed

the

to

the

tient
pa-

ment
embarrass-

he

of formication,
or
complain of a sense
should
slightconvulsions occur, life is

oedema

of the

brain,and

death

may

of
doubtedly
un-

with

ensue

coma.

most

usual

cause

of

death, during

the

stage

of

red

From
this cause
a
hepatizationin pneumonia, is exhaustion.
tively
comparaattack
this
disorder
is
of
where
the paextremelydangerous
slight
tient
where
is old or debilitated,
he is a drunkard
whose
or
are
nerves
who
need of stimulus,
trembles until he has his dram, and iu
in constant
added
whom
the privation
of the supply,
to the prostrationproduced by
the fever,soon
bringson paralysis. In like manner, a complicationwith
intestinal catarrh and icterus tends to hasten the exhaustion
; or, finally,
in
longer duration of the fever,and the magnitude of the exudation
a protracted
pneumonia, may expend the strengthof a person previously
the obtuseness
of the sensovigorous and healthy. In all these cases
rium
increases
smaller and
to stupor, the
smaller,the
pulse becomes
the

OF

DISEASES

182

with

skill is bedewed

OF

PARENCHYMA

THE

clammy sweat,

and

the

LUNG.

THE

patientdies

from

passive

hypersemia,passiveoedema, and suffocative effusion.
Death
takes placewith symptoms
quite like these in the third stage,
when
the strength proves
insufficient to
that of purilent infiltration,
the
withstand
the
duration
and
intensityof the fever. Sometimes
asthenic
arise during pneumonia, are
panied
accomsymptoms, which
may
The
pulse
by another group of symptoms of a different kind.
small and irregular,
a
slightjaundice appears, which
manifestly
grows
nous,
albumidoes not
biliaryobstruction ; the urine becomes
depend upon
the mind
of the patientis much
lent
disturbed,the delirium being vioafterward
there is much
at first,
settlinginto stupor. When
jaunJuce,this descriptioncorrespondsnearly with
found

in

of

many

the

probably have to do with
liver,
kidneys,brain,and
in detail

consider

well

as

organs,

the

of

as

With

to

the

these

monia
pneu-

cases

we

upon

of

abscess,when

an

we

have

may
the

good

ing
slightshiver-

purulent infiltration,
change into
yellow-gray discharge,containing more
in

an

febrile crasis.

accompany

largequantities
; but

violent
or

the

less

nosis
diag-

the

discover
can
microscope,we
fibres,which, from their structure, are recognizableas belonging
the existence
of a
lung, or when
physicalexplorationshows

large cavityin
death

In

degeneration upon

intensityof the

a
rigors;
pigment, begins to be expectorated
is only sure, when, by means
of

elastic

this

sequelaeof pneumonia,

rarer

formation

when

and

of

dependence

heat, and

regard to the

fits,which

bilious

the

a

then

liver,and

to suspect the

reason

pathologies.
*

parenchymatous degenerationof the heart,
In their appropriatesections we
blood.
shall
the subjectof parenchymatous degenerationof these
the relation of icterus to parenchymatous degeneration

of the animal

increase

ancient

that of

chest.

the

When

a

pulmonary

abscess

ends

fatally,

takes

similar to those which
place under conditions
accompany
death from
purulent infiltration. If the abscess heal,the expectoration
loses its yellow color,little by little,
the cavity gradually becomes
as
the abscess
tissue ; and when
is
enveloped in a capsule of connective

completely closed the sputa cease
entirely. Should a permanent
remain
behind, lined with a pyogenic membrane, and surrounded
connective
course,
of

and

gives rise

which

connective

tissue,it

we

tissue

to

have
and

its

the

same

symptoms,

runs

the

same

ties
cavidanger as do the bronchiectatic
The
formation
of new
treat in Chapter XI.
the cavity
contraction
in the regions about

the

to

affords

cavity
durated
by in-

same

give rise to those depressions of the thorax which we shall describe
is characterized
a
by-and-by. Gangrene
sequel to pneumonia
very rare
by most intense collapse,
by the expectorationof a blackish sputum
of a most
foul,putridodor, together with the physicalsigns of a cavit\
in the lungs (seeChapter XIL).
also

"

"

CROUPOUS

also take

is this

the

although the
subside
do
the

with
of

pneumonia

croupous

not

place in
case

so

not

pulse is

fever

emphysematous
the lungs, which
somewhat

moderates

completely as when
improve,the cough

condensation

by

no

means

is

fined
con-

attacked
In

rare.

the

it terminates
and

when

persons

upon

and

such

critical

percussion reveal

ent
persist-

parenchyma of the lung. After some
infiltration dissolves,
causing vast destruction of the lung, the

the

of which
of

shah1 examine

we

closelywhen

more

tients
pa-

evening
a

the

of

does

The

In the

by

cases,

day, it

in resolution.

dyspnoea remain.

auscultation

frequent ;

more

is

lungs old depositsof tubercle alreadyexist,
cially
subjectspreviouslyin good health. Espe-

whose

patientsin

but may

183

as
a
infiltration,
sequel to pneumonia,

Caseous
to

PNECTMONIA.

time,
toms
symp-

ject
consideringthe sub-

pulmonary consumption.

For

the termination

of croupous

pneumonia

in induration

cirrhosis

or

of the

lung, see Chapter XIL
Physical signs of Croupous
results

chest

regards

as

their proper

decided

shallow

pain ; and,

attack
as

hence

are

recognizethe side upon
glance,as the healthy side
it were,

side,as
the
upon

lags

chest

The

alone

of

of

pleuritis.There

spaces

the
sent
pre-

tance
great imporis,however, a
at

the

ning
beginof the

account

the

heaves

When

behind.
descend

diaphragm cannot
inspiration.The

of the

condition

of

disease,the vesicles are filled
possiimpervious to the air. It is often ble
which
the pneumonia has its seat at the

stages

to

first

sides

intercostal

since
respiratory
movements,
patientfavors the affected side on

later

exudation, and

Both

the

of
the

the

in

the

furrows, a
from

pneumonia
distinguishing
modification

of the

with

shape

thorax.

dimensions, and

of

Inspection gives negative

"

the

of

contour

their normal

preserve

in

the

Pneumonia.

normally,while
lower

both

lobes

the
are

the

; and

epigastriumdoes
by dilatation of the

patientbreathes

inflamed

infiltrated,
not

project
part

upper

(costal
type).

first

strikes the attention,upon
palpation, is an
point which
intensification of the impulse of the heart, and
(what is very important
hi distinguishing
between
and
pleuritis
pneumonia) the heart-shock is
felt in its normal
situation.
Palpation also reveals that,during the

period of engorgement,
the

of

chest

that

speaks
"

the

diagnosticsign
fact

that,in

upon

the

almost

at

narrower,

a

almost

is

grosslymislead
all

than

the

upon

the

passes

the

off from

strong, when

one,

the

who

is

This

the

tions
vibra-

patient

important

ignorant of

the

pectoralfremitus is stronger
This
is probably due
to the

is

wider, shorter, and

trachea,while
the

the
hepatization,

strengthened.

left.

bronchus

of

and

any

healthy persons,

right
right angle with

and

during that

pectoral fremitus

may

that

often

unusuallydistinct

are

rightside

circumstance

and

trachea

more

stands

longer,and
obliquely. (Seitz.)

the

left is

184

DISEASES

The

morbid

OF

this

at

of the vibrations
is

PARENCHYMA

OF

THE

LUXG.

intensityof the pectoralfremitus,during
which
depends upon the loss of elasticity

tissue sustains

wall

THE

Under

period.
from

normal

the trachea

the
the

by the tension of the elastic vesicles
of the healthy lung exerts
sort of suction
a
elasticity
surface of the thorax,whereby thoracic vibrations
are
These
the normal
vocal resonance
two
forces,by which
stillfurther

The

during

the

of

bronchi

of

of

vocal

have

chords

the

vesicular

pulmonary parenchyma.
the

the
hi

vibratile
secretion

bronchi

owing

only

the

fact that

walls
is

weakened
obstruction

contact

the chest

from

of

a

of

the

the

vibrations
trachea

and

the

continuous

a

happens

there
such

the

fied
solidi-

the

mission
trans-

one,
that

is neither

cases

engorgement
The

observed

loss of elasticity

we

often

of
elasticity

bronchial
infer that

may

lung prevents
compactly-infiltrated

vibrating.
Percussion
during the stage
purely tympanitic,hollow sound.

destroyed.

by a temporary occlusion of
unfrequentlyobserve
instances,
hepatizedpoint is permanently

not
we
by
fremitus
a
over
pectoral
is
or
entirelydeadened, when
In
nor
pleuriticexudation.

the close

check.

medium
chest,as
longer an interruptedone

It sometimes

; but

is

to the

the

no

wall),but

the

which

of

in

inner

is enfeebled

also to

is checked

waves

held

is often

to the air within

the

the

upon

not

imparted

unimpaired
they are transmitted

of air and
(alternations

of

but

fremitus,which

thoracic

; moreover,

of the lung
elasticity

vocal

is
hepatization,

to

which

the

the

hepatized lung,

pass

through

increase

stage

the

the

which

when

removed

during health,are

gorgement,
en-

sion
transmis-

to the

impeded

of

pulmonary

the
conditions,

largerbronchi

and

stage

the

the

walls

gives rise
normal

to

of

a

lung

bladder ; its ring is not
compared to that of a tightly-inflated
tympanitic. In the stage of hepatizationthe vesicles having lost their
its condition
is like that of a cluster of imperfectly-inflated
elasticity,
is tympanitic. The
Its percussion-soundthen
"hollow"
bladders.
diminution
which
the
exudation
a
percussion-sounddepends upon
in the vesicles,
in the amount
of air contained
causes
thereby reducing
the size of the vibratingbody. We
regard the expressions"full and
hollow
and
as
tom,
practical By universal custhoroughly intelligible
the sound
produced by the vibration of a large voluminous
body
may

be

"

"

M

is called

small

a

"

full

"

tone, and

is called

"

that

hollow

"

proceeding
Thus,

from

the

vibration

of

the

a

percussion-soundof
full to the ear
sounds
of the beginner ; that of the small
the stomach
who
I find that there are
few practitioners
intestine hollow.
can
nize
recogthat
the
of
with
facility
tympaniticpercussion-sound engorgement
for many
its higher
it is difficult to make
out
also is hollow, while
body

a

pitch.
when
During hepatization,

tone.

the

solidified

point

lies in

immediate

PNEUMONIA.

CROUPOUS

is

like

*ung,

The

vibrate.
with

the

When
that the

tones

Auscultation

before

the

formed

in

is to

lung

or
fire,

ear.

minute

it arises is

Then*

mode

the

of

stage

a

the

the

spaces

rubbed

bronchial

all the

finest of

the

moist

extremely viscid,it is also the

ease
dis-

extensive
upon

usually affords

is heard

are

the

of

ance.
resist-

of

seat

lung, very

engorgement

hairs

and

alteration of the sound

that which

few

dulness

When

of

roots

is,that the

of

sion-sound
percus-

increase of

generallybe perceived
is perfectlydull,the full

sound

exist without

may

the

when

a

throws

one

between

crackling (Laennec's rdle

is the
vesicles,
which

the

the

say, at

when

This

the

the

"

will

appreciated.

ear, like

the

to

case

percussion an

are

it
slight,

; when
be

during

cracklingsound
salt into the

is but

cannot

the

of
hepatization
percussion.

marked

more

dulness

that
central,

is

the

is also hollow

sound

hollow

and

much

the

a

a
point struck. This is because
hepatized
be made
to
compact body void of air,cannot
the hepatized region lying in contact
and wider

thicker

chest,so

of

act

such

the

over

other

any

only in

but

"

during the

and

deadened,

is felt

resistance

chest

the side of the

with

contact

185

the

fingers

which
crepitant),

terminations

rdles,and, as
dryest of the

and
the

is

monary
pul-

fluid

moist

in

rales.

vesicular

originperhaps
walls,which during
glued together,are forciblyseparated by the air
that portion of the lung
as
inspiration.As soon
upon

expirationbecame
which

enters

which

touches
is

the thoracic

bronchial
which

the

is
the
air

the

arrested,as

wall is

vesicles there
is

respiration

to-and-fro

healthy lung, the structure
vesicular
and
wall,furnishes
of this bad

the

and

ear

provided,that
contain

bronchi

filled up

of

become

coughing.
Bronchophony

sound,

sounds

communicate

with

them,
with

the

until

are

conducted

form

better

lung.

The
the

medium.

of

When,

lies between

audible

;

trachea,

always

that

so

the

air which

they already
chi
Moreover, the bron-

conductors

If the

bronchi

of

sound

should

be

happens temporarilyin
breathing ceases, and does

the

bronchi

conditions

sound

through

often

bronchial

along

the

stead
In-

alternations

become
the

the

ear

medium

breath.

every

normal

the

arises under

that

or

lung

respirationis produced.

iuring speech

uniform

a

air.

chi
largerbron-

to the

conducting

poor

secretion,as

pneumonia,
audible

a

of the

and

which, consistingof

ing
breath-

the

hear

we

transmitted

bronchial

the

traverse

accumulated

by

of

fro in

part

is not

of

set in vibration

which

stage

bronchial

to and

condensed

those

again

be

may

in the

third

the

either pass

air may

than

conductor

bronchi, these

the

is to say,

of the air in the trachea
which

but

impenetrable to

are

heard, that

movement

always making,

instead

vesicular
completelyinfiltrated,

have

similar
vibrations

column

become

to

those
of

the

of air in the

not

emptied by
under

which

vocal

chords

largerbron-

DISEASES

18G

ehi,but
tinct
the
a

OF

and

bad

surface

LUNG.

THE

the chest

of

as

India

an

lies between
healthypulmonary substance
bronchi
being,as we know
; the healthylung-substance
If the parenchyma become
of sound.
condensed,and

buzzing,as long

ear

the

only perceptibleupon

are

OF

PARENCHYMA

THE

the

conductor

the

as

thereby improved, the bronchi also becoming
of sound, from
the thickening of surrounding parts,
better conductors
the sound
of the voice in the thorax
is louder, constituting bronchodistinct articulate sound
is heard,which
a tolerably
phony ; sometimes
is called
pectoriloquy" If the sensory "herves of the ear perceive an
unpleasantjarringsensation from the thoracic wall,we have the
strong
its

transmittingpower

"

"

"

"

bronchophony,"
chest

the

upon

the
which

which

voice

feels

in

part

increase

an

heard

as

the

within

chest

that

means

the

of

(cegophony)there

phenomenon

Like

therefore

when

ear

laid
times
Some-

pectoralfremitus.

has
is

the

a

no

nasal,bleatingtone, for
explanation.
satisfactory

bronchial

the

while
the
breathing sound, bronchophony ceases
obstructed
tubes are
with
by secretion,and while their communication
the trachea is interrupted. During the process
of resolution of pneumonia,
heard.
the
moist
rdles are
air
when
Sometimes,
again begins

as

has

the secretion
"

that

as

bronchi

the minuter

to enter

less

the
vesicles,

than
viscidity

"

crepitation heard

is called the

sound

and

rale is

before,the
the

during

erepitatioredux.

The

but,
extremely fine,

sound

is not

"

so

dry

"

of

This
engorgement
produced in the greater

stage
rdles

bronchi,under conditions like those under which bronchial respiration
become
and bronchophony arise,may
bronchial
consonant
(Skoda)
and "ringing" rdles (Traube).
The
which
pleuritis
ceptible
constantlyaccompanies pneumonia is not susof physicaldemonstration, excepting when
it causes
a
copious
effusion.
There are
scarcelyever any audible friction-sounds in the first
stage of pneumonia, since the pleuralsurfaces rub togethervery little,
if at all,
heard
oftener during resoat that period. They are
somewhat
lution,
"

tho

the patientsbreathe
and
vesicles,
with greater freedom,producing friction of the pleuralfolds.
The
scess
physicalsignsof a great cavityin the lungs,as a result of abas

or
a

air then

"

gangrene,

further

chieflywhen

to the
as

a

"

very

membrane

with

disease

if the

fever,"with
; or, if the

as

tubercular

a

cavity.

have

In children

overlooked.
convulsions

little children

of their

child

of

do

and
not

fever

be

confined,it may

be

occurs

violent

fever,

expectorate,nor
is then

pain. Dyspnoea
diarrhoea,the

a

this

attributed

is often

inflammatoryirritation of the intestinal

bowels

For

Chapter XIII.
greatlyprostratedsubjects,
particularly

with

in

littlecough,
seat

in

is often

sets

those

refer to

we

and
children,

to tell the

fever,and,
tooth

them

pneumonia

the

by

how

In

"

in old men,

know

identical

of
description

DIAGNOSIS.

attended

are

the

reenters

mistaken

regarded
mucous

for

acute

PNEUMONIA.

CROUPOUS

hydrocephalus.

Children

187

violent fever,brain-symptoms, and

with

ried
hur-

The risk
auscultated.
frequentlyand carefully
of confounding the pneumonia occurring in old and greatly-depressed
of the
subjects with typhoid fever is guarded against by the absence
of the spleen,the eruption,the tenderness
in the ileocaecal region,
tumor
above
the initiatory
of the chest.
all,by the physicalexamination
chill,
be

respiration,must

The

differential

diagnosisbetween

considered
appropriately

more

with

the

Valuable

for the

examination
to prove

of the

The

historyof

the

the

The

"

disease.

the

The

the

and

be

the

of
filling

air-

from

ascertained

the

of

pulse

have

106"

above

hundred

one

from

in the

of death

cause

temperature
above

exhaustion

seen,

fever

majority of
increase

F., an

minating
ter-

fatal

in

the

twenty beats,renders

and

prognosisbad.
Pneumonia

to

of itself sufficient

is not

of the infiltration is to

physical

seen

tent
depend upon the exprognosis,first of all,must
Double
pneumonia is justlyregarded as the most
the
more
prognosis,however, depends much
upon

elevation

frequenceof

have

we

of infiltration

existence

accompanying fever,since,as we
in generalpalsy is the
An

familiar

case.

form.

cases.

as

be, it nevertheless

to

character

PROGNOSIS.
of the

chest

ourselves

made

be

the latter.

of

course

have

we

diagnosisof pneumonia

than

more

vesicles.

dreaded

and

symptoms

after

pleurisywill

and

pneumonia

is

drunkards,owing

fever ; and

while

from
it,the mortality

a

intolerance

their

to

but

this disease

should

Among

cause

well
us

the

as

to fear

the individual

prognosis. The absence
as
unfavorable,as must

with

of all

the

of

ana

to between

of the
and

endocarditis

heart,
ditis,
pericar-

result.

sputum
in the

sputa must,

the

persons

moderate

even

disease
tuberculosis,

unfavorable

an

aged

people amounts

occurrence

symptoms,

also

old

among

to

degrees of
middle-aged patientsdie of

of

proportionof

small

sixtyand seventy per cent.
Complicationsof pneumonia
Bright'sdisease,as

disease

extremely dangerous

an

of

appearance

furnishes

clew

a

to the

beginning,be regarded
very dark, brownish-red

state of nutrition and
a poor
signifies
of the pulmonary capillaries,
and, as a rule,denotes a cachectic
fragility
condition
of the individual.
Very copious liquidoedematous
sputa are

expectoration.
(prune-juice)

of evil.

ominous
if the

dulness
of

This

Scantyexpectorationduring resolution

continue

to

smaller

disappear,is of

expectoration,accompanied by gurgling

signifypalsy of
Delirium

the

of the

bronchi, oedema
at

gravity,and is due to
the high temperature

the
the
of

beginning

of

derangement
the blood

which

of

pneumonia,

importance;
in

sounds

but

sence
ab-

the chest,

lution.
lung, and approaching dissodisease

is

of nutrition

in

the

flows

through

a

matter

the
the

of

brain,or
brain.

no

to

At

DISEASES

188

OF

PARENCHYMA

THE

LUNG.

THE

OF

it is perperiod it often accompanies exhaustion,so that,when
sistent
tion,
be regarded as a sign of an adynamic condiand intense,
it may
The
furnish grounds for alarm.
is true of the
and hence
same
may
in the habit of calling nerwhich
entire train of symptoms
vous"
are
we
a

later

"

(typhoid). It has alreadybeen stated
twitchings,or palsy,are dangerous signs.

drowsiness, transient

that

Finally,the prognosisdepends upon the sequelaeof pneumonia. A
tion
transition from the stage of hepatizationinto that of purulent infiltrathan the termination
unfavorable
is of far more
tion
by liquefacaugury
and

the

of
more

absorption.
exudation,

The

formation

of

and

gangrene,

make

abscess,

an

the

tion
infiltra-

caseous

prognosis

and

more

grave.

TREATMENT.
of

The

"

inasmuch

cases,

unknown

atmospheric

highly

injudicious
teaches

abundant

almost

as

telluric

or

treat

to

the

under

causalis

indicatio

that

assumption

that

in

throughout

attack,the

the

arises
would

with

pneumonia

by

had

"taken

of

course

the

be
phoresis,
diaperience
Ex-

cold."

the

when

jority
ma-

from

it

instances

many

the

he

in

met

pneumonia
Indeed,

every

influences.

patient

a

be

cannot

is

sweating

disease

is especially

forget,in

the first

severe.

With

place,that

natural

the

almost

that of

than

the indicatio morbi,

regard to

pneumonia is more
disease,and that,left

other

if uncomplicated,and
patient,
ends

in recovery.

have

to thank

school and
which

from

This

the

has

the

of

success

than

previouslyin good

that,unless

that

decidedlycyclical
to

in
itself,

of the Vienna

for this
drawn.

important discovery,
Simple pneumonia

health

requiresno
small-pox,measles,or other
erysipelas,

does

there

be

warranted

of the

extent

complication. Indeed,

no

by

the

ous
vigor-

a

it almost always
intensity,
known
until recently. We
of treatment

be

to

are

cyclical
course, provided only that
and

been

not

homoeopaths

following rules

the

attacking persons
treatment

fact

of moderate

so-called expectant mode

the

not

of

course

any

must

we

diseases

disease

it has

active

more

been

active interference
specialindications,

be

of

erate,
mod-

proved
has

an

pneumonia ; and Dietl is rightin
often termi
affirmingthat this disease,when treated by bleeding,more
than where
venesection has been employed. It is quite
no
nates
fatally
unfavorable

a

different

effect upon

matter

of pneumonia
with

to

', but

the

the

compare
in

those

of

course

cases

which

in

spiteof pneumonia,
cases

in

which,

upon

and

we

bleed, not

because

for fear of certain

plications,
com-

is
blood-letting
principle,

practised.

never

practisedby JBouillaud
of the
other disciples
school,likewise
saignee coup sur coup
that bleeding
to support the experienceof Louis, Dietl,and others,

The
and
tends

number

of

bleedingswhich
"

used

to be

"

CROUFOUS

PNEUMONIA.

189

and that it does not even
cut
the
specific,
die bleedingshad to be repeated and continued
that is to say, until the terminal
seventh day
cycleof the pneumonic process was complete.
is

no

until the

day

"

Whichever

of

one

the

theories

current

short.

process

In

or
third,fifth,

arrived

when

"

inflammation

upon

fact,
the

we

maj

of them
of venesection
even
partially
adopt,none
upholds the efficacy
The
in pneumonia.
fact is,unfortunately,
forgotten,that the most in
occasion
tense
cannot
inflammation
hyperaemia,by itself,
croupous
; that
the enlargement and dilatation of the capillaries,
which we see in valvulai
disease of the heart,although they may
and oedema,
cause
splenification

produce croup of the air-vesicles. The subject of venesection
be more
can
appropriatelydiscussed while consideringthe symptomatic
indications for treatment, under
which
head it,strictly
speaking,belongs.
never

I have

made

extensive

pneumonia, and, relyingupon
this

recommend

can

the

patient,and

dipped
repeatedevery
all cases,
feel
the

yet

a

water

and

after

relief. The
reduced.

pulse,are

well

a

were
no

relatives

of

hours

Sometimes

favorable

very

I

the

cover

results,

chest

cloths which

this

of

treatment

have

the

been
be

must

compresses

procedure

of

is in almost

the

the
this

duration
one

the

that they
me
patientsassure
dyspnoea,and often the frequencyof

pain,the
retain

as

in

The

out.

wrung

Unpleasant
few

degree. My patientsoften
throughout the entire
hardlylead
symptoms would
The

all

cases
procedure.
side in particular,
with

five minutes.
even

material

In

of

affected

cold

in

cold

employment of
a large number

to

temperature

goes

down

surprisingcondition

of the

so
attack,
imagine the grave

an

of

entire

ment
improve-

that their outward
internal

disorder.

the

fail to perceivethe imdo not
provement,
patient,too, who
to which
now
at first they
readilyassist in the treatment
opposed. In a few cases, and only in a few, the use of cold affords
and the troublesome
relief,
manipulationfor its applicationincreases

the distress of the sufferers
such

I have

cases

In

the

not

much

so

insisted

hospitalat Prague

upon

that
the

they

further

refuse

keep
applicationof
to

it up.

In

cold.

pneumonia is treated with cold compresses,
of Smoler, it is exceptionalfor
and, according to the statements
relief from this treatment.
to feel material
a patientnot
As, however,
I have never
succeeded
in cuttingshort a pneumonia by means
of cold
I should
influence
to their use,
applications,
only ascribe a palliative
had

not

the

shortened
and
the

duration

and

methodical
disease

the

of the

every

disease

convalescence

in

many

hastened
In

employment.
delay its departure until

by

fact,in
the

but

instances
means

few

seventh

of
cases

been

decidedly

their

energetic

have

we

have

seen

proved
imday. Many
the fifth,
and a very large number
on
as
earlyas the third day ;
it impossibleto keep patientswith recent
nay, I have repeatedlyfound
in hospitalfor a longer period than a week.
pneumonia
Cold is rightly

DISEASES

190

regarded as
external
and

intestinal

in inflammation
of
antiphlogistics
directlytonic upon the relaxed tissues

is

harder

is

comprehend

to

its mode

of action

separatedfrom the point of application,
by
of the uterus
and
However, the contraction

bone.

muscles,when

cold

is

held

applied to

the

operation upon

justlybeen

LUNG.

THE

of parts

and

of its

OF

efficient

It
capillaries.

skin,muscle,

PARENCHYMA

Its action

organs.

inflammation

upon

THE

of the most

one

dilated

and

OF

the

abdomen,

interior,and

ice compresses

in repute for

have

the

proves

sibility
pos-

have

also the

long

meningitis,
I have no
peritonitis,
by IZiewisch.
experienceof the effect
pneumonia of the repeatedenvelopment of the entire body in cold
as

cold

presses
com-

in

upon

has

wrappings, as

been

practised often by hydropaths ; although it

that it would

be assumed

moderate

the

direct influence

an

effect upon

of

cases.

All

elevated

other

of

body,
by

all events, I

body

in

a

directlyto the

and

may
porarily
tem-

great

any

able

am

coolingtreatment

recommended

treatment

indicatio

when

At

of the

temperature

of the

unattended

were

phenomena.

addressed

regarded as
belong to the

temperature

if it

diseases,active

modes

be

cannot

local

infectious

the

the

fever,even
the

upon

that,in the
testify

reduce

has

to

such

large number
for

pneumonia

letting,
disease,but, like blood-

symptomatica

"

being required only

arise.10

specialsymptoms
Venesection
ought
only : 1st. When

be

to

resorted

the

in

to

pneumonia

has

the

following three

attacked

a

ditions
con-

vigorous

and

hitherto

healthysubject,is of recent occurrence, the temperature being
than
higher than 105" F., and the frequence of the pulse ratingat more
one

and

hundred

the violence

the

healthy and
indeed

danger
2d.

minute.

a

Here

free venesection

danger

threatens

will reduce

from

the temperature,

the

fever

is

degree,
than

unreduced

fever ; and

individuals.

vigorous

the

moderate

beats

frequence of the pulse. In those who are already
and
anaemic, bleeding increases the danger of exhaustion.
fever be moderate, blood-letting
is not
in
even
indicated,

debilitated

Should

of the

lessen

and

twenty

if he

so

apt

more

that the

had

had

to

to

It cannot

the

persist,
although in

enfeebled
pass

cut

fever
a

somewhat

patient is thrown

through a

more

short,and
more

into greater

violent fever,but with

strength.
When

collateral

a

minute,

and

when

the

in

the

portions of the lung unaffected
the pressure of the blood is reduced
by pneumonia is causing danger to life,
further
transudation
of
of
serum
by bleeding; and, by prevention
insufficience
into the vesicles,
of the lung and
carbonic-acid
poisoning
Whenever
averted.
the
in
of
are
respiration the com
great frequence
of a pneumonia
be traced to fever,pain,and to the
cannot
mencement
of the pneumonic process
as
extent
a
serous
alone,as soon
foamy
with
a
respiration of forty or fifty
expectorationappears, together
breaths

oedema

rattle in the chest does

not

cease

for

a

while

patienthas

the

after

the

to reduce

at

to

once

of blood

mass

practisea

and

erate
to mod-

collateral pressure.

the

third

The

ought

coughed, we

order

copious venesection,in

191

PNEUMONIA.

CROUPOUS

indication

of pressure

symptoms

the

upon

upon

the

appearance

brain, not headache

and

delirium,but

bleeding

for

arises

stupor or transient paralysis.
Having determined, for one or other

of
a

of

state

of the

above

reasons,

bleed,

to

misled

by the fact that the pulse may be
small and feeble instead of full and vigorous. Among
the practitioners
of the old school, a small,repressedpulse was
always an indication
the

physician must

be

not

"

"

for

and
blood-letting,
the

that

pulse

of

cases

be

may

advanced

improves immediately after,or

often

venesection,and

great number

a

the

indeed

that

when

the

during the
physicianwas

genuine or false,
debilityof the patientwas
the pulse became
take notice whether
he must
larger or smaller after
why the pulse often grows
phlebotomy. The following is the reason
stronger and fuller during or immediately after a bleeding: Ceteris
the
paribus, the size and fulness of the pulse depend mainly upon
the resistance
opposed by the aorta.
abilityof the heart to surmount
If the functional vigor of the heart be reduced
ence
by the depressing influin doubt

to whether

rule obtained

even

show

to

as

the

results from

which

an

immoderate

increase

of the

animal

heat,and

is induced
elevation of
constitutions,
by a very moderate
ing
temperature of the body, the resistance opposed by the aorta remainof blood propelledby the heart
unchanged meanwhile, the volume

which,in
the

some

reduce
this
pulse-wave is small.
If,now, we
diminish
the resistance of the aorta,
vascular tension by lettingblood,we
and enable the heart,althoughactuallyenfeebled,
increased
to propel an
the pulse rises.
of blood,and
volume
True, we may fail in obtaining
is diminished

this

the

and

effect,when,

the

weaken

greatlyto
the

as

action

happens,

of the

also diminish

resistance,
we

been

Digitalishas
of

sometimes

the

treatment

the

temperature,

the

effect

of

heart,so that,although we

is

diminish

the

propulsivepower.
employed, and with
extensively
Like

pneumonia.
diminishes

venesection

venesection,it

is

in
great justice,

lowers
febrifuge,
ing
pulse,without exercis-

the

a

frequenceof the
so weakening and
depressingan effect upon the system as bleeding.
Its exhibition
in pneumonia with a pulse of from
is indicated
hun
one
and twenty in frequence. With
dred to a hundred
a less frequentpulseit
infusion of digitalis
is not required. We
an
usuallycombine
(3 j 3 ss.
"

to

| vj) with

latter
apon

have
the

Next
S. ^

ss

influence

any

fever ;
come

neutral

the

they

the

every two

have

nauseants

salts of nitrate
upon
no

the

of

potassa

progress

nor
antiphlogistic

of

after

soda.

If the

the disease,it is

only

action.
aplastic

(antim.et pot. tart.

hours)and ipecacuanha;

and

vj to " vj.
these,quinine,veratrine.
gr. iv

"

gr.

192

DISEASES

and

inhalation

OF

of

but

and

the

has

of

By

OF

be

can

immediate

no

late fallen

THE

of each

means

temperature

have

they

of tartar-emetic

PARENCHYMA

chloroform.

action of the heart

moderated;

THE

of these

agents, the

influence.

into

is

better,in

According

discredit.

and
pulse-rate,
JBiermer,Kocher,

reducing
and

the disease

has

been

of

the

temperature

others, claim

it

surest

for it

maintain

eradicated

that
digitalis,

the

one

and
itself,

process

use

My

cent
re-

from

sive
exces-

two

hours

;

ten-graindoses at short intervals.
(a remedy spoken of by Vogt as

veratrin

is
antipyretic)

the

pneumonic

three

or

Biermer,

to

effective

very

two

fever

The

of danger
experiments with quinineshow that,in cases
fever,quinine should be given in two-grain doses every
or, what

the

reduced, and

local

somewhat

LUNG.

its

by

a

of

diminishing
pneumonia. Indeed,

means

in

direct

that, in

influence

certain

Veratrin

use.

a

has

the

upon

recent

this

cases,

advantage
pulse and

both

promptly,
upon
cumulatively. But, on the other
temperature,
apt
hand, reduction of the temperature and lowering of the pulse can only
be brought about
by the exhibition of doses so large as to cause
toms
sympof poisoning,vomiting,purging, and great prostration. Of pure
of a grain may
be given for a dose
of the
veratrin, the twentieth
over

operates

is less

and

more

to

act

"

viridis,one-sixth

resin,veratri

eight drops

to

Modern
robust
In

and

a

taken

be

may

of

experience

a

every

Of

grain.

the

hours

three

its

fullywarrants

tincture,from

in

mucilaginous

a

in recent

use

four

cases

subjects.11
measures
pneumonia all the above-named
the patient will soon
and
cold
under
improve
the better we
remember
placebo of gum-water ; still,

most

of

cases

for active

As

the

treatment,

the

greater

our

hitherto

compresses
cation
indi-

the

will be.

success

the

disease

the

debilitated
a

contractions
of

contractile

character

results if

complete adynamia
heart

lung, and
the

power

their extensive

constitution

people

the

the

administered;

the

prior to

of

embarrasses

excessive

an

of

most

the

that

seen

fever,or, independently

state

that

have

pneumonic

of the most

state

oedema

We

described.
of

to

perfluous,
su-

are

measures
advances,the symptoms often demand
is exactly the opposite of all
physiologicaloperationof which

a

hicle.
ve-

and

of the

in

of

either

of

is to

be

bronchial

attack,may
give rise
haustion
and, indeed, it is to this ex-

die of

pneumonia.

often

action,yet

cases
given
pneumonic process is

where
still

Stimulants

bronchi.
excited

muscles

traction
pro-

these,

the

into

must

is in other

diseases,from

stimulants

may

symptoms

passive
muscles
be

now

energetic action;
be raised.

must

feeble

The

to

of the

employment
of their

;

exudation, a

produce new
dangers from
commencing palsy of the bronchial
tend

evacuation
heart

who

succumb

those

the

as

tory
transi-

ing
produce very gratify-

of exhaustion

incomplete. By

Fruitless

tho

arise while

giving large

doses

generous diet. "vj fever constitutions indications as the Do distinct soon to of stimulants. physician. or of cachectic subjects be regarded as a serious blunder if a . without of Rademacher* cannot we assentingto the principles deny the success which his school has attained by the use of iron in acute febrile diseases.as tincture iron are of iron is hours).not only is the iron of the blood increased in amount. Rademacher's S.and the preparations cases of quinine and iron. adynamic state developsearly. sense Rademacher. Unfortunately.may when be indicated from the very outset of the attack. but the protein substances.musk. There is eine Eisenpneumonia which. only a of to in cold. Compensation for waste of the body by the portance than diet in far. CROUPOUS or progress of the Benzoic acid oedema. only know that. preparationsof quinine and cases. give concentrated administration of the peculiarly appropriate in these especially applicable (f not is of far carry the enfeebled begin broths. and.the obviation of which is is the quite as well promoted by the use of ferruginouspreparations as chronic deterioration of the blood in chlorosis." impoverishment of the blood often sets in during the disease. A physiological explanation form no of water. Local blood-letting.whose quantityalways undergoes diminution. For this purpose three two or hours) is particularly recommended.especially too but. if diarrhoea exist. milk.or all when It almost troublesome cases the pain is not the patientcannot bear. if we them use with sufficient boldness in of exhausting pneumonic and pleuriticexudation .as in the case of old persons. as in addition The use bold depraved wine. (gr. by alcohol. etc. ot "antiphlogistic"principles. the submit pain is not of the disturbance 14 be resorted employment of to the latter. four 193 PNEUMONIA. f im antiphlogistic and of asthenia posed pro- greater to sons.v. its removal respiration. in the of the undoubted and ss to usefulness ss two " of of the " preparationsof iron in chronic Wo impoverishmentof the blood has not as yet been found. of all treatment of cases pneumonia by Todd.particularly the globulinof the blood.to support the action Di*camphor. and it must has recognized pneumonia in a sup who. where may but is have one a of the causes beneficial effect . we often are thirt}T-six hours. is not approved. and strong wine. increases again under the use of iron. always mitigatesthe pain. should proceed to treat the malady posed gastric or nervous influenza. per- appear.arrest the facilitate expectoration. The and every aole. symptom.they are not well borne. affection des gesammt but an organismus darstellt.for about twentyof the heart. We shall easilyconvince ourselves that the action of the ferruginous preparations in acute impoverishment of the blood is quite as acute great as in chronic anaemia. by means upon an " " leeches or mitigatedby or und will not as must cups. The employment of stimulants. by his stethoscope.

