UC-NRLF B 3 135 bflE THE LIBRARY OF THE UNIVERSITY OF CALIFORNIA PRESENTED BY PROF. CHARLES A. KOFOID AND MRS. PRUDENCE W. KOFOID % < <* £.1^ •■« » A MANUAL OF MEDICAL DIAGNOSIS: BEIXG AN ANALYSIS OF THE SIGXS AND SYMPTOMS OF DISEASE. By A. W. BARCLAY, M. D. CASTAS. ET EDIX. FALLOW OF ME ROTAL COLLEGE OF PHYSICIANS; ASSISTANT PHYSICIAN TO ST. G£OKG£ : S HOSPITAL, ETC. ETC. PHILADELPHIA: BLANCHARD AND LEA, 1858. TVM. S. YOUNG. PRINTER. - * c \% b . ! ■ I .. / PREFACE. In adding another to the many manuals already in the hands of students, a few words of explanation, and perhaps of apology, are necessary. The want of that instruction which it is meant to convey was felt by myself in the commencement of my studies, and many diligent students have expressed in my hearing a wish for some guide to the systematic investigation of cases in the wards of the hospital. This branch of medical study has been very successfully cultivated on the Continent, and the English student, while conscious of a culpa- ble neglect of the curative powers of remedies, cannot fail to be struck with the precision and clearness with which a clinical profes- sor in Paris conducts the examination of his patients. When in 1847, the duties of medical registrar were intrusted to me by the governors of St. George's Hospital, a large field of study in this department was opened to me: by the kindness and courtesy of the physicians I was always assisted in deciding on the nature of an obscure case ; while the examinations after death so constantly practised, either ratified or corrected the opinion that had been formed. During the period that I held the office, more than twelve thousand patients came under my notice, and the construction of a new register of disease, classified on the plan adopted in this vo- lume, led to a more earnest attention to methods of diagnosis. In offering to those now engaged in study the observations here embodied, I have only committed to writing the system of investi- IV PEEP ACE. gation which it became my habit to pursue; and if it lead them to a more familiar acquaintance with disease, and a better understand- ing of treatment, my time will not have been misspent. I have en- deavoured to arrango in a larger type the general and more im- portant considerations on which diagnosis is based, elaborating the details, and enumerating the points of less importance in type of a smaller size. It seemed desirable that my younger readers should not in the first instance be perplexed by the number and variety of symptoms, while at the same time they should be furnished with all particulars on any subject which they wished to study more closely. I cannot attempt to trace back to their source all the suggestions received from the writings of others, and from oral instruction, or to separate such suggestions from the ideas which have occurred to myself in prosecuting this subject: and I trust that it will be under- stood that, in omitting all reference to authorities, there is no in- tention on my part either to claim the merit of originality or to ap- propriate unacknowledged the labours of others. If any of my es- teemed friends and teachers in the Profession should find their own ideas or expressions repeated in this volume, it is only because these ideas have become established as truths in my own mind, and the expressions in Which they are conveyed have become their habitual and almost necessary exponents. That such a manual should be free from faults, the utmost stretch of self-satisfied vanity could never lead me to believe; I hope that they will be found to be errors of omission rather than of commission, — that in the main the prin- ciples will be admitted by all to be true, while none of the details are calculated to mislead. A. W. B. Brtjton-street, Berkeley-square, October, 1S57. Outline of the Particulars which a Clinical Cleric ought to attempt to enumerate in the History of each Case which he records. Address— Name— Age— Sex— Civil state— Occupation— (iii Females, number of children— date of last pregnancy— menstrual function.) History : — a. Of present attack. b. Of previous illness. Present state: — • 1. General symptoms: a. Skin ; as to heat and dryness. b. Pulse ; as to frequency, force, and fulness. c. Tongue; as to coating and moisture. d. Bowels and urine. e. Appetite and thirst. 2. Appearance: a. Size. b. Aspect and expression. c. Colour. 3. Position or posture: a. In bed. b. Out of bed — Gait and manner. 4. Sensations. Survey of regions and organs:— 1. Innervation: a. Brain. b. Nerves. 2. Respiration. 3. Circulation : a. Heart. b. Blood-vessels. 4. Digestion: a. Assimilation. b. Excretion — Character of stools — Analysis of urine. TABLE OF CONTENTS. INTRODUCTION. The Province of Diagnosis — Symptoms, Various and Complex — Error of Pathog- nomonic Signs — of Neglect of Diagnosis — Object of this Treatise — True Basis of Diagnosis — in Correct Evidence and Knowledge of Disease— Compound Causes— Relation to the Theory of Disease pp. 17 — 24 CHAPTER I. METHOD OF DIAGNOSIS. History of Case — Narrative of previous Symptoms — its Value and Fallacies — Ar- rangement of existing Phenomena — Division into General, Local; Objective, Subjective; Signs and Symptoms — Plan of carrying on the Investigation — First Deviation from H^illh — General State of the Patient — Examination of Or- gans — Classificati) from Want of Nutriment \A from Imperfect Assimilation — (<7) from Exhausting Diseases— ^Causes un- defined— 3 3, Chlorosis — its definite Relation to the Uterus — Distinguished from Amenorrhcea — \ 4, Aiuemic Blood-murmurs — "Bruits" in general — Cardiac and Arterial — Venous Hum—? 5, Cachaemia, or Cachexia — Pyaemia — its pro- bable Cause is Phlebitis — Secondary Deposits — in Internal Organs — in the Skin and Cellular Tissue pp. 100— 107 CHAPTER IX. DKPRAVED CONSTITUTIONAL STATES. I) tr . I._ Scrofula and Tubercles.—? 1, Scrofula— Chiefly seen in Childhood— \ 2, Tabes Mlesenterica — \ 3. Phthisis — Acute and Chronic — General Characters of the Acute Form— its Early Stage— Symptoms of the Chronic Form— Suspicious CONTENTS. IX Symptoms—? 4, Tubercles in the Peritoneum— associated with Chronic Perito- nitis — \ 5, Tubercles in the Brain. Div. II.— Morbid Growths— § 1, Of Local Enlargements— from Hypertrophy- Deposits of Fat— Presence of Serum— of Blood— of Lymph— of Pus— § 2, Of the Locality of Tumours— Superficial— Deep-seated— their History and Symp- toms—Relations— Tumours on the general Surface— on the Head— in the Neck —on the Chest— Abscess from Empyema— Aneurism— Morbid Growth— in the Abdomen — connected with various Organs — Accumulations of Faeces— Peri- toneal Abscess— § 3, Of the Nature of Tumours— Cystic Growths— Fungoid or Encephaloid Cancer — Scirrhus — Colloid Cancer — Osseous Growths — the dis- tinguishing Characters of each pp. 108— 121 CHAPTER X. THE QUASI-NERVOUS DISEASES. I 1, Hysteria— Subjective Phenomena— Evidence almost entirely negative — His- tory and Symptoms— Simulation of other Diseases— Globus Hystericus — Hyste- rical Fits — h 2, Chorea and Tetanus — The Muscular Movements in each — Con- ditions of System— Causes and Associations— $ 3, Delirium Tremens— The Nervous Element— History— State of Pulse, Tongue, and Skin— Alliance to Mental Disease PP- 122— 12G CHAPTER XL GENERAL EXAMINATION OF REGIONS AND ORGANS. Disease often a Compound Phenomenon — All Organs ought to be examined — Negative as well as Positive Results stated — Examination of Brain and Nerves — of Chest— of Digestive Organs— of Uterine Functions— Appearance of Skin pp. 127—1.29 CHAPTER XII. SEMEIOLOGY OF DISEASES OF THE BRAIN. Causes of Obscurity— Mental Faculties confused— History imperfect— Pathology little known. D IV . L— Svmptoms derived from the Mental Functions.— 5 1, Coma or Insensi- bility— (a) from a Fall— (b) an Apoplectic Seizure— (c) from Poisoning— [d) from Effusion of Serum— § 2, Stupor, or Unconsciousness— (a) after Epilepsy (!>) Transient Apoplexy— (c) from Poison — [d) in Disease of Kidney—* 3, In- somnia — $ 4, Delirium— with or without Unconsciousness — is not Evidence of Inflammation— (a) Delirium of Fever— (6) of Delirium Tremens— (r) of In- flammatory Fever— (d) of Rheumatism and Erysipelas— (e) of Scrofulous In- flammation— (f) of Simple Inflammation — (#) of Mania— the general Characters of Insanity — its Distinguishing Features. D IV -. II.— Symptoms from Nervous Sensibility.— § 1, General Alterations in Sen- sibility— Increased— Diminished— Perverted— $ 2, Alterations in the Sense of Sight— (a) Difference in Size of Pupils— (&) Contracted Pupil— (c) Dilated— (d) Perversions of Vision— § 3, Alterations in Hearing— (a) Recent Deafness —(b) of Long standing— (c) Intolerance of Sound— (d) Noises— $ 4, Special Al- terations of Sensibility — Local Pain — Headache and Giddiness. P)j V . III.— Alterations in Muscular Movement.— § 1, Spasmodic Action— Subsnlt.ua —Convulsion— Spasm— $ 2, Paralysis— Relative Value of Different Forms— Ptosis— Strabismus PP- 130—148 CHAPTER XIII. DISEASES OF THE BRAIN. History— Condition of other Organs — Acute and Chronic Disease— Antecedent States.—? 1, Scrofulous or Tubercular Inflammation— Its Pathology — In In- f auC y — its Early Stage — distinguished from Fever— from Gastric Disorder — its Advanced Stage— The Hydrencephaloid Disease— in Adults— associated with Early Phthisis— with Advanced Phthisis— its Characters— Tubercles in the X CONTENTS. Braia { 2, Simple Inflammation — Antecedents — Characters — Variety of Symp- toms — Locality of the inflammation— Sequence of Phenomena — # :?, Chronic Disease Resembles Functional Disturbance— History — Chronic Inflamma- tion -Symptoms — Subjective— Objective — # 4, Apoplexy — Characters of the Fit — History — Partial Coma — Convulsion — Serous Apoplexy — Distinguishing laracters— Associations — # 5, Epilepsy — Convulsions — in Childhood — Perio- dicity of Epilepsy -its Characters — Hysterical Epilepsy — § 6, Functional Dis- turbance— With Disturbed Circulation — with Disorder of Digestion — Nervous States -Characters of the Class — Mental Functions — Sensations — Spasm — its Associations — with Circulation — Digestion — with Nervous Excitement pp. 149—167 CHAPTER XIV. DISEASES OF THE SPINAL CORD. Inflammation rare as an Idiopathic Disease — its History and Symptoms — Con- nexion with Caries — Spinal Irritation — Chronic Disease . . pp. 1C8 — 170 CHAPTER XV. PARALYSIS. Loss of Sensation — of Power of Motion — Incomplete Paralysis — Power of Re- sistance — Simulated by Hysteria. — $ 1, Hemiplegia — Definition — Modes of In- cursion — its Central Origin — Causes and Complications — $ 2, Paraplegia — its Causes — («) Atrophy — (b) Injury or Disease of Bone — (c) Inflammation of Cord — (. with Difference on Percussion slightly marked — (a) Slight Consolidation — (b) Slight Emphysema — (< ) Early Stage of Inflammation — (i>) Acute Tuberculosis — $ 4, with no Perceptible Difference — (a) Resonance Natural— (a) in Phthisis — (b) in Bronchitis — («) Both Sides unusually Reso- nant — (c) Both somewhat Dull— (u) Difference existing, but not perceived — Rules applicable in such Cases. S mary. — $ 1, Condensation of Lung-tissue — Carnification — Hepatization — Tu- berculization — their different Characters — § 2, Expansion of Lung-tissue — Em- physema — $ 3, Condition of the Pleura pp. 198 — 214 CHAPTER XIX. SUPERADDED SOUN'DS IX THEIR RELATION' TO ALTERED BREATH AXD VOICE-SOUNDS. Classification of Sounds — 4 L Interrupted Sounds — (a) Crepitation — (Ij) Moist S mnds — (<") Gurgling — ('/) Metallic Tinkling — § 2, Continuous Sounds — (a) Sonorous and Sibilant Sounds — (b) Friction — (c) Crumpling — (d) Creaking. Div. I. — The Clavicular Region. — $ 1, With marked Dulness on one Side — (a) from Condensation — (k) from Pleuritic Effusion — (c) from a Tumour — $ 2, with Excessive Resonance — (a) Pneumo-lhorax — (b) Emphysema — $ 3, with less marked Difference on Percussion — (a) Tubercular Consolidation — (b) Em- physema — $ 4, With no Perceptible Difference — (a) Apices healthy — (b) Both Emphysematous — (c) Equal Dulness — (n) Difference existing, but not de- tected—The more important Sounds in such Cases. Div. II. — The Posterior and Lateral Regions. — $ 1, With marked Dulness on one side — (a) Simple Serous Effusion — (b) Effusion with Pneumonia — (c) Exudation of Lymph — § 2. with excessive Resonance — (a) Pneumothorax — (b) Emphysema — $ 3, with less marked Difference on Percussion — (a) Caused by Consolidation — its various Forms — (b) by increased Resonance — (c) by a Tumour — \ 4, with no Perceptible Difference — (a) Both Sides Natural — (b) Both Resonant — (c) Both Slightly Dull — (n) Difference existing, but not de- tected — Various circumstances causing this effect. Summary. — The Real Teaching of Superadded Sounds — the Interrupted — the Con- tinuous — heard at the Apex do not necessarily indicate Phthisis . pp. 215 — 231 CHAPTER XX. DISEASES OF THE RESPIRATORY ORGANS. \ 1, Laryngitis — Acute and Chronic — CEdema of the Glottis— Varieties — to be distinguished from Pressure on the Trachea — § 2, Tracheitis, or Croup — Crow- ing Inspiration — General Characters of Croup — -Distinguishing Characters of False Croup — $ 3, Pneumonia — its History and Symptoms — its Auscultatory Phenomena — in the Advanced Stage— in the Early Stage — Inflammation of the Upper Lobe — Abscess — Gangrene — Chronic Pneumonia — Complications — I 4. Pleurisy — its Early Stage — its Advanced Stage— Auscultatory Signs — Com- plication with Pneumonia — Passive Effusion — Associations— Causes of Pieurisy — Pleuiodynia — $ 5, Pneumo-thorax — History — Symptoms — Physical Signs — the Presence of Fluid— Metallic Tinkling — ^uccussiou — $ 6, Bronchitis — Acute — Affects both Lungs alike — Resemblance tolnfluenza — Chronic — Auscultatory Phenomena — Occasional Resemblance to Phthisis — Bronehorrhoea — $ 7, Em- physema—its Characters — with Bronchitis — without Bronchitis — its Slighter Form — its Aggravated Form — $ 8, Asthma — its History — Complication with Emphysema — distinguished from it. — Hay Asthma— § 9, Phthisis Pulmonalis — its Hist ry — General Symptoms — their Relative Importance — Auscultatorj Signs in the Early Stage — their Real Meaning — in the Advanced Stages — Fallacies x ii CONTENTS. — Relations of Superadded Sounds to Tubercular Deposit— tbeii Rational Ex- position—Liability to attack both Lungs— Complication with Bronchitis— with pleurisy— with Meningitis — i 10, Tumours — either Aneurism or Morbid Growth the Auscultatory Phenomena to which each gives riee— G( I, 1; Circulation— f U» Hooping Cough— il ptoms— Sour< Fal- lacy -$ 12, Diseases of the Lungs in Childhood— Importance oi History and General Symptoms— Inflammation — Bronchitis— Tubercles . pp. 232—265 CHAPTER xx r. EXAMINATION' OF THE HEART. History and Symptoms— Changes independent of Disease — Special Signs. Div. I.— Evidence of Alteration of Size— Change of Position— Increased Impulse —Irregular Actions-Extended DulnesB— Abnormal Sounds— Mutual Relations with Irregularity — with Increased Action. ]), v . I[. Auscultatory Phenomena — Murmurs and Sounds. — \ 1, Modifications of Normal Sounds— in Intensity— in Distinctness— in Rhythm— Reduplication— their Relative Importance—?. 'J, Friction— its Distinguishing Features— Position —Characters— Rhythm — its Indications— Friction in the Pleura — § 3, Endocar- dial Murmurs— General Characters— Mode of Determining their time and Place —(a.) Diastolic— Aortic— Mitral— Characters of each— (b) Systolic Murmurs —(1) at the Apex— Mitral— Tricuspid— Blood-Sound— (2) at the Base— Cha- racters of a Valvular Sound— Aortic— Pulmonic— Blood-Sound— Rules for Di- agnosis pp.266— 2/9 CHAPTER XXII. DISEASES OF TI1E HEART. History and Symptoms— Acute and Chronic Disease— their Commencement often Obscure. S 1, Pericarditis — its Signs and Symptoms — Complications — Trust- worthy Indications — h 2, Endocarditis— is not proved by the Existence of a Murnmr— it3 Signs and Symptoms — Sources of Fallacy — the Origin of Cardiac Inflammation in Rheumatic Fever— Pericarditis— Endocarditis— Causes of Ob- scurity—Reliable Indications— Fallacies— § 3, Hypertrophy— its Indications- its Causes— § 1, Dilatation— its Signs and Symptoms— the Flabby or Fatty Heart — Association with Hypertrophy — \ 4, Valvular Lesion—its History — with and without Bruit— Evidence of its Existence— Mechanism of the Circula- tion—Circuit of the Blood — Production of Murmurs— Evidence of Valvular Lesion— ('!) from the Pulse— (b) from Existence of Hypertrophy— (c) from the Appearance of the Patient— Obscure Cases— Causes of Disease of the H. — its Results — its Associations ; PP- 280 — 292 CHAPTER XXIII. DISEASES OF THE BLOOD-VESSELS. £), v l._Diseases of the Arteries— Arteritis — Aneurism. — \ 1, Superficial Aneu- rism—its Diagnosis— \ 2, Thoracic Aneurism— Early Symptoms— Dj 5] Jogging Sound— Advanced Stage— Pulsation— f 3, Abdominal Aneurism— Diffi- culty of Diagnosis — Reliable Indications. Div. II.— Diseases of veins— Phlebitis— \ 1, Pyccmia— the consequence of Suppu- rative Phlebitis— § 2, Phlegmasia Dolens— its Peculiarities— Inflamed V- and CEdema— \ 3, Capillary Phlebitis pp. 293—2 - CHAPTER XXIV. DISEASES OF THE MOUTH AND PHARYNX. Their Associating with Diseases of the Larynx— their Commencement.—? 1, Of the Mouth— Glossitis— Ulceration and Aphthae— Can crum Oris— k 2, Oi the Fauces— (a) Quinsy— Sore throat— (6) Enlarged Tonsils— the Voice and Cough _(,) Ulceration after an Acute Attack— Scrofulous— Syphilitic— \ 3, Of the Glands— Mumps— Cervical Glands PP- 2 " 30 3 CONTENTS. XU1 CHAPTER XXV. EXAMINATION OF THE ABDOMEN. General Relations of Abdominal Disease — History — General Symptoms — Effects upon the Health — Sensations often referred to other Regions — Actual Examination — (1) of Outlets — (2) of Excreta — (3) of Abdomen itself — (a) by Inspection — (6) by Palpation — (c) by Percussion pp. 304 — 307 CHAPTER XXVI. DISEASES OF THE OESOPHAGUS AXD STOMACH. Uncertainty of Symptoms — Sources of Information — Sympathetic affections of other Organs. — § 1, The Oesophagus and Cardiac End of the Stomach — Stric- ture — Spasm — $ 2, Organic Lesions of the Stomach — (a) Stricture of the py- lorus — Scirrhus — Simple Thickening — their Diagnosis — (6) Ulceration — Hemorrhage — (c) Gastritis — its Rarity — (d) Dilatation — its Causes — its Symp- toms — § 3, Functional Disorders of the Stomach — their common Occurrence — Division — (a) Irritability — its Indications — (6) Distention — its Causes — (c) Faulty Secretion — (1) in Hyperemia — (2) in Anaemia — (3) Specific Forms — (1) Undefined Forms — Associations of Dyspepsia .... pp. 308 — 318 CHAPTER XXVII. DISEASES OF THE INTESTINAL CAXAL. Primary Division — General Relations of Inflammation. Div. I.— Diseases attended with Constipation. — $ 1, Constipation — its History — Causes — Results — § 2, Enteritis — with Previous Obstruction — Simple Inflamma- tion — § 3, Ileus or Intus-susception — its Characters — with or without Obstruct- ing Cause — Closure from Bands of Adhesion — § 4, Obstruction — its general Signification — Slow Progress — Diminished Calibre — Excessive Distention — Position of the Obstruction. Div. II. — Diseases attended with Relaxation. — § 1, Diarrhoea — (a) without Febrile Symptoms — Varieties — (b) with General Symptoms due to other Diseases — (c) ■with Febrile Symptoms — especially in Childhood— (d) Chronic Diarrhoea — § 2, Dysentery — Acute — Chronic — $ 3, Ulceration — Hemorrhage — pus. Div. 111. — Diseases attended with altered Secretion — $ 1, Disordered Bowels — ('/) in Childhood — (6) Special Alterations — $ 2, Tympanites — Sources of Er- ror pp. 319—329 CHAPTER XXVIII. DISEASES OF THE PERITONEUM. § 1, Acute peritonitis— (a) Traumatic — from Rupture of some Viscus — after in- jury — (b) Puerperal — Association with Erysipelas — (c) idiopathic — its very marked Characters — ( CHAPTER XXXII. DISEASES OF THE OVARIES. General Considerations — Ovaritis — Obscure Origin of Disease of the varies — Associations.— $ 1, Ovarian Dropsy — Resemblance to Ascites — Distinguishn: i Characters — Principles of Diagnosis — \ -. Tumours — Varieties — known by their Pelvic Attachments — distinguished from Pregnancy — Digital Examination pp. o"(i — 3S0 CHAPTER XXXIII. DISEASES OF THE UTERUS. \ 1, Amenorrhea — distinguished from Chlorosis — Dependent on Local Causes— Irregular and Painful Menstruation — \ 2, Menorrhagia — distinguished from Hemorrhage — S 3, Leucorrhcea — distinguished from Gonorrhoea — Vaginitis — k 4, Tumours — Fibrous — Polypous— § 5, Prolapsus — Malposition — Prolapsus of Vagina — h 6, Congestion and Ulceration — their limited Existence — Can — \ 1, Cancer — its Advanced Stage — its Early Stage . . pp. 381- CIIAPTER XXXIV. DISEASES OF THE RONES, JOINTS, AND MUSCLES. DJ Vi 7 — Diseases of Bones and Joints — their Constitutional Character — Periosti- tis — Rachitis — Mollities — Fragilitas. Div. II. — Diseases of Muscles — Paralysis — Fatty Degeneration. pp. 388—390 CONTENTS. XV CHAPTER XXXV. DISEASES OF THE SKIN AND CELLULAR TISSUE. General Principles of Diagnosis — the Early Stage. — $ 1, Erythema — Urticaria Roseola — $ 2, Papular Eruptions — Lichen and Prurigo — Varieties — $ 3, Squa- mous Eruptions — Ichthyosis — Lepra — Psoriasis — Pityriasis — § 4, Vesicular Eruptions— Eczema — Varieties— Herpes— Special Forms— Scabies— the Aca- rus — $ 5, Pustular Eruptions — Impetigo — Ecthyma — Acne — Sycosis — $ (!, Pemphigus— Pompholyx— Rupia— § 7, Vegetable Parasites-— Favus — Porrigo Decalvans — Pityriasis versicolor — $ 8, Tubercle of the Skin — Elephantiasis°of the Greeks — $ 9, Syphilitic Eruptions — the Copper-colour — Analogy to other Cutaneous Diseases — Changes of Colour generally — $ 10, Lupus — Scrofulous Ulcer — Cancer of the Skin— Cancrum Oris— $ 11, Endemial Diseases of the Skin — $ 12, Cellular Inflammation — its Relation to Erysipelas — to Phlebitis to Secondary Suppuration— General Relations of Diseases of the Skin as aids to Dia g nosi s pp. 391—407 lNDEX pp. 409— 423 MEDICAL DIAGNOSIS. INTRODUCTION. The Province of Diagnosis — its Uses and Abuses — its Neglect — its Relation to the Theory of Disease. The ultimate object of study in all departments of medicine — the object -which must ever be kept in view alike by teacher and pupil — is the relief of the patient by the successful treatment of disease. To this end the properties of various remedial agents are taught in Materia Medica, as they possess the power of neutralizing or eliminating poisons, of counteracting morbid action in its progress or modifying its results, and of aiding and sustaining the powers of life, -when those wonderful laws of our economy come into operation, by which the destructive agency of noxious influences is combated, and the useless and effete or injured tissues are extruded from the body. To the same end the student must acquire a knowledge of the various structures of the body and the functions of its organs in health, as well as the pathological changes in solids and fluids, which become the subjects of anatomical research, and perversions of healthy function which may be traced at the bedside in the pro- gress of disease: these belong to the domain of Physiology and Pathology. The theory of disease, again, combines, by the aid of experience, the perversion of function with the change of structure, deducing the symptoms observed as a necessary sequence from the disturbance of the laws of health to which such changes must give rise; but it also teaches us that there are other and more hidden ele- ments of disease, stamped in their operation on the human frame, with characters no less marked and distinct, which have yet evaded our most diligent search. This department divides itself into two branches: it points out the alliances and differences between various forms of disease and the prominent features by which they are characterized, and to this the name of Nosology has been applied; while under the name of Semeiology it especially treats of the symptoms of diseased action which each organ or region of the body is capable of manifesting. It is the province of Diagnosis to com- bine together these various lessons, and by the application of the symptomatology of disease in general to any particular case, to arrive at a just conclusion regarding its true nature and pathology: and though it does not enter directly on the question of treatment, o 9 18 INTRODUCTION. it has regard to all those indications on which it ought to be based. In the present imperfect condition of the science of medicine, too much importance can scarcely be assigned to the study of diagnosis, which, in its higher and more intricate departments, by separating the known from the unknown in our experience, may yet point out new relations between morbid phenomena and structural change ; and by enabling us to discriminate the finer shades of difference which distinguish various forms of allied diseases, must lead to a more perfect classification. Upon the basis of such trustworthy generalizations, we may hope ultimately to arrive at more perfect knowledge of the causes which operate in the production of each by successive elimination of those that are proved not to be essen- tial, or, as they may be called, efficient causes. But on this question we are not to enter. Our endeavour must be limited to laying down rules by which the student may be able to recognise at the bedside the diseases which he has been already taught in the schools. And however captivating the study of diag- nosis must be to every thoughtful mind, dealing as it does with facts which can be more readily appreciated than those which result from the action of remedies ; however gratifying to the observer to call into legitimate exercise the highest mental functions, and to be enabled to pronounce a judgment upon the evidence presented to him, which subsequent events shall prove to have been correct, it must still be remembered that this is but a means to an end. When elevated out of its true place, it only leads to the "mddecine ex- pectante;" which, boasting of its knowledge of disease, either leaves the patient to die unrelieved or to struggle unassisted through his malady; or it raises the practitioner into a position of self-satisfied vanity, which, pretending to a kind of omniscience, causes him to overlook any fact or argument opposed to his conclusion, until death reveal how great and how fatal was the error. When neglected or despised, it produces that trifling treatment of symptoms arising in the course of a disease, when the more deep-seated or more distant cause for their production has been missed, and when, unfortunately, both patient and practitioner are often deluded into the idea that a disease has been cured or eradicated, of which only the most pro- minent or most distressing symptoms have been alleviated. Thus guarded, however, diagnosis is to the student the best, nay, the only legitimate introduction to the wards of an hospital; be- cause, while its simplicity delights and its approach to certainty encourages him, it also best prepares him for understanding the uses of remedies; it teaches him what medicine can, as well as what medicine cannot, accomplish ; it teaches him the vanity of hunting after specifics; it saves him from becoming utterly skeptic. If it were true that the symptoms by which a disease is recog- nised were exactly analogous in all cases, it would be enough that the student should commit to memory the summary contained in sys- INTRODUCTION. 