In many adopted the in the extension the of into the of morbid air-cells the from pressure makes it than more its the alterations and which the anatomical lapsed.how favors essentially the the from the arises pneumonia pulmonary which that moreover. less by sleepthe indicatio the of use narcotics. air enclosed the bronchial tissue which of capillaries of solelythrough great majority of instances. nights. to employ PARENCHYMA THE OF cutaneous CHAPTER CATARRHAL ETIOLOGY. whether or at irritants.and simply.and and of more to seems be the of healthy children. . pneumonia the disease in question.notwithstandingthe persistence of the fever.should that Now cell-formation. In in develops circumstance the process air vesicles. This disease measles. when erated libcome be- after long persistence by augmented attended these of prising. least not until a late period. as it were. sinapismsor blisters. the PNEUMONIA The " is process and. Causes from which capillarybronchitis and the complication of in other collapse of properlycall it a a for this reason much catarrhal pneumonia.are disease commonly initial frequentlyin those childhood. or Finally. Nevertheless. " While croupous pneumonia extends. as unknown. than as its " " the are very lary capilcursors premost seen. as form a disease membrane mucous no of peculiarto with mucous the name catarrhal pulmonary vesicles. symptomatica may require and we fear to administer Dover's must not a powder at night under these circumstances.as is not quite applicableto catarrhal arises unless chitis.that course of the is most commonly of whooping-cough . but capillarybronchitis occurs latter complaints than observed the lung originate. THE other is better hand. pneumonia never preceded by catarrhal bronand its characteristic pathologicalalterations are as entirely analogous to those of bronchial catarrh.if the patientbe plagued by cough or restlessness.it should be transudation mucous occurrence. " catarrhal membranes. title.we shall retain the generally glands exists BRONCHOPNEUMONIA. ANATOMICAL APPEARANCES. 3ver. nor of this capillary hyperaemia. this disease a catarrhal cases the are catarrhal very pneumonia present.partialpulmonary collapse stages. of catarrhal pueumonia bronchitis. it is in We may children that sequel. already collapse probable that colhas alveolar appearances wall. LUNG. it not at all.194 DISEASES upon of the trie progress OF the On disease.when resolution is going on too slowly. copious brane mem- It is not in the enlarged and surcharged with blood. sur- vesicles. mucous X.

throughout an a 195 large portion of a lobe. and lie upon surfaces they of are a bluish a predominate. color. In severer and more protracted cases. under of them some already in a state of fattymetamorphosis. extending as process far the as back inflate them for the and will succeed. Their inflamed are almost midst in the affected observe air. have developed croupous the process contains pointscorresponding to the periphery of the lung.in which. inflamed Upon tion. there first bloody. the . in lobar or If which pneumonia. small them constantlyfind filled not attempt red.which lie chieflyupon the distinctly wedge-shaped. and purpose inner pink color.the find in and resistant. have then that with level throughout lobuli. we may see numerous cells. disseminated. opaque of names pulmonary homogeneous the upon pressure the a remains contradistinction lung more smooth a always obtained granulations characteristic the lateral Upon the of later. these inflammatory centres undergo the same the enclosed which in in collapsed have described we as taking place spots pulmonary tissue. that the studied These and described observers in agree exhibit portions of with resenting rep- alteration of lung collapsed the In slightercases. the entire lower lobes of each the side are sometimes involved. this alteration is limited to the lower sharp edge of the lungs. the voluminous ous numermassop . In a more advanced changes stage. upper reinflated of it has of the more often secretion.if presents of none red .and at liquid. they the there surface are the surface cut an the lighterand a of the to tissue distinct scattered firm surrounding parts. advanced coalesce into and of these centre inflammation these The in the cut of knots fillwith spots a surface uncollapsed stage. and lobular. pneumo- spot. of croupous nia. and we now irregularform and size. or a flows afterward over pale-gray the microscope. If we air. At first transudation and cell-growth grayish color.we the in at least lung. when structure even collapseis quite recent. When considerably more luminous vocollapsedparts become the remain of amount portion does deep scarlet or a An lobes.PNEUMONIA.but becomes that in the blood side but unusual an increased collapseis of long standing. insular pneumonia. unchanged Upon section dilated bronchiole resembles that while we the of the spots of centres force catarrhal of infiltration a to requisite its former vermilion separate compact knots inflate in the tenacious In is resume the lung. surrounding parts expand with *iing-substance (see above). CATARRHAL as entire lobe of rule. sec- and appearance. The gradual transition of atelectasis into in catarrhal pneumonia has recently been accuracy by Bartels and Ziemssen. catarrhal pneumonia has also hence limited to single lobuli. a proof in quantity.and to vertical stripeabout inches wide at their posterior edge upon two a either side.

but the croupous COURSE.and were the lower firm the of the more sequelseof rarer result common the of the lobes had changes with At parenchyma.or. still longer standing. in course acquainted pneumonia. this disorder hepatizationand exudation disease. chronic more a described that above.bloodless.we find that the color of the dark -brown infiltration has gradually faded from the centre toward the its firmness assumes a grayish appearance. It is difficult to pneumonia. compact.which connective by thick a catarrhal pneumonia analogous described as occurringin SYMPTOMS picture of catarrhal origin. AND more or network. interstitial connective of the traversed portionswere of pneumonia croupous one far a of of shrinking usual. cut also surface showed a presented a homogeneous. always supervenes lung proceeding from hi modifications " bands directions. during coughing. The bronchi parts of the lung thus altered could not be inflated. With the kind and mannot always characteristic.196 of DISEASES OF that induration. ingly acquired a pale. cell-growthin secutive con- all events.and forming is condensed grayish-white cords. only small quantitiesof purulent disease of the be liquidcan lung which of out infiltration. periphery. by expression complaints. the disease run of pneumonia tissue connective . which. Upon microscopic being at the same in the fattydegeneration examination. instead the as infiltration with pneumonia. in which largeportions of The may neoplastic formation and of accompanies form infiltration is of croupous in purulent stages as never Abscesses caseous wasting Bartels. by young of its countenance.while this red of fibrinous although catarrhal be the large portionof a a If the OF upon the as a less distinct disease catarrhal bronchitis.so that the middle time materiallydiminished.that coughing gives it pain.crossingone well-defined repeatedly. however. filled by yellowish caseous strikingpoint was plugs.and of the draw its is up sive comprehen- a of never bronchitis or a only symptoms symptoms of the primary collapse consist disorder the exception of the physical preceded. The most great increase tissue. signs.catarrhal series of cases. posteriorpart friable but THE expressed. are of the cough and the character of the fever furnish the most portant imler has set in. and in different ran The tissue. or when we find. smooth.The alterations we are just described analogous which of those to have we become than results often than a compact and pale-bluecolor. the distressed in its a very child. we perceivea further advance of granularmultinuclear of the cellular elements. Finally. data for the recognitionof the complicationwhich It is highly suspicious if the sick child fear to cough.strik- had The consistence. the to This induration of another termination which we of have pneumonia. and a largeadmixture which have cells (pus-cells). found. We by which it has been . adhesive but LUNG. dry appearance.so exhibits THE PARENCHYMA brownish-red.

tasis in the of has hours.or whose in whom bronchitis.we the characteristic intense must not expect first of child a day suddenly has none two or fering suf- catarrh.any rdles which may the signs of auscultation . neither diagnosticdata throughout the other fever the falls into soon cases. The of the in capillarybronchitis.void of air.which is always symmetrical. the rhonchi and rdles the vicinityof the collapsedregion. with those of a croupous pneumonia and If not period. in brief. the of no any the complaint have developed from an extensive atelecfew days. difficult and croupous monia pneu- collapsedlung.while speaking of whooping-cough. that the cessaand the occurrence.ascending posteriorlyupon both sides of almost spinal column which arisen for the evinces if the hand.it may even called to see impossibleto or with an be heard the sick child until this decide whether extensive we catarrhal have have a percussion at the to do inflammation stage with of are of be a acter ringingcharnow tical iden- hepatization. When by healthy parenchyma. in catarrh of measles. sometimes more cough just mentioned. and are auscultation nor percussionfurnishes physical signs pneumonic spots are surrounded very great magnitude.the somnolence. but. the fremitus extends becomes more outwardly. At breathingis bronchial.PKE"MONIA. and 105" to of of of the body always becomes a pneumonia upon catarrhal While development the modification rarelymiss does in extend not a narrow stripe. redder. . according to Ziemssen. or existed. short. pulse pneumonia. upon pneumonia. severe Upon often At the chest the examining grown worse.are and less distinctly audible less loud than somewhat in other parts of the collapseextend.we must a percuss The order to recognizethe dulness. As the collapsedportion of the lung at first presents but with feeble. great diagnosticvalue. few a time child measles. pectoralfremitus and the respiratory late sounds are not as yet altered.in thin layer. seldom in simple capillary the bronchitis. of the protractedcoughing-spells in their stead." are very serious symptoms . or. pectoral stronger. in same the from whose the upon catarrhal mounts. and in a genuine capillary attentive bronchitis.whooping-cough.and until a period.the dulness become becomes more more distinct. is of the 102. or genuine cough has begun to grow painful.namely. Should the collapsed part voluminous and dense. it still higher. " of the observers A will fact established that the Ziemssen by of the temperature of supervention a the temperature reaches the height of becomes and terror frequent. has where of state a bronchial fever great to viously pre- discover catarrhal whole of course the On disease. most. and should the lung. and face restlessness. elevated body. in and apathy F. CATARRHAL 197 have tion already stated.harsh.painful hacks. an a adept in percussionwill find a dulness.which toward the lateral is characteristic regions of the of thorax it.short stroke.2" catarrhal a F.

after hope has almost ceased. THE mation gives infor- repeatedlystated. producing catarrhal directions of the induration for if. rule. becomes hue bluish . while.a acute very disease children. the few a the event an livid. bron- form slowly stationarywith great persistenceoften The child becomes weeks. until death with the symptoms above ensues finally given . and pale dull grow may and lung. or of effusion had opportunity to a the as : tinction disoi occurrence tardy lateral extension of the condensed narrow stripesindicate collapseof the lung and catarrha* at first confined pneumonia . that the air-cells.DISEASES IDS THE OF (Physicalexploration.the the bronchi into the to easy disease of the understand extend Zievissen. and chronic in set as This whooping-cough rule. nance.) If.on the other hand. resolution of the infiltration and complete recovery and gradually. " is It capillarybronchitis. for many extremely emaciated. afterward. the service. and of course membrane mucous apply with regard to local recent experience of of the of treatment and same this general Bartels often of does and con- . the catarrhal as pneumonia. so for rare characteristic so lysis or a more which cases by distinction much fever seen. and the of one sometimes.not only does the a upon a termination the question as pneumonia.in the pneumonia. on the other hand. Tubercular abscess.the croupous decide and catarrhal take cases. attack It is also apparent. continuallyaugmenting of respiration.easy a lung.According to the general symptoms same latter never proves lungs following they appear when as lung. we the observe have we of the to as into OF PARENCHYMA have the its commencement. although prove In of of the is pneumonia The one. present inflammation sequelaeof croupous TREATMENT. may catarrhal course.but pneumonia the pneumonia to place.denotes The often.and. blood-letting.as the of progress the between the from malady is. and. the eyes apathy. perhaps. catarrhal hi occur is become soon a disturbance serious the to it continues follow.as two LUNG. a condensation symmetricalcondensation double to the and side. feeble if it attack especially previously red. the from will already given This is especially the case disease. whole inflammation croupous catarrhal of progress the over not days. the pernicious effects of to incomplete oxygenation and overcharge of the blood with carbonic place to acid decline sudden of to It pneumonia. fatal such in The lustreless . of resolution rapid a it does doubtful crisis a for common when even in that.spreading one pulmonary lobes. croupous is take to of true especially consolidation a those catarrhal chronic or on chitis. between even Here. counte- lips assume restlessness a gives Owing somnolence. or.and infiltration.never qualityof the condensation pleura. the of scarcelyever the the is subacute.

both cold applicationof presses com- pneumonia). excepting in that or cells. strength of the the 199 patient. such inhalation of irritating substances. and in a diminution tion the lung is solidified.lowering the of the and thus the spread inspirations. which pneumonia there is no While pulmonary consumption. The newly-formed material. occupying formerlyfilled by Chronic and follow the result of the a smaller amount of space than was healthy lung. with blood. in connective plasia of the product one of the air- as the form. of which connective The into known speak by-and-by.by which then undergoes further changes. BRONCHIECTATIC sue tislung. XI.INTERSTITIAL CHRONIC harm siderable by reducing PNEUMONIA.it afterward contracts. of air. chest has of (proposedby the INTERSTITIAL to that me. CHAPTER CHRONIC interest great stronglycommend efficient mode most been PNEUMONIA " OF INDURATION THE LUNG- CAVITIES. tending to encourage here I will again briefly call to mind of pulmonary collapse. instead of these rudiments of connective mere tissue. and the value of emetics. but only appears interstitial . in Even cases primary interesting inhalation is not a direct the induration of iron or coal-dust.resultingin an or present intercellular catarrhal and little and consists ing treat- tive nutri- no under sideration con- interlobular in a augmentation hyperof the of its cavities for the receplung. another elastic fibres to form portion serves third walls of the the to to bind together the lobules. A portion of this combines numerous the pulmonary air-cells . occurs as an dent indepenpneumonia scarcelyever observed to the disease. as The " at process tissue. when healthy. sections of a the of chronic the most lung converted interstitial frequent In chronic into a pneumonia.has but little connective with in its composition.while in croupous suffer inflammation is attacked. of which infiltration. pneumonia the pulmonary tissues disturbance. either of the affection form themselves preciselythis pulmonary tissue regarded free exudation shall we of it is the mass. caseous be must their interstices. fibrous callous.while a belongs There in which. and the frequentlack of sucenergy their in Bartels and far the Ziemssen the to It use. transitory it may as cess be. into a callous. as do all other neoplasticformations At first soft and filled of connective tissue arisingfrom inflammation. and is transformed substance of the bloodless substance.we find large ETIOLOGY. and is a large class of cases blood-vessels bronchi. of diseases.as in croupous me by- of treatment.

when chronic the separate that above processes. of the in induration LUNG.especially In other cases bronchiectasis. but. therefore. of latter. question is the excellent in the would dilatations of cases for interstitial the wall.compels to other us to sources.so that This tubes sinks structure not bronchial extra .is not in as become spaciouscanals chronic it is vacuum upon a traction. pulmonary deposits. its inner is enlarged by the pressure of stagnant secretion upon wall is impaired. We thorax tissue contractingconnective the only cause of bronchiectasis.the condition and. which or means residue solidification created chest. 4. and parts immediately result a The be must wall narrow it cavitywere atmosphere.this bronchi process of space as that The geny extensive compensated in limits. But midst of tissue air. We have it results that interstitial that seen is inflammation tant: irri- the of one the by complications the lungs. all produce apoplexy. but of the of the tissue dilatingthe exercises lung upon the of the is ascribe around and the bronchial origin of some Unfortunately. pneumonia not unfrequentlyforms a complicationof bronchitis. in spiteof and anatomy of bronchial satisfactorily explained.content ourselves chus probably the calibre of the bronby brieflystatingthat. the it first involves may occurrence pneumonia its products lung.cancer 2. by nc of Biermer its dilatation. The depositof tubercle.which the a traction exerted into far usually described discoveryof diffuse or sacculated which is simply collapsed. Interstitial the found.DISEASES 200 as secondarily. exudation interstitial must. during are incapableof expansion. from the healthy lung. which are It is thus (Virchow).thus cavities. forming bronchiectasis of the contraction the extend of is easy pressure. haemorrhagic infarctions.perhaps. and " with " nutritive of connective tissue of the bronchus. induced pneumonia catarrhal or croupous THE bronchitis the of consequence prolonged of and a OF PARENCHYMA THE OF to give rise to an Simple collapseof the lung appears sometimes of the interstitial substance.as yet.resultingin induration inflammatory proliferation of the lung.in some cases. by atmospheric possiblefor it to collapseis restricted dilated form by bronchial extensive within of pressure if the as the in the still contains bronchiectasis work an ing contract- wall. 1. lung the somewhat within of thoracic The yield. The by pneumonia capsules the named. when the resilience of the bronchial surface.and especiallythe softeningof tubercuof the lung. is a result of atmospheric pressure where of the in the of act cases portions lung inspiration. pulmonary abscess. as explanation. lous 3. from one the thence. extremely complicated the pathoupon origin is.other portionssufferingabnormal compen .

or else abscesses cavities. or in the knife. originatingfrom the bronchial walls.the pulmonary tissues sustain this intrusion of coal-dust remarkof recent well. substance. begins solidified substance the connective it the of the of air driver instead rarelyhave result the lobes coughing. find the afterward of the bronchial resistingpower struction pulmonary substance. of individuals autopsy inhaled glands results of found sometimes frequently more masses irregularly-shaped of a whitish color. They met an a later stage consist of of the disease bands. before pneumonia pulmonary of act We " be may points in the upper rush the centripetal bronchiectasis cause pressure. They surround blackened the are coal-dust often are found who in other to be of have worked in coal-mines.it the from before way than 201 arise in may Finally. again. are which by pigment. in in- this blackish. As a ably rule. depends upon the penetrationinto the lung of particlesof coal.or chial lungs and bron- occupations. Products of with. In other instances. a bronchiectatic vesicular walls tissue. and residue the tuberculous and latter of the lobes entire callous "viio the have a become may cries have " are under already of long standing. an often are cases in which this anthracosis has deposit of coal-dust) In other cases. less be wall the in ectasis is of dilatation of lung. and. When of calcified concretions. and found with but there resultingfrom in the lung.the a deeply-black hue. cavities are interstitial .in of quence conse- scanty intervesicular and hyperasniicand In paler. or if an obother impediment. composed of young tracts connective tissue. From the there is no doubt that this coloration investigation.CHRONIC In datory dilatation. INTERSTITIAL at the several cases base the of and reddened .it into such smaller the of expansion PNEUMONIA. swelling of at yieldbefore interstitial interlobular midst the of APPEARANCES. where the them bronchi. hinder proper place of pulmonary emphysema. or bronchial would that seem wall alveoli the by bronchi- compensatory of At first it is have cavities of indurated tissue. extending widely.and situated between portions of the lung which contained air.blackthe discoloration only lesion is combined pneumonia. if the a vesicles.bluish-graycolor. become caseous. emphy- We contract.I been found have had and while of opportunity of to void giving sema. air. and of a dense structure old masses which of tubercle. the black been ness (that is. which in lung in the tensive opportunity of observing exof pale-redhomogeneous substance. lung in the shape pneumonia croupous lung in the " twined en- terminates converted into duration. bronchiectases possiblethat some the the examining of that tubes ANATOMICAL then case. In much pulmonary substance.

for which Jconiosis had in black. the undergo grouped so with manv separated from wall.whose pouches are another one by ledges or valvular folds The inner crypts having flattened mucous The extension. a individual branches. which cases the extensive be to in all essential of the one the (/). the with temperature.and instead inhalation LUNG. often loses its the of the situated are of may cave and pouch or dilatation. rare quite a large tract enlargement. as it were.which OF also arise from similar is dust the of Zenker. having thus graduallylost its char- membrane mucous contain different vast of bronchiectatic surface side such ramifications of sacs of pouch a either bronchial such size either that into one : pouch side lies out sac would they expanded of the follows as rounded upon bronchial cases. the of inner We the get most in the rid also find surface at first in bronchiectatic in a greatly vermiformis. tube of dilatation greater part a that equal may tube the dilatation that of the saccular of cavity undergo change. a one any a advanced more smooth like resemblance some cavities At more of of a . yellow.which of is of ticulars. Zenker. bronchial cavities serous a contents extremely difficult latter. RoJcitanskydescribes '* We find in the bronchial a latter case another. Then.or a of the egg. is converted acts of unyielding condition becomes often size sinuous membrane. which. large of cavities. compressed if the that the synovia-like liquid. piace when It is not these common un- slough? . so axis bronchial or bronchial tubes widened a into often hen's a may In tube.stinkingichor. resembling that found obstructed in an or gall-bladder. surrounding parenchyma. and particularly lower lobes of the lung. than smooth. rise given the In color of the regarded of the lungs may induration slate-coloi a disease.which upon walls depriving severe haemorrhage the walls of their to take of the cavity. and in communication into a foul.and to out serous a of this the bean.producing smoothness. stage." is at first its secretion sac.shows as THE and to had entered the formation the lung. of iron. undoubtedly are suppurating bronchiectases. violent coughing. differing merely in to inhaled.202 DISEASES found in the OF THE indurated PARENCHYMA tissue. Hence. becoming bears over-distended a Owing which to the is not the sloughs as and for bounded of the cavities a by even are corrosive the to a the kind. however. We walnut.reported by of pneumono or siderosis. par- of the nature this of name oxide the lung.exposed to an elevated the atmosphere. the and disappeared through excessive acter. hazelnut. many Often find the together that they form. in a valuable treatise. it the secretion. anthracosis. to disease of he proposes siderotica that iron-dust. processus character. calibre upon else bronchi being greater further become retainingits normal of the fusiform.

or by the establishment pathognomonic sign of consumption) consumptive patients. enlargement of the liver. nor depression of the thoracic wall. and the ture na- sputa. rarely . circula- cyanosisappears. The regions. As this is one of the constant complicationsof the above diseases. cavitybecomes into a cheesy or calcined a transformed COURSE. which and of caseous accompanies tuberculosis. croupous that the percussion-soundcontinues dull and the respiration bronchial ration.INTERSTITIAL CHRONIC other In separate. In 203 tubes the very obliterated. the hypertrophy above which its induration and pneumonia. with blueness of the lips. Should the resolution of a pneumonia be very tardy. cases accompanied by contraction. and of idea gradually recover cheesy infiltration. if we find. since neither reduction the lung. its first stage interstitial pneumonia recognized with certainty. in induor we indistinct. We certaintyuntil the thorax commences to sink in at the affected side. emphysema. explanation of this is of the right heart to evacuation manifestlyproceeding easy .and the signs of bronchiectasis appear.caseous of cavities. symptoms which. cause inflammation or rarest instances.puffinessof the face. which causes When chronic chronic with pneumonia is associated mon.where counteracting the added to hypertrophy and symptoms of the heart effects of obstructed tion. is produced either by destruction of the pulmonary tubercular infiltration. and longer capable of at a of the later extensive. signs of dilatation heart the are period. the obstacle observe We from atrophy of the pulmonary capillaries. among by a disease of the described is somewhat right side .so that we may exclude the his no fever.which sometimes only be ascribed sion deprespanies accom- to this interstitial pulmonary consumption. the cases. the interstitial It is quite the same with to pneumonia regard infiltration the lung. anticipatethat the disease will terminate may hardly be can if the patienthave particularly health. deposit. depressionof the thoracic wall is less comthe only diagnosticsigns are the coughing-fits. as we An have learned. Although this symptom 'substance. can dimensions of of the pneumonic induration. also accompany emphysema.and finallydropsy.yet this is only the lung is destroyed is almost always (which is often erroneouslycalled is a the because one common very process bronchitis In and such of characteristic of the When is no a chronic the existence of cavities with rigidwalls.we reasonablyinfer that the dulness at the apex of the lung observed may diagnose the cannot in consumption is due the and of supra with disease in interstitial to part infra clavicular pneumonia. of contents leading to be may AND putrid diffuse ' PNEUMONIA.the bronchus its when contents SYMPTOMS of putrescence In " the the dilated lung.after the lapse of weeks.

is either quite impracticable.or follow kinds and dilatation. upon them between difference cavities tuberculous with side by the from Bronchiectatic lungs. through the lower in of similar cavitysituate one lobes. at least.and plugs.DISEASES 204 OF THE PARENCHYMA OF THE LUNG. lobes lower the of side lung.upper' while lying in bed.through bronchi whose obliquelyupward. while the body is in particular attitudes. or. of the the destruction the to fever. sputa which the patient ejectsare hand. The as ties pathognomonic of bronchiectatic cavisigns usuallydescribed losis are only met with in cases which are uncomplicated with tubercuand where the cavities are situated in the or cheesy infiltration. with the is attributable This blood is reduced hectic by circumstance ously that. announce. the in during life. cavities of the lung Easy as it often is to recognizebronchiectatic the diagnosisin other instances with is extremely obscure. that they day. containing caseous sputa. there is a double hinderance to the pulmonary although in such cases circulation. in most putrid bronchitis. cough. with of sac of the short similar often a sao vals.in we bronchus. culated and On a do to with In the and latter the former.fetid odor (particularly and is less viscid than most expectoration). certainty. (Casesoccur only practicable in which copious volumes of the thick. may two pass. will cougb .yellowish-greenfetid contents direction is of a patient. whenever or the. patientswith a bronchiectatic own clusters allowed bronchial all the other the of their half have which frothylayer.and it is easy cases.lying latter even recognizinga afforded by a bronchiectasis if we only know explicable. often margarine crystalsare it of the contents Indeed. or even a whole to of stand.) part of the body to sink laterally and bronchial incompleteness with which Owing to the difficulty lobes of the lung are cavities in the lower known emptied. extremely penetrating. form of coughs " have day.it an thick a collected the sputa of diffuse completely resembles Nevertheless.simultanethe volume of pulmonary capillaries. the accord. whitish-grayliquid. lower The manifestation lobes of the lungs is readily the extreme of discharging the difficulty of cavities in such dependent positions." patient of decide to with disease. inter- quality.even fore becavitypour from the mouth he stoops forward allows he has coughed. and to other unof a bronchiectatic causes. This the putrid sputum at the catarrhal has an of its moment separates cavities When found. to say nothing about dissection. The contents liquid contents the has the of in of a vomica at no lung difficulty flowing away apex but the the discharge from a obliquely descending bronchi. whether often undergo putrefaction. in short. into three strata. at the of apex the be distincannot guished cavities. cyanosisin the pulmonary induration which accompanies consumption.a middle layer of upper grayish-green sediment .

are pathog- of the existence of bronchiectatic well-marked cavity. This will be followed of coughing. the absence of of of however. violent which and at recur coughing-fits. its existence with a patient.and hence they are absent sacculation pulmonary contracted.there is usually period.and the irritation of the putrefyingsecretion does not appear It is only when to give rise to cough. therefore. On physicalexamination the diagnosis. In bronchiectasis of failed to find the In addition the to a symptoms cyanosis. as to furnishes toward may Upon compelling him expectoration. and the sac when its contents their normal assert that during which nomonic reach the neighboring bronchi.the the of the extensive when venous clubbed rather instances rare very signsof upon induration BO hitherto or cases even in enfeebled cavernous which to cough. long intervals. the patientwill ejectenormous a tion. ance percussion sound is exceedingly dull. directly dependent in the by induration. and is surrounded by normal chyma. however.or receivingbut a the spit-cupremaining empty for six few another attack will soon fill it to expectorationsof mucus. being due lungs (seeabove). in course of by a violent paroxysm short time.and the sensation of resistconsiuerablyincreased. . expectorates half a pint or Such of purulent secretion in the course of a few minutes. 205 but little. at a later long standing. may. in which bronchiectasis always affords lies close substance about the very beneath is not accompanied results characteristic the cavityis thoracic consolidated wall. respiration is breathing.I have hardly ever of the terminal phalanges such These cyanosis. we respiratory murmur else indistinct or moist rales.as its quantitiesof matter if in the bronchi would render respirationextremely difficult. there are some we usually forms to the comitant conbronchiectasis. physicalsigns a cavity. Physical examination the When bronchial the not thorax as in engorgement are ment enlargeof cases sistent per- not. The walls of bronchiectatic cavities seem insensible. quantitiesof putrid secreWhen the fit is over. parenIn spite. described. in which. diagnose positivecertaintywhen no aid without to sufferingany precursory dyspnoea. mous enormore could only come from a large cavity.if the patient have hear either enfeebled an coughed for some time. Upon auscultation. is completelyfull. large quantitiesof putrid sputa are expelled.and. expectoratingsmall quantitiesof catarrhal sputa. We sensitiveness. presence not impossible. or eight hours. when to be tolerably overflowing.the provoke copious often replaced by loud bronchial the other hand.CHRONIC INTERSTITIAL PNEUMONIA.dropsy. which still retain that the cough begins.because cavity is situated more the centre of the lung. another long period of exemption begins. and is also depressed at the point corresponding.

the bronchiectasis existence of the 3.for that at which stage impossibleto as resolve any powerlessto It In the " it recognizable. or by pneumonia from diffuse putrescence of the lung. hence. even the have formed. may and parenchyma or endeavor indications re"x"mmended secretion walls do interstitial of cicatricial tissue. interstitial pneumonia As " the of of disease. Patients consideration: tuberculous with . accompanied by emphysema and cular tuber- would emphysema former. life is sudendangered by haemorrhage from the walls of the caverns.as that this pro- .liver.and is often sole our spleen are displaced. consequent upon tedious accompanying chronic bronchial catarrh and emphysema. suffer but ease of strength.the This disease.and 2. means differential diagnosis between forming a turn is the of nature is scarcelyever pendent inde- an affection. and soften is other so the effect the closure foul the bronchial we and Both of must the to are us to best It met has to the see occasion not of the its relief the emptying still lungs. hoarseness diarrhoea. If it cannot be determined been though pleurisyor pneumonia.bronchiectasis are gree generally free from fever.so that the historyof the case whether the primary disease have guide. turpentine. although excluded. endured is often for TREATMENT. a cavity.alis far oftener bronchiectasis In of difference besides the taken into be of interstitial pneumonia consequence compression of the lung. or the original prognosis depends essentially upon when the malady accompanies is especiallythe case Extensive wasting of the lung. the patients only succumbing at a late period. excava- the followingpoints are situation. Saccular that. from similar a no the OF means THE arisingfrom in after either interstitial continued the and process.upon and denly of marasmus establishment dropsy. pneu- compression.from above. lung.DIAGNOSIS. caverns distinguishingbronchiectatic than to a their of from tions. Secondary disin cases of bronchial of the larynx and intestine is of rare occurrence and in a doubtful dilatation. tion diminu- distinguisha to easy LUNG. corrosion second of the flow vomicae. would coexistence in bronchiectasis of dilatation bronchi the of tuberculous the indicate no often so evidence excavation. to seems inhalation by already been We as As a of tion. the the is by scale in favor PROGNOSIS. tuberculosis. of these greater it is to equally are of bronchiectatic secretion. heart. pneumonia. form only remains.and hence often long retain a tolerable delittle emaciation. resultingfrom condition sinks wall thoracic by of consolidation and The It is often " PARENCHYMA THE OF DISEASES 206 monia. after bronchiectatic cavities long time. the question often remains unsolved.both secretion becomes pneumonia thing for any obliteration limit the which bronchi. 1. indica- cavityitself into the of oil of mentioned cavities. therefore. case. At other times.

THE have of mortification already come under others. blood in bronchial arteries.after follows. by embolus an from instances. which of of the four LUNGS. It is difficult to explain the occurrence of the of diffuse gangrene . GANGRENE " can I have CHAPTER ETIOLOGY.that of abscess as a foregoingchapters. Diffuse arises. differs from these forms of necrosis. infarction.both transition the region where putrefactionis going on.and of we quarter a cavities condition lasted for comfort.while that inflamed the stagnationof which is in the region. of 207 is effected. is especially into gangrene.and an or from means times a notice Various some an The seen selves our- coughing inhalations are patients raised to one by tolerable of XII.and their implicationin the putrefactionof its contents. daily. our in the as lung. from corrosion of the tissues surrounding a diffuse or saccular bronchiectasis.during the inflammatory stasis causing the rare nutrition. Pneumonia into the air-passages ot tood.ungs in caused drunkards. the occur. arrest. and disintegration Mortification of haemorrhagic infarction. putrefaction Gangrene may also arise with or without previous inflammation. or the by entrance residua of food.GANGRENE eedure that.and the spleen.inasmuch the dead and chemical factive Putreundergoes decomposition.in pulmonary gangrene absolute liver. OP forms hour. to run owing to the prone of these foreignbodies. secretion. part putrefies the most occurs decomposition of necrotic parts of economy commonly in organs which are exposed to contact with the air. envelopes.through obstruction of it is that such a result is arteries). violent misery extreme easilyconvince time.caused culminatingperiod of pneumonia.in the likelywhen coagulation of causes capillaries of necrosis be produced by lungs may of the heart.and inhalation evacuation repeated three this the actuallyrepresses THE OF LUNGS.putrefaction of ferment mortified of gangrene in metastatic normal if (thebronchial arteries common with brain.such as of the gangrene the as skin long dead and they as tissue is ^angrene the remain is not within so contact though circumscribed haemorrhagicinfarction the far some nutrient more to apt in the their the The " a in disease Such occurrence an the more the (a bit This into of terial) putrid maexplains why. materiallypromoted in come lungs.among of the pulmonary parenchyma sequel of pneumonia. of circulation and is the " part. and in persons whose constitution has been much . as a consequence proper.

and tolerably into ichor mortifies centre gangrenous from the spot . common sphacelousspot. but is the in oadematous or limited. In in the surrounding point. has foreign body no frequent entered and its occurrence in the course of severe asthenic air-passages. greenish-black an hard the at slough enters slough softens. a (Virchow). into decomposes its interior circumscribed into the up . Either tissue carious into form the organs of gangrene veins. If the is it mortification reach the too destroyed. we bluish-green. patientdying gangrene disturbance. and in rotten the an few a of walnut. the process is not abruptly gray ichor. constitutional takes the of general Recovery never place. may the of the . then find the parenchyma decomposed and converted into a putrid. the sloughs in pulmonary see abscess. lungs. there and the According " forms two are of find the that of the This alone.stinkingsubstance. APPEARANCES. saturated with blackishUnlike the preceding form. Diffuse of the lung not unfrequentlyattacks an entire We lobe. to of the may lead embolism. to and greater circulation.soon seat the the form. is also its as .resembling caustic potash. introduction to metastatic of decomposed abscess in thf . 2. to converted adjacentparts. diffuse: 1. hepatized parengraduallymerged chyma. pleura. is generally the pulmonary gangrene lower lobes. such as we communicates other of the gangrene indeed. black. which contains merely core. arises gangrenous follows. Circumscribed adherent fever. small-pox.and typhus. bronchitis the arises gangrene rare very scribed circum- ragged debris of the tissue.tinder-like. flows with is the also pleura cavityof the sac. a parenchyma lung fetid the eschar of the frightfully slough.DISEASES 208 debilitated OF THE by misery and in lunatics. measles. moist. interstitial pneumonia cases At firm. and ejected and cicatrization a skin produced by by cedematous ichorous liquid. It is abruptly limited. even appearance PARENCHYMA deficient OF THE nourishment where LUNG. ANATOMICAL tissue their instances.and surrounded of The cially espe- inflammatory the to pulmonary is the gangrene pointsvarying in size.from which part. the to more hazelnut a that with up of periphery of the into opens In ichor set and tube.were liable to die when disturbance its tissues exposed are further to Laennec. and cases. which already has suffered derangement of its nutrition. pyopneumothorax a diffuse and lung.resultingin incapsulationof are of isolated result. the thus circumscribed parts. as if seem.the is dangerous pleuritis a same time In occur. Not chus unfrequently a bron- gangrenous intense if the the is at first somewhat a bronchus. It would indeed. mixed distinction gangrene.

cannot infarction and metastatic generallybe diagnosed until deposits. Their general condition is scarcelychanged . rigors. a the gangrenous discharge and also liquid. sounds arise. black. we pulmonary gangrene loss of strength during the progress sudden observe of the latter a disease. percussionis tympanitic. spot be incapsulatedand atrophied. it is attended by signs of extreme adynamia. fever. When diffuse gangrene arises from the outset independently of pneumonia. and a thicker sedifrothy superficial one. leave no doubt about the nature of the case.SYMPTOMS COURSE.and in a few instances cavernous may Some patientsevince the greatest prostrationfrom the beginning . AND THE OF GANGRENE We " have LUNGS. the entrance of septicmatter delirium.if the gangrenous cease altogether. The sputa. sputum still reaches in lieu of the 15 mucous else membrane because They the the now fauces.with a small irregularpulse. The expectorationthen often ceases entirely. indeed. which circumscribed Even develops from hsemorrhagic gangrene. with its penetrating more " " odor. the disease goes on haemorrhage may arise exhaust the patient.stupor. hiccough. or.which at a may asthenic fever may develop. upon and rhagicinfarction metastatic . are added to the above symptoms. a disturbed countenance. Sometimes. now better. the foul odor of the breath.it may "When arises from diffuse pneumonia.and at last.and expectoration itself has become gangrenous patient no longer can respond to what not unfrequently swallow rhoea thus bring on an obstinate diar- . Then. take place (a very event rare indeed).and In these cases for weeks. rarelydull. and by symptoms like those which accompany into the blood. recovery the the odor of appears.like those of the decomposing expectorationby some of a bronchiectatic contents cavity.or any irritation whatever. they walk about. a liquidmiddle blackish is of the ish browncolor of The a or expectoration dirty tinder-like and It contains color. sputum disit graduallybecomes yellow.the blackish-gray the very ill-smelling sputa. after a time. containing acicular elastic tissue. a stratum. of the breath the fetid smell Sometimes precedes the characteristic days.to which the patient may succumb.etc. are without fever. it also concores. physicalexploration The sound affords further information. after Should for a long time.and the patient soon disorder this serious bear Others wonderfully well. the pulse small and extremely is the countenance pinched and livid. bronchus reaches and is ejected.either because the bronchial and insensible. worse. frequentlysoft masses. fibres of wavy. later period. In rare cases.now lingering. and and blackish the fetid breath soon liquidsputum. perishes from asthenic (putrid) frequent.soon separate into several layers. seen 209 that the haemor- signs of depositsin the lungs are very obscure. tains crystalsof fat. ment.

be of OF of is what some- by author be of arise Nourishing diet. infiltration of the tissues as with . and one mode of origin.PARENCHYMA THE OF DISEASES 210 OF THE LUNG. long contested consumption. in diffuse pulmonary gangrene at first affords Physical examination dull one a well-marked on percussion. They than more doubted. an tion aggrega- indurations or infiltration. as products lung.and afterUpon auscultation.we bronchial or TREATMENT. of whose justnessany one may easilysatisfyhimself and without will only study the subjectwith calmness prejudice. infusion itself.that destruction of cavities and frequentlya consumption of the lung are much more the majority of modern who deposit. according to modern the pathologicalneoplasms. Skoda. even term to the be the expression lungs.recommended may are is acetate TUBERCULOSIS THE the being recommended by an it skepticism in therapeutics. and of of the condition of cavities.the establishment to it. scarcelyas large as a millet-seed.have declared. although. among is the miliary form. trine.however. and afterward indistinct hear ward breathing and rdles. miliary tuberculosis.that it always It is one of the characteristics in the form of small nodules. but that they look upon entirelydifferent causes.in direct contradicand. and only recognizeone form of pulmonary I have this docform. the tuberculous tion various occasions.a proof that physiciansand clinical teachers still adhere to the teachings of Laennec. required by avail no against lead. tympanitic sound. upon of the pulmonary tissues. as deserve distinguishedby service of inhalations The ineffectual. any be stimulants patient. but one form. Laennec his discipleshave and into which they regard solidifications than inflammation tubercle as a is not neoplasm. Whether than of pulmonary gangrene those which bark. the eral gen- the grene gan- charcoal. ognized. sounds. due to tubercle still ranks views Even of tuberculosis. " cavernous The treatment in other his forms wine. THE pulmonary tuberculosis continues commonly used to signifyconsumption of most lungs turpentine. as enlargements formerly described neither tubercle. infiltrated depend upon and into grow consist All the voluminous always of extensive tuberculous tumors. will ultimatelyobtain result that of chronic The that error of tubercular general acceptation. And I hope these views. appears the of the fallen individual and that The largerso-called of many small nodules tubercular never nodules miliarytubercles. or LUNGS. recof tubercle.creasote.may bronchiectatic about of gangrene consideration.

It the pneumonic process to which be denied is right in certain cases that this view cannot . wherein arose. after a lapse of time. of their source LUNGS. infiltramorphosis^ meta- caseous long standing almost invariablyis of the disease. the very foundation chieflyindebted By Laennec this is swept away. nor of processes lungs it In the a is Laennec which The main OF diffuse upon different his of tubeicle. important step in pathologicalanatomy. by which the tuberculous of nature the process ing Accorda growth. ascribable to was tuberculosis. the converse is true . sign only tubercle but other many was It sidered con- is well with formations such as old. in a great in majorityof instances. phatic farctions. opaque. subsequently. might be determined.was specificpeculiarity be regarded as a diagnosticmark. after having exercised of the the prophylaxis and the treatment baneful both upon influence disease. Although the consolidation and destruction of the pulmonary sue tis- consumption is mainly a result of inflammation. to such views.transparent.and that it might a subjected. and it is reallyincomprehensiblethat the consumption depends upon majority of physicians of the present day should still adhere to his views. yellow.this connection is. which often appears in phthisicallungs independent of tubercle. may it has tive metamorphosis. the tuberculosis .this inflammatory product at first is moist.generally speaking.and. yet the frequent coexistence in phthisicallungs of the products of chronic pneumonia the latter of tubercle renders it improbable that the and presence tween beconnection and should be purelyaccidental. into flocculent a or cheesy masses. and against which I have long protested.that tuberculosis is the primary affecis secondary and dependent. to But the point of view. and.has fallen into disuse. suggests a causative the inflammatory lesions. and of a grayish or grayish-redcolor. curdy.cancerous nodules.TUBERCULOSIS tubercular morbid matter. the product of chronic pneumonia. especiallythe more and THE of metamorphosis caseous is obsolete.haemorrhagic inall undergo caseous incapsulated collections of pus.lymnothing in common.which has been producof great confusion. creamy liquid("tubercular"pus).is no longer tenable.however.but upon residua of pupils have regarded tubercle error the was chronic tion inflamma- tubercular as idea that tion. glands enlarged by hyperplasticcell-growth. and the term tuberculization. opinion. His fundamental idea for which the that we are teachings of all pulmonary most a neoplasm. becomes transformed into dry. tuberculosis. since. a that not of which from characteristic established which which development 211 nature. tubercle and mon According to the comtion. of to Virchow.

inflammation. moreover.whether to chronic or catarrhal. also found on the is it one hand. that nor The not always chronic.indeed. shall we accompanied by rise to destruction gives or sumption con- lungs. this product being totally different nature . and heading. The in the lungs is manifestly common a sive exten- frequentcoexistence. community the inflammatorydisorders connection which is indirect. for tubercles rare As a the of formation it as sequel to that of in a THE LUNG.in our next impropriety. is not tubercle.we may occurs croupous.but that the caseous metamorphosis of their be sume as- or relationship.in the rare instances in which tubercles have in developed in lungs which were other deposits have almost respects healthy. tuberculosis. it is simply objection infiltration phthisical is open peculiar to for. with of that. their to which and never diseases In which Chapter is not play the XIV.the found in the oldest immediate occurrence because other terminate in between chapter. CASEOUS always cheesy degeneration. to in a the diseases of catarrh. of on " this process the other. as the two pulmonary consumption. arisingfrom the pneumonic product.between and generallyprecede it. without may. pneumonia terminating and. pulmonary tis- the with the infiltration equal frequence. pneumonia [At present opinions vary widely as to the real nature form of chronic The catarrhal terms pneumonia. caseous having chronic no caseous thus Having and is and of vicinity peculiarlyfrequent there less no XIII. CHAPTER INFILTRATION LUNGS ETIOLOGY.which pneumonia.discuss the subjectsof chronic and of chronic pulmonary tuberculosis. miliary tuberculosis. AND " CHRONIC TUBERCULOSIS PULMONARY THE OP CONSUMPTION. and broncho-pneumonia do not properly characterize the .we pneumonia infiltration of attention masses tubercle caseous principalpart in speak of acute diseases belief in my the lung of the are arise which often so a causative relationship pulmonary tuberculosis.212 DISEASES OF supervening as a is. lung which does not contain tubercle in takes never place unless infiltration caseous of preceded by sue. there a upon form to OF inflammation. term " caseous nia" pneumo- cheesy metamorphosis to nor. and. . The truth of this supposition is materiallysupported by the fact that.in tubercles numerous in which organ stated distinctly called under most of the observation by so metamorphosis. infiltration. caseous always been found in other and organs. a secondary process chronic products of PARENCHYMA THE is direct no immediate and tuberculosis origin. It preexistingpneumonia.

the Rindfleisch favors the doctrine of phthisis. opinion of Buhl in a previous The induces which certain in chronic very vain in shall is in of work. slaty indurations phthisishas no pneumonia may of form any LUNGS. Under itself. this infiltration to special tubercleand blood-cells pus-cellsby their and. above-described his pneumonia desquamative pneumonia. in already been find extensive phthisis we the we lungs. specificproduct of a constitutional anomaly. not and finer all the bronchi. This happens when. He maintains of which is to phthisis is a peculiar one. The close histological disease shows relationship to other lepra. a proliferationand processes grave besides the tion accumula- epithelium take place in the vesicles and bronchi. in which cheesy deposit. obstructed becomes crosis soon by the resultingpressure. changes in the tis. JKindfleischascribes account he regards as finely-granularprotoplasm. If the proliferation sue tisof and a but and infiltration. absent though sometimes. richness the in like. as in catarrhal but views the specialnature. distinct under the for and the pneumonia. the essence in superficial inflammatory disorders. as the cause anaemic He with necrosis of calls it tubercular miliarytubercle But tissue. THE rarely. is attacked. certain of lobes trace any that has cases upper opposition to this As insidious in search direct edition 213 consumption. Although one. stroma wall. there may be hypertrophy and induration with by cheesy degeneration. as well as pressure of the infiltration.CONSUMPTION it is stated. in the parenchyma. and neensues. of a specialinflammation. Cheesy degenerationand softening follow. with Buhl. OF cast-off predominate. He believes that chemical action has to do with the cheesy metamorphosis. besides the cell-growth in the stroma. may in the connective in various ways. yet we the may origin of phthisiswould well assume that in a thus seem to be a predisposedsubject a specific catarrh . syphilis. from cells. and in end which be above the a nounced an- that ous case- induces croupous in other peribronchi- term of the of sought. because.and specificinflammations. such as typhus. adventitial This bined peribronchitisis comBuhl parenchymatous pneumonia.distinguishable white of its close it relation parenchymatous. croscope the mibecause the diagnosis is based recognition under upon disease The in the minate tersputa of the desquamation.albuminous vascular the of in of pneumonia conditions that the inflammation degeneration. a further liferation proTheir culation cirtakes place in the envelopes of the arterioles.followed inflammation. on . gelatinous.Buhl also in which envelope with calls describes whole the the an condition analogous bronchial bronchus.

a Thus. or the nourished is tubercle tissue. formerly regarded is consumption. they lose their rounded clots ( Virchow}. atrophied . with the secondary majority a endothelium. and. while of simple in the inflammation compact organs . through loss of their water. the is indirect an more in other tubercles cheesy deposits. are a is geneticalconnection since. great crowded softening of of want the seem as vessels. especiallyin the lym- of organs.and around multinuclear few a poorly atrophies. having looked now indeed. the nodules they as consequence a Microscopically. existence.shrinking into change. many property. hence. tubercle. tween (void of vessels). liquefies.bea central the well as consists enclosed. connective in the bronchioles. the pneumonia terminates inflammatory is aband sorbed. nearest to When When the disease is followed by caseous the infiltration. hard by after latter which giant-cells.where and lymph-vessels be the their and seat. Buhl has infectious disease. the cells are form. large tubercle more in cases. At nucleus.the miliarytuberculosis that generally preceded by . cheesy dephatics. translucent a connective the their The thus It consists of a proliferation lymphoma. surrounding tissues. the vicinityof the deposited. and shrink. and a special centre. specificaction the the as congregated about to take place both of cells "as THE consumption.the clustered tuberculous " tissue less fine net-work or . to and OF PARENCHYMA THE OF by fatty anaemic cause containing them. grayish. The minute points of irritation.DISEASES 214 pneumonia croupous or lead awaken may Tubercle. the " . monia. The infiltration dries up . pneu- the rare cases of the found often when caseous an posits lungs.19] in resolution. it either breaks down of tubercle masses tissues the a crease de- regarded are For brief else or mass. finer arteries may bronchi. we the it is that without found Moreover. of and all the of gravest of but as upon cell-growth seems the LUNG. it is absent Fresh tubercle nodule. oldest and largest masses. conglomerated many nodule of lesions minute. which are the J"lood-vessels. altogether in the takes the form of structure of of the lymph-sheaths of walls the shows the a of meshes in volume centre having of mother-cells like the which generally find we specific some necrosis cells recede from else. in so cheesy degeneration always are idea there conditions two consumption As assume may between the promulgated only in the closest they are very extensively already degenerating. then product undergoes fatty metamorphosis. cavities are formed. into irregularly-shaped It is often a fact that undergoes in the caseous lungs the product degeneration. fatty metamorphosis is incomplete.lie the cheesy foci.

in acute catarrhal pneumonia it is somewhat more frequent. enclosingthe inflammatory products. the in 215 the difference is frequence with which the inflammatory products of the various instead forms of pneumonia undergo cheesy transformation of liquefaction and absorption. We vomicse. natural cavilies already exist.with rare exceptions. chronic catarrh. pneumonia should generallygive rise to caseous than the form of the far more acute indeed.or than frequently.and thence into the should I certainly attach little weight to the pulmonary vesicles.and the its distinguishablefrom is The and explanationis. when occurs pathologicalcavityhas a formed.is glitter air-vesicles is to with say. of conditions.is rare. pneumonia as the only title losis. disease.by callingthe disease by its proper not only is our comprehension of the etiology and name.that pneumonia termination. chronic catarrhal pneumonia to the so-called applicationof the name gelatinouspneumonia. thus adding still more peusis are . infiltration caseous that the all forms certain of which of pneumonia. cells in the air-vesicles. fresh perfect truth. as disease tuberculous and infiltration. did I not believe that. of frog-spawn. Owing to the slowness and tedious nature of its pneumonia. it is in these dissent emphatically express our infiltration of the lung. homogeneous section dependent simply upon sphericalcells of indeterminate products of catarrhal of a through extension of young cells. but arises.with a copious secretion finer terminal bronchioles. very great in while in the I regard the catarrhal chronic the appropriate to the form and gelatinousor with is not extensive. (when lobar its color the which and the nature. or disease with of the catarrhal chronic name it is almost form and a fillingof latterlyand of name lous tubercu- or infiltration. it pneumonia is a there that sole end may and is in of peculiar It is true of confusion. usually called infiltrated tubercu- equal improprietyhas sometimes This of cheesy pneumonia. pathology of the but malady facilitated. It is not difficult to understand catarrhal infiltration.that. which in source form a of of a " contrary.and products are usuallydeposited.into the received lobular is)this it often its rule. with must caseous On The lungs.has its nature.with be may that formation varieties caseous tends only the inflammation other or from concomitant primary "tuberculous hypothesis lung is entirelyuntenable. In croupous pneumonia such a result is rare . and result this THE OF CONSUMPTION only LUNGS. constant of of cause under flammator in- theory that inflammation to infiltration caseous form no said. perhaps also by an inhalation of cells young those the from smaller to already bronchi. that infiltration the of the lungs. croupous of the tendency of which is to a perpetual accumulation progress. with young the tomical ana- pneumonia. its prophylaxis and thera- why chronic promoted.

The originof the during caseous deaths many which of measles have or chieflyascribed been to the the effect of a even person should never been observed take place after an epidemic of whooping-cough.and undergoing degen" thus eration. subdisintegrationof the lung. "sickly" that they are " do not recover as rapidly . has prepared the soil for the growth of tubercle. the measles whooping-cough.that feeble.is.which had hitherto defied ascribed to all (as interpretation are long consumption always now fully neoplasm). possessing normal resistingpower against noxious influences. reconcilable to the generallyacknowledged laws of pathology. prior to the in perfecthealth. tomore more vesicles. proceeding from a cold. reallytraceable catarrhal a above-named But in or pneumonia to contracted during the disorders.the tuberculosis is almost always preceded by a pneumonic process.has to tuberculosis. In the most or delicacy a similar manner vigorous and blooming children may be attacked by acute catarrhal pneumonia. That feeble and ill-nourished should persons be becoming consumptive than vigorous. prethe predisposition toward in filtratio pneumonia terminating cheesy inwas as is It strongest in persons feeble of and delicate constitution.has been of material assistance in explaining the etiology of consumption. to speak more cisely.well-nourished extraordinaryfrom this point of view. Predispositionto pulmonary consumption or.genuine catarrh may of apparentlyperfect health extend a feel sure that they will and into the vigor.enjoy an immunity from this disease. by caseous degeneration of its products. and that. knowledge that the majority of cases of consumption are not tubercles the result of neoplasm but of inflammation. appear Daily experience teaches us that a bad state of nutrition feeble accompanied by power without Even especialknowledge of a priori. THE the the cells are and crowded gether. although it is somewhat rare.when exist in phthisical lungs.in most cases. Numerous The well-established facts.badly-fed persons a especially prone to disease. is will usually influences. and may soon perishthrough metamorphosis of the pneumonic product. which. until recently. Indeed. in individuals who.and resultingin infiltration and destruction of the pulmonary substance. even croupsometimes terminates with in sequent ous caseous pneumonia infiltration.were signswhatever of constitution. is meant by no means by this that vigorous persons. is usuallyassumed. Healthy die of not air-vesicles acute an or catarrhal pneumonia.and gave of weakness no attack. simple. and which.it are they men chronic caseous in far greater danger of not of course noxious ones.216 DISEASES generated in THE OF PARENCHYMA OF LUNG.and of that of endurance the fact. becoming mutually injurious.

inflame. in persons exempt from this peculiartendency. than to the formation that such as The summed capable of development into new main points of the subject hitherto are up as follows: The consolidation tissue. and the longer quantity of cellular elements the more the duration of the inflammation. because disorders all inflammatory nutritive be affected by which they may with subsequent caseous show great tendency to copious cell-formation. the after period disorders But delicacyand disorders are which the not of of puberty to the lungs. badly-nourished subjects. which the greater the usually the products of inflammatory action. the lymphatic glands neither enlarge. prone of cells of a decrepit and of perishablenature. as a lymphatic glands participatein this morbid of is and dency a rule. but not exclusively. in few words. It very frequentlyhappens.While. All derangements of nutrition occurringin the former of young. be of the basis the anatomical for consumption. they derive their lymph. are form lungs. Secondly: favorable for the production of caseous most occurs pneumonia resulting in caseous infiltration frequently. croup. discussed and may. of the organs that their " the matory inflam- class and flesh does not give able perishheal.that the tenderness. badly-nourished when the formation to or inflamed. and.are more ill-developed organs. THE OF often the age of the individual.that a trifling irritation. We may now.have Persons and LUNGS. accompanied by augmentation irritability strong tento profuse cell-production. peculiarity increased which to an irritability partiallyattributable accompanies that constitutional fact and the to partially weakness. in part.are liable during bronchial flammatory haemorrhage and to in- to pneumonic and liability only distinctive marks between a of such persons.ill-nourished subjectsand those who are well nourished and strong. rise to a very profuse formation indeterminate cells.CONSUMPTION body affected are frequence with The its attacks.cerebral irritation. from disease by differs and pseudo-croup. and collected in the vesicles.nor of of intense and malignant inflammation suppurate.the relations of scrofula and consumption. degeneration. define our position with regard to pulmonary greatly-vexedquestion.which. so much readily will most pneumonia lead to consumption. the This and of wounded is copious suppuration part. since these are the conditions infiltration. very trifling that . during childhood. especially during childhood. moist other inflammatory feeble. This is partially because such persons are especiallydelicate. suffered from It is said eruptions." is apt to be followed by severe wound is. destruction then. the 217 various according to who. exceptingin case the parts from which irritants. in puny.

to an enlargement of the of their normal cellular elements.in scrofulous the tendency to glandular enlargement by cellular hyperindividuals. with the exception of the implicationof the lymphatic of the causes from which the glands. the obstinacywhich same show. can persistence. this susceptiof the lungs become of the which and other are eruption.are inflammations laitysay).and much so cells.DISEASES 218 and mild and vessels thus are OF innocent OF of inflammation suffice originate.into and PARENCHYMA THE LUNG.the greater the happen) a partialor diffuse instances is it to swollen is the in their tendency of of mass caseous result.of individuals who active an cells. " rule. more especiallyliable scrofulous the now have like. glands. of resisting noxious Now. the of the whose stimulus (and. those a circumstance which in caseous greatlyfavors their termination degeneration. the morbid action usuallylimitingitself to a simple cellular hyperplasia.particularly to scrofulous mia. is scrofulous of excitingcauses scrofulous catarrh. as of all morbid in individuals of this class is retrogression processes nate extremely tedious.the frequence of their recurrence. escape is so anatomical sign by so-called scrofulous as appears " of which a if such the as scrofulous eruptions. yet pneumonic with equallytrifling ophthalmia evince the at and the eruptions. . although the fre- affections the diseases used to of the cornea and diminished.are the circumstance lay especialstress upon that. the lymregion whence phatic glands.it is only from the insignificance scrofulous be eruption can affections nate proceed. the which various causes experience points Upon glancing over toward it will be strikingly to out us as consumption. and their obstithat we infer their scrofulous nature.the moist conjunctiva and processes have not individuals. be inflammation.that is to say." ophthal- disorders. a There ophthalmia is or a distinguishedfrom similar non-scrofulous disorders. plasia to We with constantlycombined to inflammatory disease.and the apt more degeneration of the Persons in many this to said the generaldelicacy profuse cell-formation der un- scrofulous.and." It often means marked very " spontaneously (" of themselves. production of new glands do not take place in of the suppuration the excite to the THE tion Inflammaall or even in the majority of cases."as on disease. affected.etc. predisponents that they all retard 01 particular.meantime to occur rise to apt formerly gave such pneumonic so-called obstinate from the affections scrofulous causes subsided to period when quence disease. . gland lymphatic glands participatein tissues. if this feeble power bility agents. apparent that they all agree in one disturb the normal development and conservation of the organism.from multiplication But.the glandular enlargements are exceedingly obstithe in character."and other " to came no This " that the apt general tendency a observation.

that the prevalence of scrofula institutions than proceeds from other causes air. its pauper less of fresh air is up ("verand predisposition.] by liable as the mother's regimen erroneous period of childhood. entire the ") as futtert bread. diet stands first. in fresh that asylums for foundlingsand prisons. child classes is in great also of cities. children The the among An of the quite wretched the upon well-to-do the This The consumption. or that which an insufficient of with the seeds the throughout exhausting maladies.CONSUMPTION THE OF LUNGS. Hunger in the common want a of the kept feebleness consists for accounts sow may is ill-fed scrofulous former. average worse.the number want. of begetting But it is not but inheritance. produces its perniciouseffect upon the organism . world is often consequently acquiresa identical diet of [Germany. no explanationof the mode in which continuous satisfactory sedentary and especially abode in a close atmosphere charged with effluvia. for consumption are orphans. are with The that an of influence of insufficient as with a of size towns.is untenable. time causes the constitution which in the parents. laitysay.which the to milk. such greater.than and correction. ling-babe or improper Feeding a suck- malady. increased or. had already laid which or the had from other Parents afflicted by other disease who debauchery. The tendency to consumption is. but the fact has long been established in in the open a poor far of both scrofula among The air. liability it is to congenitalpredisposition aggravated. the among measure poor dependent chieflyof vegetables. what frequence amounts to population. and to susceptibility who offspringmay of are that of to consumption is acquired. consumption consequence feebleness consumptive parents beget t o a predisposition consumption.and work or . (asis arisen 219 country quite than in baneful as and great is as We have improper supply of nourishment.instead pap. disease more ruined are into come comparativelygreater prevalence of consumption than consumption who a etc. The disease.in houses than among persons spend who take far the much of more much is the The and case yet they among are not day in exercise and at sumption con- lack of populationsof many the number of prejudicial influences the occupants of prisonsand houses equally subjectto these diseases. villagesis and factory operativeswho close room. the influences Among by which by in parent sumptive con- may of the or to or often them were properly be the malady asserted) and vulnerability of foundation far advanced are parents it offspring. as is well known. according the same thing. When cases. entire objection. the of a of the instead in years. an life. diet of the mon com- correction.in many congenitaltendency is due to the fact the of spoken which at the as inherited. the the of the weakness hereditaryconstitutional proceed that the in congenital..

"as equallygratuitous and dangerous. But. of popular idea. I therefore refer to what has been stated already as to the etiology of the The had irritation. that consumption is often the consequence indulging in cold beverages while the body is overheated. acquired through other affections. too. when protracted. phthisis.lunatics who persistently Not unfrequently.and inconsolable that I regard the wide-spread doctrine consumption is solely from which it proceeds independently of dependent upon a diathesis.whereby the prehension or assimilation of some other is undermining their health in some food is prevented. venereal excess.DISEASES 220 OF PARENCHYMA THE OF THE LUNG. stitutions well-nourished.by no means persons the suppostion that such then be and followed a now cause by may serious sudden the skin of is followed results. persons evince consumptive. with strictures of way.or which Many patients with ulcers of the stomach. which those be added are provoked by persistent suckling. by depressingor excitingmental influences. . not chilling all in but sickness and since it is noi only occasionally by cases. upon and of the treatment disease. where predisexcitingcauses position I believe.has manifestlyprevented an unbiassed one no obstinate chlorosis. I used formerly to look upon as a fable. may onanism. conis a sudden The fact that large as cooling of the skin. ultimatelydie of pulmonary tertiarysyphilis.typhus is apt. study.or at least as a badly-interpreted fact.as capable of producing fluxionaryhyperaemia of the lungs and bronchial catarrh.or " of facts.that catchingcold. immoderate grief. influence latter. that the admission The circumstance of the origin of this disease from external irritation stood in direct conflict with a theory which pretation interdared to gainsay. and am forced that a sudden to admit is quite as pable cachillingof the stomach of inducing catarrhal and hence and pneumonic processes. To these predisposing causes. as I gradually emancipate myself from the teachings of such absolute Laennec^ I dare no longer maintain views. vigorous conthe effect from a consumption tendency of their other disease. consist."and other and that it from never a arose producing pulmonary consumption. So. this result occasions how understood derangement in remote organs . all so-called exciting causes. " The deliberate assertions of Laennec and his in no pupils. have been with impunity by innumerable swallowed draughts of cold water in an overheated contradicts condition. has had the both most neglected catarrh. prophylaxis The which give rise to consumption. born with decided In like manner to persons afflicted with diabetes mellitus. sumption. finally the oesophagus. die refuse their food. Among it a predisposition leave behind to this disease. in all influences to it exists. pernicious effect. acute to disorders.

caseous masses. although it would seem predisposedto degeneration. give consumption. hatters. of incapsulation the certain degree of protectionagainst tuberculosis. of pleurisy products of pneumonia. than in acute miliarytuber(seeChapter XIV. stone-cutters. add a few words must now we regarding the etiologyof pulmonary most or as we tuberculosis. development of caseous in chronic in the culosis consumption. for the majority of con- state a complicationis sometimes at the lungs themselves.without the preexistence degeneration of the inflammatory products. caseous . sometimes seems that The caseous and the conditions infiltration reason why late in its appearance.wool-carders. pneumorrhagia alreadyexplainedwhile treatingof bleeding from the bronchi and lungs.most degeneration. the exudation caseous in pericarditis greater caseous to accompany unknown with opment (secondary)devel- consecutive to become cavities.ending in caseous terminates and pneumonia.in consist the of the great jority ma- products of not tuberculous. We sumptives. the such persons a as etc.CONSUMPTION \re in warranted not are having the same Numerous examples exist of foreignsubstances other and practiceof commenced which on the extremelyimportant is found chillingof a the every some other experienced particularday of symptoms sumption con- their appearance. are statingthat the is. tuberculosis relative The of the lung.but present word. have no degeneration. the Having discussed etiology of the pneumonic process which plays the most important role in the production of pulmonary phthisis.that they are apt cause are stricter which upon in formation the in the pneumonia. suffer from prit. in a state of condition.). con- tives opera- dusty atmosphere.in which the cough has after cold. and blood which is retained in the air-vesicles and frequently has bronchi after that tysis haemop- a have effect.iary inflammation. Of all foreignbodies which. frequence. but it cases of cases.soon followinga severe A the denying LUNGS. greatest danger.and bronchial frequentlygive rise to tuberculosis. The etiologyof these exceptional cases that persons is utterlyobscure. of the pulmonary substance rise to itself. who presence of excitingcause an great prevalence of the played by the malady constantlylive in among sumption. by irritation of the bronchial walls.and tuberculosis of of the sense lungs depends.cigar-makers. hesitation in the in the of tubercles of cases. Btomach have THE OF in the in the role as air-passages. chronic which with in of caseous affords mass Next and to the a glands in similar situated. many all such early and to us.file-grinders. made of the proof 221 of possibility the in physician. The of tubercles lung. effect.is less common is complicated with chronic which pulmonary tuberculosis.

belife advances. tendency to cheesy degeneration. upon the the more of as venous quality the products pneumonias.bronchial than the are it is of glands. disease comparative rarityin warm ones. early childhood.especiallypathological found infiltration and . tumors.are followed by tubercular In cases the discovery of cheesy residua of doubt in these organs the question in favor of tuberculosis. disease. in cold borne out Hirsch it. included in which the of the cheesy inflammatory products of the results of tuberculosis genito-urinary apparatus. will the indications for the extirpation rank among of peripherallymphatic for the performance of resections and of amputations. and is scarcelydue to the influence of the masituation of but the a depends rather upon population and lack of culture it Persons with Probably of their blood. great varietyof lesions are attacked.which the presence of the cheesy residua of enlarged lymphatic glands produces. that great alternations of temperature and favor its development. is not far to the north being wellnigh free from its that age. without rarer as even becoming quite unknown old in extreme The and Males and belief in the prevalence of former females the be to seem situated the due temperature mean to the equally liable. the morphosis cheesy metais far more bowels.222 DISEASES Under this OF PARENCHYMA THE those category cases OF also may THE be LUNG. geographical and climates.owing to the moist and engorged seldom of their lungs. but does not is rather such the paucity of in many regionsafflicted by malaria. half of which foetal life and in all deaths Toward of find traces we catarrh. heart-disease this other depend because causes. and still more thirtieth and coming years. regions is not constant. enjoy a certain immunity from consumption. decide It is quite possible may that in the future. bones. During later childhood. while in elevated rea gions high degree of moisture is rare. the intestines. which from ." the between the twentieth so period of puberty. Emphysernatous persons state are consumpbloodless different but for their flame a : reason lungs rarelyintive. regions declares territorial place has absolutelyno influence upon the production or frequence of consumption . joints. have but little they comparative frequence. the danger APPEARANCES " -A of cavities. dry. the tive nutri- Even swelling and " of the common all cadavers result supposed pulmonary consumption proceeds.extensive lungs. or consumption pulmonary phthisis.with this of that disease. but.the danger of pulmonary tubercle. or superficial lymphatics. the malady attains its greatest frequence. and even With from seventh a that and the regard to to fifth of a nearly the in disorders from frequency of consumption.consumption is rare. The its appearance rarityof consumption in malarious laria. . suffer with once ANATOMICAL in the degeneration is great.mesenteric glands.