19 tematic treatises, when he would be at once in a condition to pro- nounce an opinion upon any case put before him. But this is far from being the case : the idiosyncrasy of the individual, including in this term all the differences exhibited by various persons in their sus- ceptibility to the influence of the same noxious substance or ema- nation; and not less than this, the varying power of the causes of disease, which though unproved, and perhaps incapable of proof, we cannot deny, exerting an influence now more potent, now weaker; the combination of these two circumstances leads to an almost endless variety in the outward manifestations of their operation on the human frame. The perplexity thus produced has led men to seek for some symptom which may of itself determine the nature of the malady, which may be considered in the common phrase "pathognomonic" of the disease. Such simple indications would be invaluable if they were attainable, but unfortunately the proof they are supposed to afford is based upon false induction. Some of the greatest minds have fallen into this error, and none mpre than they who have cultivated the physical aids to diagnosis, first introduced by the great Laennec. By means of auscultation and percussion we reach a class of phe- nomena much simpler, and more nearly related to the diseased action, than those evidences which come to us through the circuitous channel of disturbed function, reacting as every function does, upon other or- gans, itself again altered or modified by them. They are, in fact, the necessary consequences of the morbid condition of the parts, but they are not the direct exponents of that state ; it is only by inference that we deduce from the acoustic signs the nature of the pathological change. With reference to the lungs, for example, we learn by per- cussion the relative density of the parts struck, but the cause of that density must be proved by other circumstances. By auscultation we discover that the air enters more or less freely into one portion of the lung as compared with another ; that it meets with obstacles which produce certain sounds ; that the acoustic properties of the lung are changed by disease, but the causes of these phenomena must be sought elsewhere than in the phenomena themselves. Crepi- tation is often spoken of as pathognomonic of pneumonia. Now it is quite true that clinical observation has shown, in a vast num- ber of cases, that when, after death, fibrin is found effused into the parenchyma, such an obstruction to the admission of air at one period exists, that it enters the lung with a puff of crackling noise called crepitation; but until it can be shown that the noise stands to the fibrin in the relation of effect to cause, it is a false induction to assume that it is a certain evidence of its presence. And when we consider how possible it must be that some other cause of obstruc- tion may produce the same effect, or one so nearly alike that it cannot be distinguished from it, how possible that some other sound altogether may be mistaken for it; when we further know that both these events do continually happen in practice, and that cases 20 INTRODUCTION. of pneumonia do frequently present themselves in which crepita- tion is not heard at all, it will at once be conceded, that though an important auxiliary, it is not an essential point in diagnosis. In another class of diseases, the changes of structure are before our eves; and here, if at all, the symptom might be regarded as pathognomonic — the pustules of smallpox, for example. But what shall we say of a case when death ensues before the pustule is formed? I have seen differences of opinion prevail regarding such a one only a few hours before the patient expired. And similar sources of fallacy might be adduced of all corresponding instances of the visible, tangible results of disease. A perception of the errors arising from this cause has led to one of an opposite tendency, which teaches that the general condition of the patient must be alone considered, and that the name or na- ture of the disease is a matter of secondary importance. In the hands of a man of sound judgment and accurate perception, such a c.ourse is probably less injurious to the patient than a false con- clusion formed on insufficient premises. Its peculiar evil consists in its leaving the student without a scheme or proposition, around which to collect and arrange the multitude of distinct and isolated facts which any case in the wards brings before him. Few minds, even those of the highest order, are able to divest themselves wholly of hypothesis in considering any series of facts; and the more un- trained the mind is, the more readily, does it frame such hypotheses for the purpose of explaining them. By the term explaining we only mean the referring the phenomena to some more general prin- ciple, which Seems to stand to them in the relation of cause to effect, and includes in itself the whole or any number of the facts under consideration, as its necessary or common results or consequences. It is impossible to avoid affording such explanations to the student who is acquiring the principles of medicine, and it seems unwise to discard them in the wards of the hospital, where every case ought to be only an example of the doctrines taught in the schools ; and if the teacher do not supply the hypothesis, which in any given case seems to him to afford the true solution of the phenomena, the stu- dent will naturally frame one for himself, and that probably an er- roneous one. At the same time it must be admitted by those who themselves are the most expert in the practice of diagnosis, that the time and the opportunity are not commonly afforded to give these explanations at the bedside of the patient; and clinical lectures can only take up the more prominent class, or the more remarkable in- dividual cases which at the time happen to be in the hospital, and much of the remainder is lost for the purposes of instruction. My object in the following pages is not to supersede the teaching of the clinical physician, but to meet this necessary imperfection by pointing out to the student how he may best frame a true scheme for himself, and still more to aid him in learning the lesson he is daily taught, by rendering familiar to him the principles on which INTRODUCTION. 21 the physician himself forms his opinion. It cannot need any de- monstration to show that one who has thus studied will, when him- self called upon to prescribe, all the more readily seize on the true form of the disease, and the exact relation it holds to the vital con- dition of the patient. In carrying out this intention it would be equally valueless to give a mere enumeration of symptoms, or to classify the exceptions which experience has taught myself and others to look for, aod the errors into which we are liable to fall. My purpose is to elucidate the principles as well as the practice of their interpretation, so that whatever be their variety or perplexity, philosophical conclusions may be drawn from their presence, avoiding unwarrantable infe- rences, and at least guiding the mind in a right direction, if no sa- tisfactory solution of any individual case can be arrived at. All true diagnosis is ultimately based upon inductions separately framed out of clinical and pathological investigations and experi- ments. By careful and repeated observation, we have succeeded, with every appearance of truth, in associating certain phenomena observed during life with particular lesions found after death ; and these form the first step in our progress. Sound principles have ad- vanced exactly in proportion to the number and the accuracy of these conclusions, because there are many conditions which we are not yet, and perhaps never shall be able, to associate with any ap- preciable change in structure ; and to them we must apply by infe- rence the truths which have been taught in other instances by di- rect observation. In so far as we are able correctly to interpret symptoms, and to trace out in connexion with them a real change of structure or of function Avhich affords an adequate explanation of their presence, in so far are we prepared to form a correct diagnosis. It is not the province of this branch of study to elucidate the modus operandi of the change; but, assuming these principles as true, our especial work is to learn to group symptoms together, and to ana- lyze them separately in such a manner that we may be able to ap- ply to them a scheme already supplied to our hand, which shall in some way account for their existence. It is by the nature of this assumption that rational medicine is distinguished from empiricism. The latter equally seeks to group symptoms together, and to assign to each group the most suitable remedies ; but the theory or scheme which it furnishes is not based on scientific principles. In the ap- plication of the theory to the case under observation, the two are exactly analogous. A comparison is to be instituted between the probable results of the supposed malady and those presented by the particular case, and their correspondence serves for the verification of the hypothesis. In short, it is the deductive process of reasoning applied to the elucidation of morbid phenomena. "We gather toge- ther in the best manner we can the fragmentary evidence of symp- toms, and we apply to it the known laws of causation taught by the theory of disease. 22 INTRODUCTION. The correctness with which this process is performed depends on a variety of circumstances. In the first place, it will be greatly in- fluenced by the amount of evidence. This evidence has to be sought, and therefore much will depend on the manner in which the investigation is conducted. "Without method, some portion of it is sure to be overlooked or forgotten ; with a bad method, the infor- mation presents itself in such a form as makes the inference of truth a matter of difficulty. The plan adopted in this volume is one which, on close consideration of the subject, has most commended itself to my own mind; but each person will probably be disposed to modify it so as to suit his own habits of thought. In the second place, the correctness of the conclusion must very greatly depend on our assigning the true value to each portion of the evidence, especially if the group of symptoms be a very complex one. We still form our judgment from the aggregate, but we know that one part is much more trustworthy and more important than the remainder. One single symptom even may, by its presence or absence, turn the balance of evidence in favour of one disease, or exclude another; but this view of its importance in connexion with the whole group, of which it is but a part, is very different from the error already pointed out of regarding any sign as " pathognomonic." On this point correct general knowledge of disease can alone give pre- cision to our judgment ; but it is also the province of a work on dia- gnosis to assign in some measure to each symptom its relative value. In the third place, the verification of the result wholly depends upon the accuracy of our knowledge of the theory of disease. The evidence of symptoms properly arranged leads us so far in the right direction for discovering its true seat and nature; but it does no more than point out a number of requirements with reference to par- ticular organs, or to the system at large, which any disease must be known d, priori to fulfil, before we can admit it to be that which exists in the case before us. From these considerations, I think -it must be evident that the more numerous and the more simple the symptoms are on which we have to decide, the more certain must be our diagnosis. Further illustration may perhaps be deemed unnecessary, but my meaning may be made more evident by comparing the investigation of a case, to the properties of figures in geometry. Suppose that through any four fixed points straight lines are drawn enclosing a quadrangular space: it is manifest that the number and variety of figures which may be produced is very great; and if these figures are placed side by side and compared with each other, they will only be recognised as being four-aided figures, and few persons could find out that they had any other property in common. But if through two of the points (the first and third, for instance) the lines are always drawn parallel to each other, the number of in- stances, is at once much reduced, and this fact is immediately recognised as being common to them all. If, in addition to this, the lines drawn through the second and fourth points are also parallel, the class becomes reduced to those known as parallelograms, of which the opposite sides and angles are equal, and the original property of their passing through four fixed points becomes much more apparent. Further, if one of the angles is ascertained to be a right angle, we are certain that only one figure can fulfil all these several indications. INTRODUCTION. 23 Again, the parallelograms may be compared with each other by the relative length of their diagonals, and we' find that in the rectangular parallelogram the two diagonals are exactly equal. Here, then, we may disregard all the other facts, and finding straight lines drawn through four fixed points enclosing a quadrangu- lar space of which the diagonals are equal, we are certain that the opposite lines are equal and parallel, that all the angles are right angles, and that only one pos- sible figure can possess these two properties, just as before we found that only one figure could possess all the other properties in detail. At the same time, if any one of these properties could not be detected on further investigation, we know that we must have made some mistake in the observation regarding the equality of the diagonals. In studying disease, it is manifest that attention to one symptom only cannot lead to truth, since the causes of its production may be various; but -when a greater number are considered, and are found to harmonize together, the possibility of the whole group being pro- duced by one or other of several causes becomes necessarily very greatly diminished. When the symptoms present are obscure or uncertain, it is much more difficult to trace them back to their true source than when they are clear and intelligible. But yet we must remember that even after we seem to have arrived at a correct re- sult from the comparison of two or more definite symptoms, yet if other important phenomena which ought to be found on closer search are absent, we must have committed an error in observation, and the opinion formed ought only to be persisted in when this exact cor- respondence can be traced, or good reasons can be assigned for the existence of an exception. Hence it sometimes happens that future examination of the same case, by bringing to light new symptoms, may oblige us to discard an hypothesis framed on insufficient pre- mises: indeed, we must often suspend our judgment altogether, till the progress of the case has determined the actual form which the disease is about to assume. Another point must also be kept in view in diagnosis. Diseased action in the body is often very complex, and the phenomena pre- sent may not be all reducible to the results of one form of disease, or a morbid condition of one set of organs: it may, on the contrary, be compounded of the effects of several causes acting together. And not only in such a case are the single effects associated together and intermingled with each other, but the product is a combined effect of the compound cause, in which the direct symptoms of each sepa- rate lesion are modified or neutralized by one another. It is, there- fore, necessary to distinguish between symptoms uniformly asso- ciated with certain conditions, and those which are merely acci- dental ; these, again, must be divided into phenomena which, though not essential, are more or less directly connected with the morbid state, and those which are wholly independent of it. And having collected all the evidence which the case affords, if it appear suffi- cient to establish any hypothesis, we have yet to make sure that no other condition of disease is present that might give a different in- terpretation to some of the symptoms; and still more, when it is unsatisfactory or contradictory, must the examination be careful 24 INTRODUCTION. and extensive in order to discover the causes of this imperfection, and the associations which modify or suppress those symptoms which each would display if acting alone. In every one of these points of view it is evident how much cor- rect diagnosis must depend on a knowledge of the true nature and history of disease. That alone can suggest trustworthy hypotheses for the explanation of the phenomena, by bringing before the mind the different states which commonly give rise to prominent symp- toms, so that when one fails to fulfil all the requirements of the case, another may be substituted for it; it teaches which among the phe- nomena are important and constant in their character, which are unimportant and variable; it also indicates the different diseases which are most likely to be associated together, and shows how they mutually re-act upon one another. And when we have reasoned to the best of our judgment upon the whole of the premises submitted to our consideration, such knowledge can alone supply a standard of comparison, whence we learn what conclusions have been true or false, as the order of events corresponds to or differs from that which scientific experience teaches us to be their known course and progress. While thus studying diagnosis, let it not be forgotten that though our first aim be to arrive at a correct conclusion regarding the dis- ease under which the patient is labouring, our ultimate object is to restore health. Therefore, while combining symptoms in our own mind to give unity to the whole, we must ever have regard to any- thing they may teach us concerning the condition of the patient. Thus, for example, in any case which may at first sight be regarded as one of the simplest examples of that state to which the much- abused term of inflammation is applied, however clear the evidence in favour of inflammation of any particular viscus, we must not act upon this knowledge alone, but must take into consideration the signs of strength or weakness, of increased or depressed vitality which accompany it. This oversight is probably the most prolific source of many a hasty and ill-formed assumption, based on insuf- ficient grounds. The self-evident symptoms alone are considered, other phenomena are too often disregarded, sources of fallacy are overlooked, and a diagnosis is pronounced to which the whole course of the disease is made to bend. Of necessity erroneous hypotheses are admitted in order to reconcile the evident discrepancy between the progress of the case and the supposed nature of the malady. Faith in treatment is shaken, because a false opinion once formed, remedies cannot be employed in a manner conducive to the recovery of the pa- tient. In the end, the student becomes a fanciful speculator in place of a sober physician. He finds the aimless impotence of quackery as successful as his own misguided efforts, and follows the fashion of the day in homoeopathy, hydropathy, the abuse of the speculum, &c, to say nothing of the errors into which some have fallen in the introduction of specific modes of treatment, when their position and their knowledge had given promise of better things. 25 CHArTER I. METHOD OF DIAGNOSIS. History of Case — Narrative of previous Symptoms — Arrangement of existing Phenomena — Plan of carrying on the Investigation — Classification of Diseases necessary to Diagnosis — Table of Diseases. The discrimination of disease, as we have attempted to show, pro- ceeds upon a knowledge, more or less complete, of all the pheno- mena which any given case presents. When it has terminated in the recovery or death of the patient, the series of events arranged in a definite and intelligible order, from their commencement to their conclusion, is comprised under what is called its "History," which ought to present to the mind a perfect picture of all its important features. Unfortunately, the perusal of the clinical case-books of an hospital, or even the published reports of cases by our best au- thors, must convince us how little the real meaning of the history of a case is understood. Without the key of a knowledge of the disease, derived from some extraneous source, it will be found too often impossible to form a correct diagnosis. Many of the difficul- ties are inseparable, to a certain extent, from the nature and sources of the information, but many are due solely to want of system and arrangement. The history divides itself naturally into two parts : the report of the patient himself, or of his friends and attendants, of what hap- pened before he was seen by the physician ; and the phenomena actually observed at the time of examination: the same distinction must be made between events occurring in the absence of the ob- server, and those noted at any subsequent visit. But as our object is rather to point out the true principles on which diagnosis is based than to give the history of diseased states, only casual reference can be made to ulterior changes, and, in general, it must be pre- sumed that the previous history is learned by report, while the signs and symptoms are investigated as they present themselves on a first examination. The previous history is often of great importance ; it ought to commence with the very first deviation from health, in so far as the sensations and functions of the patient are concerned, and it ought to give a connected account of the changes which have subsequently passed upon these, and the origin of new symptoms. This account is of itself sometimes sufficient to point out the nature of the malady. It seldom happens that all the particulars are correctly detailed, yet such as it is, this statement must very often be appealed to in refe- 26 METIIOD OF DIAGNOSIS. rence to the duration, and order of sequence of particular symp- toms, with a view to determine their immediate precursors, and the phenomena which have appeared to follow upon, or spring out of them. Practically it will be found that the more perfect this infor- mation is, whether limited to the present illness, or extended to a perfect acquaintance with previous ailments, the more valuable does it prove as an aid to diagnosis. Much care is necessary not only to get at the first deviation from health, but also to avoid being led away by a preconceived idea in the mind of the narrator, and the more so if coming from a scientific person. So much does the mind seek after causes of all natural phenomena, that the simplest and most illiterate patient is more ready to broach a theory of his illness, than to tell his sensations or his sufferings. It is also to be remembered, that although disease has a distinct and intelligible history, because it follows a definite course, yet the story of the patient is often inconsistent with itself. General inconsistency on all points is commonly an evi- dence of imaginary hypochondriacal or hysterical maladies. Partial inconsistency may arise from the existence of different diseases, either simultaneously or at suc- cessive periods, and the misplaced association of the symptoms belonging to each, or simply from incorrectness of observation. Sometimes the narration of past sensations and sufferings may tend to lead the observer away from the true seat of the malady, inasmuch as not unfrequently dis- ease of central organs first makes itself known by symptoms in remote parts. Against this there can be no safeguard but a thorough knowledge of the relations subsisting between morbid states and the possible phenomena which may attend upon them. Again, symptoms of importance may be forgotten, and circumstances which must greatly influence our opinion on the case may have been omitted, and these points must be inquired into. The same knowledge of the associations of morbid states and their phenomena leads us to ask such questions as may deter- mine whether the symptoms detailed have been caused by one condition or an- other (e. g., whether pain has been caused by inflammation from the knowledge whether fever has been present or not.) Out of this further inquiry arises one of the greatest and most common sources of fallacy; and it is great in proportion as the history and sensations of the pa- tient become the sources of information, and the alterations in structure or func- tion of which we can take cognizance are few and indistinct. It springs from the necessity of framing an hypothesis of the disease from the general outline already given of the case, and the anticipation arising out of this hypothesis, that certain phenomena ought to be present; in consequence of this persuasion, interrogatories assume the form, more or less, of leading questions, unconsciously to the inquirer himself; and this cannot fail to bias the mind of the person to whom they are ad- dressed. This preliminary investigation leads to the association of symp- toms according to their order of sequence, and we must be careful, by observing them from another point of view, to correct any false impression to which it may have given rise. While, therefore, we follow the patient telling his own case in his own way, it is quite essential that we should make a subsequent and independent inves- tigation of existing symptoms according to some systematic course, which shall have the effect of ranging them in such scientific groups as may most readily and naturally lead to the detection of the cause which best accounts for their origin, and most fully satisfies all the requirements of the case. In seeking for such an arrangement, we find that there are two METHOD OF DIAGNOSIS. 27 great classes of indications, the general and the local; each of these comprehending two divisions, the subjective and the objective, the sensations of the patient, and the alterations in structure or function of which the observer can take note. It may be useful to notice here that different names are assigned to these phe- nomena, as the indications which they afford happen to be derived from perver- sion of vital functions, or from altered relations of parts to each other, or to the external world. These are known by the names respectively of vital symptoms and physical signs: thus, pain is one of the symptoms, while swelling and redness are among the signs of local inflammation; cough and expectoration represent the symptoms, the noises produced by the meeting of air and fluid in the bron- chia] tubes are the signs of bronchitis. I believe this division was intended ori- ginally to mean much more than this; it was believed that every disease had not only its category of symptoms, which might, any or all of them, be common to it with other diseases, but that each had for itself its peculiar distinguishing sign or mark, by which it was as readily recognised as by its name (for instance, the rale crepitant for pneumonia, the rale sous-crepitant for pulmonary cedema, &c.) But we shall find as we proceed that the absence of the sign does not imply absence of the disease, and its presence affords at best only a strong presumption in favour of a certain condition of parts. Were it constantly true that general and local indications had only reference to a corresponding division into general and local diseases, it would be enough to discuss them in this order ; but the two are so inextricably mingled together, that no more can be done than merely to adopt, so far as possible, the plan of taking general indications first, and special indications afterwards; for we must often reconsider the general symptoms in investigating local dis- ease, as we must also frequently anticipate special signs in inquiring into conditions of general disorder. No observation can be con- sidered complete which has not taken note as well of the general state of the patient as of the particular condition of each individual organ, under both these aspects ; and however we may endeavour to simplify the inquiry, omissions can only be avoided at the expense of occasional repetition. It will constantly happen in practice that the same indication which has been already noted in regard to duration and sequence, must again be reviewed both in its bearing on the general condition of the system, and also in its relation to lesions of particular organs. When the student is introduced to the bedside of the patient, it is of great importance that he should carry in his mind a certain de- finite course of inquiry, according to which hq should endeavour to trace out a faithful history of the case, so that without any guide but his own investigation, he may be able to frame a history which will leave him in little doubt as to the department in the theory of disease to which it ought to be referred. We are at present only engaged in inquiring into the uses of such an investi- gation, in so far as it leads to a correct diagnosis; but every one of the separate features in the picture may be of importance in determining the treatment. Even when a correct diagnosis is formed, various remedies will suggest themselves to the mind of the practitioner as equally applicable, and their judicious selection very often depends upon a due consideration of the antecedents and peculiarities, 28 METHOD OF DIAGNOSIS. much more than upon the name given to the disease, or the place it may hold in a scientific classification. The student will do well to commit to writing the results of his inquiries. There is no means nearly so successful in giving system and correctness to his investigation; in no other way can he acquire the habit of observing all the phe- nomena of any given case, or tracing their bearing on each other; and nothing will so effectually teach him to mark correctly, and estimate justly, each succes- sive fact elicited by his own inquiries, or volunteered by the patient. From the whole evidence thus faithfully committed to writing can he alone hope to form a correct diagnosis. JTis written description ought to be a full and accurate ac- count of all that he sees, hears, feels, or even smells, and must never embody any conclusions he has formed from them until the whole inquiry has terminated. Thus, to take a prominent example, — in examining the lungs, however distinct he may fancy the evidence of a cavity to be, he ought never to put down in his notes 'cavernous rales,' or 'cavernous breathing,' but what he actually hears — gurgling sounds, loud or very loud, blowing, expiratory breath-sound, &c; everything, in fact, just as it is heard; as he proceeds, it is quite possible that other signs or symptoms may be observed so inconsistent with the hypothesis, that it would be quite unwarrantable to assume the existence of a cavity — a conclusion which ought only to be formed from the coincidence of several other phenomena. The following plan has seemed to me the best adapted for obtain- ing the information required, and is that which is adhered to in the following pages, but admits of modification according to the previ- ous course of study or habits of the individual. It is merely oifered as one which has been found practically most serviceable in making available notes of a large number of cases. It may be divided into four principal sections. After a prelimi- nary inquiry into the age, occupation, and habits of the patient, and also ascertaining if there have been any previous similar attacks or any important illness, we proceed, — 1. To inquire when the first deviation from health occurred, how it was manifested, and what was the order of sequence among the phenomena. 2. To examine into the general state of the patient at the time of observation, as manifested both by objective and subjective phe- nomena. 3. To make a rapid survey of all the organs, especially with re- ference to his sensations. 4. While doing so, to examine more particularly any organ to which the history of the case, the general indications, or the sensa- tions of the patient especially point, and now to investigate the ob- jective as well as the -subjective phenomena of the particular organ. In short, we first get all the information we can of what has hap- pened, we next feel his pulse, look at his tongue, &c, then ask, with reference to each of the larger divisions of the trunk, whether he has anything to complain of, stopping in our progress to make more minute investigations whenever it seems necessary. In endeavouring to point out to the student the probable devia- tions from health we may meet with in various parts of the body, in the order in which they present themselves according to this ar- rangement, it will necessarily happen that the disease of which they TABLE OF DISEASES. 