Thus cavities puruloidmatter. Far more commonly. last into caseous. The walls of these cavities are irregularand interrupted.but vessels. there is that homogeneous. Such event cheesy infiltration. an only takes place under and when the order dispeculiarcircumstances. result in immediate disintegration and in formation of a cavity.cheesy mass. which. when points which suggest the into.they form rounded more By repetitionof infiltrated attacked near the the lobular centres. the a yellow.CONSUMPTION other forms solidification of exhibit nearlyalways THE OF small LUNGS. If the caseous metamorphosis be further advanced. the yellow places are larger. peculiarwedge-shape of the peripheral deeply within the lung.the consolidation tube. filled with communication the is set down immediate into so-called a creamy tubercular with pus neighboring its contents are bronchus.a see.until at last the entire we solidified After as portion of the the lung infiltration has is converted become and. upon few yellow. the gray or we grayish-reddead lustre of the cut surface. As a rule. perhaps is of severity. it may undergo break tissues.a whole form the separate bronchi. and disintegration.from whatever of in the pneumonia it may proceed. or. through which discharged by coughing. of the pulmonary tissues. If the spots When seated indurations. and are is in a more The a less advanced or state catarrhal gelatinous or cheesy metamorphosis. when is cavities. At formed. the pulmonary parenchyma about them is infiltrated with caseous matter.thus through air-vesicles. It is only in substance rare that cases the diffuse consolidation the of lung- the granular aspect and other characteristics of a lung hepatizedby croupous pneumonia. together with liquefaction. exert a sure pres- deprivingthe . If the latter have but recently commenced.which presents have described the product of acute and especiallyof chronic catarrhal pneumonia.does not in all. the crowding together of the whereby they not only encroach upon extreme the It is probably brought about accumulated surrounding tissues one and upon their cells in the another. of bear where lobule become But the seat be generallyconfined situated is restricted process the lobe of vast infiltration caseous at first by lung-substance. or even to along runs by an the immediate the confluence entire lung ity vicinof course of many be may the of the solidified destruction.nor even of the seat of the majorityof cases. 223 of the parenchyma. dull-looking infiltration with smooth section. which. lustreless marblings. cut idea of miliary tubercles. and leads to the formation single lobules. diseased a of softeningof of these up and process. the solidified lobules.the gelatinousinfiltration has already undergone the transformation peculiar to cheesy degeneration of inflammatory products. to the surface. infiltration.

the of While contains of the cavities lung usually greater or apex less capacity. While necrosis inspissated. we may " and which consolidation still remains before alluded of the cut in to the of the air.the remainder small of the always found projectingabove the beware We must shape of yellow nodules.prove. break OF severe of cells from If the the become down the surface chalky or and the their detritus. the lung-substance does tissue. calcareous mortar-like one salts are elements of involved the depositsare tissues in of these the connective incapsulated. other or of the vessels. disfattydegeneration and liquefaction.which continues to shrink more than the healthyparenchyma which it occupies less room reduced in size and sinks in. and which were formerlyregarded as such.and seriouslyto compress gradually atrophied cells appears. is filled up by connective In such cases. absorptionof the caseous through supplementary masses. perfectlyvoid of air. rendered vacant The calcified by the cells. bronchi closer be with caseto ous examination. of the of sufficient volume fattymetamorphosis of the cells is and capable of reabsorption. there is finally again.the they become left arrested fied.upon section. the bronchi become dilated into rounded and elongated cavities. and mass as the connective space tissue. transversely-divided upon bronchi and surrounded thickened with walls contents. face sur- of perience Ex- to objectswhich at the first glance seem be miliarytubercles.and a THE causing them extension an into not and more into while a by OF and fluid. reestablished .the lung becomes But. anaemia cases walls still break the cell-growthbe vesicular PARENCHYMA their nutritive Perhaps in THE is going the on in the lung. the such minute solid spots to lung pointsof induration almost are that section upon permeable to immediately assuming teaches " be tubercles.traversed of caseous trace a by (bronchiectatic) cavities. find nothing except pulmonary tissue in a state of induration from interstitial pneumonia.or by alveoli.and while a large portion of its lobes is solidified upper ration and in part through indupartlyby gelatinousor caseous infiltration. In other concretion. may and more. which have suffered fattydegeneration and liquefaction. not again become the into a dense callous penetrable by air. be so complete that. This is the most form of cavity in phthisiswhere it runs chronic common a The course. infi trated with caseous in post-mor* matter. lique- is progressingin the cellular degeneration.the Little LUNG. By avoiding such errors many . the thorax replaces. as depressionof the thorax can only take placeto a limited extent.an extensive proliferation processes caseous tissue perish and pulmonary tissue of proliferation process caseous the to themselves. disorganic matter masses shrunken by little their deposited until cases.and without deposit.but is converted .224: DISEASES alveolar walls favored are of down.

organs that the of no caseous means proving vesicular pneumonia. lesions found in Hitherto we have been describingthe anatomical in the vast majority of cases. is solelydependent chronic pneumonia.exclusive of tuberculosis of the bronchial mucous in phthisical the development of secondary tuberculosis lungs is of very frequentoccurrence. upon examinaof a successfully-prepared fine section. In addition tansky. peribronchitic. pneumonic inflammation. that doctrine of are at THE the LUNGS.or ulcers with the characteristic marks. of primary or secondary tuberculous to this. in the form of phthisisin which destruction of the lung is of tubercles. we very OF arrive many solelydue believe. throughout its whole course. are also met with in phthisicallungs. same are no the are product of criterion for the the and when the miliarytubercles.consisting miliary tubercles. its lateral and terminal alveoli According to the line of the caseous " " 16 . although it must stage of the phthisis. Hence.we satisfyourselves may to that the development of the tubercle has spread from the bronchus sectioo. in the finer bronchi. lungs (notoriously regarded as miliarynodules)to be of tubercular nawhen they coexist with latter. or in which tuberculosis until does not appear upon advanced be reat an garded when.however. of innumerable often find extensive granularpatches. that not unfrequentlyhappens these translucent grayish nodules which scattered the are through lungs. 225 conclusion that not a single phthisicallungs.as was first shown develops in the mucous Even in the trachea and tubes we larger bronchial by Virchow.as well as in most other organs in acute and of whose tuberculous there cannature not miliarytuberculosis. and caused by secondary pneuby the breaking down monia the tuberculosis the tubercle generallyfirst dependent upon membrane of the bronchi.and that consolidation to a disorganizing pneumonia.as gray distinction between caseous tubercles and miliarynodules of inflammatoryorigin. memopinionthat. and not tubercle. together with caseous the nodules we have There time. Virchow miliarytuberculosis goes too far in assertingthat of the lung is also almost entirely miliarytubercles of the lung erroneous. as it occurs wherein the malady. according to Rokir ulceration. in our acceptation of the term that is.CONSUMPTION tern tubercle in exists destruction and We the shall examination. also acknowledge the yellow caseous must we deposits found in the ture.besides the evidences of purulent tion find small whitish or we catarrh. pulmonary consumption. and that nearly all so-called well be any doubt. part of the lungs. however. disorganization In tubercular consumption. found other in at are tubercles. yellow nodules.and. I again express my brane. foci of are It or bronchitic. takes little the i t but serious in most as a complication.

not unfrequentlysee with round oval mouths. bronchus. Disintegrationof dilatation infiltration is ushered in by ulceration of the bronchial depositof caseous almost wall. branches the blood-vessels. especiallymany of the of cells. at we infiltration caseous of and accompanied by purulent catarrh of then* cavity. superthe process of induration at a late period.are vessels has surface expectorationof phthisicalpersons. a or of circumstance sumption.and never gradual purulent contents imperceptible.226 DISEASES tubercular rounded THE OF PARENCHYMA formed groups this in OF THE LUNO.many indurated are bronchi.resulting from the of caseous are infiltration.with the of priordate. form no In promineni . deposit of thickened to satisfyone's easy with it appears find the the to infiltration allow to as advance a it is connection no often cheesy earlyperiod. Finally. or a lesions the results and preceded the bronchi Gelatinous great varietyof conditions. perhaps.to become solidified by pneumonic some It is also entire or.while.an does nor infiltration.or morbid some As from phthisicallungs exhibit infiltration caseous the of a finer the of process is of the apex final lung almost always It is these they are of seat matter. it or secretion source is full of young of the Many of artery the walls a the is the This bronchial seat of infiltrated cavities the and a bronchial hardened obliterated catarrh often suffered whose catarrh tissue. running either or squarely or obliquelyinto such a cavity.where profound or structural change. memdevelopment of tubercle does not begin in the bronchial mucous The is attended pneumonic process by which the tuberculosis less extensive. breaking down discharged by perforation into a large open We several bronchi. of bron- minuter tubes erated. miliarynodules appears The the majority of chiectatic which In The the the upon cavities origin. an but bronchiectasis. quite an exceptionaloccurrence lobe of a lung.and the liquefaction always begins in the immediate vicinityof the bronchus. what a be to self that that disease. conimportance in the diagnosisof tuberculous for a large part. of of the membrane mucous found the consumption. caseous has been stated above.and stage cavities to form. oblit- lung-tissuebecome closed cavity. the eruptionof profuse is the of the main nary pulmo- obliterated. or than the form in which secondary tuberculosis venes. have The contraction. bronchi.than that hi tuberculous consumption is much which is solely due to chronic accompanies the consumption which pneumonia.but their entrance is always abrupt. an appearance found in acute miliarytuberculosis where the rarelyor never brane. present manner the of appearance wedge-shaped conglomerationsof miliarynodules. and induration breaks down that true callous so and now of then of induration. on traverse tubercular in chronic other infiltrated and consumption of the side.upon and destruction. as a rule.

so that a together throughout the entire extent pleuralcavityno longer exists. thickening periphery of the thickened and adherent.they become LUNGS. with result of a subsequent decay.compact fibrous rind. It is though the process of destruction advance grow of superficially-seated caseous only through the rapid disorganization is estabbefore adhesion lished. are distended. a part into the bronchial into portion passes through the pleuriticadhesions As the overfilled and the pleura almost substance of the skin blood dischargeof is intercostal veins overloaded to become arterial blood more the into the veins. both in the pleura itself and in the pseudo-membrane. and to commences from veins. as by a cap. also through pleuriticexudations advance phthisical lung of it passes and a third receives apt appears of the upon than Thus the lung.prior to eroded so the to seldom 227 to as obliteration dangerous cause shall take this opportunity to call attention to a haemorrhage. The pleuralsurfaces be so great.with fattyliver.and conduct arterial blood to the lungs. .with amyloid liver. wall one other in the form that. occurs deposits that perforationsometimes have the adhesions before or strong enough to prevent grown air and debris of tissue from entering the pleuralcavity. that it may be may covered.no matter was the cavities have formed. It is very of the walls of a vessel. Generally speaking. those of the bronchial dilate. Part lung. resulting cavities rarelyenlarge in what from the chronic pleuritis. Many branches of the pulmonary artery becoming destroyed.and so that pneumothorax cannot occur.springing from the intercostal arteries.and at such placesit is generallyimpossibleto separate the two pleural surfaces the two without cases pleural surfaces tearing the lung.CONSUMPTION THE OF stretch from ridges. intestinal with parenchymatous intubercle. The equally common complicationof pulmonary phthisiswith ulcer of the bowels. by caseous de disorganization in what manner positin their walls. The of laryngealdisease with pulmonary con-r frequent coexistence sumption has been already spoken of in detail. and in secondary tuberculosis. especiallyat the apex of the lung. We circulation of the lungs which in the frequentlyarises in peculiarity phthisis. the sound pulmonary veins.and sometimes of ligamentous bridges. they. Many newly-formed vessels. miliarytubercles are often found. In tuberculous consumption. In many become The of the lung.too. occurs as the veins cutaneous thereby impeded. into the into always A thorax. an their increase infiltration of in their siz'e is the walls. tercostal the in- blue a chronic soon approach as the form the net-work of veins of inflammation affection of the pulmonary lung.The formerlysupposed to be their most frequentmode of enlargement of secondary tubercular that is to say. with a thick. diphtheriticprocess. to the pleura itself.

The feet are often and other crural vein is frequently or one cedematous. when tolerably and soft large coagula. is often consists microscopically cadaver of is usuallyin a state of emaciation extreme . of the bronchi by the attendant catarrli .whose outflow is always impeded. is hypertrophied and dilated. analysis of of pulmonary consumption the tuberculous may be various from distinguished served ob- symptoms consumption. dyspnoea excepting when in the some frequence transient system demands of increase an of the additional assimilation destructive supply of air.occurs respiration. SYMPTOMS varies in from complicated with from another one We shall in the and its beginning at tolerable with first make a generalityof symptoms a of the later these instances brief of course to end tuberculosis In most outset.which filaments. in which of the volume PARENCHYMA cases. and dyspnoea of phthisThe augmented frequenceof the respiration ical the is in diminution of surface of to a breathing patients due. excepting the right dissolution takes place gradually. The " type according as alone the COURSE.like palate. and in all forms proceeds from a variety of causes. as dyspnoea. with ence especialrefermorbid each symptom to the particular to which belongs. hi greater or less degree. or three are forms precision. the be to THE amyloid degeneration under In recent found OF blood is much A atrophied. Moderate acceleration of the rate of breathing is not always accompanied of shortness of breath tinual requiringconby that distressingsense known forced for its relief. The entire body is bloodless. On the the other hand. the lung. acid formed in the eliminating the carbonic system. the tongue white and the heart coating.which.contains heart. the correspondipg leg being tumeand dropsical. the skin is thin. fied stopped up by a thrombus.in part to obstruction .DISEASES 228 and flammation. rightheart.remarkably white. process shall then endeavor to draw a comprehensive picture of the progress of each of Increased the cases three main forms of the disease. and found upon OF of THE the LUNG.which with a severe may of course is liable occasionally to still further aggravation. kidney. part. respiratoryfrefatiguing be combined and persistentdyspnoea. While going at on rest and oi they are fullycapable of supplying their blood with oxygen.or as they are stage.and not unfrewith scales of epidermis (pityriasis quently covered tabescentium).will be again their appropriateheadings. referred to the small. The is generallyflabby. without any increased quence exertion. of consumption. In protractedcases.and is one burdensome of the most symptoms of the malady. and vegetable spores reduced. Even inspiration tients pafar gone in the disease at often have no all. curdled milk. AND dependent upon pneumonia become disease.

breathing while the patientis at the without area is rate simply because a ordinary circumstances. large number a tuberculous find that we a in the consumption. pain.which panies accom- malady.though they may increased The fill up of dulness percussion. the fever is evident. THE OF deed inalthough rarely.still breathe of process portion of supply of air. be seriouslydiminished The breathing-surface by the presence may tion. It would be superfluousto explain in detail why the respiratory frequence of a phthisicalsubjectis aggravated by pleuriticpain and between the small dulness of percussionand .but who hitherto has suffered but little. by exacerbation or extension of bronchial the catarrh. upon the thus in the reon maining activityof oxygenationwhich goes for the in air-cells manifestlycompensates.there is strong phthisiswhich infer the of existence to reason fear the addition Cases arise already exists. there being no increase in the of the lung or aggravation of the fever to solidification or destruction and for account the to can it.dyspnoea is only caused to fever. are so solidated conlungs Many patients. or by its complicationwith the pleuriticeffusion. by the joint chiefly. proper neither that small very of the acceleration any patient'sfeelingany dyspnoea. and partly. patient. increase in frequence of of breath. That respirationis accelerated by hydrothorax.CONSUMPTION 229 LUNGS. remain and disorganizedthat scarcelyhalf of their capillaries rest.begins to exhibit an from shortness respirationand a distressingdyspnoea. of the bronchi. As a rule. deficiencyof those which have perished.and allow more by an inspiration stronglydistended air to escape expirationthan do the air-cells of a healthy lung. the breathing surface Thus be action of several of these factors. normal at the oxygenation. in order to obtain his Nor ought we to overlook the fact that.or on signsof If word. smaller the and close many disorganizedalveoli.to pain during respiration . solelyfrom of a losis tubercu- in which the we portion dispro- the degree upon extreme ". elude physicaldemonstraof miliarytubercles. since . destroyed.whose lungs narrower are of the sense or more less solidified if at all. Hence.where the survivingvesicles are and disorganized.nor fever be present much whose the same time.provided only at to carry the on long as they healthy person. the body becomes fever justas it of is augmented by increase The every of calorification necessityfor air bodilyexertion is augmented . needs to employ but a his respiratory apparatus. great rapidityof breathing without of the most portant imis one bronchial respiration. whereby Fever consists in a morbid overheated.which. as sit still under severe or are lying in This bed.pneumothorax.and partly. frequence of the respiration. etc. a great measure. such a complication. may excessivelyreduced without and in catarrh. more lung is indurated of ordinarydepth.

formerly ascribed to a postponement time some catarrhal to of the inflammatory degenerationand disintegration of every to ascertain highly important to endeavor his pallor. have been preceded caseous products.to consumption of the these by cough and profuse expectoration. It patientwhether leads afterward catarrh. years. commonly accomthroughout the entire course form of the malady. panies the pneumonic form than the tuberculous leaves us in doubt. as disguiseof a existed evidence incipientphthisis third or immediate this have Distinct varies.OF DISEASES 230 in either process. or whether before the expectoall appeared simultaneouslyand ration copious.which precursory and fever until emaciation (accordingto Louis. depending upon into the air-vesicles . while The of in one-fifth duration of propagation of is sometimes of the which and into the develops under Conversely.and emaciation. cases.ceteris paribus. for the which generallyare used to mark the character of the very steep curves the of fluctuations considerable morning and evening temperature extra representingthe rate of correspondto similar abrupt curves hardly ever of the latter seldom exceeds respiration. it is more probable. Most of consequence well as catarrhal for improving during the those in fever months summer. or and and . of cases. and an If we in the system. subsequently. by a more or Consumption is preceded. and in many than be three four or breaths. In the first case. whether In cases where we physical examination scattered have to do with tubercle or with small pneumonic deposits. a catarrh growing the as worse in whiter and the may of an of and second is kind. extra an PARENCHYMA IBE OF of amount LUXG. this an is the advanced stage in four-fifths case of the of all only do the cough and fever begin together). In cases some acceleration no at all can detected. alveoli early in which consumption whooping-cough are as tuberculosis influenza. is consumed quantity of oxygen compare quence of temperature and the frethe elevation the rate of breathing with of air i*" that the want it will be seen of the pulse in phthisis.in a large number the less protractedperiod of cough and expectoration. of catarrh precursory process discernible instances measles the the week.The evening acceleration is not more above six or eight breaths cases a minute. extension lungs by for is have symptoms became of the tuberculosis by pneumonia and. especiallywhen accompanied by sputa tinged with blood. fever. THE acid carbonic is formed. Pain in the chest shoulders and is which symptom a is often absent It more of the disease. pleuritic pains may be of service both in the diagnosis and prognosis. while origin. that the disease is of pneumonic the lattor class of cases are probably of tuberculous nature. drawn relieved by the greater depth of the breaths partially .

of the of the have catarrh infiltration they are in well-developedand robust know have whom often we are especiallythreatened a previous catarrhs have been of catarrh. fered sufvery protractedcharacter. and THE OF the of airthis only laryngitis consumption)do indicatingdisease of of lungs.which at first seems hoarse . step by step. bronchi and to the the malady a graver aspect. for it shows sputa contain sharply-defined. in its progress measure. catarrh sometimes Finallythe sputa expelledduing the precursory of estimating the furnish a means danger. found once into is shown occur cases physicianis of this treacherous in the unqualified adherent an " smaller in the rarelycommences gradually extends such the cases patient. remains than rather of pain." delicate badly-nourished. Persons distinguishedfrom be quence fre- ramifications.and whose dreaded than veloped de- are ones. In air-vesicles.as.until they are attacked by an angina. . of Laennetfs " the very from larynx or trachea. not always commence in the its and passage. no condition.and fever.nor it. in the Clinique Medicale : of which precede symptoms his bronchi the " " greater bronchi.and it becomes the pulmonary parenchyma. It is a bad sign if the that deep-yellow streaks . the larynxis but little gravity. unpleasant later.when fair nutritive a his about LUNGS. some varietyas to the originalseat is also catarrh. Sooner the seat of a feelingof uneasiness or The in more the cough returns fatiguingparoxysms. in evident impaired.does that we have in whom tubercular whatever even than more upper those period of advanced from " portion of simple laryngitis. be The followingdescription The bronchial minuter in the air-vesicles. the trachea an pleasant unthe and a disagreeablefeeling of heat. but outset such 231 consumption appear. the that becomes tubercles extension metamorphosis disturbed. In into the Circulation is nutrition more assumes air-vesicles and to be Individuals from caseous persons. The voice.maintains the scene suddenly changes and means no process with fourth it is situated Sometimes .however. Thus in a sometimes we a genuine pain beneath may. class (who point of departure to consist to are at supervenes not So far from to a at this time at first of a more present any in the phlegmasia those of symptoms the of the tubercle. latter has the expectoration. from the follow the phlegmasia. extends sensation successivelyto formerly confined to the larynx.indeed.CONSUMPTION ultimately attack the entirelyat his ease may often is in the of symptoms There whence it the by which Andral by volume of the air-passages.now fit of coughing occasions Each and to the bronchi. of deglutition through that of the voice and through the trachea organs It is only at this period that their ramifications. in spiteof the cough his strength. and pricking sensation the sternum.

especiallywhile the sputa were and before showed the existence physical examination irregularity. Although the of at a are . mainly the products of the consumption sputa catarrh which exhibit certain complicates the disease.and one highly calculated to awaken apprehension when the sputa of a persistentcough.form a of group which symptoms physical examination disease the diarrhoea. symptoms or action of the one consumption. cough nor expectoration. and air-vesicles is most its full product is character. tubermalady. cough. if the cough have been hoarse still viscid and transparent. accompanied by of tuberculosis. of cough Absence rare very PARENCHYMA " who of in teachers clinical and THE is when implicationof most OF instances yet . in have itself is which taken tion infiltra- place without disease of the bronchial membrane.tuberculosis begins in the trachea larynx. loss of a nd appetite. mucous previous or concomitant Such often neither have patients. This the in may bronchi. an preliminarycatarrh.until account condition. signsof the ulceration of tuberculous consumption exceedingly interesting the the indurated and chief The or with of hoarseness non-occurrence with cease lungs. As we may often or already. ascribe this expectoration with yellow" (Louis) is of course regarded as a symptom instead of a sign of a mere incipientphthisisor tuberculosis. We thoroughly indorse the assertion of Canstatt. or of the complicationwith originatingin destructive inflammation.from pressure pleuriticmembranes.DISEASES 232 the catarrh cells. Fever. until culosis. are instances of the inaudibleness in which mucous of the similar membrane. intestinal accompanied by cough and expectoration be difficult to actual is in advanced even often are tone a of the cough of vocal chords. emaciation. of is seated It the the streaked finer thus OF THE situated and this of be to LUXG.that it is a most our suspicioussign. that dreaded. some caused A degree by the hoarse reveals the of stages ascribed derivative inaudible cough is in which alteration of the phthisicalpatients results the upon of extreme The recurrent voice from arise from by nerve advanced tuberculous period of of from monary pul- violent entirely. debility. is indicative of consecutive the On from the contrary. cases the the intestinal irritation. its According to and do not share our views. physicians who all consumption to tuberculosis. beginning.and only an extends into the the finer bronchi later period. general malaise.at first. any of primary tuberculosis have be said suspected. intense or the consumption of consumption to When decrease may for. that bronchi. of the and lung and the expectorationduring with met are and now degeneration caseous disease then.yet they may which serve peculiarities materiallyto help the diagnosis. tuberculosis palsy of in comparison rarity.

showing evidence of fattymetamorquantity of irregularangular together with a very considerable They also often contain elastic fibres bodies.sharplyelastic fibres. Their opacityand greenish-graycolor dum are petentia due to the of the ancients unusual amount are of an solid definitely-formed constituents they contain. modern more parts surrounding. The sometimes matter small.OF CONSUMPTION the tubercle of development The bronchitis.long THE 233 expectorationof in bronchial the acute mucous and tressing disby preciselysuch obstinate generallyattended few organic contains cough. ill-smelling fragments of caseous but little air becomes mixed with them in the . to consist of young granular cells. elastic sputa extended walls. the "sputum is membrane " sputum of defined streaks through then: would lead the from the dread.and fibresis a sure sign of phthisis. They tend to which sink to because the bottom of the vessel containing the bronchial secretion. to us bronchial of the surface belonging as curve the to happened which the appearance of cells The profuse formation has event contain to and arrangement the that referred above deep-yellow.sink slowly to or quantity of in a what some- lumps.recognizable reveal that the microscopicexamination Should know writers. from the walls of the air-vesicles.is pathogyellowish-red have we in the sputa the with good grounds course of a for inferring. and by that scanty sputa which of the crudum" ancients. a peculiar form of expectoration is generallydescribed as sumption. numulated When of of admixture intimate spit-cup. which and is often and erroneouslysupposed to be characteristic found in the tuberculosis.separated clear bronchial from one another. preserve shape of tendency sputa. the "purely mucous forms. cavity while the bronchial secretion. the space in the lung whence they have been expelled. less collected irregularly-rounded opaque ragged outline. are grayish masses Rounded. lighterweight.being agitatedby the inspirationand expiration of air. having a sputa globosafun- almost positiveindication that the microscope the lumps are found cavities exist in the lungs. of from the appearance that the air-vesicles have such blood uniform and muco-purulent sputa. of character crude the retain fever.which has been incorporatedwith them during their long sojourn in the cavity. involved.we in the formed have cavities see sputa a have greater been the These bottom.by If the mucus. The rotundityof form is owing to the general their after of the the t o ejection. also become lungs.encloses and is of numerous bubbles. LUNGS. Under phosis. color. deep glass.and granular detritus. The latter whereby the nomonic of chronic acquirea pneumonia. The discovery of such of such has into its membrane mucous we air-cells. pathognomonic of conappears. chronic catarrh. rounded.

but an bronchi the be often may pneumonic temperature.by preciseobservation of all cases. especiallyas which have .ts cause as interrupts regular march.particularlyin and and fluctuations regard regularityof the morning remission and evening exacerbation. according less or fever (four-fifths). advanced that of observations view. We conclusion upon no mention. and believe that we declare dangerous consequences may the frequence of of the temperature and that. of tuberculosis cases of the point of itself is due repeatedly called have is based Laennetfs from catarrh precursory malady. extended study of the hectic fever of phthisis.and frequentlymuch .DISEASES found from the the Chemical Fever of one tuberculous in the Ziemssen air-vesicles the most form and has by that of be actual secretion diphtheritic distinction which of consumption proceeds from in children that chronic the is of the elevation equally true The both nia. THE OF which and expectoration. pneumo- invasion considerable in adults. LOUISA that. attention to the to the of this error. important sign the air-cells. we yet the subject. patientwith sufferingfrom the the degree and a half less. This and small they are test no catarrh demonstrated catarrh temperature then to thickened of always and furnishes simple bronchial is almost thought of the cavities. very seldom the temperature is often almost normal. however.in only arises at a the upon the majority of more of presence which to stage author. evening it may rise to 102" F. infer may the The pneumonia. observable. although now sloughs from of PARENCHYMA THE in the tubercles the OF of the of statement . by the laity. monary consumption Not only is catarrh the from main the fever of by means evening fluctuations of similarity. pneumonia between consumption. while higher.and by the most careful treatment the development of pularises during the course of a protractedcatarrh..taken the We tubercle. may variations The ing morning and evenheit two or degrees FahrenIn the morning more. not paper upon existence certaintywith same extension its continuance process represent we the of of a true to the After to come that the to the tubercu- .consist tonsils. them with typhus or the to the that evidence which of averted. or even is about temperature of subsided. pulmonary tedious in the morning evening temperature of Upon tion consump- peripheralcaries. and we curves. in which fever the pulse. walls examination of sputa often are LUNG. has usuallyshow difference which of we between temperature comparison with a great not are of the that a peculiarto thermal of one difference curve who will is be all kinds of a of a furnishes the morning and wonderful a degree a consumption from diagnose abdominal in the Such afternoon exhausting fever. symptoms is catarrhal of commencement and constant that for the always accompanied by acceleration of pulse.

THE OF than better former case if the have we fever often 235 tuberculosis less. if not emaciation which to symptoms that great as die to or weight and temperature be still kept be apprised of it. through condition and be of greater than. or even thereby greatlyimproving in succeeded completely allaying the febrile action.in case either event the diagnosis.his nutritive condition large cavities and in the We strength.in spiteof still liable are persons recurrence . sustains occur. are remittingfever approaching the a will be In the of the sense chronic upon fever narrow LUNGS. the nosis prog- continued more a ing superven- Hence. For years. is a very pretty theory.vigorous look. there can of no temperature even fact has in a fever consecutive of consumption. in moderating. Knowledge consumes both the strength of and the has been absolute a siderable con- tion calorifica- with on go of of one both fact. and already shown have duration. as still hesitate to accept the by Immermann. the physical such cases (the pneumonia having resulted in induration) the patient of sputa. prognosis.the properly succeed name. an crease in- which at my been ments measureestablished. cease may often are who seen have In apices of their lungs.and cannot condition of the patient.his fresh.and are absorbed.that a continued There fever of moderate less (especially if the patient keep his intensityconsumes hectic fever bed) than a fluctuates dailybetween degree like that a of of in phthisis. then. become the caseous masses incapsulated. of the body consumption of the constituents rapidityduring the rapid rise in the temperature.since mainly that the due. the fever Patients altogether.and treatment thermometer that. of partial patient as to observation.CONSUMPTION losis (inthe be word).that we may We see. consumption most elevation in the the A as. by dint of innumerable and weighings of consumptive patients.and the globularmasses spits up morning after morning. the its doubt in in any the other of the use disease. that their loss and gain in weight stood in direct proportionto the increase diminution of or their fever. body the clinic. form. that fever either the deterioration strikingproof of consists calorification.in under owes their consumption.but no fever whatever.that substance temperature great proved truth it is the of fever phthisicalpa- . that. such recovery. but we is doubt no that and the which above hypothesis. it is to fever that soundness they theory. condition There almost which normal the and intensity. through the of would we pneumonia that advise The is subjects of the are of fever. intermittent assume if the type. but we nutritive the strength and When there was claim any such results where no morning remission. which signspresented. and of a generallymuch pneumonia.or liquefy. form a strikingcontrast with his apparent good health. of the is dependent upon rapid loss of weight in the of short losis tubercu- of the blood.

indicatinga comparative the chief wall.the cure of the symptom nutritive is rather causes of favorable derangements which warranted. the entire chest is flatter. of the it corresponds to a respiratorymovement.and.which. shoulders also are The robust. hitherto. therefore. We in forming a diagnosisof consumption. but nor infiltration. than in a attain of ness feeble- consumption. those of the neck thorax too to long.DISEASES 236 is tients. Depression of the and supra infra-clavicular fossae upon one 01 sides. persons.and cannot yield to the traction Feebleness of the muscles. no hence delicacyof constitution.by and shrinking. " phthisicalhabit threatened are by of the and body " in it. allow the The muscles are ill-developed .making the intercostal num to the sterbroader. In such a case the contracted lung is impermeable to air. nor symptomatology of phthisis. which remains stationaryupon . indicative is found which in of existence reveals the chest the Physical Signs. and the inner edges of the scapulaeare tipped up like wings.causing the neck to seem influence permit the ribs to spread widely apart.the subcutaneous little fat. not are consumption. always and solelydue to decrease in size of the apex of the lung. As this is the only process induration ing capable of causboth depression of the thoracic sign.is of similar import.has always played a great r6le in the is indicative neither of tuberculosis. THE in the of the treatment disease. of the matter a OP PARENCHYMA THE OF importance utmost LUNG. the angle at which the ribs are attached spaces and longer than in is acuter . Inspectionof " a who or phthisis. many persons phthisisand from live exempt phthisicalhabit the greater danger the robust such late.the their cheeks are slender. vade lung will in- muscular and man. unless signs of of the destruction lung be also present. habitus The of the phthisical diagnosticand prognosticsignificance muscles has been a possessingsuch a deal good a the belief that with is air-vesicles in that a does circumstance a a catarrh patientof is of a a at the this doubt. and There do conformation But old age. The intercostal sink. when depressed point in the chest. good of underrated least conflict in the not valuable tendency index to of the apex kind. The bones of such persons have a delicate redness.their skin is tliin. but tissue contains connective sclerotica is bluish. This term is used to signifythat peculiarbuild of proper nutrition and development. inspiratory If the spot. of a want who have been subjectedto debilitating persons who persons many from suffer capable of stuntingthe healthy growth of the system before have become their bodies fullydeveloped.muscular apt to sink forward. narrower. is of caseous of disorganizationof the tissues . besides the are a an advancing symptom in question.

and the degree of dislocation respiration.is equal upon of examination mode of beyond the collar bone. especiallyupon lungs are in a state of A depressionof the upper like chronic disease. relaxation the ever. under assert can each extends from three to side.and communicating with an open bronIt is also rendered the fremitus generallyis intensified. lung. the by supra- many of . which is most probably a pneumonic infiltraA feeble respiratory the percussionmovement at a point where hollow and tymsound. five centimetres the the depressionof and A contraction dulness upon supra and of the infra-clavicular apex of the percussion. There is often an unusually wide extension of the shock of the cardiac dislocation of the apex of the heart. and when diagnosticpoints lungs. ration indu- regions indicates region.I never neglect this more of the I patientswith chronic pulmonary affections. im- utmost to shut out do in (since definitely able distinguishapex).is normal. several furnishes is of resonance first caused observe to me boundary of the behind. normal that the height of the pulmonary apex. sioned occaby by tissue. as solidification small scattered spots of lobular pneumonia also weaken may the ments move- without respiration causing any dulness upon percussion.and which conditions. is often found to be much the one side. therefore.or other of the lung. Over often exhibits abnormity of the pectoralfremitus chus. wall. extensive an of the tion.denotes a patientis not to This tom. symp- partialrecovery be pronounced pneumonic process. being dull OF its normal and THE LUNGS. or somewhat is a suspicioussign of tubercle. which.in the clavicle lung.CONSUMPTION retains inspiration.containing air. consumptive unless it be accompanied by fever. large cavities. stronger which has infiltration and extensive lobular tuberculosis.the vocal have consumption. in phthisis. of a According to Seitz.howpulmonary cf for whose little diagnosticvalue Percussion Since the upper front than the opinion I Seitz in great respect. recognized even the and itself. instead of being dull.the flat.but conclusive not a panitic.when lower.and an outward of the upper bare the lobe of the left pericardiumand like depression of lung is indurated drawing the the thoracic and heart thus laying contracted. boundary.loss of flesh.when impulse. one. supra and infra-clavicular extending over posteriorlyover and is scapular supra-spinatusregions. we 237 percussion-soundover infer the existence may of it. the to left. however.and the mouth tympanitic sound of the trachea from the non-tympaniticsound that that it is then was this is open of was than the easy to mark easier when portance. convexity. sign of inflammatory or tubercular destruction Palpation. besides being serviceable in estimatingthe movements from the and a of the apex of the heart.

at the commencement with a hiss.by reduced. it may sion-sound percus- Much tympanitic.which and tubercular to I must which frequentlythey are only have not follow not masses. air. as being both most heard cough (Seitz).can new a PARENCHYMA pathognomonic laity as consult THE OF that sure of very beneath the smooth. cracked-potsound superficial cavitywith is The of a a the seat produced upon percussion. may in a series of jerks (saccade). lungs'capacityfor air is which they rise gives never render symptoms. it is a sure sign of a cavity. There is a feebleness of it is extremely harsh. or the breath at other times be respiration. dull.in time. there is no pneu- mothorax. but prevalent summit of false and the pre . If the pitch of the opening and shutting the mouth.which is characteristic " often in its advanced more the of stages. still pervious those disapprobationof the signs of catarrh of the beliefaccording to which lung are pathognomonic of consumption. regular.there hollow and percussionis not give rise to such by a in occurrence there point struck upon and baggy walls. above drawn all.whereby the air is expelled into neighboring cavity. shows no disorder.It is.and indeed beyond irregularity the signs of a catarrh at the apex of the lung.or into a bronchus bruit depot file" of the Auscultation.therefore. after the patienthas coughed.tinklingsound which From is percussion. of the lungs. my of catarrh that .with a first make must we be more condition cavitycontaining air. affected a rare its miliary tubercles. Most sufficient accords dulness of at the was that of OF preciselywhat the size and extent of last exploration. with fear the to which a LUNG. always make him from to time a to ausculting patient. the moist rdles and the crackling. But.but the and when the and of otherwise. over thin walls. A distinctly tympanitic sound over area it extends If it be a sound percussive sign when to of tuberculosis. cough to understand why peribronchialand pneumonic easy advisable. enveloped symptoms in than why tubercles parenchyma. may commonly.when Tuberculosis tissue. Dulness in these regions signifies of the parenchyma is infiltrated or consolidated physician.it is a proportionas reason The as THE phthisis.there is the times.but is a is most frequentlyheard ring be altered by inferred that large empty cavity. squealing sounds the first breaths It is deposits.DISEASES 238 the dulness the largetract a connective of by growth of consolidation Hence. state magnitude to general rule.do after a caused and produce much cavities other decidedly express and solidification. Somegreatest variety of moist rdles and peculiarsqueaking rhonchi. upon consumption. lobular is not the favorable advances. in limits is the other the the infiltration dull. More cease. the metallic. however. malady existence of presence patients.

therefore include sounds rdles symptoms. solid which sometimes the bronchi other signs. as at the apex of the lung.until fever. These noises may be produced artificially by blowing over the open mouth of a bottle.besides the bronchophony. of such Indurations fibres of consumption. and respiration.the ear being placed against it. that are amphoric breathing and metallic sounds very common and no very audible. places This where there are characteristic sign is probably produced of air into a cavitythrough an opening which at the by the entrance of the respiratoryact is narrow. we of nutrition of other evidences Bronchial in magnitude induration. but which is enlarged commencement the chest becomes inflated. suspicion consumption is obtained diagnosticinformation . sonorous near contain the from is respiration doubt. THE 1st. induration extensive Whether conglomeration alone. cavernous rdles. when bronchi.that is.or that it has already led. 2d. 3d. and the longer it lasts.or cavities. cavernous catarrhal proceed they are never traverse heard are formed they determined bronchi Sounds often and expectoration. whether them. It but rarely happens that of any value in by use of the spirometer.and by measurement of the capacityof the lungs.of the volume of air expelled from the chest after drawing as deep a breath as possible. or by lettingfall a drop into the bottle. the the which from at not are substance the certainlyregard catarrh of the apex of the the more symptom. Amphoric breathing. serious a LUNGS. pallor of skin. surface tubercle from the part heard are of infiltration result cavities or of lar tubercu- or with When the air in the lung ties cavifilled are audible.emaciation.or by agitating a liquidin a bottle held before the ear. giving negative the infiltraexcite the lobular of existence of results. where transition sudden form.has open or elastic of presence of cases consumption libertyto conclude that the catarrh has involved the lungs themselves. of so the in phthisisarise. to those to fear derangements 239 I patient. It is only when there is a it contains similar condition of the lung. The (called metamorphosing by Seitz)from a sharp hissing or sucking sound to bronchial into indistinct and rdles.the rale with as like the bursting of singlebubbles metallic resonance. or murmurs sonorous respiration.no beyond The which all proceeds.OF CONSUMPTION the to judicial lung as have we but.so much that it may lead. sound with a a metallic ring.audible large bubbles over can large bronchi. where percussion and auscultation. the and which " enclosing large of the lung. place the are Coarse existence called moist of cavities sounds.capable of producing uniform reflection of symmetrical concave the sound-waves. There are cases of obstinate cough.the metallic tinkling. or with be must secretion. when a capaciouscavitywith walls.

there whether after even is stature vital due considerable patient be skilful and practised. contraction of remains. It also occurs infiltration. awkward and or normal inexperienced. that spirometry can impediment to respiration. and region. age. however.and. it varies the weight. pneumonia.well-marked the diseased portion a . and remits toward considerablyaggravated toward in the thorax the dulness morning. as well by acute catarrh of extensive pulmonary and vesicles bronchi. when In a croupous continues. the diagnosisof an incipientphthisis. Hence.300 cubic 130 variation. about six about capacityby PARENCHYMA centimetres. beginning symptoms and termination solelydue are it not of symptoms greater or aspect less violence. passes when followed by consumption. after and The occurrence.and to be feared when when moist the audible malady terminated has in the over affected muco-purulent. the affected induration rare dulness. between and five allowance In THE Germany.so that. when inch increases feet. cubic 3.DISEASES 24:0 tion. The are by the intensityoi majority of patients die in a few weeks. depending OF LUNG. toward with hundred the of sources We upon of invasion cases of the and bronchi the air-cells pneumonia.it expectorationis profuse and the that still remain rdles caseous is infiltration and discoveryof elastic fibres in the sputa. with profuse perspiration .when it becomes evening. the sputa become very worst consumption. region. more rarely. when the fever persistsbeyond the end of the first or beginning of the second week of the disease. and the patient apprehensions. This of acute an is the case pneumonia. the vital capacityof but centimetres. The while. dispelsall doubt that the tissues hi a state of cheesy infiltration and decay. when and centimetres. But the making still remains conditions. caseous effused into coagulated within and intense during a haemoptysiscauses in the unfrequently assumes croupous the blood the of it inflammatory action.with when a into and power. cannot the of the excluding all after main be features which tribute con- acterize char- pulmonary consumption. and it is only when capacitybelow the normal amounts other several to ascribed to of want shall to describe to separate varieties in which form the outset disorder.or of adult tubercle healthy men OF THE in the is according to sex. consumed Far the fever. which slowly begins thorax sinks evidence in to over arises of is a somewhat The improve. instead of ending by resolution. and of cavernous sounds. At as lack to endeavor now the that or skill.every additional all these for lung. and size.the malady subsides after exciting the scanty. although a or remarkably great capacity of the lungs indicates that they are from a slightreduction of their healthy.no conclusions can be drawn the decrease standard.

far more however. It is excusable reliable data a'nd intense The case soon characteristic pleuritic pains. sequent we alreadyexplained. however. to the We frequentwhere the disease is less extended. in a process of this kind. into one the voluminous percussion-sound mass. and The bronchi the within blood greater the the haemoptysis. the difficult.involvingserious ganization disorundergone cheesy have As of the lung.so much the more the to fear that is there reason a 2^1 cavities.arise into the vesicles of an from the extension acute catarrh. varying pneumonia. lesce originally lobular.and resulted in induration and We contraction. wide-spreaddestruction takes place in a lung within a few weeks.the physician to acute or infection. which become the rales. bronchiectatic of as immediately upon opinion. not unfrequentlyhave the opportunityof observing is much more 17 .coathe At is dull. ringing.and. Most of and soon cases galloping consumption. is of air-vesicles.Df the lung.subseentire lobe of a lung is involved quent an of the caseous tion deposit.followed by contraction. the infiltrated tissue suffers caseous generally. in which. especially the decline of tion.however. are felt. which has become chronic. and of area LUNGS.rarelyoccurs.of be can fever ih such to obtained. and a of to the assume sometimes catarrh lung. profuseproliferation number of air-cells by an The invasion of a considerable acute such serious attended catarrh is sometimes by symptoms. more The pneumonia haemoptysisor a pneumorrhagia. and which may be called an acute When resultingfrom acute or subacute catarrhal pneumonia. metamorphosis. attack of longer it lasts. subthe of still and caseous mass are possible. the patient quicklywasting away and sinking under violent fever. where disintegrates.and the symptoms. if the pointsof solidification. by effusion and coagulationof the which dulness a similar very develops after an character. bronchial.with induraabsorptionor incapsulation Such a termination and wasting of the affected part.is caused my follows which well as THE OF CONSUMPTION retained blood and the inflamed chyma paren- metamorphosis.involvinga considerable portionof the lung. violent fever and a rapid strength and nutritive condias also its are that cases diagnosisis the if for the ascribe tuberculosis sputa begin until while. at first were time same indefinite. to an attack of acute catarrhal pneumonia. with sinkingof the summit of the lung. The of blood severityand peculiar extent. becomes It is possiblethat an and the respiratory murmur catarrhal infiltration may acute undergo complete resolution . liquefaction absorption have induration and incapsulation of the affected lung through of the connective tissue. clears admixture up.the more pronounced the pleuritic the intense and persistent fever. may often trace back a depressionof the supra and infra-clavicular region. phthisis. and tympaniticin the upper becomes hollow percussion-sound part of the chest.

infra-clavicular and supra of whose lungs the date without depression.at varying be which pneumonia and carried finally are hitherto disease bronchial may apex find many we form incapsulated caseous resultingfrom And the to who repetitionof less fortunate symptoms.as the more and of heat. in and go further suffer on for a number induration of their of years. by our chest.and of the temperature. often occasion. guests. too. subjectivefebrile symptoms. and are thrown are slight. while in winter.there is reason to perceivea marked involved in the catarrh. and When nutrition. as being generallyregarded as a pulmonary tuberculosis.even True. and air-cells in the of the we a contrast violent each again depressionof and LUNG THE attacks such survived the area intervals. lung to be the seat whose summit again. or by obvious the patient. con- deposits. and pale. Such of this alternations class often large physical furnish a where (unlessthey present some contingent to the hospitals.and to suspect decline in his strength. the the haematosis. begins to lose appetite. especiallyif obliged to work. decided of cavities in the summit spiteof the callosities and bronchiectatic their lungs. and the persons the thoracic the ex off by a described. tending itself on OF PARENCHYMA THE OF is in of the solidified and a state regionsare of abnormal pneumonia by which whenever Still. of cicatricial tractions. else misunderstood this insidious fever is generallyunobserved.or In and the find of sunken of even of the catarrh a in. chronic catarrhal inflammatory process is at all extensive. pneumonia is almost always accompanied by fever. the shivering." " uninterestingdisease.feel tolerablywell during the summer months. The chronic form cumstances tendency. by the physician. form.to grow pale and thin. the like. which is by far the most somewhat The common this in which strikingmanner of phthisis. and to expose themselves to cold. Patients lungs. general a patient with his general catarrh.thirst.the digesof the fever upon and the perniciousinfluence tion. fever. This of the of existence of careful measurement by repeated physicalexamination and the ascertain imperative duty to solidification of the lung. for a while.and become that the pulmonary vesicles have bronchial chronic it is of catarrhal pneumonia to under end shows a in induration pernicious irritation.which has no ill effect upon health and activity. entirelylatent. under favoringcirand shrinking.and callous indurations.sense into the background by the wasting. and gain in strength and weight. chronic they are apt to be unwelcome signsof especialrarity) it is called.and sometimes. the appetite.the implication unattended be may by any Upon dissection.thin.they grow feverish. has totallyescaped observation. wasted.as well as to relapse is the reason why so many persons. any clew as to become the apex of the lung has wall pneumonia.DISEASES 242 patients who have of dulness tuberculosis.yields to form .

In liable to tuberculosis the continued been be find we difficulty. later period the percussion-sound At chest give negative results. If we are informed begin to cough and expectorate until several begun to decline in strength.and its same.Where short of breath.CONSUMPTION treatment. which sumptive.it has no rule. a dull from consecutive pneumonia. a if not quite imso manner possible. no careful treatment most remittingto patientwho a be to are from fever and excessive calorification. The is THE OF furnishes development of tuberculosis in in the looked in favor argument an 24:3 of of sense from at the lungs wider our point theory.the well-known make their appearance.while intestinal or with other persons of (which is the that common) is. On the other hand. should tuberculosis young cerebral of the of appearance that continue.and to grow pale and not tuberculous to fear that he has always reason tion.as not set in constipation .sometimes as a takes place in latent as to make it extremely difficult. precursory of that weeks a the body patient did after he had The a if it meninges of developed in has tuberculous characteristic to of the membranes. Nor is it long before the signs of intes- . dietetic to especially LUNGS. treatment. to recognize the fact with certainty. or if signs appear brain. and grows of the larynx. already conresult of inflammatory action.who The are .and when very in which organs.especiallywhere many the tuberculosis involves other numerous tubercles. the respiratorymurmur may grow thin.easy. and inclined disease of fever form somewhat combined consumption.the tubercular sputa become elevation of the temperature and rapid emaciation by a marked catarrh.there is becoming bronchial. of symptoms the the peculiarly brain-symptoms may are advanced more laryngealsymptoms may do years the consumption described.arid if it spread disease if there be much tuberculous distressingsymptoms of laryngeal consumption rapidly. in development and progress of a in type from any thing hitherto essentially so the diarrhoea subjects. perfectlycomprehensible when and view. of the cough soon The sound of the voice and hoarse.but the solidification is rarelyas extensive as in the forms of consumption previouslydescribed. a the diagnosispresents consumptive patient no perceptibleincrease if. and the of word.and the rdles ringing.and if.in spiteof the change in from the if hoarseness in the hitherto and growing very dulness upon the has aphonia aid in the forming a diagnosis. consumpconfirmation if the be un receive Our will patient suspicion of the physical examination wontedly short of breath. differ symptoms diagnosisof this form of consumption In the first place.we confidentlyinfer may already consumptive lung. there are the lungs are the seat of instances.at first. wasting are not deferred until the companied eruptionbeing acprofuse and purulent.there being percussionto account for it .

and chronic it is the malady sole which approximative usuallysupposed.the orbits from which all the fat has disappeared too large for the eyes. seems zygomatic bones project from the sunken cheeks. the final stage seems to the extremely wearisome often to the patient himself. Many have perfectconfidence in their recovery the up to far into of moment the future. The emaciation decline. wasting away. Exhaustion in. It has that in whom satisfactorily even established. one or both of the feet become of an of the femoral extremely painful oedema. sumption. but that. complicawhich to be us. set becomes by profuse diarrhoea. too seems finallybecomes dying a " " The owing to disappearance of the fat and atrophy of the muscles. The abdomen lasts over The few months. without all forms of termination of has other or been of the said.or observe It the disease. succumb even sensitive and most to tients pa- sooner. are still in greater danger than other persons of been of fresh attack of the pneumonic process or of tuberculosis. of fat upon Not per unfrequentlythe temof the patient. moreover. persons all evidences of consumption have disappeared.however. haemorunoblit- expansion . Toward larynx be and expire the last.that pneumonia. the nose longer and more pointed." there is an incessant cough which robs the patientof his rest at night .or else of an in death erosion from of aneurismal an rhage.who physician and attendants. may we signed as- above-given categories. a malady seldom accelerated pressure. Very much This more is most rarelyconsumption results of usuallythe consequence erated vessel in the wall of a cavity. owing to thrombosis In such cases vein. rendering chewing and deglutitiondifficult .DISEASES 244 tinal tuberculosis and OF PARENCHYMA THE OF intestinal THE consumption LUNG. also in the midst the of plans looking sufferingis often " consumptive. the decubitus the seat causes severe pain . extreme." of the patient. dependent are what intercurrent that which to difficulty follows. ourselves. longs for his release. the nails become seem incurved." The skin loose for the body. as rare an an occurrence as tions. If the death. aphthae form in the mouth and pharynx. death is the and and frequent most that of the improvement is and consumption properly reported are one of cases of upon not are recovery most accidents pulmonary consumption. at first was now grows cheerful and kindly.and even severe.from result various however.and who are completely well of the malady.which sullen and perverse. fatal termination The usually takes place through gradual con. lead It would is far too us were to we make to attempt detailed a modifications the different forms to which descriptionof the numerous of consumption are subjected by the manifold changes of acute and I am sure. the pad the last phalanges being gone.in the forms tuberculosis.

parents in general terms potatoes.especiallysuch as are born of consumptive or ers. were similarly regarded as equallyincurable. that it should it contains It is (after pleases). whenever there is any indication of glandularenlargement. a LUNGS. to the due to introduction enabled us alreadylong results made then and now it has more a has disease led not cutting pneumotho- secondarydegeneration of of the bowels. almost consist exclusivelyof cow's milk. been plasm. when better to prescribe the drinkingwhich than merely use to of bread the other shall not eat it may food eat its bread warn and exact eat the what no the bread. and after it has done teething let it eat a little meat. which. potatoes. This diet must be kept up throughout the whole period of childhood. yields In these of and cases finallybursts. which of death cause air into the shall we becoming bronchi and of the off entrance blood patienteither rapidlybleeds the pneumorrhagia the the of pressure in the wall situated so of the support describe also are kidneys. influencescalculated morbid to extinguish such tenconstitution.af be deprived to the of trachea rax. as a rule. should not be suckled by their own still less ought they to be reared on "pap. intestinal phthisis. When The the child must the or common It is better dry food. their methodical when an signs of defective nutrition and a feeble of especiallyif already he have given positiveevidence shows individual Delicate usual un- tendency to diseases which result in caseous under be placed. and other acute pleurisy.with products. will do of milk amount harm. the only is else suffocates.and delicacy. the in first place.as than 24:5 cavityas to indurated pulmonary substance. ifpossible. but indications for remedies common vance great addepends. con- a children. instead of the customary pap of meal or bread. detail in the TREATMENT. dry.or eruption. neo- that so attained by than better application. pneumonia. of death to filled with The lungs.tubercle diseases. Prophylaxis againstconsumption requires."is wrong. " a chew be child and prop .or any other so-called scrofulous they merely give evidence of a so-called scrofulous habit. and upon to The " a blood.moist cutaneous otherwise affection. take like.let its diet be confided to good wet-nurses.he should to invigorate the dency. so that the amylum which againstthe milk that direction. mothdecrepitparents. or of occurrence consumption fact that inflammatory action.that." but should artificially After weaning the child. stitution. THE OF CONSUMPTION have of any definitely more in use.it child has drunk even may ate immoder- enough. thus is hereafter. being blood-vessel. haemorrhage. since recognitionof new This view remedies for establish of treatment the the of has case consumption. were were consumption and cancer formerly gained at a time when and somewhat treated.

appear.when Driburg.however. privatelessons to take. ulous People in easy circumstances. a I think prophylactic bronchial or deserves a more eral gen- against consumption. but. often shows itself at which scrofula.DISEASES 246 erly combined into sugar drink with and all the an if it eat for proper feebleness acquired early date in the OF it is of THE its more children. illustrating baneful life in producing scrofula and consumption.I have be demands I have met spend it.and occasions to predisposition a consumption. adoption.after which they upon have their tasks at home to prepare. as well as to with make . in the South. than measure it careful a consumption further demands of all agents calculated to cause hyperaemia of the lungs and of as catarrh. continual effect of are supply proper in-door is of equal importance with regula the above.especiallyif subjectto croup and bronchitis.where during the long winter are be the pernicious very spicuous.should made to peratively im- will be obtained the obtained a children effects at myself astonished."a the of this influence reduction of insisted it. con- with signs of delicacyand weakness.Imnau.or even " immoderate " schooling begins total cessation a Obstinate on. and which completely satisfied their parents that results fullyoutweighed the serious sacrifices which they had made.whereby more have THE is easier is of treatment OF instead of inheriting. constitution form of of fresh air facts adduced LUNG.which open in our climate would practicein Russia. milk course a PARENCHYMA saliva. or which a to is too tendency inhale hot or to an too consumption is suspected atmosphere charged cold.who. A similar plan of of assimilation. it will bread plain.who have delicate and scrofshould be children. Persons forbidden be strictly should smoke this treatment hitherto. such a mode place possiblyrepair injurious As " soon as tell. Prophylactictreatment avoidance that dust. particularly In adults. combined the use of ferruginouspreparations deterioration of the blood. A tion of the not often The diet.in a series of instances in which complete and prolonged respite from education. sicklychildren sit day after day and six hours the benches of a crowded at a time school-room.and which we have enumerated excitingcauses of in whom phthisis. etc. at an a wateringthe effects of cannot of life. so that the children may induced to spend their winters was also pass those cold. to oppositionto of such with. and often which most I their of time the in open air. account by many physicians. the chalybeatespringsof Pyrmont. has received as the etc.the piano occasional month Cod-liver oil and to play. is to be recommended. thoroughly converted Besides this. They very taken into sufficiently suffer delicate. too in the months This effects is of a common very life in-door air.

of often by injuriousto aggravated product is to and favorable a made avoidance. are urged by Bufferingfrom advanced their occupation. their condition again. Soon. present consumption. to so inflammatory while. the of the those with of prophylaxis. like any action of other flamed in- irritation.that a neglected catarrh never laid down for the prevention of phthisis have rules which we is catarrh is very rooted The carried be must the with treated sition slightestsuspicionof a predispohow slight.the in the bronchia] involved become lung where the nature physicians. or whether equal strictness. THE OF CONSUMPTION hot or spirituous great efforts in running. the extension terminate The affected poorer received or the disease imminent. in material effect beneficial effect obtained in and whose in It is atmosphere. con- weight. they have been exposed. every to care. seems of to issue. calls for morbi indicatio catarrh. When air-vesicles of the the Above inflammation. with out merely just commenced. Chillingof the skin is to be guarded against with the ut- the flannel next to wear patient should be made have What skin. that inflamed the marked the among Many patientsare speedy the death course and they worse a weeks few often with a above.therefore. seeking readmission. entirelywell.no matter is the there whenever Finally. promptly arrested and condition a return. and to other noxious .singing. hos- that a in institution. by protecting the still more like irritants to exposure tobacco-laden and over-heated their with rooms.is to be catarrh. phthisisis rightlyunderstood)is disregarded by many that patients from the better of daily occurrence It is a matter class. which further seek very leave in aid at the stronger sumption.superfluousto It from derived indications the some ress. the their careful by brought lung. is often yet they much increase in to influences. however. already said regarding the prophylaxisagainst we is equallyapplicablein catarrh pulmonary hypaeremia and bronchial the care. and the instance.LUNGS. or to drink most beverages. not sufficiently consumption.so obvious point of view. it already have whether make is. prog- mention identical are have disease made separate they as cause. Many patientsfall a victim to the deeplyfrequentlyviolated. con- detriment. months. new any simple rule (soobvious this applicableto remedies all. which utmost is not until relaxed be to the from our This rule. disorganization. and better dition.owing is of the lung from who classes.dancing.to throw from their physicianto withdraw up their and to keep away from clubposition at the counting-houseor office. chronic much how It is incredible usual the the from lung. leads to consumption.the affected shielded is to be organ. prejudice.is the wretched so pitals. rapidly having grown inclemency of the weather.

are principle. or Nizza. so that he may not he is sent has any specialcurathe air of the place to which tive suppose This dilemma power residence unless be may his upon obviated need We lungs. Algiers. Pisa. the summer. he may where he well he from try the is at home grape-cure.in my opinion. strict physician. above winter the all. by sending him to some place where risk of taking cold. in particularcases.or Pau. and upon the appliof leeches or cation coughing. Algiers. or it is always better to send them means. that patientfullyunderstands the that often better Otherwise. Wiesbaden. of himself. stages One of little value. time. however. of benefit expect' any Pau.or greater part of the day in the open air. it is not.and to maintain further harm. upon harsh the before and. grave should ern consumptive patientsto keep the house during our Norththe utmost uniformityof temperature in winter.to he where is in. and the become bloody. however. at a Acting the autumn. indefinite and remain under the he charge of For patientswho are unable to wire gauze.when the to tains ob- circumspectly. indeed. their lungs from their chamber. may very intelligent will stay at home in bad to spend the weather.Cairo. is not as yet positively The comparative merit of these winter abodes for preferringMadeira. by acute catarrh. so live be.the breath.will rator.must may by disease.Cairo. warmed a respirator. sputa patientcomplains of lancinatingpain upon drawing breath. and At the same be resorted of cataplasms. to sets lake Geneva. the answer as When same which also purpose. wherever that : be to as certain for or held of use a which the before the by the expired air.or the rapid accompanied by violent symptoms. in order to preserve counsel most ern by making the patientavoid the Northhe can spend the winter. THE I objectionsalreadydetailed. should be allowed the patientshave the When winter at Nizza. or determined." respireallybetter than a " become too warm.is of the of the and intelligent an " mouth. care home.DISEASES 248 Were it not OF PARENCHYMA THE for the very OF LUNG. in not take must he remained be sent Madeira. it were the patientshould this principle. protectedas during who be sure a nd we prudent persons. to Algiers.is advisable. Badenweiler.should to. Pisa.through handkerchief warmed is sets a A pneumonia.without of inhalinga raw. him to make should the sacrifice. Mentone. the means. Mentone. and the indications and None as but Cairo. This. omit to enjoin upon we never but the matter be made must plain to him. climate.is the When real benefit from derivable a patient has change of climate. always and. the patient. local depletion. air-vesicles in. Madeira. the patient must be required to keep his bed until all symptoms of the . like the the spreading of when invasion a catarrhal high fever is seek soon milder the liable latter. and during Soden. inclement atmosphere.by means cups." external air is inhaled.

As we in his with any appreciabledegree of fever ought to be in his room or bed. be past. Anti-pyreticsvery therapeusisof consumption. alkaline According to ner effect is equallyuseful simple catarrh. pneumonia. In tuberculous phthisis. con- by of the the waters produce the involve of Ems waters a upon of more simple of the Obersaltzbrun- mineral the It is not not substance and so (which deny) is fever.although I think but summer which is practisedthere. resting in bed.CONSUMPTION of attack. cases some of Laennec these does in disease. And. sui generis. beneficial in course disease hectic fever the beneficial a the which fever inflammation or generallyrecommend we it will tend use as The inflammation. effect will not is often of consumption. undergo marked in bed for a few improvement while the patientremains days. I fullyapprove of the customary practiceof sending phthisical patientsto spend their at Heiden. The idea. which in the theories sumptives. Gais. regions.in spiteof disease. principally severely. such disorders. The fits of shivering. have often been observed to cease amount it has in bed. other in the if tory inflammaof pneumonia waters.in many to rigors. upon closer observation. is also without advisable for any ent appar- consumptives. this the of view our is contraindicated of of upon mineral muriate enigmatical than that which catarrhal inflammation. reason. etc.where. phthisis. persistsat against the remedies from more all direct influence upon . or jcute the OF THE LUNGS.which lung.have The chronic to one waters of the which and disagree with l^ie fever. said before. when their disease " " our power to Indicatio demands the meet the indications Symptomatica.instead of regarding the hectic fever of consumptives as something peculiar.which of phthisis. a patient have the promenades at the springs. whenever remedies directed properlyplay a most It is not these that " derived Fever it is the important part exert main in the any the symptom disease which itself..that the use results better grows other of any also to mitigate then* fever. catarrh. little of the curds and whey treatment it is out of and in secondary tuberculosis.if. Hence. A in elevated abode continued is rare. and it is and diminishes just the with same as of the all believers or worse.we as an ens upon as fever a due accompanies bronchial increases Drgan. consumption depends upon chronic pneumonia. especially the rise in temperature.Weissbad. of the exacerbation old inflammatorydisorder lung. and which cases every evening. Kreuth. There is nothing strange about this. treatment. of the only does the look it chill which heralds come regularly actually on sometimes if the been main patient re- that found not the of fever.is merely of presence imperfect observation.but the journey to the watering-place.but all evening access the other febrile symptoms.

that the fever is reallyhis most enemy.. no. quinia Digitalis succeed in arrestingthe abnormal often calorification. pneumonia which they are maladies in typhus. formidable it follows. BO pillthree a scruple of a more much appropriate. rad. his Hence possiblediet without who one consumption that by immediate lasts for greater duration. diet of to us stands has case of the conjunction. flor.in spiteof the continuation of the disDigitalisis the principalingredient of the much-employed Heim's $ ss. to out brief than said. in far in that agree that of one food fever danger acute jects subwho man greater The the ical phthis- the treat A with may. that ed s. whenever heretofore mentioned. even (inGermany) English practice) that is.be immediately followed which reason patients.I the learn Now clinic.. richest in of rapidlyconsuming him. supply often comes beprescription a suspended whenever the of frequence pulse becomes subject of antipyretictreatment great propriety. excites here the It is fever. (indeed. consumptive patient often and a other common very four effect it is time when am or that repeatedlyfound the them. they are ushered pronounced the chills by which in the habit of using Heim's pillwith or without quinine. need of that a it febrile phthisicalpatients with them. digitalis opii puri pulv.the more become.in the the of addition all the by S. But. the consult day. without any very clear idea as to what be expected of them.) proves and phthisical patients. so that than it follows will proof whatever.but is of (independently only keep a in induced soon when any the patient on which no fever.for the same disease consp. and reducing the animal heat. pulv.we only deprive him of fever-diet " .exhibition reduction has f. ($.often. at my by times quinine the fever consumption. whereby we ease.indeed. and I am in. and of the to prescribeit three of clinic. pil. of course.. or croupous upon many THE OF much so is to prescribed. irid. months. periodicalthe type assumed its evening exacerbations severe fever. distinct of the as a I The will above refractoryto then. one In consultation patients pretty and stop the pills. The aa. q. to the have as become pillsis of fever the fever and which emaciation is of nutriment him wear of require the we edies rem- scription pre- good deal tunes in subsides. of combating this that we at hand must means use every enemy. have and well-merited a means as reputation.the more At of the I practice. rad. herb. pulv. pill.pulv. u. daily. more it has and temperature is resumed apparent. ipecac. helenii extract v. if we know that the dischargeof mucus has but tittle to do with the exhaustion of the patient and of pus-cells and it is often far more profuse in a simple bronchial catarrh).chronic or upon OF pneumonia than they of the other any PARENCHYMA THE DISEASES 250 do LUNG. when soon for themselves judge to resume a XX. gr.

251 evidentlydangerous to persistin so nourishing food until it becomes so-called law of nutrition this is evident. of urea. and number " of must be that the punctually. to places patients. use well agrees It is more in cannot be effects are is all the as ancient Of great the with patient. is of name faith in the be " milk-cure importance. the tains patientsconregarded as especiallyproper for phthisical of fat or of fat-generating matter. they found as patientswho. The of cod-liver oil is also highly commendable.such as goat'smilk.indeed. and. the upon a all events The disease.ass's milk. sufficiently urged upon consumptive persons.articles commended. practised at home. while. as soon that they increased appreciablyin weight. taken whether into in be combined oil.who can travel without where there dairies where a are supply of good fresh milk is to be Where obtained. nourishment mind. probable that of fat which solelydue to the large amount more as likely. and indeed wrong.THE OF CONSUMPTION LUNGS.in order follow it out treatment. for half a year at drank three or four pints of milk dailywithout repugnance. by rude experience. and a comparalargequantities tively which food is small of portion the experience. rather. able utterlyignored.are found to be in complete agreement with the laws physiological current of assimilation and All nutrition. cod-liver oil. and hence the of the our destructive nitrogenous constituents. order " from the cow.or.that protein production This substances. exerts account. but. hence iodine it is in well-tried late years I have as when it it plenty of milk. unless.which Germany. The milk of animals which pasture in the mountains. the casein of the milk. obtained very good effects from an extract of . but have no other object in so doing than that of preventing the milk from being skimmed. above all. and it is desirable to send danger. the is as doing. to which limbs. is hardly ever held withinfluence any specific is so that it trifling." three tunes warm pint of milk a day. which is impossible immediatelyafter drink a milking. which rarelythe is I often case. is in especialrepute.is augmented by supply of proteinsubstances. give it in the form of whey.cannot be It is altogetheruseless.by a simultaneous assimilation with accords of increase an free supply assimilation and consumpfatteningfood. patientsmay have I have treated this cannot The the done.may doubtful than at phthisis. the whey agree with the of fat or the than patient better patientsto my milk.it is flagrantly time out of for consumptives. for This consumption. of most of the organs are body importance the plumpness of their little children owe the use of milk. As soon In selectingsuitviolated. and to to remove however.and from which corpulentpersons do well to abstain. dog'sfat is a popular remedy and time with this quantity of a all its beneficial it affords. the destructive tion in Thus the diminished.

attributed are (In almost question.) be employed in quite indispensablein consumption. and various sold under It may other for be liquid." is not the .but it is because more that they cough less and easily. seven parts of albuminous of a part of phosphate of or proteinsubstance.and tannin. eighty-two hundredths lime and magnesia. to certainlydue. made diluted in gluten. dex- sugar. however. one and are what catarrh. is not parts trin. Preciselyaccording to the least another to much are catarrh which catarrh. eighteen hundredths of alkaline salts. containinga large amount like THE bitter consists extractive seventy-sixparts of grape is acid. in the treatment absurd as desirable. cough and exsaid regarding after one use.of the so-called the chronic bronchial other of form articles conditions tune. spoonsfulof it milk spring-water.which Broth. contains food good reputation. water. prepared by a PHE OP OF This the Hoff^s malt extract resembling other extract constituents hops.252 DISEASES PARENCHYMA Trommer. or warm of coarsely-broken rye-meal. the already been indiscriminate pectoration. the as With animal of respect of treatment the bronchial another.and of and Trommer and greatlyextolled. mucilaginous.but so officinal malt. genuine a of the soluble the of hundred malt or sugar. senega. LUNG. adding. lentils and bean- preparationsof late.it have action of the first few doses of the opium soothing. carbonic matter One apothecary. of treatment has An expectorants Iceland is less moss."that their cough is looser.and of Griffith's mixture. hops. the at still another chlorides other may stimulants diminish articles which be required at be may alreadyexpressed our preferencefor the balsams and resins latter purpose. laid down at symptomatic simply refer we the to or sacchaacetate of of the for the lead is effect is to order As to we allaythe cough. (revalenta meal with mixed is a the as cacao-meal. such long enjoyed a as arabica). " above. the alkaline or squills. Jellies such vegetable substance and the jellyfrom the snail-soup. and sixteen bitter of parts of The patientsalmost always enjoy two or daily. and said already.besides deal of and has the amylum. malt. we for the have condition of accompanies phthisisas it is in any cent The sweet.and it usuallyagrees well with them. that of lead is held hi great esteem by many authorities as a remedy in it is used given in combination with every The to the narcotics lead are case opium. I must again say a word or two in favor of the rum myrrhae. where which acetate some cated. appropriate.soporific they find or morphine which gratifiesthe patients. choco- of various is also names.resin of hops. indi- As secretion. Soup well or three table- good a consumptives.mineral water. and the of be can the prepared by every about of it contain of alcohol extracts. preparation of strong beer."demulserviceable of all. soothing.

and an organs.we the to CHAPTER ACUTE EiiOLOGY. mucous it consider we TUBERCULOSIS. It seems also.gr. from it not unnrer-pded fection inthat bv . when a chial coughing is an irritant to the bronis the principal of the secretion. questionable. efficient remedy againstthe night-sweatsof consumption. of something else. source diminution of the inclination to cough it is best expectoration. the progress necessary of the consumption becomes more rapid. soon." drink the patient may or a cup of cold sage-tea. most With regard to the treatment required by the complicationof laryngeal and intestinal phthisiswith consumption of the lungs. ("galloping")consumption. extract of powder. depends upon is bear affections XIY. whose persons This of acute the other disease.if the antipyretic fails to do good.or in which sections described.as. the boletus laricis (a very unsafe as a physiciansrecommend article). of the disorder. highly probable that the in most as founded con- infectious malady arose were products (JBuhl). as the patientof rest both " night-sweatswe may order small doses of Haller's acid.as it becomes doses of to give large soon as opium. patient of relief from this distressing that there are Some no means symptom. happen that they fail of gr. or in the form of a syrup. a when too and. be must they injectedsubcutaneously. are organs refer to those is well of seen rare caseous occurrence an course of In the lungs the cumstance cir- miliarytuberculosis acute the fact.an additional reason against becomes too hasty employment of a remedy which a indispensableto the narcotics the patient. Nevertheless. MILIARY ACUTE the need the for has them become most of a tormenting cough laryngealphthisisdeprives and by night by day. instead of opium.and. indeed. When not tolerated by the are stomach. when quite probable seems result in may to not By earlyresort too a effect at small begin with virosa. it may narcotics. by the secondary diseases of the liver and kidFor the must etc. Acute " with eruption of and other acute tubercles organs that would a those of in strong make of contain the the occasional the blood lungs symptoms the disease old caseous and symptoms by although as the resemblance it appear the TUBERCULOSIS.that. is not which to be miliarytuberculosis.in to ss doses to later period. diseases. The of the above articles is sometreatment efficacy what but it would be tell the cruel to n o doubt. as well as that demanded neys. acute in deposits. j. urgent.. MILIARY accompanied by great majorityof cases . the narcotics using lactucaria that of the decrease commence should we a 253 that which membrane.

the acute at that has disease granulationsalways yellow. caseous showing of the of the course died of with tive nutri- disease of acute an acute The tinuing during life and consettles to the and after death.about the new liver.arising. complicated with hectic When of an acute inasmuch it can as night-sweats. AND advanced " stage commencing velops miliarytuberculosis deconsumption. the most SYMPTOMS at an COURSE.it is very difficult of recognition.giving rise to extensive pulmonary hypostasis. per- of other of former who has died has the ventricles. translucent appearance surfaces of the with fresh tubercle. together with acute The parenchyma looks injected and otherwise it is generallyfree from serum. content but this deposit. never gradual one. and even and softened. if the pleura be also strewed with decide positivecertaintythat the miliary tubercles. APPEARANCES.DISEASES 254 miliary tuberculosis unknown yet that is LUNG.do not modify either the proportion sound although the dispercussion or the respiratorymurmur. as the innumerable everywhere enclosed in tissue containingair. traces who one young less infiltrated or person kidneys chiasm inflammatory or the cases pia mater. resemblance febrile disease.that find. us.the In most spleen. some The disease assumes a different guise when it attacks persons ic . granulationsare base of the brain.especiallyin often numerous the culosis tuber- found. the fever and the rapid decline of the pahardly be decided whether tient due to the originalcomplaint or to the complication. by stating that.Physical are and examination of the chest gives negative information as to the new little granules. swollen muscles the spleen is often somewhat are red. with which exception of The there. though we patient has had acute what nothing of the this uniform are dissemination the covered by been miliary tubercles.the is with coexist In chronic been.upon we the lungs are studded uniformly from top to bottom with miliarytubercles. a peritonaeum. whose nature we are equallyignorant. a the also of the perniciouseffect other proceed from We must. ANATOMICAL If " dissection. in most in secondary disease. The blood is dark and liquid. upon the intense extension between of dyspnoea and the trifling old point of induration perhaps may aid the diagnosis. cases. particularly and pons. of if the miliarynodules present that gray. tuber- gray Finally.we may know even miliary tuberculosis. from to may THE OF ourselves therefore. dependent points.the found the in the the hydrocephalus of the opticnerves. be may the that resembles miliarytuberculosis of corpse a of more sons. contradicts caseous as PARENCHYMA THE OF of causes. manner some cheesy deposit. and cles.being depositof miliarytubercles . the tubercle of deposithas disease. disturbance. acute plausible hypothesis.

but here. to miliarytuberculosis.the in acute chest reveals No depicted are so very experienceddiagnosticiansacknowledge we in which instances of the perceived.that chills for intermittent intermissions the with recur are complaint is fever. conversely. constitutional disturbpulse. he delirious or lies supine in a state of stupor.and basilar bronchi.especially and of all difficulty distressing . of typhus reallyhad diagnosis miliarytuberculosis. march have patientperishes. quinine fails in its the disease.if the be mistaken that the effect.accompanied by fever.when by fever. the set attended are pulse by no becomes often patient sinks visibly day. the sensorium deranged. can those toms symp- of less violent The smaller the the symptoms clew afforded of the the malady. most more The week. distinr- . they as interpret.just as he falls smaller and more and of typhus. More rarelydeath does not take place until the end of the by the fifth spleen. not plete. cases bronchial violent resembles an ex" if the cough catarrh.at its commencement. pulse becomes the pulmonary veins are no longer able to pour their blood into finally.the sixth or rapid the sounds typhus. com- attended mittent respiratoryfunction.which is unusual in interthe increase. too.too.consumed he dies a rule. escaped MILIARY frequence of sweats the in. A ing becomes rapidly-increasand these prostration.and suffocative effusion are established. catarrh The rales. great frequence of often symptoms tokens of 255 pulmonary has affection hitherto unfrequently begins with repeated ance. that with to having met the two was absolutelyimpossible.its the fatal the outset is modified course termination takes (see appropriate place with still even greater rapidity. degree some shall We a that that of In tensive be very At of it may regularity. observe.as we a prey to fever. of the lungs. cough. If tuberculous the meningitis accompany chapter)and attack. that the frequence of the pulse is constantly on the entire character of the complaint is more perniciousthan disturbance .palsy of the oedema the imperfectly-emptiedheart. hard local disorder. as said. it is day to true. but the nowhere that be the most and died of fine rhonchi few a and have scanty like a diagnosisbetween where patientsdying with a and tuberculosis.or about in the same patients usually die of typhus. abundant from TUBERCULOSIS.ACUTE those health.or whose rigors. The difficult does the distinction more patient may succumb few days after the lapse of a fortnight.however. the tongue becomes dry. dyspnoea accompany symptoms. so much become. chronic It then attention. a or in which time longer. and of soon that by " in the simple intermittingfever.and severe not the . other the disease. save which the of persistentphysicalexamination substance of the lung is infiltrated. to The exceedinglygreat. The more frequent. DIAGNOSIS.