29 are the indications should be discussed in a similar order ; and as it is not my wish to create for diagnosis a distinct place in the science of medicine, but to make it subservient to practice, it seems desirable to adapt it as much as possible to a scientific and practi- cally useful classification. For this purpose, that has been selected which is in use at St. George's Hospital, which, it is hoped, will be intelligible to all, as it is most familiar to myself; but it is not put forward here as possessing any claims to perfection. Its principle is — I. To throw into a large group at the commencement all those diseases which, while perhaps manifesting themselves in particular organs, are more or less proved to have their origin in general con- ditions of system. This is again subdivided into twenty-one heads, grouped in the following order': — 1. Those which are believed to have a specific origin; of which the febrile diseases are placed first, including many of the so-called "zymotics." Next come rheumatism and gout, followed by such as are wholly adventitious, the poisons, entozoa, &c. 2. Diseases of uncertain or variable seat, dropsies and hemor- rhages, which, pathologically, might be regarded as merely indica- tions of deeper-seated lesion, but which, from the consistency of their signs and symptoms among themselves, and their dependence on a variety of causes, also demand separate investigation. 3. The chronic blood ailments — purpura, scurvy, anremia, &c. 4. The constitutional ailments of solid parts ; scrofula, tubercle, and morbid growth. 5. The quasi-nervous diseases; the symptoms of which are prin- cipally derived from functional derangements of the nervous system, in the ultimate distribution of its filaments, and in relation to mus- cular fibre: they thus stand in juxtaposition to diseases of the brain and nerves immediately following. II. To take in detail the diseases of special regions, or systems of organs. In this class we commence with the brain and nerves, and de- scend regularly to the thoracic and abdominal viscera, which are ranged in several groups, and we conclude with the bones, joints, muscles, and skin. In each subdivision the acute take precedence of the chronic diseases. The following table represents this mode of classification : — I. Fevers. 1, Continued fever; 2, Remittent fever; 3, Influenza; 4, Epidemic cholera. II. Eruptive Fevers. 1, Measles ; 2, Scarlatina ; 3, Varioloid ; 4, Erysipelas. III. Intermittent Fevers. 1, Quotidian; 2, Tertian; 3, Quartan; 4, Irregular. 30 TABLE OF DISEASES. IV. Rheumatism. 1, Acute; 2, Sub-acute and slight; 3, Chronic. V. Gout (including rheumatic gout.) VI. Poisoning. 1, Irritant poisons; 2, Narcotic poisons; 3, Gaseous poi- sons; 4, Animal virus; a, Syphilis and gonorrhoea; b, Hydrophobia; c, Glanders and bites of reptiles, &c. VII. Colica rictonum. VIII. Entozoa. 1, Intestinal worms; 2, Echinococcus hominis, &c. IX. Dropsy. 1, Anasarca; 2, Ascites. X. Hemorrhages. 1, Epistaxis; 2, Haemoptysis; 3, ILematemesis ; 4, Ha?ma* turia; 5, Intestinal hemorrhage; 6, Uterine hemorrhage. XL Purpura and Scurvy. XII. Anaemia. XIII. Chlorosis. XIV. Cachsemia. XV. Scrofula. XVI. Tubercular Diseases. 1, Phthisis pulmonalis ; 2, Tubercles in peritoneum ; 3, Tu- bercles in brain. XVII. Morbid Growths. 1, Cysts; 2, Encephaloid cancer; 3, Scirrhus; 4, Colloid cancer; 5, Growths from bone. XVIII. Hysteria. XIX. Chorea. XX. Delirium Tremens. XXI. Tetanus. XXII. Diseases of the Brain and Spinal Cord. 1, Cephalitis; 2, Chronic disease; 3, Apoplexy; 4, Epilepsy; 5, Functional disturbance; 6, Insanity; 7, Inflammation of cord. XXIII. Paralysis. 1, Hemiplegia; 2, Paraplegia; 3, Local paralysis. XXIV. Neuralgia. 1, Tic douloureux; 2 ? Sciatica; 3, Hemicrania; 4, Angina; 5, Other forms of neuralgia. XXV. Diseases of the Heart. 1, Pericarditis; 2, Endocarditis; 3, Hypertrophy; 4, Dila- tation ; 5, Valvular lesion. XXVI. Diseases of Blood-Vessels. 1, Aneurism; 2, Phlebitis. TABLE OF DISEASES. 31 XXVII. Diseases of the Respiratory Organs. 1, Laryngitis; 2, Tracheitis; 3, Pneumonia; 4, Pleurisy; 5, Pneumothorax; 6, Bronchitis ; 7, Emphysema; 8, Asth- ma; 9, Pertussis. X XVIII. Diseases of the Mouth and Pharynx. 1, Glossitis ; 2, Quinsy ; 3, Enlarged tonsils ; 4, Ulceration ; 5, Mumps. XXIX. Diseases of the (Esophagus and Stomach. 1, Stricture; 2, Ulceration; 3, Gastritis; 4, Dilatation of stomach; 5, Dyspepsia. XXX. Diseases of the Intestinal Canal. 1, Constipation; 2, Obstruction; 3, Enteritis; 4, Diarrhoea; 5, Dysentery ; 6, Ulceration ; 7, Tympanites. XXXI. Diseases of the Peritoneum. 1, Acute peritonitis; 2, Chronic peritonitis. XXXII. Diseases of the Liver and Gall-bladder. 1, Inflammation and congestion; 2, Enlargement; 3, Cir- rhosis ; 4, Jaundice ; 5, Gall-stones. XXXIII. Diseases of the Spleen. XXXIV. Diseases of the Pancreas. XXXV. Diseases of the Urinary Organs. 1, Nephritis and nephralgia; 2, Abscess; 3, Ischuria; 4, Albuminuria; 5, Diuresis; 6, Cystitis. XXXVI. Diabetes. XXXVII. Diseases of the Ovaries. 1, Dropsy ; 2, Tumours. XXXVIII. Diseases of the Uterus and Vagina. 1, Amenorrhoea; 2, Menorrhagia; 3, Leucorrhcea; 4, Tu- mours; 5, Prolapsus; 6, Ulceration; 7, Congestion; 8, Vaginitis. XXXIX. Diseases of Bones and Joints: XL. Diseases of Muscles. XLI. Diseases of the Skin and Cellular Tissue. 1, Erythema; 2, Urticaria and roseola; 3, Lichen and pru- rigo ; 4, Squamous eruptions ; 5, Vesicular eruptions ; 6, Pustular eruptions; 7, Pompholyx and rupia; 8, Vege- table parasites; 9, Tubercle of the skin, lupus, &c. ; 10, Cellular inflammation and abscess. Although this arrangement will be followed as much as possible in the order of investigation of symptoms and signs, yet it will often be found matter of conve- nience to refer the local symptoms attendant on the first great division to the ex- amination of the organs in which they are severally found, and, in some instances — as, for example, phthisis — in which the general symptoms are so essentially combined with local changes, to defer almost the whole consideration of the dis- ease until we come to the organ in which these changes occur. 32 CHAPTER II. DURATION AND SEQUENCE OF PHENOMENA. Dividing Diseases into Acute and Chronic — Long Ailment — Pain in Reference to Duration — Order of Sequence — Established Course of Disease. The inquiry into the first manifestation of any deviation from health, the duration of the disease, and the order and sequence of the phenomena, is of considerable importance, as defining in gene- ral terms not only the whole period of the illness, but also in some measure the continuance of each particular derangement, and esta- blishing a certain relation between each new phenomenon and that which immediately preceded it. From the preliminary inquiry as to the age, occupation, and habits of the patient, valuable suggestions are sometimes obtained. "We need not dwell upon the variations in the character of diseases, when they occur in infancy, youth, adult life, and old age, because these are rather associated with stages of development than with periods of years; but we may refer to the information of tardy growth or premature decay, Avhich the contrast between the actual and the probable age of the individual sometimes reveals ; and to the liability at certain ages to the occurrence of specific diseases. In a still more marked manner does the occupation of the patient become the direct index of the disease under which he is labouring, as we know that in the pursuit of certain trades men are necessarily exposed to the influence of various morbid agencies. Nor less im- portant is a knowledge of his previous habits in enabling us to calculate the strength of his constitution, or the tendency to un- healthy action, in warning us that certain modes of treatment must or must not be adopted, and in pointing out the diseases which will be the probable consequence of baneful indulgences. 1. Duration divides diseases into acute or rapid, and chronic or slow. 2. It sometimes tells of a previous condition of weakness and long ailment, which, though it does not negative the subsequent occurrence of acute disease, guards against a hasty decision, and is of immense value in determining on treatment. 3. It gives a measure of the intensity of pain and suffering, by enabling us to compare its effect on the patient's health with its alleged duration. 4. The order of sequence helps us in tracing back the phenomena of disease to their origin, while the first deviation from health some- times points at once to its seat. DURATION AXD SEQUENCE OF PHENOMENA. 33 5. It sometimes enables us to exclude certain possible diseases to which the symptoms might lead, by the knowledge that in their course events occur at fixed periods, which may have been already passed by. • 1. The question whether a disease be acute or chronic is not one merely of in- tensity. The clinical history, the pathological changes, and the treatment, are all of them often very different, not only in degree, but also in kind. Little is known of the essence of disease; and when similar causes give riseto somewhat similar groups of symptoms, we are content to assume a similarity in the disease. This we do even when in detail it may be very difficult to point out an exact resem- blance between any of the particulars in two cases bearing the same name, of which the one has been of long duration and minor intensity, while the other has been of shorter duration and greater intensity. The name is merely the mark or sign by which we agree to distinguish the group of symptoms; and its relation to other similar groups is conveyed by the resemblance of their denomination. But the inquiry has a further application ; for, inasmuch as the existing phenomena may be produced by one of two causes, of which one develops its effects in more rapid succession than the other, the duration of the disease will often aid in deter- mining to which of the two they are to be referred. 2. Long ailment may imply either a peculiar susceptibility in the constitution of the patTent which exaggerates minor sufferings, or an actual depression of the- vital powers, from protracted illness. In each case, evidence of a recent severe attack must be unquestionable before we give our assent to the existence of acute disease ; in the one, because the susceptibility of the patient so greatly influences the character of the symptoms; in the other, because the depression of the vital powers renders the supervention of active disease more improbable, and stamps it with a character different from that which it has in a healthy individual. In both cases, bearing in mind the subservience of diagnosis to treatment, the information is most valuable in directing the selection of remedies. 3. The important bearing of the duration of pain will fall especially under con- sideration with reference to hysteria and neuralgia. Here it may be observed how impossible it is, from the description of the patient, to form any idea of the exact amount of pain and suffering, or to institute any comparison between the expres- sion of it as employed by different individuals. One will talk composedly during a severe operation; another looks pale and haggard and seems to be in great pain, perhaps really does suffer much from a mere nervous affection, which exists chiefly in the imagination, and is principally maintained by the attention being conti- nually directed to it. Here, there is the inconsistency that a very unimportant distraction serves to withdraw the attention, and thereby removes all recollection of its existence and every indication of its continuance. A third person suffers severely from paroxysms of pain, which no amount of preoccupation can prevent, no distraction during its continuance can suspend: yet in this case there may be no structural change to account for the presence of pain. The power of distract- ing the attention is often the only distinction between that which is unimportant and transitory, and that which is of grave import and exceedingly untractable, until its duration and recurrence, and the exhaustion it produces, point out its reality. Duration is, therefore, a point of great value in judging of the intensity and im- portance of expressions of pain. a. Severe pain of long continuance must have told on the health of the sufferer, b. The pain of a nervous affection may be actuallv greater than that accompanying a severe disease in the same locality; but the continuance of disease produces far more important changes than can result from the mere persistence of pain. c. When local pain is of short duration, if it be only one of the features of long-standing illness by which the constitution has not been affected, it must be regarded as of minor importance. 4. A certain amount of caution is necessary in adopting the patient's descrip- tion of the order of sequence of symptoms. It is remarkable how, in slowly ad- vancing maladies, nature accommodates herself so completely to immense altera- .1 1 DURATION AND SEQUENCE OF PHENOMENA. tions in structure, th.it untiWome unusual event occurs, the patient is utterly un- conscious of any deviation from health; or it may be there is only a sense of malaise, without the possibility of tracing this feeling to its cause, or of naming any Bingle symptom which has attended it. Suddenly some change occurs of which the patient becomes cognizant, and then other sensations which previously existed take form and shape in his mind, and consequently find place in his de- scription, after that which is in reality their effect and not their cause. Again, so intimate are the relations maintained between all parts of the body, that it may not be in the very locality in which disease has commenced that symp- toms of its presence first arise; and hence it sometimes occurs that the first feel- ing of illness may not directly point to its true seat. This must be corrected by knowledge of the theory of disease, and the various symptoms by which it is ac- companied. With these qualifications, the first real deviation from health is of much value in leading us back to the true seat of disease. 5. Most diseases have a certain established course, which, either in broad and general outline, or even in minor detail, is followed by all the examples coming under observation; and although we cannot prescribe the exact limits of these se- quences, either in days or weeks, in the majority of instances, yet there are, in all, general periods of greater or less duration, during which certain phenomena must present themselves, or else our diagnosis has been utterly at fault. This fact forms one of the elements of prognosis, and points out its association with a just discrimination of the nature of a malady in the first instance. 35 CHAPTER III. GENERAL CONDITION OF THE PATIENT. ■ Objective and Subjective Phenomena — General Symptoms; Skin; Pulse; Tongue; Bowels and Kidneys; Thirst and Hunger — Appearance — Position or Posture — Sensations — Particular Signs. We next proceed to inquire into the general state of the patient at the time of observation; our information being derived from a consideration of all those phenomena which are not confined spe- cifically to any particular organ. They are either objective or sub- jective. Objective phenomena, in their relation to a general state, are those changes in the condition of vital functions of which the ob- server becomes conscious by his own perceptions. They may, to a certain extent, point out the actual seat of disease, but generally they acknowledge a variety of causes, and therefore only pave the way for further investigation. They are much more trustworthy than subjective phenomena, because to them we can apply the test of experience and comparison, which gives them a certain relative value, in all cases in which they are found. They are independent of the patient's sensations or imagination, and are less under the control of his volition; they are therefore less liable to be simu- lated or exaggerated. Subjective phenomena have special reference to the sensations of the patient; they express to a certain extent his consciousness of general derangement of vital functions; but their more direct ten- dency is to point out the particular function which is disturbed, and hence the particular organ or portion of the body where disease is located. The two classes are in great measure inseparable. They may be divided into the four following groups : — 1. General symptoms, as pertaining to — a. Temperature and dryness of skin; b. Fulness and quickness of pulse; c. Appearance of the tongue; d. State of bowels and kidneys; e. Desire for food and drink. It is indispensable to a correct result that the whole of these should be always taken together, as the indications derived from one source serve to correct those drawn from another, and any one of them is valueless as standing alone. 3G GENERAL CONDITION OF THE PATIENT. 2. The general appearance of the patient: — a. Size, including emaciation, and increase of bulk, whether general or local; b. Aspect of face, and expression ; c. Changes of colour of skin, general and local. 3. His position, or posture: — a. In bed; the manner of lying — on the back, on either side; quiet, restless, &c. b. Out of bed; posture, gait, stiffness or loss of power of limbs. 4. The sensations of the patient. § 1. The indications of a general condition of system, derived from a comparison of the symptoms exhibited by the skin, pulse, tongue, bowels, thirst, and appetite, are of the first importance. They determine at once whether the condition be one associated with febrile disturbance or not; and in this view, the intensity of one symptom is of very much less value than the complete agree- ment of all. A mutual relation of some of them points out the opposite conditions of vigour or weakness, on which so much of correct treatment depends; while their harmony or inconsistency is one of the very first elements in rational diagnosis. a. The temperature of the skin may be either colder or hotter than natural, and each of these deviations from health may be ac- companied by moisture or dryness. This relation must be consi- dered in determining the value of the observation; heat and dry- ness generally becoming expressive of febrile excitement, coldness and moisture of prostration and weakness: a hot and moist skin, or a cold and dry one, are each of them less significant than the opposites. We have also to pay attention to the casual ehanges'in external circumstances by which its condition may be modified : such as the effects of exercise or fatigue ; the temperature of the surrounding atmosphere, and the immediate consequences of exposure; or even the temporary effects of mental excitement. In ordinary changes of temperature, moisture, by a natural law, attends its elevation, dryness its depression; while these again react upon each other, evaporation producing coolness, and vice versa. In disease this association is sometimes, but not always, broken through ; and hence, while a hot, dry, and pungent skin indicates a febrile state, a hot and moist skiu may, or may not, be the consequence of disease, and its value can only be estimated by determining the causes which have given rise to it* Similarly a cold moist skin, in severe disease, is a most alarming evidence of collapse, and a clammy skin generally indicates debility, while a cold and dry skin is either simply the effect of exposure in perfect health, or is found, as the cutis anserina, at the moment of rigor in fever. b. The characters observable in the pulse are chiefly change of rate or frequency, of volume or fulness, and of force or firmness. These changes may be considered as, to a certain extent, expressive of really different conditions of system; but here we must rather view them in their relation to each other, and to other coincident phenomena, among which, perhaps, the condition of the skin is the GENERAL CONDITION OF THE PATIENT. 37 most important. It is from these two sources that we derive evi- dence of the difference between inflammation, or inflammatory fever, and simple or continued fever. The skin is more apt to be moist when its temperature is raised by inflammation ; to be dry when it is the accompaniment of fever. The pulse has more fre- quency and less force in fever; greater force, and commonly less frequency in inflammation. These distinctions are all-important in treatment, but in diagnosis they do no more than give a general impression that one or other condition is most probably present. The age of the patient has an important influence over the fre- quency of the pulse; sex and habit over its fulness and firmness. The pulse may be quickened by mere excitement; the tongue may be at the same time coated from disorder of the bowels ; but this condition must not be mis- taken for fever, nor, if associated in a delicate female with pain in the left side, be taken as indicative of pleurisy. The state of the skin, as well as the absence of thirst and the character of the urine, will here probably decide against any such supposition. Acceleration of pulse, to be important, must be constant and persis- tent, not transient and varying with temporary excitement, &c. Certain chronic states are also accompanied by acceleration of pulse, such, for example, as heart disease and phthisis; and here agaiu the indications from other sources, even with- out considering the special indications derived from its force or firmness, enable us to correct an impression of acute or febrile disorder. Changes in volume chiefly give rise to impressions of the pulse being full or empty, large or small; but these are necessarily associated with conditions of hardness or softness, strength or weakness, which are expressive of changes in force. The impressions of this character are conveyed to the finger by the greater or less degree of compressibility; the pressure required to obliterate the current. Deviations occurring within the limits of health generally combine fulness with firmness, weakness with smallness. We do not expect to find a similar pulse in a man of sedentary occupation, and in one of active, or perhaps laborious, pursuits: the pulse of the female has neither the fulness nor the force of the other sex. And while these point to real differences in constitution, which guide us in the adaptation of remedies, they are not the less to be borne in mind in judging of the extent of deviation in disease. Certain names have been given to unusual combinations of the characters just mentioned, with which the student must make him- self acquainted: thus smallness, with force, gives rise to what is termed a hard pulse, or, in extreme cases, a wiry pulse; largeness, with want of force, to a soft pulse; emptiness and frequency to what is often called a rapid pulse. Irregularity of pulse has very important bearings upon special forms of disease, but is of less consequence as a symptom of the general condition of the patient. c. The state of the tongue is to be noted with reference to its coating and its degree of moisture; and the latter is probably of more importance than the former in its bearing on our present in- quiry. The characters of its coating are derived from its thickness, extent, and colour or general appearance: whether it resemble a thin coating of white paint, or of paste, or be thick, like buff-lea- ther ; whether the fur be limited to the back of the tongue, or the tip and edges alone be left clean and red, or whether a red streak be observed in the centre, or the organ have a general patchy ap- 38 GENERAL CONDITION OF THE PATIENT. pcarancc; lastly, whether the coating be white, or yellow, or dark and brown. Sometimes, on the other hand, the tongue appears un- illy clean, and has a smooth and peeled appearance, or is chapped, or marked by prominent papillse. Each of these conditions is, again, associated with differing degrees of moisture or dryness. Some- times the excessive moisture gives it an appearance of flabbiness or oedema. Its relation to the condition of the bowels must not be overlooked. No organ more quickly indicates derangement, however slight: in every state it sympathizes, and many of the variations just mentioned have especial reference to particular forms of disease: but its varying characters have great significance, as symptoms of the general condition of the patient; the least important being that in which the fur is confined to the back of the tongue, or is thick and yellow, and bears evidence of large accumulation. The moist, flabby, or cedematous con- dition is wholly opposed to the idea of febrile excitement; the red patch in the centre, and the peeled or chapped condition of the mucous membrane, are very important evidence of the form which a febrile condition has assumed, but they may be in various degrees exhibited without the existence of fever, properly so called: on the other hand, a bright red tip and edges, or a dark brown fur, are more decidedly characteristic of fever. As a general rule, dryness is more indi- cative of a febrile state than any appearance which the coating presents. Acci- dental circumstances must not be overlooked: a patient in a weak state waking from a short sleep after taking food will have a dry tongue; one who has recently taken any fluid will have a moist one, in cases in which neither condition is per- sistent or permanent. d. The state of the bowels and kidneys is at present to be con- sidered only in general terms, whether there be constipation or di- arrhoea, abundant or scanty discharge of urine. These questions must again present themselves in investigating the separate organs, but the knowledge of the condition of the bowels is here necessary to qualify the observations made upon the condition of the tongue; and the quantity of the urine has a similar relation to the existence of thirst. In discussing the diseases of the intestinal canal, we shall have to refer not merely to the great fact of the frequency of the stools, but their appearance and consistence will be found each to have a definite bearing on diagnosis. The ex- istence of constipation or diarrhoea deprives a coated tongue of much of its im- portance, considered with reference to a general state of system. Hence the value of the observation is in proportion to the explanation it affords of the appearance of the tongue. It is also sometimes suggestive of disease in remote organs, of which the diarrhoea of phthisis, and the constipation attendant on inflammation of the brain may be taken as examples. With regard to the urine it may be remarked, that while an abundance of pale limpid urine entirely negatives the idea of acute or febrile disease, an opposite state, its being scanty and loaded, although a constant concomitant of such dis- orders, may depend on a great variety of causes; and is of importance chiefly when conjoined with thirst. The special diagnosis must be deferred to a later stage of the inquiry; but in the present day, with all the advantages of chemical analysis, something more ought in all cases to be done, than merely to ascertain the amount of the secretion or the degree of its turbidity. e. In regard to thirst it may be stated, as a general rule, that the dryness of the tongue and the desire for liquids are proportionate to each other. All febrile states present this phenomenon in greater or less degree, and too much importance must not be attached to its presence, inasmuch as copious discharges from the GENERAL CONDITION OF THE PATIENT. 39 bowels or kidneys invariably give rise to it, whether tbere be fever or not. The only chronic states in which it is very marked, are diabetes, and its simulation, diuresis. In the former, it is accompanied by hunger even in a more remarkable degree. Loss of appetite is' so common that it hardly needs to be inquired into, except for the purpose of noting as an important symptom the circumstance of the appe- tite being unimpaired in cases where other indications would lead us to expect it should have been lost. § 2. The general appearance of the patient affords to the phy- sician very distinct indications of the nature of the disease, and of the organ in which it is probably located. This group ought to be studied with care, because they are apt to lead to hasty conclusions. a. Alterations in general bulk are chiefly important as evidence of long continued diseased action. Emaciation implies imperfect nutrition depending on a variety of causes, which are generally slow in their operation. It also sometimes supervenes very rapidly in acute febrile disorders ; but here the cause is unequivocal. In chronic maladies it arises either from deficiency, from waste, or from perversion of the blood-plasma or nutritive material. Hence it oc- curs in organic diseases of the abdominal organs, in suppurations and diabetes, in phthisis and cancer, in its greatest degrees. Along with some general resemblance in all these cases, there are certain spe- cial characteristics forming part of what may be called the physiognomy of dis- ease, which materially aid an experienced eye informing a diagnosis quickly; but too much reliance is not to be placed on them, and their only use is in direct- ing the practitioner where he is to look for disease, the nature of which must be afterwards determined by its own special phenomena. General increase of bulk — obesity, is to be regarded as a dis- eased state, but it cannot be traced to any special organ as its source. General increase also arises from universal anasarca, and in rare cases from universal emphysema. The doughy feeling of the one, accompanied by the remaining mark of the finger known as pitting on pressure, contrasts strikingly with the elasticity of the other, and the peculiar sensation of crepitation it conveys to the hand of the observer. It is worthy of remark, that in what has been called acute dropsy, especially as occurring in children after scarlatina, the increase in size sometimes has a feeling of elasticity, and scarcely seems to pit at all. Firm continued pressure over a superficial bone, such as the tibia, will remove any doubt. In such a case, I have heard the suggestion thrown out whether the case might not be one of emphysema. Local changes of size are more particularly connected with local disease; those which are attended by increase will be discussed separately under the head of morbid growths; those of which emaciation is the evidence have their source in imperfect nutrition of the part, and are merely the concomitants of some other more important lesion; e. g., the wasting of a limb which is the subject of para- lysis. b. Aspect and expression are to be studied in their relation to the physiognomy of disease, of which they are most important ele- ments. The former especially points to physical conditions; the latter to the sensations of the patient, as revealed by the features. They are both of much value, but nothing further can be done here than to indicate this as the direction in which they must be studied. 