sis acute miliarytuberculo- suppose disease acute typhus. while there is no eruption in acute miliary'tuberculosis. of the Enlargement 3. disease great diagnosticsignificance. discover repeated search.DISEASES 256 OF violence the vanishes. especiallythe shortness of malady. in which tuberculosis as to be either who lung the the in to the the of issue of Only that malady terminate rarities.after symptoms and careful the region of upper when and tuberculosis. iary mil- reaching 104C rapidityof the pulse.as malignant course tion soon OF PARENCHYMA THE of the THE LUNG. In abdominal likewise. seldom do scarcely not were spots ever eruptionwould of the 4. while magnitude.to as : istence ex- unnecessary.tenderness Meteorism. and even though are not exist hi acute rarelybe can is fail to found render this clew miliary of much the These typhus the typhus almost in typhus. we here .certainlymust and the among us atrophied. rarely fail. acute The miliarytuberculosis most is of important sympton? . it earlier chitic far is greater likewise true.. A differential diagnosis between miliary tuberculosis the followingpoints: based upon the cough and 1. TREATMENT. dyspnoea appear.the is the entf expected. those of apex phthisishave followed. found hardly ever we it spleen few a which abdomen. as with period and thematic typhus. so tions observa- deposited The in recovery. but intensitythan the find distinction in a absence and typhus rule. Typhus rarely supervenes upon tuberculosis seldom acute miliary berculosis. too.and become the of save any the at absolutelyunfavorable. ileo-ccecal symptoms are region. of Wunderlich 6. " cases.we typhus (typhoid).and which is in strikingcontrast with the of is the of breathe the physicalsigns of disease.at an typhus. In exan in a early and is easy. miliarytuberculosis. and attacks Dulness disease. arrested. but breath which often renders it impossiblefor the patientto recumbent position. not served ob- in acute 5. violent bron the eruptionof exanthematic typhus is highly characteristic and scarcelyto be overlooked. (Wunderlich) allow may than proportionto Prognosis as to almost be must lower of all is out that observed is much tuberculosis F. In tuberculosis. course the acute greatest pronounced more lungs.the rapid collapse. seldom enormous the in temperature has a very tubercles become The thus much brain-symptoms. in exanthematous in abdominal absent of roseola find it in abdominal liquid stools. while such sufferingfrom are is therefore has PROGNOSIS. chronic a mere " The treatment treatment of of symptoms. miliarytu- enlargement an the upon in acute found. and fever.and violent more few the sooner be the chronic considered fever.afford data for diagnosis. 2.

when theytouch the pleura. of the lungs. and of a few of is propagated into conversion matrix this the and cancer nodules.are apt to show a flattened the sothe disease umbilicated as or depression. a but present the rounded old The conversion makes of contour of an originof into cancer-cells of latter case.cold is to be applied. is to be anticipated. rare disease. almost ANATOMICAL assumes the medullaryform. particularly develop themselves. On the of isolated cancerous nodule? hand. Sometimes appears the previousvariety. epithelial neighboringconnective tissue.that. and a it is infiltrated cancer.and the acids. far more rarelythat of the scirrhus or exclusively the form of rounded of alveolar degeneration. For the dyspnoea.too. varying from the size of a hemp-seed to that of a fist. Large doses of head. . the cancer-cells originate in the lung. cancerous infiltration into cancer. of of the Cancer LUNG. of the breast.with regard to the appearance that here.is due to proliferation other 18 . cancer APPEARANCES. that. OHAPTEK CANCER ETIOLOGY. that 257 the those majorityof tacked at- at quinineshould be given. that occurrence the point at is to which say. does not present parenchyma. should appearances Combat the existence of apply ice to the meningeal tuberculosis. a few the tissue-cells of and of the into the connective nor .almost always precedes cancer In the lung. The enlargement implication cancer-cell of the original of the tumor therefore. cancerous constituting appearance which. the outset of the disease and at a later period use nitre. digitalis. the the first Cancer of other organs.CANCER THE OF is the fever .we must suppose furthei and then without from the elements of the tissue. for it is of the fever alone LUNG.particularly and as long as the rigorscontinue to occur. the latter form Unlike called infiltrated cancer. the surrounding does the disease has been we had abandoned to do with . the adjacent alveoli. Little success. proliferate of the contiguoustissues in the disease. after the transformation of the connective tissue-cells of the lung.in believed now distinct limit between the cells of the vesicles. It sometimes assumes isolated masses. lead us to the cough with narcotics .and primary cancer lung is a somewhat unusual especially ever lung is scarcely is of of this organ of the substance OF The " those as XV. it of traces " and soft connodules of a marrowy sistence. suspect perish.in the the gradual transition a hypothesis. THE scure pathogeny and etiologyof this malady are as obthe malignant neoplasms in general. however. and.

pleuralfolds rapidly of the chest.and thus cause Niemeyer's theory that with caseous P. lung disease aside and soften. rarityof tuberculosis frequent relapsesof the malady. the directions P. THE LUNGS. hemoptysis.after extirpationof cancerous masses. being pushed the of The cavities.which it often walls penetrates. cer- pated. into the into the LUNG. able to prove objects in the sputa." flammatio haemorrhage may lead to inhas phthisis.especially as. in the of no instances.DISEASES 258 alone . the It is and PARENCHYMA THE for exceedinglyrare break down.and. the oedema. blood-spitting. Diagnosis will be confirmed if percussion and auscultation consolidation tainty.symptoms in such we wherein great majority lung the prove discovered. the the the of cancer cases in which or appear of In " Of " The lung." (Edema be can OF OF 1880. rea relaxation sequel of the of the lar vascu- walls. EDITION PAEENCHYMA THE of cause idea of no REVISED THE DISEASES of its according to 1. to is much more the pleura. TREATMENT. 2. AND characteristic marks hardly ever possibleto in except be body can pain in a should and Should of bear in mind the disease breast of with has been other of the chronic of apprehending disease of the the formation the is not cancer We are situated habitually seldom very in the of the summit cancerous unlike sons. of at the The the of tubercle. OP as the death-agony the actual due to lung is treatinga cancer adjacent parts. and it is observed. extir- and dyspnoea.must hyperaemiain be ADDITIONS SECTION treated TO III. often. certain by the perforation of into the of the substance of parts carcinoma. bronchial . the existence of any diagnosis is more commonly thorax by the disease and its the lung. be of disease indicative of are existence cancerous case. whereas failingheart-action and it is garded erroneously. perof monary pul- show a tubercle. the form lung. and death as I think . istic characterrendered extension integument. lungs. instead to carcinomatous a extensive chest.as them spread through THE medullary fungus form to as so OF substance surrounding pulmonary liable to extend to OF adhere.cough. 149. degeneration. 142. SYMPTOMS COUKSE. alreadygiven. there course.

25 pro dosi). which with thinks that. aq. 259 The objectionsto this theory are based sharply controverted." P. moreover. 3.How which bleeding into the alveoli it that in pulmonary infarction. 3.0. there is no tendency occurs." In aquaeos. although healthy persons sound lungs may easily pneumo-catarrh. secal. the cases P.05to 0. hypodermic injectionof Boujeatfs ergotin not be neglected (0. a soluble This foul. should processes also follow bronchial a subject . Buhl. and that they do follow is haemorrhage in the human indicated by the fever. atous be there P. gramme. observers ? Some decidedly deny Niemeyer's hypothesis consumption looks upon the bleedings as the consequence Buhl (never cause)of the He holds that as difficult to necrotic a croupous whether determine of the inflammation tuberculous and pneumonia pneumonia caseous also may arise may (in which haemorrhage suddenly as be pendently inde- it must case the lungs. yet in delicate persons.and elements signs of a catarrhal been pneumonia such hence. Sommerbrod. caseous degeneration and phthisis may follow. Sommerbrod the lung. one to be 1. or else .0. dest. This presumption of a phthisicaltendency may also well be in to as of their circumscribed well get is pleaded to the question. 5." Weber lodge which in the Under the some blood veins the 159. jected. found celluin the the alveoli injected. 4. in his experiments.or gangenous substance infectious substance either spot within the is enters generatedin body. into whose lar Lipmanri).0. caseous pneumonia without vice or and then. cornut. pain. 164.TO ADDITIONS THE REVISED EDITION OF 1880. matter an would organs the medium without pass the of some of the arteries pass that capillaries . and small rales in the affected part of arise a few days after the bleeding. suppurating. that in many points out directlyinto emboli 157. inS. certain with the conditions embolus. the lower the negative results of experiments made aniupon upon has been air-passagesblood injected (Perl and "mals. of phthisical habit. catarrh chronic bronchial catarrhal nor pneumonia nor croupous induces (and still less pulmonary or bronchial haemorrhage) ever a preexistingspecialtendency to it . glycerine2. and of cause the be flammation in- maintains that neither versa). bad should actually declared parenchymis still sub judice. even unless not present the At pneumonia. . however. so pulmonary system might afterward kidney. Ext.

are epidemic at the same (See of such an epidemic at Wetzlar in 1872. is not At several to of escape the white and rupture this of the stage. rum (Klebs). Microspoorganisms. additional and a the disease that is grave disorder the Such form. then. a (sepsiri)." According the heim. regarded of P. although the ever the as after a former be called. the capillariesconvey is blood-disks tension to the the circulation observers. a croupous parenchymnia. to from evolved medium zealous most ammonium) of substance independent an the LUNG. into the ter." culization. THE the through ordinary product carbonate and ammonium OF regarding the formed the seems PARENCHYMA THE OF putrid ferment. degenprecursor has forerunner diagnosis of degeneration post infer that than consequence Buhl regards If. Formerly cheesy degeneration. during life. that we latter pneumonia." Sometimes in limits.the most formidable " P. was the upon Cohn- air-vesicles the but capillaries. facts circumstances such suppositionthat infectious course in Under succession. tissues exerted it used as common Latterly. or.DISEASES reaches the system from without In spite of of impure contact. 7. no nature this material.however.tuber- to of croupous stoutlydisputed the idea of a caseous eration. septicum nature. croupous atous as migration. Herr*s description to attack both P.perhaps narrow following case there is have assumed find also in case in the support its that symptoms. 167. must but find not that is pneumonia which we a caseous he our the diagnosiswas by the before. opinion has yet been To it some or of the air of of or fixed research. 8.adherents competent red of result 168. pyaemia. putrefaction(sulphide of it is others . less blood pneumonia.and that other inflammatory disorders time.that it tends lungs. and induces that generally fatal fever called septicaemiaor grave sequel to a surgicaloperation. for the epidemic an within exceedinglyprevalent particular street a quick warrant strong a is disease the often may view might has mal prodro- fatal. or certain certain houses. owing exudation.) Dr. quite arrested never into of wrong. matter of animal of vegeto the presence or Finally. 170. spore its presence Whatever its however.that there is a swelling of the spleen.it has been ascribed table of and late to to or a vibriones. pneumo- (accordingto mortem process of has turned BuhT). 6. lat- .

has as Although one might be disposed driving back that respect. there. there in which is not begun.accompanied resonance. point the heart of bath. to produced by a persistent by systematic cold bathing. contraindicated not are high fever. Indeed. 178. dissipated such have erysipelas. however. a of engorgement. showing the engorgement which. editor of nature fever. paralyzing effect the ceives per- steadily-marchingone. may we Waldenburg pneumonia and of rather or hepatization. both the before of results heart and . the of blood the a the 10. and in a typhus. through hepatization. and Jurgensen earnestlyurges that a .abated abortive and subsided. but the often promptly disorder the subside continues never for strong analogy a We a and several remember migrans. nance) physical signs of engorgement (crepitusand tympanitic resofever here and with arise fitfully. . instead of passing on pneumonia. be effects. and the pain or obscure sometimes by a but for faintlyaudible a circumscribed tympanitic little blood-stained a of of meaning as all the early period been have 261 understood go very Instances would 1880. the the upon dread tions vital func- after if the ill yet bathing by cold in to organs. pneumonias allied are the migratory monias pneu- described In these and cases by Wiegand Waldenburg.by the ous numer- Liebermeis- Indeed. just as a been obtained priori a inner better given of champagne. pneumonia is a wandering and likewise in this Believing as chief danger one. last German the abortive of red resolve may author once OF P." high temperature.TO ADDITIONS THE REVISED that of the remark pneumonia. Thus and weeks. has already reported certain cases been have repeatedly observed in without the chest. treatment has used been in typhus. gray a be to must edition crepitation. be likened Cold baths by the ordinary treatment. hepatization. port. in the lungs. madeira." This EDITION sputum. of itself at was which of and pneumonia. therefore. the made of is heart) which upon sipelas ery- course 190. but reaction or have ordinary P. do that in consists those (particularly trials which and ter Jurgensen have bath than in condition wine be in pneumonia. with and period into that To of these its stages the of mation inflam- The course. such been now applied in pneumonia. fears. this form between must into on go both servers ob- mortality by the able are always suitby an asthenic of stimulant to insure a red ous vigor- weak. 9.

and more in full effect is obtained. 12. 192. and to of will doses has veratrin the of influence the resorted and the the upon first is tardy. Thus that miliary tubercle it seems is not the characteristic mark of a specificdisease. and for grm. charcoal. however. but the premature occurrence often slowness of the and pulse compels suspenprostration. On the next day. 11. injected into the blood-vessels of Guinea-pigs and rabbits. of vomiting. within one repeated for forty-eighthours. substances A further shows. in fevers marked by strong natural less strongly indicated quinine is much be of the fever. and caseous from matter pneumonia and from degenerated lymph-glands. order. third a even subsided. a development of fresh Hence. in this sense. to declares Liebermeister remissions in age In intermission or given be must quinineis cases collapse. remission large doses each induce it cannot desired the class of latter inflammatory process the in the of a porary temtinued con- the belief temperature. on an incomplete. The average.but that a distinction is to be made between tubercle as the product of simple inflammation and tubercle as dependupon the with . however. in order the lower to test the animals have infectious been made by Villemin of tubercle. nodules would also form. upon dose or often about is the after often pulse its action temperature number perhaps again. to its effect LUNG.cause in them tubercle. moderate some pneumonias. by keeping down actually curtail hours. or quicksilver. for c. sion febrile antiits before of the drug (which requires constant watching) been action has gained. 214. it time." Inoculations and upon others. and 2% far a sub-continued or lowering fever may that continued artificial that not intermissions or a need dose 1" " children.DISEASES 262 PAKENCHYMA TUB OF P. a than in high quinine both to preferableantipyretic. experimentation that a great varietyof cellaneous injectionof pus. They unquestionably that yellow or gray tubercle. of misdead animal matter. is fever the asthenic be smaller a Veratrin purpose. of blotting-paper. In the since year of Such hour. of ten all at taken fifteen or the 10 gr. P." Veratrin shows two . eight or twelve hours . as usually happens. miliary sponge. be then is reduced.cork. consumption have nature settled is infectious. because the temperature There is some by danger for warrant veratrin. THE OF the answer pneumonia in robust subjects hepatization is not far advanced. if. in whom In when may adapted high runs it is best cases avoided. gutta-percha. very or once about bring to adults.

process new glanders. circulation the been lymph fine of all probable most seem always not very found has which tissue into taken are would are Walderiburg" aniline the emboli such to disks. the found tubercles miliary impart lymphatic nuclei. secondary deposited Buhl formative endothelium in particles. pneumonic disease. it We of lupus. characteristic about nothing between An tubercle. and injected. in EDITION REVISED THE TO of cheesy through connective production of . but know is tubercle neither being OF consumption. specific the the first blood- than in of cording Ac- tubercle. or deposits.ADDITIONS ent syphilis. consumption. bigger the forming the believes irritability in steps about awakened tance impor- constant nor deposited a events. infection The author matter and cells had diffusion and and of which to the then blood no is and of fresh as a that a of into tissues. upon with compared the step. embolism deposit 263 At intermediate the original the 1880. speck the poison.

the of of proliferation a essential the Regarding refer the of also effusion an and the of second to fibrin exudation. a especially depraved individuals especially and upon the and in of cases robust attacking from occurs all calling broken-down disease. pleurisy. gives PLEURISY. in affection frequence of of pleuritis convalescents predisposition. We pleurisy secondary vigorous Even the opinion. into young are pleura. individuals in the denounce here must but it cause never . PLEURA. time interstitial an contains. thick- proliferation to pleuritic young epithelial been already The risy. or disease. but should such in secondary a rather debilitated which and protracted such requisite arises without in for this as the for possess. THE OF OHAPTEK INFLAMMATION OF As ETIOLOGY. the rise pleural tissue their owe of the of The forms two are thickening causes of less or more there presently. pleurisy.SECTION DISEASES IV. to and ening. merely same connective of find opposing adhesion and normal form the at PLEURA shall we " THE I. surfaces. trifling exciting malady. pleura. due of pleura.which of the is the regard effusion tissue its cover of the puscles cor- surface. in one class of provocation of all question. persons. persons some to "he and kinds A among increased of very provoke kind. dependent looked be often so of suffered already which instead with subjects have complications. result to origin has what to and surfaces The the in points said the of cells pleural The ening thick- effusion the connective which etiology with the cells. pleu- produces cells. inflammatory diseases. PLEURITIS. after is who pleurisy my in occur of impropriety which. we may etiology of pneumonia. depend other some upon and constitution. is renal occurrence the upon disease Bright's common constitutions. The first adhesion of but its containing sac. disease. The the not. complication.

may 4. sero-fibrinous exudation into the panied by a very profuse pleuralsac.the pleura The tissue of the off.and into entrance the contents the latter of cavities. In commencing pleuritis. although it sometimes is very copious and sero-fibrinous. Pleuritis often arises through propagation of inflammation from of the pleura. ribs and foreignbodies.formerly itself is somewhat swollen. may develop in the pseudo-membrane. or else it results in of the pleura.air.or which of influences. or we to have the no In this disease. dis- of any new derangements which proceed infection of the organism by putrid matter. which is an independent. Microscopically.and the blood.and to ance. there is a the quantity and character of the effusion.or This like.looks dull. secondary pleurisy. Besides often find slightextravasations we of blood. is reddened Connective by injectionproceeding from the sub-serous its surface tissue. firmly attached surface. shaggy appear begins to assume This is due the of minute delicate folds. 2.with considerably-elongated laries. from the loid forms one of the nutritive of pleurisyare membranes. of the adhesions the the very come pleura of effusion into the sac tubercle plentiful form.and are these not to be confounded granulationsconsist filaments of wavy which are connective coiled into with fibrinous deposits. Pleurisyis action of other definite often the consequence atmospheric or knowledge. in which of to " the is ramifications of small vessels are visible. Such of a pleurisyarises independently accompanies other the infectious action orders. smooth and cast glossy. tissue. neighboring organs. and tender newly-formed fusiform cells. and which great deal varietyas is form. scarlatinous poison. especially is pleurisy dry. the epitheliumis nearly all infiltrated. capilwithin them (Foerster). "erous The excitingcauses Injuriesof the 1.idiopathio usually called rheumatic pleurisy. Next in order is caused tubercle by and Here the surfaces opposing instances in which pleurisy of neoplasms. ecchymoses. of telluric to exposure cancer cold. Such accom excitingcauses generallygive rise to a form of pleurisy. by inflammation and irritant. " pleura. or. a'nd septicaemia.scarlet fever.or else a more less or numerous to the advance carcinoma.the pleura surface. development which to the are papillarygranulations.1 free surface Graduallythe a rough. loops of . as from the lungs to the substance In these cases the exudation generallyis scanty and fibrinous.which generally produces a puraexudation full of young is attended of other cells. finally.INFLAMMATION The OF is different in case the THE PLEURA.forming irregulardark spots. 3. pleurisywhich sometimes puerperal fever. the pleura ANATOMICAL APPEARANCES.and producing fine rose-red points and stripesupon this distention of the capillaries.such of 265 as pus.

is absorbed. form every place in the of whether pleuritis.however. fibriiious effusion other cases. more deposit. nevertheless. after undergoing fattydegenerationand liquefaction. no symptoms occur. this very Of and we of becomes discern cannot we until pleuraitself. pus-corpuscles. found.half much like a croup a line brane. Such a pleurisywe almost always see complicatingchronic affections Here independent disease.2G6 DISEASES These take changes in occur THE OF PLEURA. The tions alteraexudation.dry may with It is true.and thickness. alterations above described.somewhat by or the scraped off upon coated which fibrin. was period. dethis form of pleuritis the pleura. and a quantity of coagulatedfibrinous masses. indeed. scanty \ but very jibrinous. However. the described the sole from pleura just forming abnormity. so that and or have we more may in then observe course. accompanied by are great very pain. soft. that nutritive exudation. even consists of two This exudation a lowish-g yelcomponents pounds or more. 2. not.and. pleurisy. ecchymosisof the the fibrin with the scalpel-handle.having undergone we are often unable in the cavity of liquideffusion the fibrinous posit. In pneumonia accompanying croupous of the lungs. very almost without givingrise to any symptoms. form of the disease.both upon takes place in the pleuralsac. effusion of serum to this. exudation been found has free the outto exist. to find any " serum. many It is to this source alone that pseudo-membranes and adhesions of the their origin. which have formed we and for but this fact would indicate find that very small Pleurisy with we that they must exudations without occur exudation. It may also occur as the inflamed pleura. That scribed. the only coagulatesat exudation a the cate extremely deli- it to causes the is somewhat pleura a in these white more appear very cases profuse. growths no possible(Foerster). the coagulated one besides later an an or injection.and adhesions generallyensue.an in addition to ten amounting. 3. the outgrowths of the opposing surfaces of the pleura are brought into contact.to two or three. excepting those just deand the of to which we name give pleuritissicca. soon coagulum membranous opaque. mem- originally liquid.exudation. When recovers. Pleurisy with abundant sero-fibrinous in this in the tissues of the pleura are usuallyvery extensive the pulmonary and costal surfaces .or pleurisy purely scanty. extensive adhesions of the pleura are often Besides this. . pleura owe The forms of pleurisyare most common in which 1. but. not unfrequently. whether the effusion latter be pleuralcavityor profuse much few little or or or or fibrin. contain " anatomical examination of a rarelyhave opportunityto make in its earliest this has whenever been dry pleurisy stage.

when chest.suris often This incapsulated.or. taking on organization. According changes of to which take extensive manner lucid more or and and place in the effusion.whereby condition these not come thin-walled of tissue. receive to seems connective rhagic exudation.are prominent. and flattened into a cake. blood or costal lead and is coated a color. THE and lumps. pulmonary pleura.but from accessions. The greater third a the quantity of much so pus.and air. void atrophy at the edges and surface. the contents. the in the symptomatology of the disease.although here. while a it lies in portionis precipitatedupon the pleura. the is the turbid more the and serum.sixth. In of It the the displacement partialpleuritis. fibrin in the and increase to The fits and by blood of the young in the of the serous delicate the is We a of after-flows pleura. however. unless old adhesions offer resistance. do the constantlyfind agglutinationsof well exudation. that the transition from this form of pleurisyto the next. degree correspondingto the amount and.and to the even eighth part of its normal volume.as the effusion. Indeed. is quite gradual.in which great amount the increased fibrin is secreted in the pleura. consequence the the a and astinum medi- effusion itself is pressed com- of the effusion.without. longer the effusion remains.in thorax intercostal is forced of account spaces the is dilated are The lung in widened abdomen. and leathery.upon which The the form of a membrane. surfaces often vessels of the the immediately from vessels exudation as latter great importance opposing rounding commencing adhesions. Both any grow find a few and in the fibrinous depositwe in the serum pus-corpuscles. from which extends coagulum of fibrin.we often find an admixture effusion of chronic pleuritis. loose net-work. the is the as concise thorax follows: less apparent. find it reWe duced against the mediastinum to the fourth. its color is pale reddish or bluish to gray. too. the serum and the deposit. in consequence of rupture thus with haemorcapillarywalls. The proportion between fibrin varies. until they finally rigiddo the masses fibrous. the diaphragm heart symmetrical. according to the old-fashioned theory.also causes quantity of the yellow more blood.and in a externallyby to the its consistence state the of is tough. we warranted in regarding not are fibrinous exudation the consequence of a hyperinosis(augmentation as of fibrin in the blood). so much the stronger and more become.lie displacedto are in the middle and its "The down into the other of the Rokitanslvy. it is constantlypushed upward and inward and back-bone. it is far more of a probable that a pleurisy. in which so far more are pus-corpuscles abundant. side.INFLAMMATION Part latter floats in the the of another OF part the traverses in the form of 267 of flakes form in the serum serum PLEURA. . forming pleurisy fibrinous by As starts.

and.cheesy fibrinous unabsorbed are more imbedded cellular deposit and between the consistingof masses.and present may intercostal spaces . portionof lung corresponding to a its extent. The liquidportion at length disappearcompletely. becomes and (sothat concentrated the seat of intense Should oedema.and may expand . great quantitiesof pus-cells Here too. in fatal cases. . becomes spinal column dislocated liver. found yellow. Pyoihorcux.268 DISEASES and compression are seat and limited OF to THE PLEURA.at first often displacedto beyond the rightedge of the is drawn back as far as the left axillaryline. and the dislocated all regain their proper places. The Should and occur.the heart. of the pleuralsurfaces." The lung the upon side is unaffected always collateral fluxion. The time requiredfor the production of If absorption of the this condition be cannot given with accuracy.the far in the opposite pleurisyof the left side. Pleuritis with purulent effusion. The sometimes direction. nar- the even right side. may In other cases the alveoli become adherent tinued agglutinatedor by conWhen else depositsupon the compressed lung prevent its reinflation.roughened may The fibrin also undergoes by fibrinous deposit. adhesions.the compressed lung may again become pervious to the air. absorptiontakes place early. which are usuallymuch thickened. after undergoing the often-mentioned be absorbed but there is another to pleuritissometimes.is now the a cave conrower.a vacuum afterward tends to form. and is absorbed. the pleural surfaces. previously deeply depressed. The fibrinous portion also contains and seems soft. Not only are frequently also the free surface.coming into contact. and the mediastinum. the and it most this form of follows malady. of collateral take the place-in this form of pleuritis.and irregularlosses of substance opaaue an opaque. ap which. sternum. as high as the third rib.always takes more at first far more Sometimes place. the or pressure. exudation covery re- gradually the absorptionproceeds rapidlythan it afterward does). thick fluid. to fill the adjacent organs thoracic wall and suffer displacement. and then adhesion an fattymetamorphosis. elements of remnants of the exudation. may heart and liver.but the fibrin and metamorphosis. pus. The instead until affected of a the dense side convex fibrinous of the chest . but they are pus-corpusclesgenerated upon latter becomes formed within the tissue of the pleura itself.and In pleuritisof curved.Empyema.and not only the serous part of it. diaphragm. softens. the exudation. In " liquidpart of the effusion is here so rich in pus-corpusclesas to form yellow. the surface in. the intercostal spaces return to their normal state. sequel may . now 4. the finallytouch ribs sinks shoulder become sinks.and of a very yellow color. liquefies. exudation should take place.

and physician. Besides of friction. observed where there is absolutely whether satisfactorily cough.as and ribs and greatly increases the affects The increased an covering. and sliding upon one thus prevent a uniform expansion of the lung during inspiration(see is a slightdyspnoea. The consequence which is only felt when unusual excites bodilyexertion or other cause Extensive and supply of oxygen. vicarious often emphysema). may remain dischargeby in such costal empyema lung In similar its recovery the upon OF bronchi the into the empyema sometimes be may happen. and respirationof the patient is shallow tension of affected intercostal muscles the the pain. symptoms. Dry pleurisyhas no symptoms. We sometimes find adhesion of the entire pleuralsurface in the bodies who have of persons been never AND ill. seriously pleurae hinder COURSE. or. In like manner a the upon pressure pleura immediately.during ordinary by the limited and slow movement the strong and than that from arising breathing.similar to that arisingfrom it is due to a complication of pneumucous membrane. or whether monia with The the bronchitis with pleurisy or pleurisy. but a rare. are and side. scanty no and accompanied by extensive inflammation of the lung. is usually unattended by fever. and it has not as yet been determined the inflammatory irritation from the cough is a result of reflex action irritation of the bronchial of the pleura.recovery manner. lung and SYMPTOMS PLEURA. sensation of or There is also cough. they cannot the disease which it accompanies.or serious derangement of the health. 269 capable of redistention. some scratchingat although cases the toward generally bent some patients have point of the now and then a intercostal this the The cautious.external take place. already stated painful symptoms its foot severe originto the of which is one pleuriticstitch.is far greater rapid and motion of forced sneezing are especially respiration.for We medical have the most owes often unless go on to the or clinic. at if it have be distinguishedfrom those of least. tably of croupous pneumonia.as these acts compress a demand for within. " rigidadhesions of the pulmonary and costal the two from surfaces another. is penetrationof a of the way instances THE pleura and penetrate deeply. and which indubialmost constant complicationof the latter that the . body lessens is the its inflamed distinct thorax. their room. the sufferingproduced of the pleura.INFLAMMATION they be situated the perforationof the if especially the result. is accompanied by Pleurisy icith scanty fibrinous exudation severe piercingpain when a breath is drawn . even Many patients never fibrinous exudation. as a rule . to the other keep office of their aid. attitude cles mus- pain.and in fortunate cases.Coughing the inflamed pleura from painfulto the patient.

disease with the under now pleuritis of form lung. Besides the lung. in a manner begins rigor. the effusion is very large. THE OF is generally consideration. lateral plainlyattributable to the coldistressing hyperaemia and collateral cedema of the uncompressed part of is obscure. cough.or sudden the even provement im- general ceas- . tional excepshould and of disease of the cause suspicion grave occurrence. A intermitting fever.and by which the breathing surface of the latter is materiallydiminished.the difficulty where of breathing diminishes. and severe symptoms of local disease.and which often becomes extremely severe. the varietyof pleurisy. and The which is often fails. succession tertian an of the that back course.is the into which felt at also form the last described beginning often of this passes. or especiallybefore the effusion is complete. and be the almost more of which coated tongue. may. Pleurisy with profuse sero-fibrinous w ith violent general phenomena. than the other symptoms of pneumonia. of briefer duration Perhaps the pleural surfaces cease this is because one another.270 DISEASES PLEURA. which scarcelyever extremely more is sometimes and persistent. After disturbance increasing in intensityfor take place.the often for acute intense by and of commencement an runs is followed the headache the like the very there are well-marked a possibleto mistake it is an quite incipientpleurisy type.usuallyreferred to the side chest.before the pleurisy pain abates somewhat. even and often ceases altogether. the copious and richer in serum. slidingupon infiltrated. Ushered fever.which aggravated as the effusion It is important increases. on so and inflammatory and chill. play an important part in the production of dyspnoea. At other times its source these symptoms.the in see The pneumonia.just as in may and dyspnoeaundergoing six or croupous a marked eight days. and often ceases has attained its climax. exudation sets in quite often. and that the by lateral col- the uncompressed portion. At all events. But where even a large portion of the lung has become it supervenes in disease the when occurs spontaneously. becomes there is dyspnoea.justas it does in croupous nia. in mind to bear of the pressure the fact that effusion hypeKEmia and upon cedema part only of a a the portionof the arisingin dyspnoea is caused lung. decrease. the pain usually ceases in a few days.it acutely. one take may by a severe frequentpulse. pneumoas soon as the fever with abates. altogether.with however. several. all violent than malady in full and limbs. clironic disease Its persistencefor weeks is an especiallyif properly treated. exudation ing becom- As the disease advances.which we There diseases. and it the need of additional oxygen. sharp pain.and pain in the parching thirst.or when of the lung. a pneumonia.

patientsin whom great many form of pleuritis tion.and exthis the than In ever. disease. and. where he is unable of his attack. air for for once absorption. of " a he or a physicianbecause fallingoff perhaps may in he " strength. examine The worse now fever.coughing hard. we breath. and its concentration slower and slower.absorption patient has still be can found. we ance. higher way with for nates months. as a rule. breath he himself. This depends upon a rapid abatement the reabsorptionof the effusion also In fortunate of the fever. has grown . in which have seen cases physicianin good practicemust confined the patienthas never been to the house. and. but progress febrile exudation on of further the of take the end no subsidence At beginning to end.and often without attractingattenits subsequent progress being of an equally tedious character.termidrags on fluctuatingsymptoms fatally. as the volume absorption goes on most ing totallywithin hours. a of the exudation the remnant greater.the begins immediately and progresses of rapidlyat the outset. being tedious or these to lung .even grows becomes weeks after the apparently entirelyrecovered.and time some having the become only varieties of the least of none hitherto disease of comparativelyslight shortness patientlabors escapes the notice of the patient seeks become has pale and chronic disease some the past pain.when fever. develops slowly. patient short of the chest.too.the of assistance of aware thin . originallyacute. and.which their may we sider con- pleuraeare amount to . in pleurisy the right depressed positionof the liver may cause bulge. the more as.OF INFLAMMATIOM THE 271 PLEURA. which.so that. few a liquiddecreases. wait which cases. afterward exudation complete a are the at fever The little later. in the apparently favorable again one day find the spittingbloody froth. Next those a in vain and the acute The character.at no unfrequentlythe which under often right side. come outset. and pain which ushers in all no severe Not described.and think for of he has that the of so abdomen. anew inflammatory fever. Every hypochondrium to of this kind. this there are a Thirdly and lastly.and in preciselyto fix the date of the commencement which physicalexamination quantitiesof effusion and debilityof that filled up these in the demonstrates pleural cavity. general disturbdiminish begins to of the and . midst of this There is that prospect. but. if we find that the effusion has increased tends we by a hand's breadth. patientsare seldom the free easy they are by an exceedingly albuminous from of existence The of extreme enormous prostration explanation. and create tension in that region. As alreadystated. the enters more from acute moderates at makes last the compressed parts slow a the first week. . cases rapidly.and that effusion.

careful of where ness to be line of also be due have become relaxed and forced in mind exudation. young than . These of the condition of the cases intercostal has become always must patient. as and it PLEURA.should not be despaired have absorption may at last take place after we is very its hopes sinks the toward diminution diagnosticatinga the may the hard of such compressed an of event. in effusions the disease.are just the same in effusions little As containing already mentioned.if otherin good health.etc. the by (which it duced. of too given in which as soon. fill the to arising from being employed vacancy organs up be regarded as terminating absorptionof the effused liquid. but to in most empyema. yielding. all up When extremelytedious dulness muscles borne reabsorptionof large effusions. of the lung.but owing to blunted of condition the serious complaint whatever.the remaining portionsof the lung can always uus sheath. It has on sufferingany serious inconvenience already been at mentioned that is apt first. it terminates exudation. exudation A chest. attack. lung. With the so regard to all that of its insidious account on the implicationof sensorium. are hardlyto be regarded as rendering the incomplete. end in Adhesions of the pleuralsurfaces. or oxygenate long as the the its alveoli blood and sufficiently.even the of the in fact that to the farther the the the downward. Such would circumstances. of gradual multiplication the by shall under effusion. pleuritic pus. Pleuritis occurs or before apt.the pleurisymust thus wise in incomplete recovery. patientabstains from an eliminate overactive the carbonic bodilyexertion acid. and the thorax when to admit boring collapses.alternately as we finally. pounds. only be very favorable is very THE OF long duration of of as compression. the termination of all forms of the disease pleurisy. and. is no longer able the neighair and to expand. be the dul- of diaphragm rapid must in all wall and facts if We decrease thoracic that last.as .or more judging An be obstinate reabsorption. . reproin pyothorax.as patientsmay attain a very great age without recovery this account.. effusions often form during septicaemiaand other diseases arisingfrom in which abundant cell-formation takes an blood-poisoning. that the relyupon must we it is not and system the to patientsfrequentlymake subjectivesymptoms no wanting. of the hardly be diagnosticatedotherwise can the most slowly reabsorbed see.272 a DISEASES of twelve weight fifteen with entirelyabsent purulent in any case. or nearly always remain. The decrease and be cases cells form sumption con- when are never alreadydescribed). an to said. either being enclosed in a firm fibrin- being occluded or adherent.which always may recovery. and are objectiveones. In persons affected. the commencement. place from symptoms However.