40 GENERAL CONDITION OF THE PATIENT. Aspect tolls of a general state — cachexia, tuberculous or other, scrofula, anaemia, &c, that which accompanies cancer is frequently called malignant; or it may tell of ill-ventilated blood, of dissipation, or of exhaustion. Expression, on the other hand, has more distinct reference to the nervous sys- tem. It may be tranquil, or it may indicate pain or anxiety; it may be listless, depressed, wandering, unmeaning; or it may be excited, or maniacal. But, fur- ther, ii may be used as a test of the reality of complaints made by the patient, or, at least, of their exaggeration; and the rapid transition from smiles to tears in the hysterical female is often a valuable sign. Both are to be noted with as much precision as possible, because they have an important bearing on the particular form which any malady has taken or may assume. The mind will naturally revert to them in confirmation of an opinion formed on other grounds, or as a cause for modifying a conclusion which other symptoms might seem to warrant; and the observant practitioner will always let them have their due weight in the treatment of the case. It is scarcely necessary here to remark, that, of the two classes, those having reference to aspect are less liable to mislead than those derived from expression; the former belong to objec- tive, the latter are in great measure subjective phenomena. c. Alterations in colour are in some respects more specifically diagnostic; some- times inseparable from aspect, as the waxy complexion of chlorosis, the pale puf- finess of advanced albuminuria, the sallow hue of malignant disease, or the par- ticular blueness of the nose and lips with dark-coloured unaerated blood; some- times distinct from it, as the yellowness of jaundice, the muddiness of enlarged spleen, or the blueness of Asiatic cholera, and the eruptions of measles and scar- latina. Local changes may point to a general state, as in scurvy or purpura, and the blue line of colica Pictonum, or the specific colour of syphilitic eruptions; to a state partly local, partly general, in erysipelas or erythema, and the red patches over the joints in acute rheumatism or gout; or to a' state purely local, as in the formation of abscess. Cutaneous diseases are all more or less associated with local changes of colour, which must be particularized when this class of diseases comes before us. § 3. The fact that a patient is first seen in bed, or going about his usual business, serves to give a vague impression of greater or less severity of the attack, which may turn out to be very false. a. Position in bed is to be considered with reference to its being horizontal, or more or less erect; to the position of the limbs, whe- ther flexed or extended, fixed in one position or moved freely about; to the quietude or restlessness of the patient in lying, or the main- tenance of a constant posture, whether on the back or on one side. These circumstances are chiefly indicative of the state of respira- tion, or of sensations of pain, which are aggravated by one position and relieved by another. In many instances the breathing is felt to be much easier when the head is elevated, and occasionally the horizontal position cannot be tolerated at all: to this last the name of orthopneea (erect breathing) is frequently applied. It is in- dependent of frequency of respiration, which may attain to three times its average rate without any consciousness of dyspnoea, and while the patient prefers lying perfectly flat in bed; but it is generally accompanied by a certain degree of hurry of the breathing. Such a distinction is often to be seen in the effects of disease of the heart or aorta upon the respiration, as compared with those of lung disease in phthisis and pneumonia. Occasionally the freedom of breathing is more in- terfered with by inclining to one side than the other, and this generally when one lung is from any cause obstructed, and free movement of the ribs on the opposite side is sought to be obtained by elevating the shoulder: this is seen in cases of GENERAL CONDITION OF THE PATIENT. 41 extensive consolidation of one lung or effusion into one pleural cavity. But, on the* other hand, pain on the diseased side may be aggravated by such a position, and therefore this indication is by no means a certain one. Then again, pain of very slight character in a fanciful person is sometimes said to be aggravated by lying on the affected side; whereas pain of a rheumatic cha- racter may be relieved by it. In congestion of the liver, although there be pain on the right side, a still more painful sensation of dragging is felt on turning to the left. ^ In the pain of colic the patient may receive so much relief from pres- sure as to be induced to lie on his face. Pain dependent on inflammatory action is always increased by pressure, fre- quently by movement, and hence we may generally conclude that it has this source, when it obliges the individual to maintain one constant posture. A most striking instance of this is afforded by acute peritonitis, when the patient lies flat on his back, with knees drawn up and breathing restrained, lest by any possible movement the pressure on the abdomen should be increased or the relation of the viscera disturbed. What a contrast is this to the effect of pain in colic. The absence of pain or serious discomfort, on the other hand, induces a patient who has any feeling of weakness to lie quiet, without his being in any way con- strained to remain in the same position. This again is very distinct from the still- ness which is expressive of complete prostration, or of some loss of muscular power: the one patient may be characterized as listless, the other helpless. It is impos- sible to describe all the differences in words, and yet to the experienced eye how instructive the observation. Watch, for example, the apathy of the patient first seized with malignant typhus, and his subsequent helplessness, and compare with them the quietude of the convalescent, and the powerlessness of the paralytic. Observe, again, the marked stillness of acute rheumatism, when, for example, the patient sees some one accidentally about to touch a painful joint, and knowing that that touch is agony, yet he dare not move the limb out of danger. Information may also be derived from seeing the patient in bed, which may aid in determining the reality and amount of alleged want of power, by ascertaining how far he ca°n move those muscles in bed which seem to be useless when he is up. . These and similar indications must only be trusted to in so far as they are borne out by other symptoms, and in fact derive their chief value from pointing out the probable seat of disease and leading to further examination. b. Out of bed the presumption is strong, that the disease is not active or acute; yet this is not to be absolutely relied on, because of the difference in sensations and constitution already referred to, which lead one person to regard as trivial what is considered of se- rious import by another. An erect posture indicates a state of ge- neral health and strength, and freedom of respiration; a crouching one, general feebleness, or laboured breathing. The gait may be halting on one side, or equally imperfect on both; and here it is very important to notice, whether the imperfection arise from stiff- ness, or* loss of power; in the one case the movement is firm and steady, though impeded; in the other it is irresolute and unsteady. The action in rising up or sitting down is often of use in determining this point with reference to the legs: and in the upper extremities the dropping of the limb when raised by the hand of the observer best discriminates these conditions. r ILe features, too, are sometimes distorted by partial loss of power. Paralysis will be subsequently discussed. Stiffness leads to inquiry into the state of the joints, and especially as to rheumatic affections. As a striking contrast to these conditions, we have the involuntary jerking movements of chorea, and the quick, hurried and rather tremulous actions of de- lirium tremens; we may also observe the inconsistent proceedings of one com- pletely delirious, and the perverse stupidity of the imbecile. 1- SPECIAL INDICATIONS. I. The sensations of the patient have not much relation to his general state. They include those pertaining to temperature, of excessive heat or cold, feverteh- or chilliness, which Bomelimea contrast .strangely with the actual temperature of the skin: feelings of weakness, malaise, or pain; insomnia, giddiness, or head- ache; Bhortness of breathing; hunger, thirst, and their opposites; — all the sub- jective phenomena, whether related in the history of the case, or in answer to our inquiries regarding general symptoms, serve to point out the direction which sub- Bequent investigations ought to take. We note not only their actual existence at the time, but also their previous occurrence in the past history of the case; both in their bearing on the general state of the patient, and in the light they mav throw upon special pathological conditions, when the various organs subsequently pass under review, bearing in mind the sympathetic and indirect, as well as the more evident and more direct sensations. Sometimes they are such as we feel assured can have no existence in reality, and then we are led to inquire into disordered innervation, distorted imagination, or perverted function of the brain. This is the proper period of the examination at -which to inquire what the patient has to complain of. We are preparing to enter into the investigation of the special phenomena of disease, and it is a good plan to ascertain, first, in what direction the sensations of the patient point. Then it is important to remember that every person has a tendency to express a theory of his malady, rather than to relate the simple facts of which his sensations have made him conscious; not satisfied with the knowledge that such and such effects have followed, he always fixes his mind on what he assumes to be their cause, and when asked what he has to complain of, his answer is commonly framed in the language of this theory. The French physicians have a form of question which seems to me very well suited to avoid this evil ; they ask, " ou avez vous mal?" and it would be well to adopt something of the same kind among our- selves, rather to ask where is the complaint, than what it is. In making the observations which have just been detailed, it not unfrequently happens that some particular or unusual condition is present, which of itself has a direct bearing upon the diagnosis of the disease ; not, let it be understood, as a distinctive mark, or special diagnostic sign, but as a phenomenon which, in the majority of instances, has been found associated with only one form of disease, or at least with a comparatively small variety of cases. Some of these are very dis- tinct and unmistakeable, while others scarcely admit of description, and are only learned by repeated observation. Even to the most practised eye, such signs are more or less uncertain, and the student should never place reliance on them: they are but solitary indications, and his object should be to acquire accurate knowledge, which is only to be obtained by testing conclusions drawn from one series of observations, by others which are as distinct from them as possible. The sources of fallacy which especially affect all these special indications have been already noticed, and it is most essential to remember that they have no necessary or absolutely inseparable connexion with any one single morbid state, to the ex- clusion of all others. The deeper seated the lesion in all these cases, the more liable are we to fall into error. It surely needs no argument to prove that instead of trusting to such special signs, a systematic examination of the whole symptoms of t lie case may not only lead to the discovery of some other disease in addition to that which the particular sign, however truthful, may have indicated, but it may also point out peculiarities in the case under observation which a more cursory view must overlook; and with reference to treatment, both these of circumstances are of much importance. A few of these indications are here ranged under the Jbur groups, under which the subject generally has been reviewed, several of them liaving been already incidentally mentioned. . SPECIAL INDICATIONS. 43 Particular indications derived from Group I. a. The skin. a. The skin feels peculiarly thin and detached from the subcutaneous structures in phthisis: and to a less degree also in similar wasting diseases. 8. A feeling of fulness and tension exists in the eruptive fevers, amounting to a sense of hardness in erysipelas, and of grittiness in small-pox. y. The nails become clubbed and the hair falls off in tubercular disease, but these circumstances are not limited to such cases: in secondary syphilis the hair also falls, and during recovery from fever. 8. Disease of the abdomen, especially of a tubercular character, is often accom- panied by a dry, harsh state of skin, which is most marked in childhood. i. The skin is remarkably moist and soft in delirium tremens. £. The perspirations are profuse and sour-smelling in acute rheumatism, but this is not specifically diagnostic as has been supposed. In some of the m intractable forms of the disease, the odour is peculiarly rancid and disagree- able. Excessive perspiration of any kind is frequently attended with an erup- tion of miliary sudamina. r t . Colliquative sweats are constant attendants on the later stages of phthisis and on profuse suppuration, such as lumbar abscess. 6. Rigor, as indicated by the cutis anserina, is the common precursor of fever; its recurrence at intervals, if not from the presence of ague, or its sudden su- pervention during any existing illness, is indicative of the formation of pus. x. The crackling feeling of emphysema, and the doughy character and pitting uuder pressure of anasarca are each very characteristic. (See also changes of colour.) b. The pulse. a. When frequent, the pulse is observed to be remarkably full in acute rheuma- tism, and generally firm in all acute inflammatory diseases. ,6. It is hard and wiry in abdominal inflammations especially. y. It is weak in fevers, properly so called ; either large and soft, or small and feeble. S. It is rapid and jerking in hemorrhage. f. It is simply hard and unyielding in old age, and in all conditions of arterial degeneration. _ f . The rapidity or shortness of the stroke is very observable as an indication of excitement. !». Its frequency is most remarkable in acute hydrocephalus, varying with un- appreciable causes, and generally uneven or unequal. 0. It is still more unequal and depressed, or it is slow and laboured, in cerebral disease, especially where the case is marked by pressure on the brain. x. Irregularity of the pulse is most commonly associated with disease of the hearf, and, along with this, it is remarkably faint and feeble if there be mitral regurgitation. ?.. A hammering pulse indicates aortic regurgitation. ,u. The pulse becomes imperceptible in syncope and in cholera, and more or less faint in all conditions of collapse. v. It is sometimes felt only at one wrist, when disease, chiefly in the form of aneurism, affects the origin of the subclavian, on the opposite side. More rarely, this circumstance is the effect of accidental obliteration. c. The tongue. a. The thin white even layer is generally indicative of slight gastric disorder. ,8. The thicker coating, from accumulation, exists to its greatest extent in affec- tions of the fauces, and less remarkably in conditions of general debility: it has a creamy look in delirium tremens. y. A peculiar buff leather appearance is presented in cases of enteritis and he- patitis. 6. A patchy tongue is often indicative of considerable irritation, or even partial inflammation of the stomach. 44 SPECIAL INDICATIONS. # i. Its yellow colour is generally believed to be bilious; a dark brown colour ex- ists only in malignant fever, and in hemorrhage from the mouth. C. The shining ami glased tongue, especially when chapped, is very common in ulceration of the bowels. r. The papillae project most remarkably in scarlatina; the general surface being either coated or unusually red, (the strawberry tongue.) 6. A less degree of projection through a thin white coating often accompanies hysteria. x. Aphthae and ulcerations indicate imperfect nutrition, and tendency to diar- rhoea. d. 1. The character of the stools. o. Motions simply watery are the characteristic of diarrhoea, and their opposite, of a Condition of constipation. /3. Undigested food is sometimes seen in the stools. y. They are of an ochrey colour, as well as thin and watery, in fever. 6. They resemble rice-water in cholera. c The feces pass in scybalous lumps, with blood or mucus in acute dysentery. C. Mucous and purulent discharges are seen in the same disease in its chronic form ; pure pus comes away when an internal abscess discharges itself by the intestinal canal. r. The motions are black and pitchy when blood becomes mixed with the in- gesta in the stomach, or upper part of the canal. 0. They are streaked, or more or less mixed with blood of more natural colour in hemorrhoids, and hemorrhages lower down in the canal. x. The stools are clay-coloured in deficiency of bile. x. They are sometimes frothy and yeasty-looking, as if fermentation had taken the place of digestion. p. They may contain fluid fat, which solidifies on cooling; this is sometimes connected with pancreatic disease; or, they may contain biliary calculi, in- testinal worms, and even calculi from the kidney. v. Occasionally the form of the evacuation is altered by passing through a stric- tured portion of the gut, when that is placed near its lower orifice. d. 2. The character of the urine. a. It is remarkably pale, limpid, and abundant in hysteria, but not persistently so. (3. It is generally dark-coloured, with or without deposit on standing, in febrile ^ states. y. There is a copious deposit on cooling, when the watery portion is deficient, and much acid is secreted. 8. It gives a red stain to the utensil in disorder of the liver, in connexion with the foregoing state. i. It presents a dark porter colour in jaundice, from the presence of bile, f. It has a smoky colour from altered blood when acid, and a pinkish hue when alkaline; becoming quite crimson when much blood is passed. r. The conditions of albuminuria, pyuria, and diabetes, the characters of the sediments, and the effect of chemical re-agents, will be afterwards noticed. e. 1. The appetite becomes — a. Excessive in diabetes. |3. Craving in mesenteric disease, or when intestinal worms exist. y. Depraved in hysteria — eating of chalk, cinders, slate-pencil, «fcc. S. Fanciful in pregnancy; expressed as longings for certain articles. i. It is very variously altered in dyspepsia. f. The name of bulimia has been applied to that conditiou which seems to con- sist in nothing more than extraordinary voracitv. c. 2. Thirst— a. Is remarkably increased in diabetes. (3. It is very urgent in cholera, and also in a less degree in diarrhoea. y. Diuresis with uncommon thirst, when no sugar passes in the urine, is gene- rally due to hysteria; it is not attended with hunger. SPECIAL INDICATIONS. 45 Particular indications from Group II. a. 1. Emaciation seems to affect — a. More especially the arms and thorax in phthisis, and the face least. p. The lower limbs and the face in abdominal disease, y. It is most marked in the features in malignant disease. a. 2. Local increase of bulk becomes remarkable — o. When the upper half of the body is anasarcous and not the lower, or when one limb only is cedematous. /3. When the head is enlarged in chronic hydrocephalus. y. When one side of the chest or the abdomen projects from effusion of fluid, or internal tumour. b. 1. The aspect is often very significant. a. A delicate appearance, with long-fringed eye-lashes, often serves to point out the tubercular diathesis. p. The thickened alaj of the nose and upper lip of scrofula are most marked in childhood. y. The pallor of anaemia is very important; it is waxy in chlorosis, and pasty in disease of the kidney. 8. A puffy appearance about the eyelids, along with anaemia, is very generally the indication of albuminuria. i. The sallow hue of the malignant disease appears to be only another form of anaemia. £. The blue colour, especially of the nose and lips, in heart disease and chronic bronchitis, is equally remarkable, and forms a striking contrast to »;. The dusky flesh of pneumonia, or 6. The hectic flush of phthisis. x. The congested features and suffused eyes of typhus are exceedingly charac- teristic. %. A bloated, blotchy face generally indicates irregular habits of living. ix. The features undergo remarkable change in erysipelas, parotitis, facial para- lysis, &c. b. 2. Expression. a. The face is remarkably anxious in disease of the heart, and in urgent dys- pnoea, e. g., laryngitis. p. It is at the same time pinched and contracted when there is much pain or suffering, especially in a vital organ. y. Its immobility is most remarkable in catalepsy or in states of unconscious- ness, and perhaps under the influence of spasm, as in tetanus. 5. The opposite state exists in nervousness and hysteria. i. The expression of the countenance is most materially altered by the swelling of oedema or erysipelas. (Many of its characters have direct reference to the brain, in treating of which they will be further discussed.) c. Alterations of colour. a. The whiteness of the skin is remarkable in all the varieties of anaemia already noticed, and contrasts strongly in limbs anasarcous from albuminuria with those in which dropsy is connected with disease of the heart. It is also very striking in phlebitis (phlegmasia dolens.) |9. There is a certain yellowness of the malignant aspect, which is distinguished from jaundice by the pearly lustre of the eyes. y. The yellowness of jaundice varies from a pale orange to a deep green-yellow. i>. Redness of skin, when local, indicates congestion; when general, is more fre- quently due to measles or scarlatina, or simply to febrile heat. It is the marked characteristic of erysipelas, erythema, gout, and acute rheumatism. i. The skin has a muddy hue in disease of the spleen. f. It becomes blue in Asiatic cholera; it is also blue in morbus caeruleus, and in forms of diseased heart and bronchitis. 4G SPECIAL INDICATIONS. r. Tt is livid in commencing gangrene; and it might also sometimes be called livid in disease of the heart. 6. Spots and patches of discoloration are of value in recognising certain fevers, purpura and scurvy, colica pictonum, syphilis, and most cutaneous affections. From ( I ROTTP III. a very large number of particular indications might be drawn : we shall here enumerate only the more important. a. Position in bed. o. The head is elevated chiefly in disease connected with the heart, less fre- quently in diseases of the lungs. /?. The head is leant forward when there is pressure on the trachaea. y. The patient may be unable to lie down from pain of head or "iddiness. h. Lying on the back is the position of debility; it is then combined with list- lessness: it is also the position of paralysis, when it is combined with inability to alter it; and of stiffness and pain in acute rheumatism, when it is chiefly characterized by stillness. t. The same position is generally assumed in acute peritonitis, when it is com- bined with drawing up of the knees towards the abdomen. f. The patient assumes a prone position generally only in abdominal spasm or colic: much more rarely in consequence of the pressure of internal tumour. r r When fixed on one side, we may generally assume that the breathing is much obstructed in the lung of that side on which he lies. When he is unwilling to turn to either side, it is commonly from the sense of pain accompanying inflammation; pressure produces pain on the affected side, while turning on the opposite causes a sensation of dragging. b. Posture and gait. a. Inability to stand depends on weakness, vertigo, or paralysis: in the two for- mer the patient reclines, in the latter he sits. p. The body is bent to one side in curvature of the spine, and also in disease of the hip. y. The gait is quick in excitement; 8. Slow in debility; t . Laborious, staggering, or uneven in diseases of the brain and paralysis. £. It is stiff and halting in rheumatism and disease of joints. r t . There is constant movement in chorea. 6. Tremor exists in nervousness, and more especially in delirium tremens; it is seen in fever, sometimes with what is called floccitatio; it also accompanies severe rigor. x. Tonic spasm occurs in tetanus, in disease of the spinal cord, poisoning with strychnia, &c. When long continued, it is probably associated with inflam- matory softening of the brain. a.. Catalepsy is a peculiar form of tonic spasm; cramp is its mildest manifesta- tion. ju. Clonic spasm occurs in epilepsy, eclampsia, chorea, and hysteria : subsultus is also a form of clonic spasm, allied to tremor. v. The muscular movements generally are exalted in mania and delirium, are diminished in idiotcy and imbecility, are lost in paralysis. There is a certain restlessness sometimes belonging to hypochondriasis, and more rarely to hys- teria, allying them with delirium in this external manifestation. Groit IV., when applied as particular indications referring to disease in dis- tinct organs, would include the whole of the subjective phenomena of disease. Here we can only point out one or two which are remarkable for their indirect in- dications: — a. The contrast in genuine cholera between the corpse-like coldness of the body SPECIAL INDICATIONS. 47 and the sensation of heat with which the patient is oppressed ; in diarrhoea there is generally chilliness. (3. As a sensation of an opposite kind, may be mentioned the common complaint of chilliness in fever when the skin is burning hot. y. The sensations of the hypochondriac are opposed alike to the evidence of the senstB and the conclusions of reason. S. A patient's complaint of want of sleep is almost certain to be exaggerated : the report of the nurse or attendant can alone be relied on. t. The sympathetic pains form an important group. Thus pain of the right shoulder may proceed from disease in the liver; pain of the sacrum, from disease of the uterus; of the thigh and testicle, from nephritis or nephralgia; of the knee, from disease of the hip ; of the meatus, from stone in the blad- der, &c. £. Complaints of pain are often exaggerated in persons of nervous susceptibility. In this enumeration let it be remembered that the circumstances detailed only give us hints of what we may suspect, that they afford no certainty: and I think it will be found that the physician who is most familiar with such indications, and who sometimes astonishes by the rapidity with which he arrives at a correct conclusion by catching up some such clue to the disease, is often very grievously in error. 48 CHAPTER IV. • FEBRILE DISEASES. Div. I. — General Febrile State. — Fevers — § 1, Continued Fever — Epidemics — Cutaneous Spots — Subdivisions — Complications — § 2, Remittent Fever — § 3, Influenza — § 4, Epidemic Cholera — Its relation to Diarrhoea. Div. II. — Eruptive Fevers — Measles — Scarlatina — Varioloid — Erysipelas. Div. III. — Intermittent Fevers. The object -which we have in view is to direct the student how to proceed in the investigation of any case submitted to him, in such a manner as may naturally lead to his forming a correct judgment regarding its nature and causes. With this purpose we have di- rected attention in the preceding chapter to certain signs and symp- toms which have especial reference to the general condition of the patient, and have endeavoured to show what conclusions may be legitimately drawn from these taken in conjunction with the history of the case. We have also inquired what the patient has to com- plain of. The next step is to take a rapid survey of the various organs, and also to examine more closely any one in which evidence is given of an abnormal state by the sensations of the patient, or by facts elicited in inquiring into the history of the case. A reference to the table of diseases shows, however, that there is a large class in which local disorder, as manifested by symptoms belonging to particular organs, is only secondary and subsidiary to the general disease. With regard to such, the most important facts are those which have a relation to the general condition ; and while the examination of the various organs must be by no means omitted, the evidence which is obtained is chiefly negative. Occasionally more positive results are developed, and then the examination must be more minute. The plan which I would venture to recommend, is to bear in mind the order of arrangement in which the organs are placed in our table of diseases, and to ask such general ques- tions regarding each in succession as may lead to the conclusion that they are or are not in a normal state. We inquire whether there be headache, giddiness, or insomnia : whether there be pain in the chest, cough, shortness of breathing, or palpitation ; sickness, flatulence, &c. The care with which this is done must depend upon whether the whole history of the case and category of symptoms correspond to the special disease which we are inclined to assume as their cause, or whether there be anything unusual or unaccounted for in the notes of these which have been made. FEBRILE DISEASES. 49 The first point to be determined is the' presence or absence of a febrile state. The evidence of its existence is derived from a com- bination of general symptoms, pointed out in the early part of the preceding chapter, taken in conjunction with a history of a com- paratively recent origin. When symptoms of fever are present in a case of longer duration, its history must be more closely investi- gated; because, on the one hand, we may find that, with a certain amount of general or local ailment, the patient has been able to go about his usual avocations till within a very short period, when more severe illness has set in with rigors, alternate flushings, and chilliness, &c. ; or, on the other hand, we may find that the fever is only an aggravation of long-continued suffering, and caused by ex- haustion supervening. Rigor is an important, but not an essential, element of febrile disturbance; it attends on the most acute diseases, but occasionally it is not observed. When present, it often serves to mark the commencement of the illness, and is therefore of value in the his- tory of the case. Recurring frequently in the course of the attack, and described as "cold chills," it is especially characteristic of con- tinued fever. In inflammations it may frequently be observed in a severe form at the outset, and then is more commonly absent till suppuration commences, when the occurrence of rigor is very signi- ficant. Its periodical recurrence is the chief distinguishing feature of ague. The next point for consideration is, whether these general symp- toms make up the whole of the disease, or whether it accompanies inflammation of some particular organ; whether (to use the hard words of science) the pyrexia be idiopathic or symptomatic; and this can only be ascertained by the negative results obtained from a survey in detail of the leading phenomena connected with each of the various organs. A suspicion or guess may be formed from the circumstance already mentioned, that when the skin is hot and dry, and the pulse feeble and frequent, we are more likely to have fever to deal with; and that when the skin is moist, the pulse firm and less frequent, the chances are in favour of inflammation. If pain be complained of, this may lead at once to the seat of the disease when inflammation is present; but pain is often absent in the most severe inflammations. Fever is only accompanied by sensations of general pain and uneasiness, often spoken of a3 "pains in the bones." Pains in the limbs must be localized; those which are general, in the bones or in the muscles, a feeling of aching rather than pain, are the accompaniments of fever; those which especially affect the joints, and are more distinctly painful and tender, point rather to rheumatism. The essential element of fever is so entirely beyond the reach of our present means of investigation, that its diagnosis is partially imperfect. It must be made out to the satisfaction of the inquirer that no local disease exists of which febrile disturbance is a symp- 4 FEBRILE DISEASES. i mi, and that those local derangements which do exist, are the legi- te consequences or natural signs of the presence of fever poi- son in the blood. Hence, if any local disorder lie present, of which pyrexia is not a symptom, that must be for the present set aside as not belonging to an inquiry into the causes of fever; and if no local inflammation be discovered, the febrile state must be taken evidence of fever simply. Division I. — Fevers. Fevers arc divided in the table into three groups; two of which are characterized by well defined symptoms common to the whole of each group, viz., the occurrence of cutaneous eruptions, and of regular intermissions. The remaining group which we take first into con- sideration, has no such common symptom, and to these we have ap- plied the generic name of fevers. It comprises many diseases be- longing to tropical regions — plague, yellow fever, &c. We shall consider those only which are more or less common in this country. § 1. Continued Fever. — Accurate diagnostic signs, which in their totality give pretty sure evidence of other diseases, arc much wanting in this, and many cases fall under our observation of which this is especially true; a state of general discomfort, with very slight febrile disturbance, lasting only a few days, in which no dis- order of any particular organ can be made out, must necessarily be called fever, or febricula. At the same time it is quite certain that, from ignorance, or from imperfect examination, many cases are so classed which in reality belong to some other genus. The history of the case may occasionally show that the individual has been placed in circumstances likely to engender fever; the fact of a previous attack of the same sort neither increases nor dimi- nishes the probability of the present illness being fever. Its mode of commencement is very various; either there have been in the first instance some days of weakness and depression, and undefined feeling of illness, followed by rigor or cold chilis ; or there has been a pretty smart shivering to begin with, followed by considerable heat of skin. Loss of appetite is invariable, and observed early; thirst is later in its occurrence, headache is generally an early symptom, as well as a foul tongue and quick pulse. In reviewing the general symptoms in detail, we find that the temperature of the skin is generally elevated, except just at the moment of a rigor, when it is peculiarly harsh and dry (cutis anse- rina.) It has, in the majority of instances, a hot pungent feeling; but there are numerous exceptions, in which it is constantly or oc- casionally moist, nay, whole epidemics in which it is invariably so. The pulse is always frequent. This may amount only to very slight acceleration, or it may reach to more than double its ordinary rate ; it may be more or less large, but is always soft and weak, and some- times very feeble. The tongue is invariably furred in the com- FEVER, 51 mencement: subsequently, in some cases, it becomes peeled and chapped, having a tendency to be dry while fever lasts ; in other cases the fur thickens and adheres, especially to the centre, leaving the edges bright and red; in the severer forms of the disease this coating is often brown or even black, and sordes collect on the lips and teeth; thirst is complained of in these cases while conscious- ness remains, and thus its presence or absence may be of good or evil augury, as it indicates decrease of fever or diminution of sensi- tive perception. The complications of fever as manifested in symptoms derived from the different regions, and the presumption they afford of its existence, will be referred to presently; but among the more direct evidences of fever we must regard the very common occurrence of de- rangement of bowels, as manifested in the diarrhoea dependent on enlargement and subsequent ulceration of the follicular glands of the intestine. When this is the case, the appearance of the stools greatly aids the diagnosis. Either thin and ochrey; or darker, watery and mingled with curdy solids ; or even black and pitchy, from admixture with blood: they are always highly offensive. Along with this there is very generally some tenderness in the coecal region, and a gurgling sensation communicated to the han# on making pressure there. But the circumstance that the motions are nearly natural in appearance, and the existence of a certain amount of constipation, must not be taken as a proof that the dis- ease is not fever. The urine is generally scanty, the appetite always lost, and the desire for fluids increased. Such are the leading symptoms of fever ; their varying intensity may serve as a basis for classification, and they are all of much importance in treatment; but, while no one by itself is diagnostic, we observe that there is some derangement of each of those which are classed as general symptoms. Some are more important than others, but a perfectly normal state of any one must put us on our guard in pronouncing an opinion of the existence of fever. Corresponding to the variations in symptoms there are differences in the intensity of the affection, from its slight and transient form, febricula, to its worst and most deadly shape, malignant typhus. But, while no two conditions can be more widely separated, it is to be remembered that there are numerous intermediate links in. regard to severity and danger, which are so closely allied together, and pas^by such fine transitions into each other when a large number of cases is examined, that no absolute line of demarkation can be drawn between them. There are certain modes of division, which, so "far as they con- cern diagnosis, must here shortly be referred to. Thus there are epidemic, endemic, and ephemeral fevers. This classification can- not be regarded as of much practical value, as we know not that it corresponds to any real difference in the ultimate nature of the disease. We know not whether an endemic fever may ever become I 02 FEBRILE DISEASES. epidemic, nor by what circumstances such a change of character can be produced. The only importance of these distinctions is de- rived from the observation that each class presents for the time being certain peculiarities, and the general features of individual examples have a degree of resemblance to each other. It is indeed surprising hovr great a similarity all cases of fever have to each other for a given time and in a given place, and how much they differ from cases occurring at another time, or in another locality. 1. Epidemic fevers, spreading probaljly by means of some poison suspended in the atmosphere, are generally believed to possess the property of communicai by infection; with their specific characters the student should make himself ac- quainted by observation, as soon as possible, whensoever an epidemic begins to prevail. 2. Endemic, or endemial fevers, not so clearly infectious, but arising appa- rently from some local influence, are generally found also to present, in each lo- cality, distinctive characters, which must soon be familiar to a practitioner in any given place. 3. Ephemeral fevers, breaking out quite unexpectedly, in consequence most pr 'bably of a sudden atmospheric change, and disappearing with the same rapidity, differ from the other two chiefly in their being comparatively less severe, and com- monly marked by one prominent symptom. A very good example may be • in the outbreaks of influenza. To this fever we have assigned a separate place in r classification, solely because its symptoms are so peculiar, and its occurrence frequent. Another mode of division is that obtained from the presence and absence of cutaneous eruption, and its" special characters. If it be true that the same cause cannot engender a fever with, and one without spots, and if it be further true that the same cause cannot generate fevers with spots of dissimilar kinds, it is plain that the correct distinctions of fever spots would lead also to the true diag- nosis of species of fevers. But this is not yet proved. And, at all events, the absence of spots altogether neither warrants the con- clusion that the disease is not fever, nor that it belongs to a par- ticular class of which this circumstance may be considered charac- teristic. Further, if it be true that these different species of fevers are prone to affect special organs more than others, and each species a different organ, it would be a most valuable indication in treat- ment; but this is yet so far uncertain, that we must receive the probability with great caution, and so much the more closely in- vestigate the symptoms appertaining to each, forming our judgment of the character of the fever from their co-existence, rather than assuming their presence from the type of fever. # In a treatise on diagnosis it is obviously impossible to discuss disputed points in semeiology, and all that can be done in this place is to point out the different characters the spots are liable to present. In hospital practice the patient often exhibits, especially about the neck and upper part of the chest, a number of mi- nute puncta of a blood-stained appearance, perfectly unaffected by pressure with the finger, and having more or less of a triangular shape; when once observed they can be easily recognised and distinguished. They are merely flea-bites, but they have this value in diagnosis, which is often overlooked, that the accompany- ing ecchymosis indicates depressed vitality. The true fever spots present three varieties, each of which may be miugled with petechiae. FEVER. 53 1. A very copious, dusky, purplish-coloured rash, which often accompanies epi- demic typhus. A patient "is found with rather a dusky colour of face, depressed countenance, listless, or even partially unconscious expression, eyes suffused, tongue dry and brown, with a thick crust on the centre, lips and teeth covered with sQrdes, skin dry and hot, but not pungent (the vitality being so much de- pressed;) his pulse is quick and weak, and his movements are few and tremulous, or accompanied by subsultus. In such a case, if the skin of the abdomen and thorax be inspected, it will very often be found covered with a mottled^measly- shaped rash of a purplish or mulberry colour, with no perceptible elevation, and of more or less persistence under pressure with the finger, becoming fainter, but not disappearing altogether; and, in the worst cases, passing into or mingled with ecchymosed spots, which are wholly unaffected by pressure, in the latter case the colouring matter has actually become extravasated as in purpura, and to this the name of petechia? is applied ; in the former there is merely a retardation or stoppage of dark-coloured blood in the cutaneous capillaries. 2. Perhaps in an earlier stage of the same case, or in a similar case, when the fever is not epidemic, this general rash is not seen; but there are numerous dis- tinct, rounded, scarcely elevated spots, not so dark, of a crimson colour, with a similar character of persistence, not wholly disappearing under the finger. Oc- casionally one or two of these may put on a blacker colour, and become altogether persistent by ecchymosis. These two classes mingle with each other. 3. A third sort of fever spots occurs in cases more commonly of an endemic kind, in which there is much less general depression, rarely suffusion of eyes or congestion of face; subsultus is less frequently seen, the movements may be tre- mulous, but there is much less apathy and listlessness. The skin is hot and pe- culiarly pungent; the pulse, more, or less quick, is not so feeble; tke_tongue,_pre- senting at first very red edges, soon becomes peeled in the centre, is sometimes chapped, raw, and glossy, or, occasionally, with a dry^thin crust over the abraded mucous membrane — perhaps it is evenly and thinly coated, or has a patchy ap- pearance, according to the condition of the intestinal tract; diarrhoea is frequently present, and in such cases, when spots are found, they are few in number, three or four over the abdomen, rounded, slightly elevated, of a pink or rose colour, and disappearing entirely under the finger^but returning rapidly as soon as the pres- sure is removed. These are generally of small size, but may sometimes be considerably larger than those already described as dusky spots ; occasionally, too, they are much more numerous, and the colour becomes deeper; they then assume some degree of persistence, but are very rarely, if ever, associated with, or transformed into, ecchymosis. By some mistake of nomenclature, these spots, and the fever they accompany, have been called typhoid (resembling typhus,) because the symptoms of typhus are in great measure wanting. The term typhoid ought to be restricted to symptoms resembling typhus, in diseases of heterogeneous type, not to homo- geneous diseases with distinctive characters. 4. Petechial spots may occur towards the close, with no previous rash. 5. In addition to these spots, we observe that some epidemics are accompanied by miliary eruption, when there is copious diaphoresis; just as so often hap in rheumatic fever. They have this general relation to the others, that perspira- tion is necessary to their development, and appears to be opposed to the existence of true fever spots. Of this classification it is most important to note that there is no character of disease with spots of any one of the forms noticed, that may not have its exact counterpart in a case where there are no spots at all. But the student must work out for himself the question whether there he any specific virus that produces one ap- pearance or the other, as, in fact, their cause is yet quite undeter- mined. The coincidence, when they are present, is of great value in diagnosis ; for it does not as yet appear that they are ever seen 54 FEBRILE DISEASES. in any other condition except that which we express by the term fever. Whatever light may be thrown by future investigation upon ir relation to internal organs, whether the hypothesis of two dis- tinct fevers be confirmed or rejected, it is quite certain, from long- continued observation, that ulceration of the bowels seldom goes along with copious cutaneous eruption. Another classification is derived from the prominent symptoms in the majority of the cases which occur simultaneously, and fever is spoken of as fever with head symptoms, fever with chest symp- toms, and fever with abdominal symptoms. The name in most common use, both in this country and abroad, in connexion with division, is gastric fever, or abdominal typhus. This brings us to the complications, symptomatic or simply con- comitant of fever. The prominent feature of the disease must never be lost sight of — that it is not inflammatory. The blood is in a state of depressed, not exalted vitality. This is exhibited by lassitude and weakness, great in proportion to heat and dryness of skin, and by feebleness of pulse, increasing in the ratio of its fre- quency ; it is a condition of asthenic pyrexia, in opposition to in- flammatory fever, or sthenic pyrexia. Local congestions occur in its course ; and in consequence of the irritation thus caused, a sort of inflammatory action may be pro- duced. In the peritoneum there may be actual inflammation in consequence of ulceration or perforation of the bowel; but these secondary actions are not of the elements of fever. a. In the head we have delirium, insomnia, unconsciousness, coma. That these are not due to inflammation is proved by the history of the case. They have been gradually developed, beginning with restlessness at night, occasional muttering at that time, with perfect consciousness by day; there has been no intolerance of light; the headache is diffused and general; the pupils have not been early contracted ; the symptoms have only attained in the later stages to their maximum, and even then they still continue to be much more marked at night; they are accompanied by listlessness and depres- sion, as opposed to excitement. Deafness is a very common condi- tion in severe cases of fever, sometimes persisting, more or less, during the whole period of recovery. It would seem to be only one expression of the general obtuseness of all the senses, which is often so remarkable. b. In the lungs congestion almost always comes on more or less from position, and especially in those cases where the blood is most altered in character. This is not true pneumonia; it only degene- rates into low inflammation in consenuence of the stagnation of t!ie blood in the pulmonary capillaries. Here, too, the history points out that cough and rusty sputa have not been the early indications of the attack, but have supervened during its continuance. A condition of the mucous membrane allied to that of the skin in fever may produce a certain amount of bronchitis. This sometimes FEVER. 00 occurs early; but it will be remarked that the febrile state is far greater than any that experience teaches us can be caused by bronchitis, however acute; in addition to which, the febrile state accompanying acute bronchitis, when it depends on an inflammatory condition of the membrane, is sthenic; that of fever itself is essen- tially asthenic. The combination of fever and bronchitis, bearing the name of influenza, will be noticed afterwards. c. There may be tension and tenderness of the abdomen. Here we have quite a different class of phenomena; for ulceration of the intestines is peculiarly a concomitant of fever — not in every case, but in so large a number of instances as to show that the affection of the mucous glands of the bowel — which, if unchecked, pas into ulceration — is a primary morbid state in certain forms of this disease. In some instances it would appear that, when other vital organs are more severely implicated, the poison remains in a qui- escent state; and after death merely elevated prominent patches of glands are found, while in other instances they rapidly run into a state of ulceration. Of this phenomenon it is still more true than of the passive congestions already noticed, that subsequently, a condition of real inflammation of a low type occurs; in fact, ul- ceration is itself an action of this kind; and as it extends to th< other coats of the bowel, and especially the peritoneal covering, the symptoms become more and more closely allied to abdominal inflam- mation. In its earlier stage the state of the stools shows the tendency to ulceration; and after a very short time slight tenderness comes on. which may be soonest detected in the right iliac fossa — often not noticed by the patient, not complained of, and not produced by slight handling, but shown to exist, when gentle, firm, deep pressure is made, by its causing a pinching of the features, and transient expression of anxiety, accompanied by a gurgling sensation. Sub- sequently great tympanitic distention occurs from loss of muscular contractility, which is an evidence of more decided inflammatory action; and this may pass, by almost unnoticed gradation, into peritonitis, or may end in sudden rupture and extravasation of the bowel contents. The tongue, as already noticed, shows in such circumstances a tendency to peel, especially along the centre ; it becomes red and shining, often dry at the same time, and subse- quently, chapped, aphthous, ulcerated. It would appear that this state of tongue is sometimes unaccompanied by other general symptoms of ulceration of the bowels, and is not always present when we believe ulceration to be going on. It seems to depend on a general cause, affect- ing most commonly the whole mucous tract, at least as far as the ilio-ccecal valve. but sometimes more limited and local. The one coudition is not to be presumed to be derived from the other. The fieces in this condition are thin, watery, curdy ; sometimes of an ochrey colour, often very dark, and occasionally pitchy, from the presence of blood derived from an ulcerated surface; always 5G FEBRILE DISEASES. fetid and offensive. When consistent or natural in appearance, we - be sure that ulceration is not going on. . In addition to the severe kinds of bowel ailment accompanying one of the more intense and well-marked forms of fever, an allied lit ion is found in milder cases, or what may be termed febricula, ing of irritation of the mucous membrane, which may show If in sore throat, or in gastric pain and tenderness, or in diar- rhoea. In all these conditions the distinction to be drawn between ;1 disorder per se, and such disorder arising out of, and accom- panying a general state, must be arrived at simply on the principles already pointed out — first, febrile disturbance, out of all proportion to the "local disorder; second, its character being asthenic, as op- posed to inflammatory fever. . The character of the fevers of the present day most unquestion- ably tends towards debility; and we rarely find a pulse that has even any degree of hardness, never one that suggests the propriety of bleeding; the powers of life are wholly prostrated, the nervous centres are partially insensible to impressions from without, are unable to exert steady muscular movement by energetic^ stimulus tn within. But, if we trust the observation of men of judgment and experience who have preceded us, it was not always so ; and at some future period the disease may again put on a more inflamma- tory character. The bowel complication so often seen has been a subject of considerable con- troversy of late years, with reference to the question of what circumstances deter- mine its presence or absence. By the Vienna school it is asserted, that a typl lent exists which finds its outlet either by this or by other channels: and, it is I that, when typhous pneumonia or bronchitis exists, typhous exudation in itinal glands is more commonly absent. The French school, to whom we owe the name of typhoid, assumes the existence of two distinct diseases, as repre- 7 typhus, and typhoid fevers. To this has been added the distinction of 'ready alluded to, which are supposed to be diagnostic of each. These subjects afford scope for the observation of the student, and, ere long, bably be definitively settled. For the present, I would warn unjustifiable confidence in any theory, and rcmhid him that the i of importance in regard to the immediate treatment of any case is not which I .rv he shall adopt, but what phenomena are actually present, and may best m ■ t them by suitable treatment; whether there be congestion of the h or ulceration of the bowels, not whether he has got typhus or typhoid fever to deal with. All the complications alluded to are apt to be overlooked or forgotten in the consideration of the existence of fever, and yet they are each of greater or less im- portance in treatment. And again, while exact knowledge of their true character i sntial in arriving at the very important negative conclusion, that inflamma- tion of some particular organ does not exist, their very presence becoi addi- 1 corroboration of the belief, that wc have to do with a case of continued fever. Under the general head of fever there are also classed, in the table of diseases, remittents, influenza, and epidemic cholera. § 2. The name of remittent fever is applied to a disease peculiar to warm climates. It is now very generally believed to be only typhus as modified by atmospheric influences and the condition of INFLUENZA. 57 the nervous and sanguiferous systems of Europeans residing in tropical latitudes. The same analogy holds with reference to the only fever of this type ever seen among ourselves — infantile remit- tent. The excitable frame of childhood portrays more vividly the ex- acerbations and remissions which, even in adult age, are in greater or less degree observable in a case of continued fever ; and in them the remission becomes so marked, that for a time the disease seems almost to be gone. In truth, the prominence of this one symptom is no sufficient reason for separating this disease from the endemic fever of adults ; and there is nothing to show that infantile remit- tent may not arise even from the infection of typhus. The great question in diagnosis is, how to distinguish this, generally one of the more unimportant diseases of infancy, from the much more dangerous malady known as acute hydrocephalus. The same rule must be followed as in the study of continued fever in adults ; our conclusion must rest more on negative than on positive evidence. We have positive evidence of an acute febrile disease ; we seek for negative evidence that there is not inflammation of the head, the chest, or the abdomen. The investigation of these points will occupy our attention at a future period; and in the consideration of acute hydrocephalus reference will be made to the points of resemblance and difference, in so far as they can throw light upon the discrimination of these two diseases, which are unfortunately often mistaken for each other. § 3. Influenza. — This disorder is characterized by an irritation or inflammatory condition of the mucous membrane of the lungs, implicating also that of the nares and the conjunctiva ; but, super- added to this, and constituting its essential feature, is the lassitude and exhaustion of fever. A common catarrh, or an attack ^ of bronchitis, it is now the fashion to call influenza. In scientific diagnosis they ought to be distinguished ; still, cases must occur in which these different diseases so merge into each other, as to render it difficult, *or even impossible. Thus, in an enfeebled constitution the least disturbance may provoke symptoms of general derange- ment, with fever of an asthenic type, closely allied to influenza; exactly as more severe disease may in the same constitutions cause typhoid symptoms, or symptoms resembling typhus. The determi- nation will be much aided by observing whether the attack occur as a solitary instance, or whether similar case3 are numerous at the same time. It is unnecessary to enter much into detail, with regard to the history and the ptoms. Whatever is true of common continued fever in its milder form, is likely to be true of this disorder, bearing in mind the great distinction, that in the one the mucous membrane of the bowels is the subject of a peculiar affection, and in the other the mucous membrane of the lungs is the principal seat of morbid action. The history points out its recent commencement, even when supervening up n previous ailment. The general symptoms indicate a febrile state; the aspect 58 FEB KILE DISEASES. of llio patient is more or less depn ied; hia sensations lead him to complain of a sense of lassitude and general discomfort, and of cough, tightness of chest, &c., siM.li as are usually present in catarrhal affection. The chest symptoms are those of acute bronchitis. Influenza differs from continued fever with superadded bronchitis, chiefly in the greater prominence of the symptoms of irritation of the mucous membrane of lungs, and the affection of the nose and eyes, as well as in the comparatively milder character of the fever; but this is often only a question of degree. § 4. Epidemic Cholera. — This frightful disorder, which has come to us from the tropics, and has visited us so frequently of late years, is classed among the fevers, chiefly on account of the increasing conviction that it is one of the acute blood diseases, and the evident febrile reaction after recovery from the stage of col- lapse. It must be admitted, however, that in very many instances the fever, as such, is very slight in intensity, as compared with the previous depression; in others it is a formidable event, and not un- lVcMjuently the cause of the fatal termination. One characteristic, which must not be lost sight of, is its epidemic influence; though we cannot exactly trace the manner of its propagation, it clearly follows the general laws of all epidemics — such, for example, as ty- phus, the commonest and best known of those of this country. The history of the case may ultimately be the means of our learning its mode of propagation, as it has already served to de- termine that its cause is not simply an atmospheric influence float- ing about over our heads. In diagnosis it is of little service, except so far as it may preserve us from paying too much regard to the presence of collapse, as indicating cholera, when there is any other antecedent cause of exhaustion. Collapse is, in reality, only an accident, which may co-exist with any condition of extreme de- pression — e. g., the colliquative diarrhoea of phthisis. The general symptoms in the commencement of cholera are very different from those commonly seen in fever. The skin is cold and clammy; the pulse feeble and not frequent; the tongue cold, moist, and not much coated; the stools remarkably copious, pale, and free from odour; the urine suppressed; there is almost always severe vomiting; and the want of appetite and thirst are such *s naturally result from the excessive discharges from the whole course of the alimentary canal. As the disease proceeds to collapse, these symp- toms increase in intensity, the coldness of the skin and its blue- ness or lividity become most striking; the pulse probably imper- ceptible; and the stools and vomit assume the characters of a thin, colourless fluid, resembling rice water. In reaction the skin is often very long in regaining its temperature, and is, perhaps, never hot and dry, as in ordinary fever; the tongue becomes dry and more coated; the pulse returns, and is frequent and feeble; the diarrhoea ceases; thirst abates; and in favourable cases the urine, at first scanty and albuminous, is gradually restored to its normal condition. If this event do not occur soon after reaction is esta- blished, the issue will probably be unfavourable. EPIDEMIC CHOLERA. 