not. a hard.in rare thorax may ensue. and great dyspnoea numbed. carbonic-acid poisoning follows. the pulse grows small. enormous Here.that which pus in occasional live for many stantly con- profuse years. ing through the diaphragm.either Cashes. It is reoccupationof the space restored by discharge of the pus. into the lung. At other it takes times ing place without warning. frothy and often bloody sputa.leading to intense oedema in the healthyportionsof the lung. or into neighborproduces violent peritonitis. part of the pulmonary capillaries heart. at the swellingof the integument makes its appearance. the extremities cool. which is then always somewhat hypertro- that right side of the phied and dilated. which. termination and finally This of amount dischargesa large very pus. pneumothorax. In other cases.INFLAMMATION notwithstanding in the sound 273 a the blood PLEURA. results in reinflation of the and in lung and rarely complete recovery. causing disturbance of the circulation. A When and in a patientwith empyema thoracic fistula continuous stream a such a forms.the from the foramen suffers flexure at its point of emergence vena cava quadrilaterumof the diaphragm. the slightpneumonia. A fatal result in recent pleurisygenerallyarises from collateral hypersemia. " " cedematous an points or opens externally. is sometimes preceded by the symptoms of a perforation bloody sputa. however.and to engorgement to incomplete filling the and veins of the aortic system. compression of the lung and its capillaries givesrise and obstruction of the left ventricle. too. much and for for the thorax in such cases to collapse.not imperfect filling and concentration only to a small pulse. organs. more common Still more commonly secondary displacementsof the organs to occur.but to an excessive diminution Perforation of empyema 19 .is THE OF the current accelerating lung as to avert derangement still capable of the parts of so of the of the circulation. the patient suddenly dischargof purulent sputa after a violent fit of coughamount an ing. an flows. tion retrac- of pyo- (seeChapter III.are the of the more with instances. in displacement of the heart to the right. Rattling sounds. firm tumor protrudesthrough show the intercostal after to a fluctuation. a renewal of the stitch in the side.recovery very but usual symptoms result of or without or suffocation. This of the aortic system frequentlygives rise. is to say. from or fistula may pointsinwardly. of the right ventricle B artels points out that.). time. bebecomes arise. the thoracic closure of there remains an pointing opening (after imperfect When of an empyema empyema). the sensorium the action of the heart is weakened. begins space.etc.but generallyin the neighborhood Soon of the fourth or fifth rib.and the sufferer soon expires. most dependent part of the chest. has perished.

and it is the same Df the liver when the effusion is upon the rightside ." prominent. Where of the chest but the over spaces the inner a enlarged in of the vertebro-mammillary diameter. the chest of should the patients spare intercostal 1. persistent. which in ensues of consumes hectic.displacementsof the heart can often be made with displacement out by inspectionalone. the effusion is not When so when hi the it is and lower large. blood. within. and. an natural unBesides this of evidence from prominence.the affected half all directions. therefore.inspectionreveals the fact that depending upon is no longer affected by the traction be). OF membranous to " the symptoms When coating upon of consumption. In death cases into the ema in other lungs. they effaced. results burstingof empy- still more frequently erate. in the pleura produce prominence of some other portionof the thoracic appears wall. without. dilatation of the thorax is limited to the region which contains the effusion.however. fibrinous the to leads cyanosisand to outflow from the cylindersfrequentlyappear renal in the urine. 3.are are upon sometimes a area level with surface the elastic of the lung (as it exudation. the entire pleura. Finally. the results of inspectionusuallyare negative.abdomen unabsorbed of consequence Death etc. of the veins to obstruction dropsy. indeed.in fever. although modconsequence the organism. It is only when tremely respirationis expainful that side.8 the When pleuriticeffusionis large.owing veins. in the former the impulse of the heart being too low. and is which. the pleuralsurfaces. pressure exerted bv the effusion upon the surrounding parts. gions reusuallyincapsulated posterior of the pleuralsac.but is exposed to the pressure of appearances. Very much more dations incapsulatedexurarely. the exudation is scanty. materiallyencroaching upon its space. in the latter.inspectionshows . effusions.most of empyema pneumonia. In effusion of the left side.tedious or imperfectabin tuberculosis.or when it is liquid.and. but in the line chiefly are somewhat the effusion fills up 2. median indeed.albumen. called Finally.and PLEURA. the PHYSICAL patientsuccumbing SIGNS thin forming a results sorption commonly of all.274 DISEASES of the urine OF THE Distention (Traube). and sinks to the more dependent part of the pleuralsac. indeed. The shallow grooves.and other that we its perceive that respiratorymotion the can is not free as as upon fected af- the side. of the effusion the series of are no longer " ribs. and too much the toward jase line (sometimes. being perceptibleto the rightof the the right hypochondriacregion shows sternum) . in chronic destructive or PLEURISY.

but to ascertain the length of the the to after place. no lung again undergoes perfect expansion. is said to shape. sign form shallow is complete. to not only. and their proper out corrected.instead rare the rising. inspiratory every of course. however. THE OF INFLAMMATION now.the depressionof the shoulder. " grown so great out Finally." where the lung has not reexpanded after absorp . the and of reaches. and spinal column.there generallyremains When the which has the disease of absorption justpassed away.and even overlyingone another.remains comes expand as the effusion be- of more the ments respiratorymove- fixed become heart. and form.far that.in This respiratorymovement. If to form a as projectioninto and when paralyzed.from chest.during inspiration. and callipers. still the watch to the the measure draw is to shoulder curvature of the of that spine. effusion. if wish we of the two Wbillez. The dilatation once more exposed to thorax of the has of the the the loses thorax the much has exudation its rounded is its more the remain circumference by of the means A measurements. side side results accurate of means ribs of the affected will the the compare the other upon of the progress eters vertebro-mammillarydiam- two thorax.by is its absorptionof the lung.as absorptionof a pleuritic progresses. situations. time to time.the effusion the as 275 PLEURA. tends these surface. from chest is physicallyimpossible pressed dediaphragm be so much the the with organ.owing some muscles of the contraction wall does thoracic is. more antero-posterior diameter. and of the restoration of reabsorption.sinks. it tened.which flatten the to the take not degree. convexity.the is are descend.the be not act. if its muscles and abdomen. the convexity of which is often it becomes more capacitydiminished. flat- although where cases chest. much halves The the lower are be of the laid the more the greater is the the be can to method surer one in Hence. to undergo reducabsorbed.as in the palsy of intercostal partlybecause the dilatation of the lung cannot expand. The ribs coming close together.who of side.which at leisure. and collapseof the much so one half of lateral curvature toward the sound patient.the of derangement dislocated the ceased. is its lower on instances. upon side where the effusion is situated. so so returned perfectabsorption by adhesions.however. effusion the compressed If.all the dimensions its length and and. commenced.in very pait filtration in- to collateral fluxion. the intercostal again furrows.so that.even same. having the liver have and heart Sometimes.being spaces traction of the elastic the lung. If. the lung do not of the chest seem tion.the epigastrium. especially.in of cases as seriouslyto deform mended urgently recom- halves two and of the The the of the the two ideal tions sec- Kyrtometer of accuratelycompared pressedtogether.

upon very little space.in order the vacant caused to fill up by the space disappearance of the liquid. compressed lung touches the side of the chest. often furnishes important diagnosticsigns of Palpation. the chest. the greater diagnosticimportance than is of or the less lower this diminution When the hardly . wave-sounds weak. large this sensation which distinguish well the treating of under conditions the as which it been greatly quantity of frictionis perceptible considerable a sensation liquideffusion. terms.when weakened .from the peculiarcharacter which the In general exhibits in cases of pleuriticexudation. wherever 'a liquidpleuritic the with the thoracic wall .moreover. above the limit of the effusion. the abrupt transition regions of exaggerationof the fremitus limit of more of the exudation. fremitus vocal weakened. Posteriorly. effusion.as while discussed be auscultatoryphenomena. mitus than upon feebleness absence of pectoralfreof the chest or .and even is not. inspectionwill often show that the heart beats fat The of this is line.and that it will the vibrations of the latter. gradual Seitz.the fremitus is intensithat a profuse liquid effusion will impede It is quite manifest of sound-waves the conduction to the thoracic wall. high-pitchedvoice. it may be asserted that the pectoralfremitus is much effusion is in contact or entirelysuspended. viouslydistended A compressed lung occupies complete absorptionof the exudation. extensive.than does the normal unretracted lung. that the restoration We observe of the normal sions dimenfinally may the secondary contraction of a chest pre* of the chest. but. and it also act as a powerful damper upon is equallyplain that the retracted ductor pulmonary tissue forms a better conand disturbs of the vibrations to the chest-wall.the vocal resonance plainlyfelt upon the right side the left. cause as that the heart. even always is a for room Upon palpation.but over decreases patient has a is a valuable exudation it is is to the slight. As. for the passage them less. when portion.there in the after and. and even gradually toward the level of the liquid. under normal is more conditions. effusion.276 DISEASES OF THE PLEURA. whose it is anterioi absence from accurate very fremitus In the of means however. pleurisywith profuse effusion. and even far as the axillary to the left.is now left pleuralcavity.the upon and the of occurrence rightside same lateral symptom upon the left side. which at first was pushed to the right by the pleuritic tioii of the far into the drawn as reabsorptionof the latter.will and sensible liarities pecu- signs. by itselfa sufficient proof of the by effusion. the the upper some the the to determining the signs change in a fremitus is observations only more is lost over merely lessened.where fied. reduced size. According manner. in pleuralcavityhas of characteristics The from other arises. a number of cases of pleurisy.

even scanty and into felt several be Percussion when effusion copious exudation of cases the Over the with the percussion-sound retracted ever.how- thoracic wall.the edge of the breadth fingers' information no the On coating. percussion is the tympanitic.or affords it is and part of the wall. is lung the pleura in the form bulk of the of a thin. soon patient.but only reaches as far as At other nearly the whole pleuralsac times. The conditions under which the dull.that dull form comes gradually be- sound and the depends boundaries upward. large effusions. effusion generallyfirst becomes perceptiblein the region of the back and it spreads toward the front.coagulated is checked.by separated from the diaphragm characteristic the Over of other still contain may the border below which chest. below the scapulae. body graduallydiminishes The upon . arise have and tympanitic sounds already been fullyand repeatedly of the explained. by the lower back breast. of dull Anteriorly. aid to the In tion.hollow.palpation is of use inspecdisplacementsof the neart and liver.as agglutinationand adhesions which. lack circumstances.8 the surheard whenever faces Upon auscultation. the lies upon 2.furnish very /egion where the side of is dull. the less distinct.smoothness fibrinous through deposit 01 the growth of rugged vegetations. are generallyaltered by changing the attitude of form about the effusion. the liver of the result from which and often may ribs. dulness reason is is this is. signs upon liquid effusion lies in contact where space exudation of presence hand.friction-sounds are of the pleura lose then. and the air)touches the erable consid- a thoracic and percussion: 1. all vibration the subsequent reabsorprightpleura. we any important an effusion. diagnosisof pleuritic existence in ascertainingthe of the Finally. its lower.oppose their separationby the pressure of the exudation.OF INFLAMMATION reach the thoracic wall under THE 277 PLEURA. which for the The occupied is but little percussion-sound the as posteriorly.alluded to in speaking of tion. . lung (which. but these sounds of course are audible when when and the surfaces in are only roughened contact.when the boundary of the dull sound effusion. No disease is better adapted for the demonstration hollow and difference the between dull and the hollow percussion-soundsthan proceeding from pleuritic The dulness pleurisywith copious effusion.although they still allow the pleuralsurfaces to slide upon of the dulness each the than abruptly to fainter the reaches the changes upper which far up found not dulness the cases not other.the behind. line. As it ascends dulness The extends far upward in front as it does as scarcelyever In many behind. upper the axillary in at all over front limit of thickness of the the and the empty effusion is from effusion below sound tympanitic approached.

at the sides of the thorax.the respiis loud and puerile. They are usuallyperceptibleboth upon inspiration and and distinct of give a expiration. loud as a rhonchus. impression scraping or of scratching. unless it be the seat of collateral hyperaemia rhonchi when and rdles are to be heard. ever Of course. the physicalsigns of pleuritis are greatlymodified whenfrom collecting old adhesions of the pleura prevent the exudation the the ietail most ah1 dependent part of the and these modifications. callingto mind the creaking of new leather. the latter sometimes there is severe dyspnoea. known chophony. is heard more against the disease.faint be surrounding parts. at the utmost. the over whole not profuse. in cegophony.or. that we as having a bleating tone. only the air-cells murmur is not the effusion is very compressed lung lies close to the thoracic hear a feeble bronchial respirationand a faint broncan wall. of that it friction-sound. the fibrinous depositis not rough enough at first.It is most foi is likewise often perceptibleto the touch. audible become after now more once of the evacuation into come liquidby tapping. both upon the diseased and healthy sides. at all events. the and while they patients. undergoes a always ceases It is also somewhat change.is not altered by coughing.where are obliged to spite of the compression of the lung. the them to rub together with certain a causes respiratorymovement degree of rapidity. as however.which reabsorbed. the ear Over the uncompressed lung.breathe cautiously. In a few instances. can vesicular heard breathing. the pleural surfaces The characteristic the serum.which A friction-sound. that is to say. as time which at begins be to also They a that so pain.loud bronchial points where there is of the bronchi breathing is a large mass are heard of over compressed and the whole liquidbetween do chest. rub do not together with sufficient quickness. when continue suffer to separated by previouslywere contact. catarrh. the is heard whatever over the scapulaeand It is only between very faint and indistinct. suppose not contain at even and and in that where the the greater part air. the exuit is audible most dation frequently is when the faces of the pleura. is scarcelyever almost rhonchus a besides. or.278 DISEASES THE OF PLEURA. When region of dulness.and when but the bronchi are compressed by it. whereas after a vigorous cough. a buzzing rhonchus. and although we the spinalcolumn.and there are liable to be mistaken often little jarringinterruptions. lated effusion of very considerable chest. the When transmitted exudation by the sound is very large. we shall It would merely magnitude may lead state form us that too far to incapsu- between the .no respiratory the dull region. and. when the stethoscopeis pressed rather firmly distinctly This sound is rarelyheard in the beginning of the chest. ration lung.

When obtains. the dulness often intensified. the intercostal of dilatation of the thorax. Pleurisyscarcely this is the while in pneumonia singleviolent chill. In downward. displacement liver. absence of the respior percussion. The rule. and and not are we have unfretained ascer- by palpationthat the liver reaches below the border of the ribs. upon then* retain indeed.the not are spaces the pectoral fremitus situation. should fills up the right hypochondrium.and. a the in state expiration. pleurisythe sputa indicative are that observe we of catarrh or of streaks of blood . made to project abnormally pressed upward. or an is reaches we farther upward reasonably infer may that the liver is pressed which.is heart and be the liver is seldom enfeebled. The following : when same liver time find than the that there liver 1.and we at the below the border in abscess.INFLAMMATION OF 279 PLEURA.and be very difficult of recognition.or crisis. the two ditions conpoints of distinction between rarely pushes the diaphragm upward . is almost respiratorymurmur effusions in their right side Patients having pleuritic and when quentlysupposed to have disease of the liver.while the opposite condition border.feebleness ratory upon the whereas. in pneumonic infiltration. which intimate pneumonia. and often remain quite unrecognizable.the effaced. pleura and instances rare from (usually liver of the thorax dulness 2. and with upon is then it the inspiration and place when there is line of upward upon transition kept from in the liver is enlarged. It is not with DIAGNOSIS.and 4. and sometimes stained that peculiartough expectoration. and intercostal enlarged. This the pleuralsac. yellow or yellowish-red. by is of admixture of blood. diaphragm the into cavityof the thorax. expiratoryexten- feelingof resistance. is there nor cyclic. chest is not heart of the dulness absolute murmur . The 3. of the ribs. and sudden in rely for the purpose : 1. and the followingare exudation the chief abundant of the base the and diaphragm " points upon which ever begins with 2.presented bv the .its lower downward percussive dulness. The the the are extends a normal is an in the hepatic dulness effusion in the very the which should do.faintness or absence of pectoral fremitus. effacement furrows. hence. lute. but there never contain is oedema. always easy to distinguisha pleuritis from a pneumonia. so never which better. THE lungs. it is important that we the organ is enlarged or able to tell whether merely depressed. through enlargement a cyst of and echinococcus). In pneumonia. percussionis not so absoalways bronchial. pathognomonic of exudation 4. we a may of course pleurisyis a for the complete change 3. the dulness reaches farther up in the in nearly every case of pleuritic effusion the front of the chest.moves large effusion depressed. as of permanent does the not take diaphragm sion. The pleuritic principalphysical signs indicative are.

or echinococci. puerperal fever. although the pain which the dyspnoea. and pallorof Finally.tuberculosis This sequel.the persistenceof the fever. reason so to hope that the lung may expand again.from it are the them. so that no deformity of the augury Ihorax when may the remain Symptoms ihe blood behind. may effusion. Itthe patient. As there in the majority of regarded is to be cases. of oedema at the of the commencement lung and of the imperfect decarbonization disease are to be viewed of as un- . septicaemia. pneumonia or tubercuAmong the varieties the creeping.to thoracic THE OF liver projectingfar into cavity.augments the danger the primary disease whatever or pleurisy with acute the much malady more grave. the produced by that wall. give rise to of true foregoing variety. a it.being a main cause losis. In downward.DISEASES 280 whereas border ribs and the of 5. Dry pleurisyis an altogether insignificant does effusion.that of the is also involve commencement which runs favorable most type. the is prospect complete absorption. how- spaces. small pleuritic effusion of The main a point of distinction between left side and an enlarged spleen consists in the change which the thoracic the not the place in takes dulness of pleurisy. evei pleurisy with scanty sero-fibrinous of should in kept thorax the be " nor cause of of danger. and ploration physicalex- repeated again and again. must is as a of the beware more it is to be or favorable less as of sources danger regarded sign. affection.the uneffaced.may should be not forgotten that both fever and wasting may be solely cipient dependent upon a latent pleurisy. patient possesses have we much the more the earlier reabsorptioncommences. as appears nature the from course When profuse attends quently fre- when empyema the effusions which bad prognosis. we already alluded to.lies in contact with the side of the chest.but the threatening phantom of inshould consumption be always view. namely. quently yieldinginterval small a somewhat are huge cyst of surface bowed is enlarged liver.ip from sumption con- of favorable Finally. in which instances rare of the abscess an has intercostal the immediate between lower liver.while diseases which a an prognosis. of the Decrease the error effusion diagnosis of which.etc.but in occur line and which does during respiration. PROGNOSIS.of itself. develops purulent from of the the from the admits after be. the displaced ribs not unfreever.the emaciation awaken the suspicionthat phthisisis developing. been . easilyperceptiblein enlargement of the is spleen. usually discoverable is of liver which a the of enlargement the outward.excepting in still remaining a the PLEURA. a vigorous constitution. insidious a even from sero-nbrinous outset is of as. however.

treatment a by diaphoresiswould in " an at were can "antiphlogisticsystem.and who be also Charite". be considered must as unfavorable. local and morbi. effusion. cya- in persistent the more the fever which accompanies it.the of amount incompletelyfilled are of the of over-distention symptoms 281 blood nosis. which gives evidence of great inby Joseph Meyer '. procedure. absolutely Indicatio in causal pleurisythan they can cold. Finally.and who modes effusion is enumeration number of a such of cases it of consequence as cases who were large effusions. Indifficult of reabsorption.and inunction of mercurial blood-letting. did not the recent have at limited which the the number cases of taken never profuseness of admission somewhat the have nothing. the fact that a certain number of patients. in the last ten years. caused attack of pleurisywere by catching all intense.INFLAMMATION favorable prognosticsigns . with albumen. the are THE OF is also as indicates that PLEURA. being treated by copious The have not converted me. secreted. has gradually has fallen into discredit. venesection be can exception of a dispensed with few rare cases. TREATMENT. and mercury any not therefore But even observed and by Myer of pleurisy. have not been bled.which formerly used to be the treatment of pleurisy. in the where ment treat- certain ."if the be The " of arguments and this author against the in favor less active the of method former ever. should our other than predictionsbe. cases did not result in blood-letting. and that the of active is inferred a neglect these did yet who seek not others. even treatingpneumonia. a The of indications injurious.the greater the wasting of the patient. that of reabsorption. given. and its tion subsequent derivathe general practice by blistering. prognostically although. of if we were that aware fever be more no in treatment met In fact.who treatment. been mended recently urgently recomagain in work dustry.. tedious.are. as quite erroneous. the greatest danger in this respect is to be apprehended from the pleurisies which in a manner almost and come on imperceptible.so much the worse all sequelae. with large pleuritic upon exudations. always terminates I consider effusion deed. ointment The " until salivation is produced.have been received into the Berlin Charit6 Hospital. assertion that pleurisywhich is ushered in and accompanied by very almost in profuse acute symptoms. the danger may vary in degree.and lasts." with its general its exhibition of calomel. unless proves bled. howbased Thus a great weight is laid upon very slender foundation.which urine Still worse urine. of . if left to itself. etc. whose duration is 1 still believe of extremely that with pleurisy. but which. casts. and the appearance The longer the effusion of the in veins.in The treatment.as shown above. diminution a the arteries dropsy.

but.if the pain.from my own Having convinced alluded cases to. if the latter do not dread the application or the pain and dyspnoea in an hour or two. the patient.although its action is then far less easy to observe.should be applied.which which. to be of service in certain applicationof large vesicatories seems used at all. and. prevents nor I it.recurs hesitate to the repeat the local of course a blood-letting permanent.half certain more daily.of tartar of calomel the exhibition is not without problematic. effusion it neither that convinced am the PLEURA.or it will exhaust customary It does not use of affect the . moreover.It is sufficiently for employing this impormoment tant highly essential that the proper evil may should then be prenot be neglected. do good service. digitalis the of commencement fear that very the attack. THE OF DISEASES 282 this and. I regard the practiceof bleeding as still more in pleurisythan in pneumonia. must be too heavy. or relieved should we this. and of calomel. tients of cold compresses.I regard as highly potash. is of pleurisy. ancl. a tolerably ber large numleeches.as much treatment vented. in unnecessary treatment when called cases. of remedies for want ointment be may of rubbed obtained of other from the into the at affected suspended once As appear.they must be used early. attack of pleurisy.its efficacy of recent pleurisy. that the fever reported in the work of Meyer above of the articular is not materiallyaggravated by former advice not to resort the vesication to of use I blisters. serous be inunction action. large hot poultices. which. relieve of is almost day two. tedious course.demand symptoms malady. of an At the commencement however. and the tendency to exhaustion which already exists.owing the its to always liable to lead to deterioration of the blood. its dangers. The action of antiphlogistic emetic. short cuts disease. Antipyretic nitrate of save my Indeed.and twice chest that the moment in depletion. as it tends to augment the impoverishment of the blood. is difficult to repair. Internal medication. Indicatio is always proper treatment Symptomatica. gerous danand to consumption. while retract now fever lasts. the " when the when it is fever so is very high at the persistentthat there is reason to this object in view.or cut-cups. When the paafter-period. With is to be recommended in certain cases. I cannot the use recommend of cold and of local blood-letting. however. when In protractedcases. not for by specialsymptoms. side a of mercurial decided ointment inflammation particularly membranes. as . and from the observation myself.but the inunction must signs of mercurial sore mouth is sometimes in inflammation the by not of mercurial drachm benefit an relief becomes Besides of the at always until the a is should always be tested in cases capsules.

If. a is is to be apparent and effusion. the juniperselves promise our- of tartar. especially cases. In recent in the form of usuallygive digitalis I have circumstances and is of cases. when it arises from collateral hypersemia of the uncomwhen eral signs of commencing collatparts of the lung. diminished rapidly under as Schrotfts treatment the in the idea of physician charge. of the blood producinginspissation by diminishingthe supplyof water to it.the effusion remain both and is to be rejected.indeed. to high. conges- of foundation. prejudice. is very uncertain. case. j for a dose. pulmonary circulation. makes it seem rational the administration of to diuretics of the effusion. upon absorption of pleuriticeffusion depends. usuallycombined (gr.dropsy. charge of inconsistency.INFLAMMATION primary disease at all. It is far venous of the tvhich often je the to about entirelyvoid Remedies paid to at an wasting The old the laid not ings. tion of blisters is of very doubtful The fact that pleuritic other use. undiminished. which bitartrate of attempt and to reduce the water in drastics.when by loss of its water.and almost entirelydeprived . efforts to remove what is known it.that iron causes tion. where the THE OF as I did bleed not ordered often to the cure I danger arisingfrom the hyperaemia.imperativelydemands oedema such fever PLEURA. 1 latent more already exist.and potash. with watched which had withstood all attention.after the inflammatory cation. for the promoting of reabsorptionof the effusion deserve little reliance. pressed Dyspnoea.conceiving . action of the blood to of the promote by sorption ab- of diuretics. and the perniciouseffect of the drastics digestionand assimilation forms a serious objectionto their employment. or pathologicaleffusion has been rapidlyabsorbed during an attack of the blood had thickened become cholera.I give it in subwith equal parts of quinine). and other symptoms of engorgement of the aortic system depending upon disturbance to requirevenesection. stance character. more Especial attention of the three have Under venesection.fed coming the patient upon the driest possiblediet.but successive the for rare becomes hesitation no four or cyanosis. questionablewhether it be possible. by about the to conditions the which therapeutic bring any means.instead of attempting to abstract the water from it. There fever.all medisymptoms have subsided. volume should ferruginous preparations. upon In one I which did not but treat I which myself. It is.boracic cream berryare the best. bleedof the account on myself open deterioration of to by of the the the to the earlyperiod. where infusion (3 283 the ss a fever is in tedious " vj).owing induced administration nourishingdiet.a pleuriticeffusion. of and pleurisy.so that we cannot much from their use. order the Unfortunately. external and the applicainternal. blood.

during which the lung is exposed to pressure.the so-called dropsicalcrasis. It is to diminish."which. other cases.but of In most into the pleural sac.the discovery sorptionof pleuritic that their evacuation is attended by surgicalmeans by much less danger than was formerlysupposed. than does of a disease or tissue. " Hydrothorax is not the result of an exudation. aquse the affected of the side that I destil. to OF allowed was and also may inward this treatment a be failed. contrary wine certain on sorptionby has days. both in cases a well-known and of empyema of of tapping of serofibrinous and its various Indications effusion. where seen all reason.being the result of some process. is one the chest.and decrease in the amount of blood. as. 3 ij. no more Hydrothorax. iodid.DISEASES 284 him I have of drink. large dropsical albumen " in the serum of the . which for the productionof a pathorise to the conditions logical necessary given deserves the transudation.in conjunction with the external applicationof a every two weak 3 ss. be must practiceof such operationsin cases of pleurisy in therapeutics. slender ability to excite or to hasten reabeven Considering our effusions by means of internal medication. cannot chest. markably rapid absorptiontake place under the internal use of syrup fend iodidi ( 3 ij)with syrup simplic. and time is allowed of complete for cells to multiply in the exudation. name dropsy of the subcutaneous the cavities of It is merel other into effusions v body. the chances recovery increase. increase of a lateral pressure the within the veins. details given are in for the ure proced- the hand-books surgery. of the laity.which I have seen such rereputation as an absorbent. the patient An attempt outward the THE PLEURA. therefore. compound solution of iodine (iodini. " ij). copious supply of made administration to of excite reab- iodine. the introduction will promote of paracentesis thoracis.namely. Every additional considered an important advance day. potass. garding rehelp upon the beneficial action of this prescription as probable. ETIOLOGY.4 II. Hartels.in the most pathologists and is never an primary affection. CHAPTER HYDROTHORAX.a teaspoonful being taken hours.although I do not regard it as proved. instances its dropsicaltransudation of the well-known is easilytraceable to one other tions condior source under which pathologicaltransudations arise. and Ziemssen. independent morbid has always secondary. to the minds Water of on the older formidable which view of maladies.( " ij). and the danger of a fatal termination be hoped that the experience of Kussmaul.but is participated. and the frequent and early with effusion.

ANATOMICAL but effusion many pounds. have and have a milky opacity.and produce venous ment engorgeIt occurs of the aortic circulation.is one the lung which action the compliance with list of disorders by augmented of the (aswe have right side shown custom. and the veins of the aortic system. with equal frequence in certain diseases of the heart. right the of in 285 from heart.HYDROTHORAX.whose pathogeny as shall we show of while treating grave cachectic of the is somewhat Bright'sdisease. pressure within accidents occurringin formidable more of the ancient in the veins of diseases previous chapter)obstruct a of the heart.in malignant malarious disease. pleura is a clear.are driven up against the spinal column. infilslightly by serous When the effusion is very large. It is easily albumen.the lungs. dependent upon diminution in the serum of the blood. SYMPTOMS the AND beginning water on described the with diagnosishas the the an great fulness been confirmed affections " From the most present century. as we degeneration of its muscular byalso the outflow of blood from the the side of the impede and-by.caused the of pleura.the This ancients was cause be- apply to which ultimatelyresults effusions into the pleura. of one the especiallyof companiments ac- mations inflam- occurring in chronic degeneration of the kidney with albumiand in dysentery of long standing.have not and accuracy. condition. but other a few due whereas cavities.and of matter a it in the Hydrothorax. the to contains is almost ble.unless they are held down by old adhesions. which. and the salts of the serum from a pleuritic distinguishable effusion. of water.namely. derangement of its valves and shall show substance. largeportionsof them being in a state of compression. Whether of venous hydrothorax be a consequence engorgement.as symptoms the class of in of COURSE. Hydrothorax " sometimes from into period when is sometimes contained udation late a APPEARANCES. usually symptoms the of a from When former general dropsy. in by post-mortem to of all dissection.and both they and the subserous tissue are swollen tration.yellowish liquid. of Hydrothorax. it arising precedes the sometimes always at appears Its pleura one varies amount movable. by the absence of the fibrinous The latter coagula and inflammatory changes in the pleuralsurfaces. of morbid the of it is but the state of or a one blood. pleura. lost their polished appearance. ascribed of the dropsicaltransudations ancient times symptoms and independent disease.is conditions. It the other.and many in by the down course only to of been instances. .consisting hi the of the blood. nuria. but. always dou- liquidthan more to ounces it almost latter.and men albu- of amount obscure. the disease lungs and heart kinds. usuallyis The transincapsulatedby old adhesions. as included I have that convenience. the chest.

it repeated physicalexplorationof the chest.or in any other malady. although complete. attichange slowly patient the region of dulness. is dull dulness over does the not it it is hollow above effusion. always in diseases distress give symptoms. manner of exudation. until the days of Laennec. but the existence of as formerlymust have been as common which and was entirelyunknown overlooked. pressure engorgement.its upper or upon level both before and and behind. not the the being paralyzed by collateral oedema. But. offer of the liquid.post mortem.that as compels from symptoms event common that which which patient is us be may as to make of aware fact of its appearance. greatly aggravated by such a complication. heart. particularly oedema of the lungs.without or similar as hydrothorax is rise to these a dropsy very and of the the the means not from occur pleura.do and slightexertion. suddenly startingin terror cedematous swelling of the malleoli and eyelids. sound is weak. The to incipient physicalsigns of hydrothorax to those great similarity bear resemblance is not intercostal but the astinum a dilatation the intercostal of the furrows the to the venous heart is is and wherever effusion The chest are in the region of since obliterated.while above increased. Inspection reveals transudation. disease a which it is now.DISEASES 286 others. and described was In the such.the respiratory over Upon auscultation absent. of the behooves we vere se- sleep. The which is often enlarged liver. which The is almost total or touches effusion side.but of its the intensityis percussion-sound tympanitic. hardly ever displaced. the and denote the of diseases we existence know the of lungs that hydrothorax. was generallysupposed to be a dropsy of the chest.aggravated by every patientto sit upright in bed.accompanied by generaldropsical cachexia. not resistance by pleuritic effusion.as the symptoms of dyspnoea. the scapulaeand Between or even the spine there is feeble bronchial respiration. Physicalexplorationof of recognizing the the chest likewise existence of the furnishes the only certain hydrothorax occurring in Bright'sdisease. that emphysema.as the pressure upon the medi each usuallytolerablyequal upon Palpation gives an enfeeblement fremitus the muscles. among There is OF THE doubt no PLEURA. as present of science state know we that such symptoms dyspnoea. Moreover. are equally attributable to other sources. is depressed when the effusion is large. extend itself in the peculiar When pathognomonic limits are the patient stands the same sits upright.which attend its development and progress. the boundaries shape when of dulness the alters of the area his tude. indistinct. pleuritic . the of arrest thoracic the pectoral wall.

the pleural surfaces usually become another the morbid as approaches the surface.upon percussion. I effusion may pleuritic a pleura without least.as yet being discoverable. PNEUMOTHORAX.ah* caseous the cannot enter the lying at the surface of the lung. of but The a single lobule in a state of rapid destruction perforated. the pneumothorax of the patient having suffered but slightlywhen forms. or from with- injuryor gradual degeneration of the tissues upon the surface of the pleura penetratingthe lung. of the lung.at the apex of the the strength and nutritive condition lungs. entrance of the trance en- The air into the or pulmonary surface.and very of 287 is transudation. ETIOLOGY. upon which the consumption depends. have been not absolutelydeny that decomposition of will give rise to to most the development such it of air . of the benefit the Treatment " is identical hydrothorax main disease. Most is comin phthisis(notin tuberculosis. III. pleura. is often JHAPTEK be can When upon with the ment treat- effected to dyspnoea is profusion of the The very a benefit temporarily marked.so that. less one here remark that chronic consumption is far liable to result in pneumothorax tnan a consumption whose progress When the disorganization of the lung prois rapid and subacute. ceeds firmlyadherent to slowly. libertyto at secreted are gases not are by that the surfaces the of the which facts. which have and of the cases consumption.and. good. as usuallybut is seldom our success latter. an sac. It is by the first of these methods of the lung. been reported. at pneumothorax an in occurrences that suppose is the under any pleura and such cumstances cir- collect theory of falselyinterpreted.or bronchial breathing. might induce the pneumothorax.have occurred as monly into the pleural of the opening of a vomica in consequence said). out. intense.very rare. is of recent origin. arisingfrom destructive catastrophe. there are other rare but well-autheni icated cases . no dulness. that pneumothorax arises in pulmonary abscess. Quite often the pneumonia. TREATMENT.PNEUMOTHORAX. through wall.if process I would a tedious cavityof the pleura.its manifestlydependent evacuation obtained in such by tapping circumstances little the is indicated. We " in its the It is manifest sac. of the pulmonary pleura disease of the take may lung attackingthe place from within.upon originof pneumothorax is based. but common of source pleuralcavitythrough perforationof Perforation the destructive the of gases in the opening thoracic a the are. gangrene of pneumothorax. Besides disease and infiltration.