59 The aspect of the patient is depressed, and the expression listless, and there is a remarkable appearance about the eyes, which, during the existence of epidemic cholera, has often served to warn myself and others that an attack of diarrhoea would proceed to the more fully developed disease. It is hard to describe in words; but con- sists of hollowness of the orbits and sinking of the eye, with a leaden colour around, and a listlessness of expression. The colour of the skin first assumes an earthy hue, subsequently passing into complete lividity, which lasts, especially on the hands, during the greater part of the stage of the reaction. The patient makes little complaint of pain, except that de- pendent on cramps. By some the occurrence of cramp is regarded as the symptom which distinguishes cholera from simple vomiting and purging: it is simply an accident; a very common one truly, but one which may not occur in real cholera, and may be present when the case is Unequivocally not cholera. There is no complaint of nausea, though the constant and urgent vomiting can scarcely be supposed to exist without it ; there is also no complaint of pain with the purging: th» sensations no doubt are blunted; but this painlessness is an important feature in the case, and it may even excite surprise on the part of the patient himself, that such enor- mous discharges take place from the stomach and bowels, when he has so little feeling of internal derangement. In the beginning of an attack, the existence of diarrhoea without pain or griping, will cause the medical attendant to be on the alert; but, unfortunately, it has just the opposite effect with the patient, who cannot fancy that anything is seriously wrong when he has so little feeling of dis- comfort. Another remarkable feature is the sensation of burning heat and oppression so often complained of, while the skin is cold and corpse-like; the patient obstinately resists every attempt to raise the temperature by artificial means, and, in the restlessness of the disease, throws off the warm blankets in which he is wrapped. Among particular symptoms are ranked the change of the natu- ral sound of the voice into a hoarse whisper, the vox choleraica ; and the circumstance of the tongue and the breath being sensibly cold to the hand of the observer. These facts may be interesting in any particular case, but, as they belong to the accidents of the disease, they must not be elevated into diagnostic symptoms. The mental faculties are not obscured till an advanced period, when the pupils become contracted, the brain oppressed, and the patient comatose. Prior to this, there is only a condition of rest- lessness of body and inactivity of mind. Dunne the existence of an epidemic cholera there can be no difficulty in classi- fying the°cases which present well-developed features of the disease ; but its march is attended by coincident diarrhoea, and there is in reality no definite boundary between the one and the other. Every link is filled up by cases of varying in- tensity, from the very worst of cholera to the mildest of diarrhoea. The indications by which we are guided, the characters of the evacuations, the existence of cob -e, and the suppression of urine, are not directly connected with the essence of CO FEBRILE DISEASES. and rs. This affection, commonly known as "drop-wrist," may met with occasionally without the prior appearance of colic ; this . however, and is chiefly seen in cases in which the lead has n introduced exceedingly slowly. In its last stages, the general health also suffers, and there is sometimes considerable emaciation; the poison tells upon the brain, producing epileptic seizures. &e., and a well marked condition of general cachexia is established. Division II. — Extozoa. A class of disorders is next to be noticed, which, like the pre- ceding, owe their existence to the presence of a cause which is wholly adventitious, and is cognizable to the senses, but differs from them in this respect — that, in place of depending on the pre- sence of foreign animal or vegetable matter, or of some mineral poison, their symptoms arc due to the presence of a parasitic ani- mal, living not upon the surface of, but within the human body, having a distinct and separate existence, and endowed with certain powers of reproduction. The chief point to be noticed in regard to diagnosis is that the symptoms alone cannot be taken as conclusive evidence of their pre- sence ; and, however distinct the indications may appear, we are not justified in asserting that they have this cause until specimens of the parasite have been seen. Two divisions only of this class are included in the table of dis- eases, because the others are comparatively rare and unimportant ; and, it may be remarked, that these present special sources of in- terest, with reference to diagnosis ; because of their relations to other forms of disease: they are the intestinal entozoa and the echino-coccus hominis ; the latter closely connected with the occur- rence of hydatids, the former a^ociated with disorders of the di- gestive organs, § 1. JEcldno-coccus — Within a very recent period, careful obser- vation has proved that this creature is only a transformation or stage of development of the taenia, and this in some measure ac- counts for its comparative frequency. The discovery is pregnant with interest to us as physiologists; but, as physicians, we are more concerned with the very different habitat of the animal in its two extremely dissimilar conditions of existence. In the form we are now considering it is found in hydatid cysts, and would seem to be in some way concerned in their production. We have not yet learned to recognise the distinction between the acephalo-cyst, in which this parasite is present, and those in which it has not been found after death ; and, therefore, the question of diagnosis is limited to the recognition of the existence of the cyst, except in rare cases, in which its contents are evacuated and the echino- coccus seen during life. Any points of interest will, therefore, be ENTOZOA. 83 recorded when we come to the consideration of cysts as one of the forms of morbid growth. § 2. Intestinal Worms present themselves in three principal forms, as broad or tape-worms, round worms, and thread-worms. a. Tape-worms, so named from their appearance, are discharged as a number of flat fragments of various lengths, crossed by trans- verse joints, where separation is liable to take place, and each por- tion of the animal which is discharged has, consequently, a square termination. They are of two species: — 1. Taenia solium, marked by notches on either side, irregularly alternating along the edges of the flat body, one of which occurs between every two joints, and is situated rather nearer to the lower than to the upper one. 2. Tsenia lata, or Bothrio-cephalus lotus, marked by a line of depres- sions, one for each segment, running down the centre of one of the flat sides of the parasite. Their presence is apt to be overlooked because they give rise only to such symptoms as may readily be regarded as those of dyspepsia; — pain of a gnawing character at the epigastrium, unea- siness after food, cough and headache, usually accompanied by a craving appetite; the patient is out of health, and generally some- what emaciated. This craving is to be distinguished from the large consumption of food which sometimes accompanies emaciation in the course of a wasting disease, when the digestive apparatus has not been deranged; and also from the ravenous appetite of diabetes. In the former there is no disorder of the intestinal canal, in the latter there is thirst as well as hunger: when the symptom depends on the presence of tape-worm, there is always derangement of the digestive organs, and the sensation is one of craving rather than of hunger. The diagnosis is only complete when portions of the worm come away with the feces. Their shape, as each small segment is more or less elongated in proportion to its breadth, enables us to form an idea of the length of the entire worm: when they are lono- and broad, we may conclude that it is of considerable length ; when short and broad, the remaining portion is probably not great; when narrow as well as short, the fragments come away from near its head or fixed extremity. It is a curious circumstance, in regard to the two species of fenia, that they relatively abound more in cer- tain localities; the bothrio-cephalus is usually imported into this country, and is soon expelled from the body, while the solium among us lives and thrives. b. Round worms {lumbrici,) seldom solitary, are chiefly lodged in the small intestines, where their presence does not seem to give rise to any very marked symptoms ; occasionally, however, they are productive DISEASES OF VARIABLE SEAT. the distribution of its blood-vessels, will greatly aid in determining in what portion of its current the blood is obstructed. Acute phlebitis is almost always associated with oedema, but the occlusion may also be one of long standing. "When obstruction is produced by pressure, and its cause is situated externally to the great cavities of the chest and abdomen, the diagnosis must be extremely simple; but when the pressure is occasioned by some tumour lying within, it is oftentimes made out only with extreme difficulty, and by very careful examination. Local oedema also accompanies inflammations of limited extent, whether in the skin, such as erythema and erysipelas, or the diffuse inflammation of the cellular tissue, or even suppurations of the bones, joints, and ligaments; and cases will occur in which it is difficult to determine whether the inflammation of the skin and cellular tissue have been caused by some irritation of a limb already tense from oedema, or the effusion of serum have been the conse- quence of the local inflammation. § 2. Ascites. — Depending, as has been stated, upon more than one cause as its source, and demanding treatment often distinct from that of the disease from which it springs, ascites claims our notice when it is either unassociated with anasarca, or itself forms much the most prominent feature of a case in which there is more or less general dropsy. In rare instances, too, it appears to have sprung from some transient morbid state, and to persist merely because the accumulation of fluid, by its pressure, prevents the due action of the absorbent and eliminating process by which it might be removed. "When associated with anasarca, it is very important to determine whether it is to be classed as one of the many local effusions which acknowledge the same general causes; or as having an independent origin and cause, which simply co-exists with the others; or, lastly, ■whether the anasarca may not itself be only the consequence of the ascites. The history, if absolutely correct, would always decide the first and last of these questions, especially if taken in connexion with the inquiry, which ought never to be omitted, into the several conditions of system usually associated with general dropsy. "When these have been for some time in operation, and oedema has been observed distinctly prior to effusion into the abdominal cavity, the presumption is strong that ascites is merely casual and coincident, an evidence of a general tendency. When, on the other hand, fluid has been first detected in the peritoneum, and the more commonly, acknowledged causes of anasarca are absent, it is highly probable that an oedematous state of the lower limbs is caused only by obstruction to the returning column of blood through the distended cavity, in an impoverished state of system. Unfortunately it very often happens that accumulations either of flatus or of feces are mistaken for dropsical swelling, or that the enlargement of the abdomen is not taken notice of until after anasarca has supervened: DROPSIES. 89 it is, therefore, very generally necessary to inquire into the causes of each condition separately, and not to rest satisfied -with the hypothesis that they are both part of the same disease. To a certain extent, information may be acquired from the history of the case, regarding the causes and progress of ascites ; because we either learn that it has been preceded by pain in some part of the abdomen, or that, to the patient's own consciousness, there has been nothing, but a gradually increasing fulness and tension. The history also enables us to exclude local enlargements which have been first observed in some particular region of the abdomen; and affords prima facie evidence of the case being one of ascites depending on disease of the liver, when the patient has been a person of intemperate habits, or has had an attack of jaun- dice. The presence of fluid is learned from the existence of fluctuation ; by which is meant the sensation conveyed to the hand, across the abdomen, by a wave-like movement through the fluid, of a blow struck at a distant point. The accurate determination of this fluid- motion requires much care and frequent practice: the extreme mobility of the contents of the abdomen, or an accumulation of fat which, at the temperature of the body, is in a semi-fluid state, are each liable, in certain circumstances, to give rise to a sense of resi- lience, extremely like the feeling of fluctuation. On the other hand, the intervention of a portion of bowel distended' with gas may annul the wave of fluctuation when fluid is really present. The first step in the examination of a distended abdomen ought to be to place the patient flat on the back, and observe the general contour of the abdomen, and then to proceed to determine by per- cussion the position of bowel resonance; next, to seek for evidence of fluid where that resonance ceases or is greatly diminished, observing how far the fluctuation extends in various directions from the part struck; and, lastly, by change of posture to satisfy our- selves as to the relations of the fluid to the other abdominal con- tents, whether it be freely moveable or comparatively fixed in one locality. And, having made out to our own satisfaction that fluid is present within the cavity of the peritoneum, we may then, from a consideration of the whole history of the case, the various symp- toms which have attended the origin and progress of the disease, and the present condition of the patient, form some idea of its cause. And, if we would avoid false deductions and injudicious treatment, the actual state of all the organs of the abdomen must b» analyzed with great care. The history of the case affords more assistance in determining the particular cause of the effusion than in assuring us of its locality, except when it speaks positively of local enlargement. And here a caution may be offered to students that they guard against either confounding for themselves, or leading the patient to confound, pain for enlargement; a mistake which, in my own experience, has led careless observers astray. Patients are very generally first conscious of ab- 00 DISEASES OF VARIABLE SEAT. (luminal tension by a feeling of fulness at the 'waist; and Loth sexes will alike as- Berl that their increase of size l>e:- ;il > there, when we are* perfectly certain that the fluid was at the time collecting in the lower part of the abdomen. The patient's .statement of local enlargement may he often verified by the liar shape which the abdomen presents in the horizontal posture: in ascites it ually uniform. Percussion resonance determines the relative position of the tine, iu which gas is almost always present, and the foreign substance, what- ever it may be. It may indicate a distinct level line all round to which fluid rises, or it may Bhow that one coil of intestine dips down below it, or that a very large portion of intestine on one side is altogether below the level of the dull part on the other; on the other hand, it may prove that the whole surface is resonant, or thai dulness is very limited and local. The e\iilence*of fluctuation is much more liable to be indistinct when the fluid is contained within some cyst, than when it is free in the peritoneum. Fallacy is best avoided by producing the effect in various ways; tapping gently, giving a short sharp stroke, or rubbing the finger rapidly along; fluctuation will result in each case if. fluid be present. In addition to the evidence it gives of the actual presence of fluid, we learn from fluctuation its amount and distribution, by com- paring the effect at different distances, and observing their relation to what we have' already ascertained of the position of the bowel by percussion. In very many instances, the remarkable distinctness of fluctuation when the hands of the ob- server are placed near to each other, and its entire absence at a greater distance, afford conclusive evidence of the limitation of the space in which it is contained; or, on the other hand, its indistinctness when the hand is placed over the surface of tympanitic bowels, and its precision when the hand is passed beyond them to the' lumbar region, prove with equal clearness that it is free in the abdomen. But the examination is not complete till we have observed the effect of change of posture. Immediately on any change, fluid which is unlimited by membrane gra- vitates to that which is now the lower part of the cavity, and all the relations of percussion' and fluctuation are more or less altered. This cannot occur to the same extent when the fluid is encysted; but it is to be remembered that it is spe- cifically heavier than intestine, and, though more slowly, it will still obey the laws of gravitation, as far as its mobility will permit. The cases in which diagnosis is most difficult are, (") when a unilocular cyst in a female has come to occupy the whole of the abdomen, (6) when fluid contained in the peritoneum is limited by adhesions. a. The history shows, perhaps, that the disease began on one side, and the pa- tient's health is not seriously affected, except so far as inconvenience and derange- ment are caused by pressure. For further particulars on this subject the reader is referred to the chapter on diseases of the ovaries. The physical examination has reference to two great considerations; first, that, in the necessary displacement of the viscera, they are pushed to one side by a cyst which has grown up among them, either in the iliac region or in the hypogastrium, while they are forced directly upwards by fluid, which has been always free, and has, therefore, neces- sarily accumulated in the most depending part of the peritoneum. The second consideration is, that fluid, having always this tendency to gravitate among the intestines, will naturally, in change of posture, flow to that part of the cavity which is made to assume the lowest level, except it be restrained by the cyst membrane which surrounds it; and, connected with this, that the intestines, being fastened to the body by long loose folds of peritoneum, float at the surface of a fluid wdiich immediately surrounds them, but cannot so float if the fluid be separated from them by being contained in a distinct bag; although it be true that the fluid^is heavier than they, and, if the cyst have room to change its place, it will tend to occupy the lowest position. If these principles are steadily kept in view, the details of their application will readily occur to the mind. Thus we map out by percussion the relative positions of the fluid and the more resonant contents, and observe whether the line of dul- ness passes horizontally or in a curve, when the patient is in an erect or semi-erect position. We make her change her posture and again observe the course of the resonance, whether it dips down below the fluid at any part. We place her hori- DROPSIES. 91 zontally on her back, and mark whether resonance about the umbilicus appears, and move her from side to side, in order to observe whether there be any indica- tion of the intestine floating in the fluid. Such experiments, conducted with a right understanding of what we want to prove, will generally leave no doubt as to the nature of the case. b. It now and then happens that, when ascites exist, old adhesions of the intes- tines are found binding them down in certain positions ; nay, more, almost the whole of the bowels may be fixed in their places, and the fluid poured out into one portion only of the cavity, where it is retained even more firmly than when con- tained in a cyst. In considering such cases, information sufficient to put us on our guard against mistake may be derived from the early history of the case and the condition of the patient, with reference to the date of formation and the actual size of the supposed cyst. The pain of peritonitis, such as must have existed to cause the adhesions, and the whole character of the seizure can never be simu- lated by the pain occasionally attending the first appearance of ovarian dropsy. Neither does the same disturbance of the general health manifest itself when an ovarian cyst has become filled to the same extent for the firsttime, as must of necessity accompany ascites with adhesions so extensive. A mistake is most lia- ble to be made when the patient asserts that swelling existed before the occurrence of pain, and other causes have led to derangement of health. Hydatid cysts are much less liable to be mistaken for ascites. They are discri- minated by the history and mode of growth, their firm feeling and less distinct fluctuation, and often by their irregularity of outline ; but, more than this, are they distinguished by the position of the fluid with reference to the intestine, as ascer- tained by percussion, not obeying the laws of gravitation. Hydro-metra is only liable to be confounded with the earlier stages of ovarian dropsy. A distended bladder cannot lead to any mistake, except by neglect of one of the essential inquiries — the condition of the urine, and extreme careless- ness in investigating the case. Diagnosis is necessarily incomplete, except we can ascertain •with more or less confidence the cause upon which ascites depends. This is most apt to be overlooked when anasarca exists to such an extent, and its causes appear to be so definite, that the ascites is considered as only one manifestation of general dropsy. Unques- tionably its most common cause is obstruction of the portal circula- tion in disease of the liver, causing effusion of serum from the capillaries of the various venous branches which unite to form the vena portre. When this is produced by chronic inflammation and shrinking of the liver, inflammatory thickening of the peritoneum often goes along with.it, and probably aids the effect by interfering with absorption. It is also believed that chronic peritonitis may thus, without influencing the portal circulation, lead to accumulation of fluid, but acute peritonitis is never in the first instance associated with effusion. In the recognition of these two causes we are greatly aided by the history of the case ; the symptoms which may more or less directly point to either will be reviewed in discussing the dis- eases of the liver and peritoneum. Occasionally no distinct indi- cation is afforded, but the kidneys refuse to act, and the intestinal secretions, though goaded on by drastic purgatives, are insufficient to pump off the accumulated fluid, until the abdomen is tapped, and then there is no further difficulty in keeping the accumulation under control. In the diagnosis of such cases we must not pretend to refine too much. 92 DISEASES OF UNCERTAIN SEAT. In a small number of cases occlusion of a vein produces ascites, just as it produces local oedema. "Where the obstruction occurs be- fore the intestinal veins reach the liver, the fluid will be limited to the peritoneum ; when it affects the inferior cava, anasarca of the lower limbs is also present. All of these are exceptional ; but when the cava is obstructed, evidence of an attempt at collateral circu- lation over the surface of the abdomen will give a clue to the true explanation. A genuine case of tympanites, when from distention with gas, the abdomen is everywhere excessively resonant, cannot be mistaken for one of ascites; but let us avoid the opposite error of overlook- ing the presence of fluid when much tympanitic distention exists. A very small amount of fluid, sinking low in the cavity of the ab- domen, may readily escape observation, and yet it may be of much importance, as leading us to seek out the concurrent disease in the liver or peritoneum. Division II. — Hemorrhages. The diseases included in this division are in great measure inde- pendent of the lesion in virtue of which the blood is poured out. They are only met with casually during its existence; each of them is found in association with a considerable variety of causes ; and they form well-marked subdivisions, according to the organs from which the hemorrhage occurs. The distinctive character by which they are recognised is essen- tially an objective phenomenon ; — blood is poured out, and is to be known by its sensible qualities. Those forms of disease are no less genuine hemorrhages in which blood is poured into an internal cavity; but, fortunately, they are not of common occurrence, and must be regarded merely as the effect of internal injury, just as the bleeding of a wound is the effect of laceration. The cases which we have to consider as belonging to the class of hemorrhages occur cither as the result of a general condition of system, or as the effect of local disease ; this distinction is more evident in some members of the class than in others. § 1. Epistaxis. — In young persons, bleeding from the nose is no necessary indication of disease: slight exertion, wringing of the nose, or a blow in the face readily excites it in those predisposed to its occurrence: it seems, indeed, to act as a sort of outlet by which injury to the brain from an excessive supply of blood — "plethora," is obviated. It may become a habit, and under such circumstances be excessive, or more than the necessities of the system require. In adults, a general condition of plethora demands more attention ; when it is merely local, and cephalic congestion is associated with epistaxis, it is frequently dependent on disease of the heart. Epistaxis is sometimes the form of bleeding which indicates the existence of the hemorrhagic diathesis. In this condition, the HEMORRHAGES. 