pneumothorax does occur. owing chest.with If the be faces deeply displaced. from a rupture of dilated emphysom- subpleuralpulmonary vesicles.and do has of pus amount surface. The pyoIn this form of converted into a pneumo-pyothorax. which also involves the pulmonary pleura.DISEASES 288 which m the disease has OF resulted THE PLEURA.through the orifice. which coughing-fit which a empyema.by than A gradual perforationof of its external this acute traumatic frequent already stated. scarcelyever passes freelyinto the pleura.the extinguishing a the obliteration abdomen diaphragm may to opened downward.by which the empyema incapsulated. If the track of the wound be oblique. through a mere penetrating Around of the thoracic wall. If ah* light held a knife gushes before 01 out the . ANATOMICAL often be or guessed find first. atous The majority of of traumatic pneumothorax are not. which with It is the same the fistulous the air from entering the chest. which usuallyremain after the spontaneous external opening passages. and if its direction the chest be tolerably narrow. or APPEARANCES. have already stated that all perforationsof the thoracic wall cause through the pneumothorax. ulceration pulmonary pleura. if the thoracic the wall be penetrated be sufficiently large. to We been much a corresponding quantity of with the next inspiratoryact. As into the similar a the dischargedby lungs more have we and its After manner.it sometimes happens that the pulmonary pleura is lacerated by spiculaof bone.the result of entrance of air into the pleuralsac. other intercostal the or or is the of pneumothorax cadaver. aa that in exIt may be mentioned. as a rule. air flowing in and out of the pleura. stomach oesophagus.but merely is firmlybounded by adhesions. the of an On empyema. of air from In fracture of the escape ribs. causing pneumothorax. but of a stab or gun-shot wound.the bursting of an empyema evacuation through the bronchi take place in occurrence a certain follows perforationof naturallyenters the sac air the thorax is thus disease the enters a air space not wall of the perforation. the contrary. rare pneumothorax arises through the perforation of the pleuralsac by ulceration or degeneration of growths within the and perpendicularly. without perforationor appreciable wound cases of the of the wall chest. side of the chest. the chest heaves and falls. we and that be trocar witn a of of the prominence that the thrust liver The " existence simple inspectionof upon distention enormous opening one the spaces.is the which shall allude we prevents integument forms a sort of valve at its outer end.thus permitting the the lung into the pleuralsac. it from separate the rest of the cavity. spleen distended capable of the side of the convexity of into the hissingsound.a dition con- again while discussingthe symptoms. finally. ceedingly instances.

scribed de- of Then. now traction. a considerable lateral displacementof the heart and mediastinum is generallyfound in pneumothorax. pleuralsurin spaces all sides. uninjured side retracts as far as the mediastinum can yield to the exerted side of it alone. and though the patientonly survive the pneumothorax a day or two.and we find sero-purulentor purulent exudation the air. ration.the lung retracts by virtue of its elasticity. so that it contains nothing except the effusion.while the amount air it contains be very small. to contain above to. The quantity of the effusion is variable. is the rule in pneumothorax from perforationof an but it empyema. adjacentparts dilated the heart and liver This latter not tion condiare partially displaced.and the uniform and air which enclosed of the the has firm anatomical of the adhesions of the escaped adhesions by lung are alterations retraction is contained upon lung on all faces. the Whether dation. the effusion may almost fillup the pleura. the pleura besides the pneumothorax is of longeststanding. only. is met with also in cases of perforation of a superficial occasionally cavity.can be discovered.Even the lung of the a perforation. when the air enters the pleuralsac during life. completely the And void of air. dilatation of the chest is usuallysufficient to produce the monstrous It is rare alluded for the pleuralsac air alone. Finally. against attached adhesions the when thoracic it is partially to wall only by that it occupiesany other position. such as find upon we occurs opening the thorax upon the dissecting-table. and generallyis largestwhen of Again.and is pushed up it is spinal column. the cavitv only contains the 20 . Even important variations take place when above from Many sides is prevented by Sometimes small extensive the capacity.all the air may disappear may from the sac.or of the thoracic wall. . the consequences which of the pulmonary pleura. but nitrogen. after must ensue necessarily symptoms and characteristic.at the moment through either externallyor internally. one Immediately after upon the establishment of the pneumothorax. In many it is with cases only great the under that the trouble.exupleura contain air alone.A retraction of the lung. strikingand in mind " The and the thorax of pneumothorax are are easilyunderstood. instances Besides the abovementioned downward displacementof the diaphragm. In other the orifice is already closed. perforation The pleuralcavitybeing no longer hermeticallysealed. point of perfowhich fibrinous is usuallycovered by deposit. SYMPTOMS AND generallyvery if we bear COURSE.or both air and pleuritic the lung is compressed into a very small volume.and by inflating lung water. gas which 289 consists escapes of principally carbonic acid Its quantityvaries. is only compressed. in pleurisydevelops.and contains but little oxygen. The orifice.PNEUMOTHORAX.

can upright. the aii with the next the pleura during inspiration cannot which enters escape remains the thorax pressed. If. and no compression of the lung. and its compression is com- is process the to character peculiarragged pulmonary pleura. The normal extraordinarydegree the and due room. even or cavity. and the compression of the vessels of the diseased one. or burst. the moment is usuallydistinctly perceptibleto the patient. out the of chest of the chest become air passes nol in it. opens air which valve a the of gets during inspiration. penetrate perpendicularly. lung. THE expelled from the lung by virtue of the chest an next inspiratorymovement the pleuralsac. and the lung does not suffer compression.which. it generallyhappens cases in cannot get reached shut. are like the no more point of perforation. although nation agglutiduring inspiration.DISEASES 290 With has the of PLEURA. this normal to which distention excessive undergo. air when a which the of pneumothorax the the in which instances rare walls effusion consecutive words. exceeded. has generallybeen emptied of its air by other causes. dilated. consequent upon sound In side of his chest. the pa- . act of expiration.and the lung is comwith the This which dilatation Owing forced a driven been all air has repeated until the thorax attains the utmost produce in it. inis the owing to the sudden dyspnoea is partially compression of one lung. frequently also takes which liquid. can expansion which forced inspiration pure the exceed that air enters of the adhesion In the opening in the pleuralsac in most compressed ration expiby pressure the tension of the within after air the Finally.so only as to rapidly assumes lie upon give the the affected freest the utmosi side. and. He feels as if ward Immediately aftersomething had given way.as occurs in spacious fistulous and communications. commences. the valve is permasufficient degree of intensity. of perforation perforatesthe pleuralsac. in other In the thorax. and in part to the collateral hyperaemia and of the alveoli in the sound obstruction lung.and until inspiratoryact can out of the plete.there is no dilatation of the chest. the pleural cavityand a with rigid resistingwalls running between of the large bronchus.in his chest. however. has does produce limit is often the a up pyo-pneumo- freelyin and out openings which fistulous in large wounds or thorax.or else play possibleto tensity. collateral oedema.however. all the cases of This sudden pneuraothoraxwhich I have seen.through which the air enters of pneumothorax. a nently there is no and. pleura has orifice the is closed and The again. if this air can enters which air OF air been of its elasticity. additional pass tity quan- again out its expiratory to succeeding expiration. to or.the thorax returns state. the the dilatation of pneumothorax." When " a vomica a dyspnoea The compelled to patient sit which commences.

lung after death expand again.death The sides.the effusion itself may be reabsorbed. may orifice of the I treated in a condition lying for weeks was daily expected. the urine channels added are of patient be not very the right side of the of its efferent observable completely filled. and patientgrows warm the pleuriticeffusion as worse. tienls began soon the of contents already. partly in Some If the by pleura. but mediastinum the ulcers of even symptoms. mothorax first changes into a simple pyothorax. who. if circumstances favor. Then. some and marry. which and from time in between the patulous that of course extensive still remains time the somewhat a communication misery. reported by Henoch) part has of the cavitywhich the bronchi contents entered is discharged by the perforationof a cavitycauses the admission of coughing.or even and collapse. of breath the and from perforationof effects of want skin consequence vomica a the from blood receives the to air. and. pushes the heart lung.exhausted by pulmonary blood.which complain of to 291 decarbonization the of pleurisy. soon patientbecomes strain the escape is vessels of the the to region of the lower the diaphragm. perforation hei three business. ity pleuralcav- in the pressed com- lung. to carry of the forms large bronchus. it occurs.partly because lung only. insufficient to of the consecutive and The other the left is not panies accom- serious from sooner. so far months In the if meantime other and to as wide a cases. again . in- bined com- instances.and hence one of the commencement. grows by compression above cool. that it is diffused among the adjacent vessels.and so augmenting the pressure upon air contained in the pleuralsac.the Magdeburg. very hours. air lias . swelling of scanty.PNEUMOTHORAX. and firm where adhesions. the collapse which pleuralsac. the liquid exudation the accumulating in the chest.the the heart of signs of engorgement bursting of such the as does in patients die take not into few a for place days the or of the and more dropsy also and and cedema perhaps die increase. cyanoticand is often extremities side the deprived of half of the lung. In other the juries. When to " but when the " air into or where a space an which empyema has nas been enclosed pointed into in old the and lung. which The pulse is small.or to fever and by the profusenessof the effusion. upon is excited into vomica in the pain severe either pleurisywhich else to the or attributed is to be ribs. only patient attitudes has been related in assumes a particular (as interesting very in Bomber of the liquid case a g*s clinic. the pneuWhen Recovery from pneumothorax is rare.marked anaemic heart. so utmost recovered on in patient a be closed.and the and increases. The cyanosis against the sound The patients finallysuccumb more face stomach. weeks.and dropsical. collapsethen subdyspnoea continues.

of does the thoracic wall tympanitic.Gerhardt).as in pneumothorax of the well as downward displacement of the liver. certain a is laid upon becomes diameter long believe is sound.as the Great stress of the pleuralcavityin that.while in the erect attitude (jBiermer.the regularvibrations.clear. sometimes. or whose as days ago we exhibits signs of great dyspnoea. and the long supposed that the diaphragm is depressed by the effusion. Finally. If we attitude he lay in bed left walking about.and. in The a percussion-sound very few days. was perfectlyunconstrained)now of this that he lies upon one side. in the different from those described cases. pneumothorax upon pleura. the symptoms In such above. chest far as heard of the exudation upon has reverse very effusion erect posture. occurs. even an it has tised unpracthe eration oblitundergone. been mark if the change (particularly alone these symptoms position.and when too the far thoracic hinders pressure and downward. Displacement of the heart toward the sound side. especially latter instance.physicalexamination find that a consumptive patient(whom a few Inspection.a the percussion.that the cardiac impulse is visible to the rightof the sternum. THE OF pus " awaken place suddenly) should has established. I cannot help doubting the constancy of this rise to a increase and when in the indeed there metallic car feeble. in the cavity.anxiouslyavoiding all alteration entered take to the place of the PLEURA. the sound upon the Over " the full. and the absence of respiratorymovethe the affected when is in the left side. and the chest of the the malady is only discovered accidentallywhen the quantity of air in the pleural sac When is patient is examined. the the extends. Upon a strong suspicionthat looking dilatation the the at which have taken pneumothorax chest. wall the is very when of the left too much formation disturbed. that percussion does not produce any sonorous when all.and. mitus the can eye " side than affected Percussion. gives the followingresults : large. of the intercostal ment furrows.is still more and is always fainter upon is generallyquite imperceptible. sound is intensityof and the sometimes at waves When the one. even practisedwith heavy strokes. A . diameter of the pleuralsac is increased.DISEASES 292 which has been evacuated by the of pneumothorax are and course altogether bronchi. So tense become.and right side it extends far inward. region of the pneumothorax the percussionthe pneumothorax is of tympanitic. Palpation. perceptibleupon palpation.especiallywhen during the operation. The pectoralfre? rightside.there often are no subjectivesymptoms whatever.dull clang amount is often dull. that is.only gives sound is not recentlybeen laid upon the change of pitch in the percussion-soundof pneumothorax sioned occait being or by the patient'slyin^ down sittingup (JBiermer).

is a symptom of which. the sound in front may be full. in pneumothorax but one dilated (emphysema is bilateral. the his chest. account of of his with confounded instances.even the chest. closed.In its stead. of a " patient. if he stands Auscultation. chest.whenever the both are far up extend may metallic distinct sac. In emphysema.by laying my hand upon lungs.PNEUMOTHORAX.the is While reverberation. both sides of the chest.the rapid development and constant are him receive we pneumothorax In all other place the It is that of suffocation that have liquidwash feel the cases. when against the quickly and only when we after he is unable anterior with to matter its full burstingof side of the be extremely gradual beyond a percussion- an empyema extreme- was the thorax. "When he lies upon his of the lower to the border back.that the limits of the dulness change as the patientalters his posture. putting the up to ear when or position. rely upon the followingtokens. dulness When there " a in half-filled air and splashing (likethe bottle)is often audible. If the space containing the air be too small. previous illemphysema. a up. we the metallic and tintement breathing. he is shaken (succussion). so that the affection is then very be absent when the pneumoof them may many easy of recognition. especially rattling(the patientsuddenly changes metallique)sounds which walls. to be capable of assuming a regular bulbous too irregular or metallic sounds of the air and exudation. murmurs the his and in harmony. few a most the establishment the a bedside condition ness. with absence of respiratorymurmur. in conjunctionwith the full percussion-sound.JSTo vesicular respirationis to be heard. when suddenly called to into hospitalin such give any is liable to and the energy.after perforationof a vomica. pneumothorax is almost always monolateral). over at not are into the and communication generated in the lung givinga metallic above signs arise with great completeness where the air is capable of free movement cases of the out pleuralsac.2. that also may air flows arise when largevomicae with smooth. is 1.in Besides into the y to upon himself patientraised DIAGNOSIS.concave of such as metallic sounds also heard are We sounds. regular. in a cavitycontainingthe air and effusion been able.the I irregular. heard. 293 sign of pyo-pneumothorax is. is incapsulated. Ihorax in shape. dyspnoea in pneumothorax in emphysem? doubt. either this. In emphysema the intercostal spaces are shallow furrows In the less obscure cases we may .or which. liquidin sound of without the pleural shaken water. trustworthy sign of incapsulatedpneumothorax is sound. hear metallic and sounds phoric amgreat significance. the in most cavityof the pleura. from the existence libertyto infer.no form under are pressure The percussion or auscultation.down characteristic libs .

superficially are 4. In pneumothorax 2. pneumothorax a tive pallia- particularly in the urgently demanded matic trauat the venesection. and of hence relievingthe encroaches The upon laid principles cable to the treatment a the of the unperforated pleura. Where there is only a cavity. and upon " is thorax metallic but vesicular murmur. yet diminished. mitigation of Puncture the of of the distress the The thorax patient. pneumothorax they have disappeared. down of the for more the treatment advanced CHAPTER TUBERCULOSIS L acute GRAY of pleuritisare appli stages of pneumothorax. is displaced by pressure of the accumulated ah* and exudation. in pneumothorax 4. Where it is dilated. almost miliarytubercle of the pleura occurs exclusivelyin with tubercles of the miliary miliarytuberculosis. OF THE PLEURA. pneumothorax it is imperceptible. in pneumothorax not the displacement are is generallywell marked.The does benefit the lung not operation of the affected side. blood malady. The a cavern large superficial a depressed over . 5. the effect obmeans tained patient. in The rdles in a cavityare usuallyloud and numerous . pneumothorax it Pneumothorax cavities situated which over " hear percussion we upon the metallic in which ble amphoric breathing and metallic tinklingare audiauscultation by the followingpointsof difference : 1. they are few and faintlyaudible. the neighboring organs dislocated . in is hardly ever present. cavityexists. a frequentlyis strengthened .the pectoral fremitus 3.and with to procure fine trocar him rest.294: DISEASES OF THE PLEURA. is to be distinguishedfrom large.simultaneously . This is not the case in pneumothorax. In a cavitythe pitch of the tympanitic percussion-soundis altered by opening and shutting the mouth. hyperaemic as to be intensely so to repeat arises from pain which strainingof the diaphragm and should be treated commencing pleuritis by local a nd cold for the blood-letting applications.empty.but rather the sound when the mediastinum lung. and one.although dyspnoea is merely palliative. the where a of the We outset. hear we we the hear never sounds ly frequentemphysema the pectoralfremitus is perceptible. is as a indispensable. should the unable to The of treatment of treatment volume form the " of the is not be uncompressed lung fulfil its function. IV.as as venesection even may In symptoms.Opiates are indispensable. 3. but in its of bronchitis sounds prominent. In audible.or emphysema the vesicular breathingis weak. become ID or . In is not absolutelywanting place. TREATMENT. over thorax pneumo- ring. many be may required become only be can cases.

effusion. in the by cancerous depositsof the vicinitywhich nodules form of bulbous swellings. V. contains between and dropsical inflammatory surface. It is this tuberculosis of pseudomembrane which is best adapted for the study of the originand metamorphosis of tubercle ( Virchow). which have coagulateuntil depositin the become a late the period. cancer pleura is then either perforatedfrom withsprout inward. Cancers ju"t as seat of that is to say. a liquid degeneration is somewhat collects in the cavityof the pleura. CANCER a of the lardy. before to the intensity succumbs tubercles undergo further metamorphosis. which the haemorrhagiccharacter accompanies tuberis liable to of occur It appears pseudomembranes. of about the size of a hemp-seed. THE OF 295 meninges. spleen. We have that seen rupture sels blood-ves- small of the new which tions vegetaduring the inflammation and with are as delicately-walled large supplied (profusely they for of in have to a relapse pleurisy. Miliarytuberculosis of the pleuragives rise to no peculiarlocal symptoms. very little contissue. IL Tubercular granulationsdevelop with far greater frequence in from the pleura after repeated which false membranes the young grow *ung. in the form of lar nodu- numerous prominences. we of the find it in other disease.marrowy and appearance. it graduallyprecipitates ph coagulatingmasses. and of the mamma. The symptoms of this form of from those of a pleurisy tuberculosis of the pleura are indistinguishable with hsemorrhagifexudation. afterward acquiringa yellow color. inexudation.attainingthe size of a fist. a nodulated or more or less level have nective pleura are full of cells. It most and particularly in other organs. (Hydrops lymaticus.Virchow) (Hydrops fibrinous of Vbgel.liver.or else independent cancerous and presenting spring up upon the pleura. complicates cancer of the lungs. often continuingso to do for days.which. as it were. the cancerous When extensive. pleura never has arisen advanced cancer in infection. This accounts capillaries) undergo culosis of the exudation.and relapsesof pleurisy.and arises with especialfrequence after extirpationof out. which at first are white. CHAPTER OF CANCER PLEURA. stands midway It fibrin deed.and where general cancerous quently frein those adjacent to it. the patient the of the fever in this malady. The of the breast.but.CANCER PLEURA. THE and only is met with occurs primarily.upon lowing al- liquidto stand after evacuation.) the " " . of the mediastinum.und belong to the class of medullary sarcoma. As we have alreadyseen.but cancerous we find no serous it does fibrinous not sacs.

or exert pressure upon the greater bronchi . * In the very great majority of diagnosticated. di- lymph-corpuscles added changes are soon consistingof liquid fibrin and these a or more cell-nuclei. THE important changes. that particularly breast. which of the long-standingcancer of the cancer cases. cyanosis. it is others a membrane of the fibrin ous product of the supposing it to else or forms pleuralsurfaces.will assist of the of the case. however. Should in of case a effusion an the pleura cannot be in the pleural sac gradually form breast.the historyof tumor previousextirpationof a cancerous chest. we entitled that a cancerous to suppose are growth exists upon the innei wall of the thorax. and. may Thus dyspnoea. of the spurious murmur it is compressed. exudation. cause Large tumors compression of the lung may or displacethe heart. the pulsationas aforesaid is always weak and the false murhear the double. Wagner). less In the is scanty. They in always are lated. thorax against the pulsationmay after thorax. is immovably tached at- extirpationof a mammary cancer. easily-detachable the like surface a opposite points of contact differ as to the origin of this serous P. never fail to hear in an aneurism which we seldom murmur lying in contact may be with the the Finally. 265. extensive exudation so-called fibrin forms either covers Virchow 1880. generally contain a clear liquidpoor and with OF lymphatics show The the EDITION REVISED that membrane. OF PLEUEA.and dizziness may arise." To (E. may However. if the to lie tumor This aorta. while dry or adhesive pleurisythe serum film. is seldom symptoms When reach the wall of the chest. whose rightly interpreted. produced in the aorta at the point where which be perceptibleat the feebly pulsating point of dulness.false is always merely a systolic We inur one. the of diagnosis. We cannot pleura. the arise. meaning. or be cancer all the the mistaken for easily.296 THE OF DISEASES PLEURA.and happen may with posteriorly. which a grayish or yellowish. great vessels.as we of consistentlyspeak confine must efforts to our treatment of of palliation its any cancer more ing distress- symptoms. action have in the its source some bands tween be- ties Authori- believing tissues of the direct from . ADDITIONS TO SECTION THE IV.as more in front aorta aneurism an a of it.the tumors large cancerous sion-sound percusbecomes at the point involved absolutelydull . DISEASES 1.

in ribs. of the effusion 3. Effusions one in in that shown may moderate a Since In other not . which compression. two adhesion. bounded curve by normally gives a tympaniticsound a three to three semi-lunar below and by a space the half on margin inches of the stomach in and . surface ribs. That the at muscles first retain of which inspiration their contractile lie in the but power. sphere afterward lose it. which opposing surface. and from them analogous to those found in the casts urine. parent always 2. while sometimes they the do not . be better cells appear membranes form. persistentcase but exudation.origiAccording to JRindfleisch. 2. forming permanent the to the on propagated by contiguity from apt These elongated. there a The white epithelium. 3. sometimes retain their mobility downward and forward.ADDITIONS E. the the and has of contents obtained even in Wagner immediate an REVISED THE TO OF has instances rare connection the EDITION between 1880. all motion affect the This spiratory re- may still retain may the at tion direc- one manner. by Traube as the chest. Because the in the and dilatability motion natural other. to become now of of the blood-cells. That the by large effusion compressed lung mere able are more do not much exudation we cramped of the case the be or equal size patientsin equal of different be gauged than measuring apparatus by in the arrested.partly (Cohnheim) the cells. above which described of the P. JKiegelhas be" prolongations connect. emigrating up which nuclei cells and in Soon in the arise organic processes undergo fatty resolution In a more behind. blood. not in the fibrin itself. it will is sometimes motions 1. can parts upper of in moderate effusions escape lung. chest expand unnaturally. 277. blood-vessels first the from surface serous Abnormities by in the of means region above will to breathe of one Since is followed neighboring flammation in- inflammation by they as ganize or- Pleurisies irritation of seat ing pushthe are P." the partly be of this class." There the of is a space left anterior the width. by the diaphragm if the increased be of the thus it may either more explains that Riegel some vessels membrane. surface. mildest fibrin pleurisiesthe disappear. nally appear. 297 demonstrated scopically micro- fibrinous the filaments superficiallymph-vessels of the pleura. and here it contains. 274. serous a movements inspection. readily coalesce.leaving no trace In and the the to originate from round.

When " alarming dyspnoea.is indicated the of the and pus. 4. to acute 1. a period. lying THE OF especiallyimportant in of of hypertrophy the by lung area left the left ventricle the distinguishing between pneumonia of the left side and a pleuriticeffusion . fistula remains by the then. simple of late been others. and emphysema is It it. covery re- tion opera- since phthisis. even has fistula the prolonged by it even appropriateworks on surgery. a is not tion a the During have of treatment months the leave the exudation or one. 3. an dangerous may air. thickened. life may prompt at tardy reabsorp- a purulent a other by air. a non-purulent one.because. down 284. and of closed. ascer- chance of of dangers of a subsequent that complete lung retains its distensibility or the the sumption con- tuberculosis. it is true. or fullylaid more of procedures two by puncture else free of incision the racic tho- kept manently per- open. of access purulent nature operation reabsorption intercostal an free fistula with permanent ment abate- compressed lung permanently impervious of air into the chest operation the entrance through As 2.DISEASES 298 bowel enlarges it.while and PLEURA. reduce of act diaphragm the of lowering Each behind. we refer to the . only when take can thorax the is not the be should the of the exposes the be operation to must air. inspirationdiminishes Contraction lung. has effusion . One evacuation subsequent closure. displacesthe of relief . for nothing but effusion can so pletely a depress the diaphragm as to comlarge pleuritic this the tympanitic sound of deaden region. in the presence exudation acquires the perniciousqualitiesof incision duration subside may cessively ex- heart After . by Kussmaul. weeks' several years there and no be Free an large non-purulent dispositionto reab- remove shown effusion. refractoryto other means determining the quality of of a means air is indicated the causes and mediastinum. is afterward danger a The of a as soon as pyema the of by fever. for indications The adopted be may either : with cavity paracentesishave and Bartels. even later is inflammatory stage. spontaneously that guarded against. but space. When of presence details For it is otherwise._p. which serofibrinous sorption in spite of Such means. for place to continued no presence patient to risks the in been is there the after contracts contraindicated the or of establishment and em- tained. cheesy exudation It is the . with Puncture exclusion large effusion of the exudations. The open.

almost these. persons which The all. . habit we of greater robust. the erroneous laity. whom so in are is etiology treating scrofulous in sources other it the to cold to muscular are constantly. and. snuff-takers. EESPIKATOEY (Schnupfen). Far more they NASAL COLD are almost MUCOUS IN THE "cold solely disorders frequence extreme in by nasal head" of course is attacked " characteristic the in the in the MEMBRANE HEAD. and larynx in remarks same different ing " inveterate to us. delicate. by above the in general. and with dividuals. GRAVEDO. infectious maladies. CHAPTER BYPER^EMIA AND CATARRH CORTZA. the of the in and suffer to words. The " OEGANS. however. who membranes coryza In who diminishes made already individuals. in- numerous. they in almost colds may which causes and there " are be occasion catarrh from it is in from the chilling which detect to other which catarrh. which apply. is known un- to peculiarity predisposed very in adults in tendency any the greatly " irritating nasal of children than from able of varies comparatively of much not impression proceed that find are head Gradual predisposition distinguished universal always we catarrh persons. predisposition.APPENDIX DISEASES OF THE DISEASES OF NASAL THE CAVITIES. catarrh of where membrane. The catarrh. by diphtheritic or croupous mucous inflammation. are remarkable a nose less are prevails of the of and harden foi rare their nasal Besides quite among skin. individuals in regard Predisposition feeble. and nasal the OF nutritive be to are I. in the that " in or. . functional called membrane mucous THE and with seen rarely. ETIOLOGY. have we bronchi.

is the nasal spreads into lip. dark-green crusts.indeed.from the number cells which This of young it contains. succeed hi implanting the disease the membranes of mucous upon secretions of persons to them healthy persons by transferring suffering is contradicted catarrh from in its several ANATOMICAL stages. the tissues are infiltrated. from a copious admixture In chronic catarrh the nasal membrane is considerablyswollen .while secretion. blood.and particularly upon Next the or . it discharges a secretion.a Nasal this to coryza intense abscess membranes mucous boring neigh- of the nose always accompanies coryza of the from of the gum of constitutional frequentlya symptom . APPEARANCES.the some chief of symptoms iodio category.saline At a later period. nasal catarrh. swollen by hypersemia and oedema. Nasal may accompaniment of other diseases.local in such bodies of cases CAVITIES.DISEASES 300 although.the capillaries with and the membrane.also. boil a superiorincisors. irritants entrance snuffing blows and be the as do coryza exposure frequence. particularly produces catarrhal surface. cachectic subjectsT . gives out a colorless.but usuallyprofuse and purulent.caries.that common cold a in the head is contagious. pas- foreign or unaccustomed persons nose of to it .the secretion becomes of young cells. and vol. often peated re- violent dung). spreading into as a superficial. ii.and upper belongs the of troublesome very of the the tobacco which upon catarrh also blowing of the nose. transparent.and great tendency to putrefactionwithout in any assignable cause.too. disease. NASAL THE OF catarrh. which coryza probably and an catarrh.necrosis often organs thus. also the during iodine bones.comes somewhat The the Inflammation and exanthematic accompanies measles typhus the do also form of scarlatinous milder class. by the catarrh cause acrid nasal the gases encounter. In many instances the cell-formation the substance rule. often dries up within some persons the it evinces nose a into hard. etc.outgrowths (Neubil- an The of shocks or hot of depend of the feet. coof congenital syphilis(see syphilis. who could not by the experiments of JFriedrich. in sometimes. " At the of commencement an acute nasal of the nasal mucous membranes are charged surcatarrh.most cold.which attacks a great number prevalence of the influenza-epidemics. dirty.ulcers.dust. forming the of symptoms general very which coryza. constitutes in this poisoning. and may sages. likewise to exposure air. one of In the of persons of one respects.but They scrofulous remain and ulcers.).but not of the chronic nasal catarrh confiningitself to the mucous membrane. opinion.as ryza. the hyperaemia and swellingof the membrane thicker less and mucous diminish. thin.scanty in a few instances.

and.which usually precedes the complicated group of reflex as and sneezing. of smell In membrane greater We as of and sodium taste in all instances of the frontal of far the intensity. chloride suppose. at within nostril. they need but very brief notice here.which material may are inclination prejudicial there arises intervals. nostrils. taste. swelling extend In from catarrhs the mucous of .pyriform shape.and in the growths. growths circumscribed. They gelatinous growth from the from its the matrix of firm.of the and nose.but which may also occur symptoms known every now then without This dryness of the nosbeing followed by the sneeze. a as the redness eye and its salt taste perverted. which produces an decomposition is almost extremely bad odor. assuming a rounded. tril succeeded abundant is soon a parent transa by secretion. very short the to blow the From nose. and and air-passages. 301 bones. Gradually. very watery liquid. mem- cases. to on particularly surface. thickening over a large surface of the mucous brane. time to or titillating pricklingsensation a time.and a foul In of simple chronic other diffuse a nasal catarrh gives rise to " the the turbinated wart-like developing Sometimes catarrh. growing protuberances with an uneven fold-like and ridges.and more give caused the caries. the growths are constituted is converted into which become SYMPTOMS more connective tissue. an occurrence secretion destroythe perichondriurnand may rise to caries and In nose. to lead The voice senses is nasal. finally may openings The " block or of the . AND presumed to of the membrane. or which induces or more a of glands. had having personalexperience of them. feelingof pressure perceivethe can incessantlyfrom it is less than become almost patients complain the forehead. polypous outthe latter sometimes Rokitansky. is due secretion the sometimes saltish redness is able if the extends attack of the into be the severe. colorless.CORYZA. probably. The patientfirst complains of a feelingof dryness and of a less complete obstruction in one both nostrils. of the only occasionallyobserved nasal chronic necrosis cartilagesand secretion from the ulcer. mucous and frequentlydegenerates into cysts. of or and to tone distressingpain in cous swellingof the mu- reach.especiallyone necrosis of the cartilageand bones.fibrous be tissue They contract visible in the COTJESE. a constantlygoing on. they penetrate and periosteum. appear. consist of a pedunculated.while to membranes mucous the one the to proportion of would the Donders." of symptoms generally known be the up nasal acute catarrh everybody. According as first. the the catarrh sinus. bones of the vvliich has deeply.flowing almost cording producing excoriation of the upper lip. Acqualityof the now irritating strongly-alkaline of ammonia which it quantity contains.

NASAL conjunctivitis.because all times feed narrow. it takes indeed. or the spreading of generallybegin febrile rarely. the loss of appetite. and nose from Should cheeks. as common the at at are less.into hard crusts. which lasts the fifth. neighboring mucous cease intensityor even entirelytoward . of nasal acute generallybecomes secretion the on even opaque.who . accompany tube induces disease into the eustachian slightpain and roaring in the of hearing. The titillation in the less frequent. be or acquired great intensity spread It surface. complaint as dangerous to infants it difficult for them such cases into acute their nasal of in most subjects.and. In chronic liug in the nasal nose. yellowish or ish-green yellownight. predisposed to be may febrile irritable persons. with do not in ill-nourished a or spoon feeblo children.while bronchial treatingof duration The catarrh.and dries. life itself may appertain to cold a in the chronic a a which passages.the frontal headache sneezing are membrane abates. suck.302 OF DISEASES membranes of the complicated by often and skin the to copious CAVITIES.The a flow tears THE the into eyes in participate is light. it is harm- breast.the nasal passages nostrils the and The free again.that catarrh too. swallowing hoarseness the and Propagation of the cough symptoms.or from seldom membranes. nostrils and nasal the catarrh. catarrh the we do sneezing not and usually find the frontal the feelingof prick- pain. into their first week of the only catarrh lose to constitutional Those two. if the which symptoms always accompanied by fever have if the catarrh particularly over a who wide extent but little are of of air-passages have we be just described is almost and general constitutional disturbance . slightin reaction persons. It is very head in becomes tracted pro- affection. be If we endangered terminates disease eighth day. in are it is usuallyspoken highly oppressive. firmlyto the mucous which . implicated. and the febrile . the as alkaline catarrh less second usually short profuse. on a tinge. sixth. or a temporary hardness the over there fauces of difficulty is The of group .etc. thicker grows and the more loses its salt taste then . ears.especiallyduring the adhere membrane. We have of catarrhal the already depicted fever. It third or is less marked reaction is . all liquid come beor inspissatedsecretion having been discharged. the painfulbruised sensation of the limbs.. the swelling of the mucous subsides. and the on disturbance symptoms.the symptoms often-recurringchill provoked by every change of temperature. . the patients avoid their reddened the cold in the head A cheeks.and day. many others.'ongerthan a day the the end complete recovery and in and While scrofulous changes acute nasal it sometimes the obstruction makes in proves an is the to cases.

It is often whether the malady have led sense of the others while posteriorwall catarrh defying to mentioned. impossible. emit continuing for years. may. existence secretion should the nostrils are tracted unusually condecompose more readilywhere all condition is not and at an analogous improbable." Stockschnup" " the fen. however7 general suffering.under of two It is foul pharynx covered with extremely obstinate for those an a blackish-green are then are of the ulceration present of the the to The word.the sowhere observed punaisie" ozcena. more nasal quires a is sometimes purely which called the of such has punaisie depends and not halves the and of voice ac membrane mucous muco-purulent. expelledby blowing the nose.often all of the secretion is not pathognomonic that and it may made it necessary nose. its vulgar name of This disease owes or snuffles.above which the from mination illuEven do not membrane. that we are be and is nose an existence able to only see very and also to that fact of ulceration forms when them that nostrils. term ulcerous rowest nar- brane. and of the in the by a of of means fetid nasal are an odor the of the of the ozaena. and so catarrh both or " stinknase" is one impeded.and purulent. which penetrate to the periosteum or perichondrium. mucous the That secretion. ulcers ozaena. of the and mucous air is of tion profuseand purulent secrethe greatest tendency to putrefy. the close adhesion of the mucous membrane nasal cartilages it almost to the bone renders or impossible for the edges of the ulcers to mucous approach one another. instances cleft between narrow putrefy. the physicianswho include offensive discharge. nasal has coryza.that the it has asserted been the from putrid that membrane. and so a low dilatation to non- down and positive diagnosis is possible. " The tone.to determine treatment. the and are many the in sore to apt copious crusts. varyingintensity. The swellingof the mucous creates a permanent narrowing of the nasal passages. behind children who in young suffer from intertrigo events. ulcers of the superficial of some sucked hawked into In up. Apart from the constantly-repeatedprovocations which they suffer upon blowing the nose. frequently form." to the nose. and sometimes the always its more fetid exhalation a upon the upon diseased in chronic scanty. with or even difficult. the secretion the head and secretion is very be the similar find the we Chronic crusts. be adduced the ears.a condition which . pharynx through the posteriornares.are very refractoryto treatment. disorder. closure complete inhalation which by less or stench from catarrh. in whom the ear If the odor. mem- all diseases situated suitable the in mucous simple chronic ozaena.CORYZA. even been overlooked. 303 membrane.of stony hardness. In fact. is sometimes shows secretion of the secretion It is not quantityvaries. accompanied by suppose the ulcerous form.

to the classical work of my colleague.1 In most cases. but none swabbing the nostrils with or charpie. and to in order lip-salve.or at the to change to The stages of has at hot some not action irritating vapor dangerous.nor syringing. as Various " catarrh care. The productionof active nasal which cut short acute diaphoresis.while breast. of the snuffingof cold vulgarlysupposed. is advised nose into film two. to vapor make or cotton. have methods abortive of for treatment acute been of them. neither proposed. torpid conof pinch snutt. both in front neglect exploring one examining large polypi and the symptomatology of surgery. by many. and procedure advisingthe to and linen. point at CAVITIES. with The method this subject. from obstructive catarrh (Stocksight or patients suffering schnupfen)of more less or should and never rear. process. upon should depends. above TREATMENT. referringto the surgicaltextall. books. powder. nasal utmost of affections the or the of such by both when the secretion is nostrils. I therefore pass belong to the domain well of the other that growths in the nose. to of a by means The secretion. but given place to air. latter membrane in the fresh In infants outset even even the to of a acute coryza. The questionwhether the nasal passages are obstructed by swelling and hypertrophy of the mucous membrane. we the cavities of the nose. inhalation of warm of a the In the mucous long accelerates walk the cure. the smear or heroic ourselves confine all the observing one. we for a day patientto keep his room drink from time to time. Where tunity who direct is offers for a Russian a beginning to bath. an a cold.who after the more occasional are acrid water it fails protract the to appears use them protect it. has. of this somewhat which the succ