93 bleeding from a slight wound is stopped with difficulty, and hemor- rhages from various organs are met with when there is no other evi- dence of disease. It also accompanies poverty of blood, with wasting of the albuminous principle and coloured corpuscles, in antenna, and especially in albuminuria. In such cases, a condition of simple hypertrophy of the heart, so often associated with disease of the kidney, may possibly have something to do with its occur- rence ; but this is certainly not its constant cause. As a conse- quence of local disease, it most commonly arises from polypoid or fungoid growths in the nose. § 2. Haemoptysis. — Literally, spitting of blood; the term is now restricted to hemorrhage from the lungs. The appearance of blood in the sputa from any other source may be called spurious, that from the lungs genuine haemoptysis. a* Spurious : a very frequent occurrence in hysterical females ; or a consequence of a relaxed or aphthous state of the tonsils, or sponginess of the gums : it is derived in both cases from the mouth or fauces. In the latter their altered condition will be seen on inspection ; in the former the general state of health, and the pre- sence of hysterical symptoms, will serve to confirm the opinion we are led to form from an examination of the sputa. The blood, which appears as streaks or small clots, is mixed with brownish and sometimes fetid saliva, which has a glairy appearance, is free from froth, and is only partially intermixed with bronchial mucus; the secretion from the lungs floats upon the saliva, is untinged with blood, and does not differ from that which is occasionally expecto- rated by all persons in health. b. Genuine haemoptysis occurs in very varying quantity, from a slight streak in the frothy mucus secreted by irritated air-tubes, such as is met with in early phthisis or bronchitis, to an incredible amount of pure unmixed blood. In the former there is little diffi- culty in making out that its source is pulmonic, when we have the evidence of existing cough, accompanied by expectoration clearly coming from the lungs, with which blood of a florid colour is evi- dently intermixed: but when the quantity is larger, it is sometimes not easy to say whether the blood come from the trachea or from the oesophagus — whether the case be one of haemoptysis or haerua- temesis. We are guided in great measure by the history of the precursory symptoms, and especially by the existence of cough; this one fact, indeed, is often conclusive. Pain, if it exist, is re- ferred to the middle of the sternum, or said to extend right across the thorax in haemoptysis ; it is referred to the epigastrium in hae- matemesis. In haemoptysis there is first a sensation of tickling in the throat, and then the blood comes up with a hawking or a true cough: in haematemesis the first sensation is of sickness, and an effort of retching is accompanied by a free discharge of blood, or of blood and glairy mucus: subsequently, if a considerable 9-i DISEASES OF UNCERTAIN SEAT. quantity continue to be brought up, it seems to be accompanied by retching in both cases, and then, the diagnosis may be more obscure. If the patient be seen during its continuance, there is little chance of mistaking the two. If he have not been seen till after- wards, the persistence of cough, with a few blood-stained sputa or clots of blood surrounded by frothy mucus, decides in favour of haemoptysis: the appearance of black altered blood in the stools proves it to have been hamiateinesis, especially if hemorrhage by the mouth have entirely and at once ceased; it can only get into the stools by being swallowed, when it comes from the lungs. ]>oth conditions may be simulated by blood from the back of the nares trickling down into the oesophagus or the trachea ; but here cpistaxis indicates its source. Hemorrhage from the lungs is associated with four different con- ditions of disease : (a) phthisis, and more rarely bronchitis ; (b) dis- ease of the heart, especially with mitral regurgitation ; (c) aneurism ; (d) intra-thoracic fungoid growths. a. In phthisis the quantity is very variable. It may be little more than a few streaks mixed with the purely bronchial expectoration of early phthisis, or with the muco-purulent fluid of its more advanced stages. This slight streaking, al- ways an important symptom, is of more weight when appearing in a chronic af- fection of the lungs than when the expectoration consists of simple mucus. It may be impossible to assert positively in any given case that the lungsare entirely free from tubercles; yet where no trace of their existence is detected, it would ap- pear that the strain of a laboured cough with scanty expectoration, especially if emphysema be present, and the mucous membrane congested, occasionally gives rise to a very slight amount of genuine haemoptysis; and in such circumstances experience teaches that we may be justified in taking a more favourable view of the case. A cough of longer standing, with any opacity of the sputa, makes the appearance of blood to the very smallest amount a serious and alarming symptom. It may be in very considerable quantity, while yet the disease has made com- paratively little progress. In these circumstances it causes obstruction to the passage of air through the tubes, and its particular locality may be traced by the sounds heard with the stethoscope at or near the apices of the lungs. In some rare instances, when it is very abundant, coming, perhaps, with a sudden gush, it proceeds from the erosion of a vessel in a vomica or abscess: the other signs of phthisis are then well marked. The blood is at first always florid, and, except when in very great quantity, also frothy; it becomes scanty and brown, or blackish, as the attack is _ passing off, when no more is poured out aud that which remains in the tubes is gradually being got rid of by expectoration. b. In disease of the heart the amount is seldom or never great, and it is more variable in appearance, partly florid and frothy, partly mixed with darker clots, which generally indicate the existence of what is called apoplexyof the lungs. The blood is mixed with mucus or muco-pus, according to the previous condition of the patient, as suffering more or less from bronchial irritation. Dyspnoea is its invariable precursor, from the retardation of the passage of the blood through the lungs; and this very frequently gives rise to oedema of the lung, broncborrhcea, or bronchitis. The essential condition is one of obstruction to the onward current, as the blood ente^ or leaves the left ventricle of the heart; and the effect becomes most marked when this obstruction is caused by a backward flow of blood through the mitral orifice, in consequence of which a double supply of blood is thrown upon the pulmonic veins. The examination of the heart ought to leave no doubt as to this cause of hemorrhage, and sometimes auscultation and percussion indi- cate with great precision its exact seat. HEMORRHAGES. 95 c. In aneurism the gush of blood is generally great, sometimes terrific, followed by almost instantaneous death. This is what we should expect from the very na- ture of the disease; because, though partial hemorrhage may occurfrom erosion of lung tissue by pressure, or from partial obstruction of vessels, in by far the greater number the blood comes from actual bursting of the sac. The indications by which aneurism may be discovered will be afterwards considered. (See Dis- eases of Blood-vessels.) d. In fungoid growths the blood is never brought up in any quantity. It has sometimes very much the same appearance as that caused by disease of the heart, and then it would appear to be the result of pressure and obstruction; more fre- quently it is seen as small clots, or as a sanious discharge, or it has the appearance of currant jellv. The diagnosis of intra-thoracic tumour will be afterwards dis- cussed, as one of the forms of disease of the chest. In addition to these, the more ordinary associations of haemoptysis, it must be remembered that the sputa of pneumonia are really tinged with blood, which, though in the later stages it acquire a brown or rusty colour, may be in the first onset of a severe attack, quite florid in appearance. Conditions of congestion from gravitation, in fevers and blood diseases generally, may be accompanied by an oozing which gives the expectoration more or less of the same character. Bleed- ing-from the lungs may also go along with other hemorrhages in cases of purpura hemorrhagica; but such conditions, although they may rank haemoptysis as one of their symptoms, cannot be classed under that head. Vicarious hemorrhage, in suppression of the habitual flow from the uterus, or of that from the hemorrhoidal vessels, is alleged sometimes to put on the charac- ters of haemoptysis. Among females such a condition usually belongs to the spu- rious form; the blood comes from the mouth and fauces, and not from the lungs at all. It is very often entirely hysterical; an excited fancy finding something in the teeth, the gums, or the throat to work upon, and the blood being really pro- duced by suction. Strange to say, this incident very often occurs, without any intention of deception, at or about the time when the catamenia should have ap- peared; probably from a notion being very widely spread among mothers and nurses that the blood is liable to "come some other way" in amenorrhcea. Well authenticated cases of hemorrhage from the lungs for the relief of plethora, an event so common in the mucous membrane of the nose and the rectum, are very rare indeed. Perhaps scarcely one is on record which is unexceptionable ; at all events, the probability is very greatly against genuine haemoptysis depend- ing on such a cause. § 3. Hsematemesis. — It is unnecessary again to go over the points which serve to distinguish between hemorrhage from the stomach, and hemorrhage from the lungs. The history must be our guide ; and not whether the patient say he brought it up from his chest or his stomach; a statement which, from the confused ideas generally entertained of the relation of internal organs, is quite valueless : the question is, whether he felt sick or faint before he brought it up, or whether he had a cough. This faintness is often well marked, in consequence of a large quantity of blood being poured out into the stomach before its action is inverted so as to produce vomiting ; but this is by no means constant. In quantity the blood is sometimes very considerable ; in consist- ence clotted, or grumous, and mixed with the contents of the sto- mach ; in colour it is almost always dark : occasionally the clots are partially decolorized, indicating that the blood has lain some time in the stomach. The formation of a true clot leads rather to the suspicion that a vessel is ruptured ; but in any form of hemorrhage, where the quantity of blood poured out is great, it is more or less 9G DISEASES OF UNCERTAIN SEAT. clotted. The action of the acid in the stomach has the effect of blackening the colouring matter; but occasionally the discharge of blood goes on for so long that the stomach becomes entirely emptied of its natural secretion, and then the latter efforts of vomiting bring up pure florid blood. This condition is that which is simulated by prolonged and profuse hemoptysis when retching accompanies its advanced stage. The blood in hrcmatemesis is derived from three sources : (a) from erosion of a vessel; (b) by exudation from the surface of healthy mucous membrane; (c) by oozing from a diseased portion of the stomach in cancerous formations. a. Erosion is found either as the result of ulceration of the mucous membrane, or as the fatal termination of an aneurism when the vessel has burst into the sto- mach. Both forms of hemorrhage are severe, and very often fatal. Ulceration of the stomach, however, is generally preceded by symptoms of dyspepsia and a burning sensation after eating: it is more common in young females than in^males or persons of advanced age. The evidence of the existence of aneurism is less direct. (See Chap. IX., Div. ii., § 2, Tumours.) b. Blood may exude from the surface of the mucous membrane under a variety of circumstances; and this is especially associated with disease of the liver and spleen. In quantity often great, the exudation may go on for a considerable pe- riod, so that the stomach may be emptied three or four times in succession; the intervals are usually long, so that the colour continues dark throughout. _ The age and habits of the patient are to be considered, as well as the evidence derived from other sources indicating hepatic or splenic disease. Hemorrhage from such causes very seldom occurs in early life, and persons of dissipated habits are more liable to it than others. Hsemateraesis is sometimes vicarious of menstruation: this is by far the most common and the best established of the instances of hemorrhage recurring at pretty regular intervals in cases of amenorrhcea; hence jt is always important, when hiematemesis is present in a young female, to make inquiry into the state of the uterine functions. It is not uncommon as one of the forms of hemorrhage in purpura and scurvy; it occurs as black vomit in yellow fever; it sometimes follows the ingestion of some irritant poison. All of these are purely symptomatic, and their diagnosis is based, not on the mere existence of hamiateniesis, which is casual, but upon the other symptoms of each form of disease. c. A certain admixture of blood with the contents of the stomach in persistent vomiting is an early and only too certain indication of commencing scirrhus; after ceasing for a time, it is very apt to reappear as ulceration proceeds. Its distinctive characters are a grumous and scarcely clotted appearance, much re- sembling " coffee grounds," and its small amount on each occasion, even when ulceration has proceeded to its greatest extent. This is to be explained by the circumstance that previous disorganization has generally rendered the vessels im- pervious before they are perforated by the ulcerative process. § 4. Hsematuria is the name given to any escape of blood with the urine. The presence of blood must not be assumed from its colour: some vegetable colouring matters give to the urine a pink or bright red hue; in some disorders, deposits of a red colour closely resemble it ; and an admixture of bile produces an appear- ance very similar to that caused by dark and altered blood. The details of this subject will be given afterwards (see Chap. XXX., § 3;) but, as a ready test, it will be observed that, when blood _ is present, the urine is not only changed in colour, but has lost its HEMORRHAGES. 97 natural transparency, and this opacity is increased by heat and ni- tric acid. When the microscope can be employed, blood-globules will be seen, and give certainty to the diagnosis. In females it is further necessary to ascertain that the blood does not come from the uterus or vagina at the time of micturition. Its source may be in any part of the urinary apparatus, from the minute tubes of the kidney to the extremity of the urethra: in quantity and colour it varies very much. When the amount is considerable and the colour florid, it probably proceeds from some abrasion of surface, caused either (a) by the presence of a calculus, or (b) by ulceration or other injury, or it is the result of fungoid growth; (y the intermixture of a small quantity of blood, which has been altered in ap- fiearance by the action of the acid present in the urine. When the urine is alka- ine, th( colour has a pinkish hue; it has seldom the florid look of unaltered blood. Exactly the same appearances are often found in the urine passed after an attack of scarlatina when dropsy occurs. In both cases the distinguishing feature of the disease with which this form of hemorrhage is associated is that there is a much larger amount of albumen pre- sent in the urine, as proved by chemical re-agents, than could have been derived fnun simple admixture of the actual quantity of blood necessary to produce the red or brown colour. These observations all tend to show that bsematuria is almost constantly a symptom, though a casual one, of disease in some portion of the urinary appara- tus ; and all the points which have been alluded to require further study, if more than a mere guess at its cause be sought for. In giving it a place among the he- morrhages, we only seek to point out its accidental and uncertain character, and that it is rather to be regarded in many instances as an intercurrent disorder, making its appearance in the course of some more severe malady. § 5. Intestinal Hemorrhage. — When blood is passed by stool, it is necessary to determine whether there be hemorrhoids, internal or external. In their absence, we must proceed to inquire into the constitutional and precursory symptoms. Whether it have been preceded by ha^matemesis, by fever, by diarrhoea, or by dysentery, the colour of the blood will aid in determining from what portion of the canal it comes. The darker in colour, the higher up is its source; the brighter, and the more nearly it approaches to the or- dinary colour of blood, the nearer is its point of discharge to the anus; black and pitchy after hasrnatemesis, it is bright and florid in dysentery. When not proceeding from the stomach, its most common source is ulceration of the mucous membrane in some part of the canal. It is not unfrequently present in purpura, and sometimes appears to depend on a state of simple debility and extreme relaxation of the mucous membrane; but when such cases terminate favourably, there must always remain a doubt whether ulceration did not exist. § 6. Uterine Hemorrhage may occur in perfect health, or as a consequence of disease: the mere fact of the continuance or fre- quent recurrence of hemorrhage is not of itself any sufficient indi- cation of disease of the organ. The character we would assign to it, as distinguished from monorrhagia, is the irregularity of the periods of its occurrence ; but so great is the tendency to periodicity in this organ, that such a rule is liable to error. Menorrhagia, properly so called, consists in an increased flow of the menstrual discharge, the actual quantity being greater, the time of its duration longer, and the intervals of repose shorter, but all perfectly regular in their recurrence, and gradually developed. Hemorrhage, again, comes on suddenly, and is quite independent of the menses ; if it happen at one period, it does not follow at the next, but may again recur at some future one, or at any intermediate time. a. When it is found in apparent health, it is generally the conse- HEMORRHAGES. 99 quence either (1) of sudden alarm, especially soon after the usual menstrual period, or (2) of abortion : in such cases it may continue at intervals for weeks or months afterwards, from want of care and proper management. b. As a consequence of disease, it is most commonly associated with (1) polypus or fibrous tumours; (2) fungoid growths and can- cer; (3) sometimes with the hemorrhagic diathesis, when it is fol- lowed by intense anoemia, and may even prove fatal. The local diseases which give rise to hemorrhage from the uterus must be ascertained by tactile examination : their consideration will be re- sumed at a later part of our inquiry. (See Chap. XXXIII., Dis- eases of the Uterus.) 100 CHAPTER VIII. THE CHRONIC BLOOD-AILMENTS. § 1, Purpura and Scurvy — their Discrimination — § 2, Anaemia — Causes and Associations — § 3, Chlorosis — § 4, Ansemic Blood- murmurs — § 5, CacJuvmia, or Cachexia — Pysemia — Secondary Deposits. § 1. Purpura and Scurvy. — These two diseases have this feature in common, that they are forms of subcutaneous hemorrhage, oc- curring spontaneously without pain or injury, and having no assign- able cause other than a peculiar condition of the blood. Their phenomena are essentially objective; their existence being deter- mined by the presence of dark-coloured persistent spots or patches of varying size, having the appearance of purple stains or livid bruises of the skin. These states are not identical with what has been already denominated the hemorrhagic diathesis. Spontaneous hemorrhages are liable to occur in both conditions; the external characters differ in this respect, that in the one blood is effused under the skin without assignable cause, and with no apparent alteration of texture, while in the other it is only poured out where there is some breach of surface, and is then stanched with extreme difficulty; fatal hemorrhage has in such circumstances followed the extraction of a tooth. It is probable that the spontaneous internal hemorrhages in each case follow the same rule, and that there is really some abrasion of the mucous membrane, or rupture of a small ves- sel, in the one and not in the other. They differ from each other, — (a) in scurvy being very frequently accompanied by sponginess of the gums, which is never the case with purpura, but this indication is not always present; (b) in the characters of the spots themselves. In purpura they are generally small and of a very dark colour; the skin seems to be stained through with a purple dye : when larger patches exist, they seem to be composed of innumerable smaller ones run together, some of which are found quite distinct in the immediate neighbourhood, or in other partg of the body; the spots are soft and flaccid. In scurvy the patches are generally large, and always more or»less hard ; their colour is more livid than purple, resembling bruises rather than stains of the skin. Purpura is not unfrequently associated with hematuria, or intes- tinal hemorrhage ; it is then usually called purpura hemorrhagica. It is liable to occur in any circumstances which deteriorate the quality of the blood, and is therefore found in disease of the kid- ney, liver, spleen, &c. It is also met with occasionally in conditions of blood-poisoning, such as pyemia and severe small-pox : it forms the true petechia: in typhus fever. When it arises spontaneously ANiEMIA. 101 * there must have been some antecedent cause for the altered condi- tion of the blood, though this cannot always be traced. Scurvy, on the other hand, is especially associated with deficiency of some element ordinarily derived from the vegetable kingdom, and gene- rally believed to be an acid, because of the prophylactic as well as curative powers of lemon-juice: it was much more common than usual at the first outbreak of the potato disease, when the poor were deprived of this their ordinary vegetable. § 2. Anoemia. — In the classification of symptoms which afford indications regarding the general state of the patient, reference was made to those derived from the aspect and colour of the face. None of these is more striking, or perhaps more valuable, than that pre- sented by anremia; — loss of that natural complexion which is pro- duced in health by the fine network of capillaries spread over the skin, especially of the cheeks, and also over the mucous membrane bounding the lips and the nose ; by inference deficiency of blood, but mo|p particularly of the red colouring matter. This condition depends therefore either on absolute want of blood, or on dispro- portion between its various elements. Its causes are very various : they may often be detected in the history of the case. The exact duration of the disease can seldom be ascertained, except when loss of blood has been occasioned by hemorrhage, because its commencement is generally insidious. Patients cannot associate their pallor with those conditions out of which it has arisen; but more commonly, in describing the com- mencement of their illness, refer to those secondary states which have first made them conscious of loss of health, such as palpitation or dyspnoea, headache, dyspepsia, general weakness, and among females diminution or suppression of the menstrual discharge. The history ought, if possible, to go beyond these, to the antecedent state out of which the whole category of symptoms has sprung, and to take note of the order in which the circumstances of which the patient is cognizant have successively appeared. The inquiry on the part of the physician embraces the following points: — a. The existence of hemorrhage, b. Want of proper nu- triment, c. Causes which prevent the nutriment from being con- verted into healthy blood, d. Conditions of system which directly tend to deteriorate the blood. a. Hemorrhage first diminishes the quantity of the circulating fluid ; and when this is again made up by the absorption of liquid, its quality is impoverished. The hemorrhages most commonly producing this effect are from the uterus in fe- males, and from the bowels in both sexes; anaemia frequently follows on haema- teraesis, and more rarely on prolonged epistaxis; it is also to be seen in patients who have been frequently bled. When associated with haemoptysis or haematuria, it is rather the result of the disease of the lungs or kidney than of the loss of blood. It must not be forgotten that the hemorrhage may be the consequence and not the cause of the changed qualities of the blood. b. Simple anaemia is generally the effect of insufficient nutriment; when the food is improper in quality, special forms of disease are more liable to be engen- 102 CHRONIC BLOOD AILMENTS. (I led, cachexia, purpura, scurvy, &c. Starvation implies absolute want of Wood, and the disproportion of the constituents is only referrible to excess of water. Fhe caosea which prevent the formation of blood include especially disorders igestire apparatus, the stomach, the liver, and the intestines; as well as ion to the absorbents, as seen in mesenteric disease. We must bear in ■ r, that derangements of all possible kinds may result from the ana> mia in place of causing it. "We may be somewhat guided in forming our judg- ment by the history of the case, pointing out priority of occurrence in the dyspep- vmptoms, or in the general feeling of weakness, and by the relative intensity ach class of indications; the anaemia is much more intense when it produces the dyspepsia than when caused by it. There can be but little difference between the want of blood arising from imperfect assimilation, and that from insufficient food. d. Special forms of amemia are directly traceable to conditions which, without interfering with digestion and absorption, seem to act by deteriorating the quality of the blood, inducing especially disproportion among its constituent elements. Of this kind are the effects of cancer and of disease of the kidney: to the same class we must refer chlorosis and leucocythaamia. All these subjects must again occupy our attention in considering various regions of the body: meanwhile it is only needful to remark, that the anaemia is rather an accidental symptomin the case of Gancer and albuminuria, but is an essential one in chlorosis and white-cell blood: in the latter, too, it serves to draw our attention to the spleen, au^we have no other direct evidence of splenic disease. In cancer the pallid appearance is combined with a sallow hue, which has been called the "malignant aspect;" in disease of the kidney there is usually some puf- finess of the face, and the cheeks are occasionally mottled; in chlorosis, as its name implies, there is a slight tinge of green, with a transparency of skin which makes the face look like a wax model; in leucocythzemia the aspect is muddy, earthy, and a similar appearance may be seen in the tuberculous cachexia of early life. These differences well-marked in advanced cases, and frequently sufficient to an experienced eye for the discrimination of the disease, must not be much relied on by the student. They are to be regarded simply as aids to diagnosis, not as the grounds on which it is based. In rare cases none of the conditions just mentioned can be made out as having had any share in the production of ansemia : even when fatal, no organic disease has been detected. This anemia is of slow development; it seems to exist alone, and is marked by no symptoms except such as are referrible to a deterioration of the circulating fluid. For the present we must rest satisfied with determining its presence and ascertaining that it is uncomplicated ; we cannot get beyond the fact which the name anccmia, or spanremia, as used by some pathologists, implies. The general state, from whatever cause derived, is followed, in most cases, by the symptoms already enumerated — dyspnoea and palpitation, headache and general weakness, and frequently by emaciation, the latter being least observed in those associated with hemorrhage and chlorosis. Having got the clue from the objec- tive phenomenon of aspect, we have only to observe what are pri- mary and what secondary affections among the symptoms present. The pulse is pretty full when the change is rather in quality than quantity; if weak and small, there is certainly deficient amount of blood; with a soft pulse— both conditions are probably present. The tongue is very generally clean, always remarkably pale, and sometimes slightly furred and inclined to be cedematous, bearing CHLOROSIS. 103 marks of the teeth on its edge. The coincidence of depraved appe- tite and irregular bowels with anaemia is rather the rule than the exception. Local congestions of various organs are very frequently met with, and the full recognition of the general condition of anae- mia is essential to the rational treatment. The association of oede- ma is also not uncommon; probably every case of anemia, at an advanced stage, would become more or less dropsical in circumstances favourable for its development ; but we must be particularly careful in investigating the origin of this symptom, and must not rest satis- fied with the ready explanation that the condition of anaemia offers, till all the other causes of its existence are fully examined. (See Chap. VII., Div. i., § 1, Anasarca.) § 8. Chlorosis. — Although essentially a form of anaemia this con- dition demands separate notice, from its peculiar association with perverted function of the uterus. It seems to exist under two pri- mary forms: (a) previous anaemia, followed by scanty menstruation, terminating in complete suppression of the menses; (b) sadden sup- pression of the menses, terminating in general alteration of the blood; the aspect betraying something more than mere anaemia. In the former case, the limits of the disease are not well defined; in the latter, the peculiar characters are unmistakeable : but in both there is some specific relation between the symptoms, and in order to constitute chlorosis this relation must be clearly made out. Suppression of the menses under the name of amenorrhcea be- longs especially to the diseases or disorders of the uterus. Any fe- male may be anaemic from some one of the causes already enume- rated, and, as a casual result of debility, the catamenia may be scanty or absent; but this ought not to be called chlorosis; neither should the name be given to amenorrhcea when there is no condition of anaemia associated with it. But when, in a young person, there is no distinct cause for the anaemia, and when along with it, defi- ciency of the menstrual flux occurs early, and total suppression soon follows, or when suppression precedes anaemia, the classification seems legitimate and useful. § 4. Ansemic Blood-murmurs. — The diseases which Ave have just been considering are characterized by a deficiency of red blood. W hen the condition is produced by a change in quality rather than quantity, when the red globules are diminished greatly out of pro- portion to the loss of other constituents of the blood, unnatural sounds are often to be heard with the stethoscope at various points in the course of the circulation; over the heart, the arteries, or the large veins, while there is but little obstruction to the current to account for their production. This subject must be again referred to in speaking of diseases of the heart and great vessels; but its importance seems to justify a few words here to point out to the student how he may make himself acquainted, so far as possible, with the diagnosis of a "blood-sound." 104 CHRONIC BLOOD AILMENTS. The essential point which must ever be borne in mind is, that all "bruits" whatever are produced chiefly in the blood itself, and not in the solid structures; they are supposed to depend on vibrations among the particles, or globules; the sound is really quite independ- ent of the nature of the disease in which it is heard, although modi- fied by it, as it causes alterations of form in the channels, or simply gives rise to changes in the qualities of the blood. Such vibrations may be produced in any fluid by placing some obstruction in the course of its movements, and much more readily in thin fluids than in those which arc more tenacious. The aptitude for their produc- tion in disease therefore varies with the quality of the blood, and the chance of their occurrence, with the condition of the solid struc- tures. In a perfectly healthy condition of the blood they can only be produced by changes of certain amount in the form and calibre of the passages, or by counter-currents ; in slight deviation from health, less important alterations will serve to throw the particles into vibration; in the more advanced forms of anremia, even the natural diiHculties which it has to overcome in passing through channels of varying size is sufficient to produce the effect, which will be more or less marked in proportion to the force and rapidity of the circulation. No such phenomenon is observed in health, simply because a due proportion exists between the tenacity of the fluid and the form of its canals. Bearing in mind these different elements in the production of the sound, it will be readily understood that no certain diagnosis of the nature of the disease can be formed from its tone or intensity. Ge- nerally speaking, those which are unaccompanied by structural change have a very decided character of softness; but this is by no means peculiar to murmurs of this class. On the other hand, in considering the locality in which it is heard, we have to remember that the true blood-sound is only secondarily dependent on local causes, because we know cl priori that a very slight impediment is sufficient for its production; and it is reasonable to expect that, if any circumstance give rise to its presence, it will be heard most rea- dily where the current is most superficial. Another consideration affecting its situation is, that when the blood is thus liable to be thrown into sonorous vibration, the sound is propagated in every direction, after it has flowed past any trifling obstacle, to a much greater extent than when healthy blood is forced into the same vi- bration by some more powerful cause. Accordingly, we find it very readily produced by slight pressure on a blood-vessel ; e. g., the ca- rotid artery: again, in traversing the heart, the blood passes through channels of varying size, and it is churned and mixed together in the ventricles in such a way as would naturally lead to the produc- tion of "anaemic murmurs," whether on the right or the left side: the pulmonary artery is most superficial in the chest, and therefore the sound is more frequently heard there; but when the apex of the heart comes much forward, and its base is thrown back, the arteries CACHEXIA. 105 being deeply covered by lung-structure, the murmurs may be best- heard through its walls, and even towards its apex. In decided ansemia, a blood-sound can also be heard in the veins; a little ma- nagement in tilting over the stethoscope towards the patient's head, so as partially to impede the returning current through the jugular veins, will generally develop this venous hum. It differs from the arterial blood-sound in being continuous, and not intermittent: its tone varies in different individuals; but the best general idea of its character may be obtained from the roaring of a large shell, applied to the ear; it is called by the French "bruit de diable," from the sound of the humming-top; but this is both louder and shriller. Both sounds may often be heard together in the neck, as pressure is made with the edge of the stethoscope next to the thorax, or the most distant from it — more firmly, so as to s|op the venous current altogether — or more gently, so as merely to impede it. When the experiment is well performed, the short whiff of the arterial sound contrasts strikingly with the prolonged continuous hum of the vein. If the venous murmur be heard, there can be no doubt that the blood is in a condition in which bruits are readily produced. The same conclusion may be safely arrived at if slight pressure on an artery develop a short whiff, which seems close to the ear, is syn- chronous with the pulse, and ceases to be heard when the pressure is removed. Similarly, but not so certainly, may a blood-sound be diagnosticated if it occupy the whole of the region of the base of the heart, being especially audible in the pulmonary artery, where the blood is generally most superficial, but evidently not confined to that locality. § 5, Cachsemia, or Cachexia. — Mal-nutrition may exist without the remarkably ex-sanguine hue of aniemia, under the form simply of general derangement of health; there is perhaps emaciation, with a tendency to ill-defined cutaneous eruptions; wheals on the finders, resembling chilblains, and afterwards forming watery blebs or blains secreting purulent fluid ; unhealthy pustules on the lower limbs, &c, and yet no organ gives any distinct evidence of disease. This condition is apt to be generated by improper or insufficient food, ill- ventilated apartments, and all those conditions to which the poorer artisans in large towns are exposed. On the other hand, cachsemia may assume a more definite character from the previous accident of a poisoned wound; and while, as a general rule, inflammation of the absorbents is the more common consequence, yet we do occa- sionally meet with cases in which the whole circulating fluid appears to be deteriorated in its qualities. The general class is an unimportant one, because in a great many instances, some definite malady may be detected as the basis of the depraved state of the blood, — scrofula, disease of the kidney, con- genital syphilis, &c. Of such states nothing more need now be said; but there is one form of cachsemia which is well marked, and 106 CHRONIC BLOOD AILMENTS. of grave import: it is characterized by contamination of the blood from an admixture of pus, — pyaemia, or pyohsemia. Not unfrc- quently arising in unhealthy subjects after operation, it has been lied that the pus secreted in the wound actually finds its way into the blood; but it is by no means limited to such cases, and is constantly mot with under circumstances in which there is no chan- nel by which the pus globules could find their way into the circu- lating system. Its probable source in all cases is the lining mem- brane of the veins, which puts on a form of suppurative inflamma- tion, and secretes pus; this is washed into the general current of the circulation, and so produces purulent contamination of the blood ; its existence must therefore be secondary to a form of phlebitis. We find it as a sequence of almost any extensive suppuration, but more especially after diffuse cellular inflammation. It very rarely ap- pears at the termination of phlegmasia dolens, the "white-leg" of parturient females, a form of phlebitis unattended with suppuration. This circumstance seems to negative the idea of its existence being ever due to the absorption of pus; because the direct admixture of pus with the blood has been shown to produce its coagulation, and the phlebitis of child-birth probably arises in this very way, from the entrance of unhealthy fluid, purulent or sanious, into the open mouths of the uterine veins. The condition which we call pyaemia must therefore have some different cause, and none appears more rational than that the pus is secreted from the lining membrane of the veins. The history of the case is therefore important; but most com- monly the disease commences under the practitioner's own eye, because it supervenes on one which has already required medical treatment. Sometimes, however, the cause of the primary suppu- ration has been so insidious and obscure, that the first evidence of the presence of pus is derived from its general diffusion through the blood. It is marked by fever of an adynamic type, quick feeble pulse, dry brown tongue, shivering, often intense, followed by co- pious perspirations. These are only the general signs of extensive suppurative action, and it is to be presumed that they indicate a fur- ther formation of pus, not improbably in the blood itself, but still more certainly in the various organs in which what are called se- condary deposits are found. These, in their turn, become the di- rect evidence of pyaemia: the pus is believed to be obstructed in its passage through the capillary vessels, and at each point where it rests to become a focus of inflammation which rapidly terminates in a small abscess. "When seated in internal organs, the existence of secondary de- posits can only be inferred from the previous knowledge of suppu- ration elsewhere, taken in conjunction with the general evidence of its extension, and the local symptoms of pain or altered function in the particular organ. Those most liable to be so affected are the lungs and liver, and secondary deposits are rarely found elsewhere CACH^MIA. 107 without their being also found in them. Very often, however, the suppuration takes place near the surface; it commences with a patch of intense redness on the skin, accompanied by but little ten- sion or tenderness, and thus proving that the inflammatory action is of a very low type ; it passes in a few hours perhaps, into suppu- ration and abscess, becoming soft and fluctuating. Erythema no- dosum occasionally presents characters which might be readily mis- taken for the early stage of these small abscesses; the previous history ought to preserve us from such a mistake, and the course of the disease will soon clear up any doubts that may have remained. In cases of erythema the redness probably acquires a bluish tint, or remains unchanged, and though the swelling feel soft, there is no fluctuation and no formation of pus. In other instances the presence of pus in the blood leads to the formation of small pustules on the skin itself; not very numerous, they are prominent, fill rapidly, do not pass through any prelimi- nary stage of serous exudation, but evidently from the first contain purulent fluid: they can only be confounded by a very superficial observer with a varioloid eruption. These two forms of deposit are each very characteristic, and are generally associated with larger collections of pus around the joints, or spread abroad in the cellu- lar tissue and burrowing among the muscles. In the absence of the pustules and small abscesses just mentioned, the inflammation around the joints may be mistaken for acute rheumatism, which it simu- lates in attacking several in succession; but it will be observed that the swelling is very much more extensive, and the redness more erysipelatous-looking than ever happens in rheumatism. This is caused by the tendency to diffuse cellular inflammation, which gene- rally also shows itself in other parts, at a distance from any joint, over the thorax, about the eyes and face, &c. Cases of pyaemia bear»a close analogy in many respects to glan- ders, and when the primary suppuration cannot be discovered, they are somewhat perplexing. A sallow aspect, and a peculiar odour of the breath have been both urged as characteristic of the disease ; but while they may aid the diagnosis, they cannot be made the principal grounds of discrimination. v> CHAPTER IX. DEPRAVED CONSTITUTIONAL STATE?. Div. I. — Scrofula and Tubercles. — § 1, Scrofula — § 2, Tabes Me- senterial — § 3, Phthisis — Acute and Chronic — § 4, Tubercles in the Peritoneum — § 5, Tubercles in the Brain. Div. II. — Morbid Growths. — § 1, Of Local Enlargements — their Causes — § 2, Of the Locality of Tumours — on the Surface gene- rally — on the Head — in the Neck — the Chest — the Abdomen — § 3, Of the Nature of Tumours — Cystic Growths — Encephaloid — Scirrhus — Colloid — Osseous Growths. Division I. — Scrofula and Tubercles. § 1. Scrofula. — There are some specific forms of mal-nutrition, derived, in all probability, in a majority of instances, from heredi- tary taint, of which the scrofulous and the tubercular diatheses are the most important. Along with general derangement of health and imperfect growth of structure in childhood, the lymphatic glands tend to enlarge and to form an ill-organized yellow deposit in their interior, which readily suppurates, and yields unhealthy pus. This condition is most readily noted in the superficial glands of the neck, where casual exposure to cold is very likely to excite the quasi-inflammatory action which leads to the enlargemgnt. The history of the case probably shows that the child was always delicate, suffering more than usual from teething, perhaps liable to convulsions ; or, if itself healthy, other members of the same family have suffered in this way. The ailment comes on insidiously, with- out any assignable cause ; and when first seen, there may be un- healthy discharges of an acrid and semipurulent character from the eyes and nose ; or abscesses may have formed on various parts of the body, of an indolent character, which, when they open, leave unhealthy ulcers. Very often cutaneous eruptions, particularly of an impetiginous character, are found spread over the head and face; these are obstinate and intractable, and are not unfrequently the cause of the enlargement of the cervical glands. To this general state we give the name of scrofula. The tongue is often habitually coated, and the intestinal discharges unhealthy; such children are very liable to be infested with asca- rides; the aspect is generally characteristic; the skin is clear and thin, the face often anaemic; the limbs soft and flaccid, and the belly tumid; the upper lip is sometimes thickened and projecting, but this would appear to be chiefly a result of acrid discharges from the nostrils. A scrofulous child may very readily become tuber- cular, but the two diseases are seldom fully developed together. DEPRAVED CONSTITUTIONAL STATES. 109 § 2. Tabes Mesenterka. — Sometimes, in conjunction with some of the external symptoms of scrofula, emaciation proceeds to a greater extent than usual; the limbs dwindle, the skin becomes dry and shrivelled, the abdomen is hard and tense, and the little patient appears to suffer pain when pressure is made ; the evacuations are very offensive, and the bowels irregular in their action; there is a tendency to diarrhoea, which may become urgent and obstinate. In such a case we have great reason to believe that scrofulous or tuber- cular matter, or a mixture of both, in what has been called scrofu- lous tubercle, has been deposited in the glands of the abdomen, and especially in the mesenteric glands: hence the name tabes mesen- terica has been applied to this form of the scrofulous cachexy. § 3. Phthisis. — True tubercle has the peculiarity of being chiefly developed in the lungs: it may exist in other internal organs, but it is very unusual in such cases to find the lungs wholly exempt. Its commencement is always insidious, and its subsequent progress is sometimes tardy; but, more commonly, it proceeds with considera- ble rapidity. This circumstance has given rise to the division into acute and chronic phthisis; the distinction being based upon the extent of structure simultaneously attacked', and the rapidity with which it spreads to surrounding parts, and not on any difference in the na- ture of the disease. It is practically useful because of the diffe- rent train of symptoms set up by a speedy invasion of the whole lung, or a gradual disintegration of successive portions of it. Ex- posed as all ages are to the ravages of this disease, it especialty prevails soon after puberty, when both forms are constantly ob- served, and seem to merge into each other. In elderly persons acute tuberculization never occurs; and, on the other hand, it may at least be said that true chronic phthisis is extremely rare in children. The acute form sets in as an attack of influenza — that is to say, with symptoms of bronchial irritation and adynamic fever, the pre- ceding coryza, however, being generally absent. This condition becoming persistent, the pulse continues rapid and feeble; the cheeks are flushed; perspirations occur, especially at night; ema- ciation and increasing weakness follow in rapid succession, even before any physical signs in the lungs themselves indicate the pre- sence of tubercular matter. The full consideration of this subject can only be entered upon after the physical signs of disease of the lungs are detailed ; here we have only to do with the general features of the diathesis. "While the pulse is quick, the condition of the skin alternates be- tween dryness and moisture, is never harsh or burning, as in fever, and the perspirations are sometimes excessive; the state of the tongue is very various; and the bowels may be either natural in action or inclined to diarrhoea; the aspect is often instructive; a certain degree of anaemia prevails, with a bright colour on the 110 DEPRAVED CONSTITUTIONAL STATES. checks; the eyes are soft and brilliant, with large pupils, and fre- quently fringed by long eyelashes; this is especially to be seen in childhood. The accompanying emaciation, and the languid manner and sense of feebleness, afford additional grounds for a suspicion of the presence of tubercle. In its early stages accurate diagnosis is, perhaps, impossible, even with the aid of physical signs; in children the supervention of such a state upon measles is most probably due to this cause, especially if the patient have previously suf- fered from any of the symptoms of scrofula, or if scrofula or phthisis exist iu the family of either of the parents, or have been evidenced in others of the children. The absence of coryza in the first onset of the disease, points to some local cause of bronchial irritation, and not to a general affection of the mucous membrane J the persistence of adynamic fever shows that the attack is not one of in- fluenza or bronchitis properly so called, in each of which the febrile state is more transient; the condition of the tongue is seldom that of common continued fever, it is only at an advanced stage that it presents at all the patchy redness or chapped appearance of fever accompanied by diarrhoea, and it is very seldom dry; indeed it is rather aphthous or ulcerated than patched and chapped : the recurrence of perspirations is also unusual in fever. The whole characters of the case are more closely allied to those presented in a tardy convalescence, and then the previous history of an acute attack with much thirst, loss of appetite, wandering delirious nights, &c, is quite different from the history of a gradually increasing malady; but it must be remembered, on the other hand, that the debilitating effects of an attack of fever predispose to the incursion of tubercles, and it may be impossible to say when the one has terminated and the other begun. The march of chronic phthisis is always insidious. Here the deposit of tubercles is much more local aud more easily made out by a physical examination of the chest; but in the earlier stages the signs may be dubious, or null. The more important general symptoms are emaciation, night-sweats, and hemoptysis ; when these exist along with a dry hacking cough, wandering pains in the chest, an habitually quick pulse, a degree of huskiness of the voice, and diarrhoea, scarcely a doubt can remain that the disease has com- menced, even though the stethoscopic signs be very obscure. It is remarkable how unwilling patients generally are to confess to " spitting of blood; " and when the amount has been trifling, it may require much cross-questioning to elicit the truth. As it proceeds, the hectic flush on the cheeks contrasts strangely with the clear, transparent pallor of the rest of the face ; the eyes are often bright and luminous ; the skin becomes soft and velvety, and, when pinched up, is found to be thin, and detached from the subjacent muscles; the ends of the fingers become clubbed, and the nails unciform; the gait is stooping; the shoulders curved forwards; the chest flat- tened, and but little expanded in breathing ; while every movement of the body gives token of feebleness and languor. Any of these symptoms may be absent, and on a just appreciation of their col- lective value often depends the correctness or incorrectness of diagnosis. Ema- ciation is never wanting, but is often associated with other affections, of which cough may be a concomitant: night-sweats, though more frequent in this disease than any other, may be merely the effect of debility: haemoptysis does generally appear at some time or other in chronic phthisis, but not necessarily so, and the disease has already made some progress in most cases before the symptom is seen; SCROFULA AND TUBERCLES. Ill when present, and there is no disease of the heart to account for it, and it cannot be explained as the result of hysteria, or as vicarious of menstruation, it is more to be relied on as an indication of phthisis than any other. A dry, hacking cough without expectoration, or with mixed mucilaginous-looking sputa, where it is ac- companied by pains in the chest, aud there has been neither coryza nor sore throat. to indicate a simultaneous affection of the whole mucous membrane, may be very safely set down as having a tubercular origin. HusSiness of the voice, caused by slight laryngeal affection, derives its sole value from its association with other symptoms; but it may owe its existence to previous syphilis, it may be simply due to an ordinary cold with sore throat, or it may even be caused by pressure on the trachea or larynx. An habitually quick pulse, when coinciding with cough and other indications of affection of the chest, is exceedingly suspicious ; but both may be caused by obscure disease of the heart, and, on the other hand, phthisis has often proceeded to its most advanced stage without this symptom being present at all. Diarrhoea tends greatly to confirm our fears, because, although there be no specific ground on which its tubercular origin can be determined, yet the liability to it is greater in phthisis than in any other disease, except common continued fever; in both a specific affection of the intestinal glands exists. The further symptoms are those of hectic fever, and its accompanying emaciation ; and as such they generally serve to stamp the phthisical character of cough, but they may be very closely simulated in cases of persistent bronchitis. The correct diagnosis of phthisis depends upon the harmony of general symp- toms and physical signs, and while a complete array of symptoms, or very strong evidence derived from signs, may lead to the conclusion that in all probability this disease is present, a combination of the two can alone justify a decided opi- nion. To this subject we must again recur. (See Chap. XX., \ 9. Phthisis pul- monalis.) Much attention ought to be given to the liability to hereditary transmission, which certainly in some families is very marked; strict inductive evidence of its relative power is yet wanting, and its subordination or superiority to other predis- posing causes is not determined; but the existence of scrofula or tubercles in the parent is a sufficient ground for leading us to suspect their presence in the child when other indications point in that direction. § 4. Tubercles in the Peritoneum. — Next, perhaps, in frequency and importance, is the development of tubercle in the peritoneum. In children it sometimes occurs alone, or with scrofulous tubercle in the mesenteric glands, when there is no corresponding deposit in the lungs : in adults it is seldom separable from phthisis. Its symp- toms are those of peritonitis, -which will be detailed in a subsequent chapter; and it is enough to say here that the tubercular form is to be distinguished by its gradual and insidious incursion, and by the presence of general symptoms corresponding to those seen in phthisis, if due allowance be made for the difference of the region in which the tubercular matter has been developed. Thus there are the same quickness of pulse, accompanied by perspiration, the ema- ciation and languid feelings, and very often the diarrhoea of early phthisis; to these are superadded, a sense of tension in the abdo- men, which has a tumid feeling, and does not bear pressure without pain; the tongue is very commonly furred, but not to any great degree. Evidence of tubercle in the lungs is of much value in aid- ing diagnosis ; as is also the presence of diarrhoea, because it is less common in simple peritonitis, and is probably caused by the exist- ence of tubercle in its very common locality — the solitary glands of the intestine. But we may be defeated in our endeavour to form a 112 DEPRAVED CONSTITUTIONAL STATES. correct diagnosis, either by the history recording that the attack has been, or has appeared to be, sudden, or by limited suppuration, in the form of deep-seated and confined abscess of the peritoneum, producing symptoms of hectic. To this it must be added, that perplexing symptoms sometimes present themselves as the effects of pressure on the nerves, the blood-vessels, or the absorbents, or as the more remote consequences of adhesions between the various coils of intestine. Perhaps our best guide is to be found in the general adynamic character of the symptoms throughout, and in the previous existence of the cachectic state which preceded them. des in the Brain. — "When we come to diseases of the brain, we shall have to discuss a form of meningitis, which is unquestionably related to the scro- fulous and tubercular diathesis ; clinical observation and post-mortem examina- tion alike proving that inflammation of the brain attended with the effusion of se- r ,m, and hence often called hydrocephalus acutus, is constantly associated with the presence of tubercle in other organs. We shall then also have to consider the symptoms which may result from the actual presence of a tuberculous deposit in the brain itself: but we may remark that the tubercle is'often solitary, and that it mav have attained a very considerable magnitude without making its presence manifest by any symptoms until the more acute disease supervene; it is only rarely lute size or peculiar position impedes by pressure the transmission of nervous energy, so as to produce paralysis or loss of sensibility. Division II. — Morbid Growths. § 1. Of Local Enlargements. — Local increase of size, as one of the objective phenomena of disease, requires careful study. It may be found in any part, whether of the trunk or the extremities: it embraces the whole class of abnormal growths, but it may also be caused by hypertrophy of natural structures or deposition of fat; or it may be clue to an effusion of serum, of blood, of lymph, or of pus; or it may depend on periosteal thickening or inflammation of bone. In simple hypertrophy there are no symptoms of disease present except those attendant on increase of size: the natural structures hold their due relation to each other, and are all increased in equal proportion. dipose tissue is more liable to general than to local increase. It is in the ab- domen where its accumulation is most likely to occur; the parietes, when pinched up, i isibly thicker when the deposit of fat is in the subcutaneous tissue, and an elastic fulness of the whole region, with considerable flaccidity, is given by its deposition in the folds of the omentum. We are led to the conclusion that this is the true nature of such an enlargement by the absence of indications of disease, beyond the existence of dyspeptic symptoms, and by the persistence of general ndness and fulness of tlie limbs which we know to be incompatible with organic ase. The presence of serous effusion gives rise in the head to the chronic hydroce- phalus of childhood, with its unnatural enlargement; in the thorax it causes of the intercostal spaces and enlargement of one side of the chest; in the abdomen it prod rites and ovarian dropsy; in the scrotum it occurs as hy- drocele; in the limbs it is the evidence of general dropsy or of local oedema. An accumulation of blood contained within the distended vessels or in a pouch communicating with them, is found as aneurism or varicocele. When extravasated it quickly c< and forms a firm tumour of undefined outline, as may some- limes be seen after a strain, or more distinctly in the testicle as hematocele; within MORBID GROWTHS. 113 the cavities it can only give rise to symptoms of the presence of tumour when it exists as an aneurism. Effusion of lymph, as the consequence of local inflammation, is commonly fol- lowed by the formation of pus; but it may remain stationary at the first stage, and be removed by absorption, the tumefaction being very generally increased by the coexistence of serous effusion around. Such swellings are to be met with among the muscles, but more especially in the lymphatic glands. Pus can of necessity only exist after inflammation ending in suppuration ; but yet large collections of matter sometimes form when the signs of inflammatory ac- tion are almost wholly wanting, and this is especially true of scrofulous subjects. As with serous effusion, the presence of pus may cause bulging of one side of the chest: in the abdomen, collections of pus are more commonly local, and limited by surrounding adhesions of the peritoneum; one form of abdominal suppuration is entirely without the peritoneal cavity, psoas or lumbar abscess, pushing out- wardly over the edge of the pubis in front or above the sacrum behind. In addi- tion to these the parietes of the cavities may become the seat of local collections of pus, from diffuse cellular inflammation, or caries of bone. Similar events oc- cur in the extremities, and especially in the proximity of the ends of the long bones of scrofulous children. The lumbar abscess, already mentioned, is very fre- quently connected with caries of the spine. Inflammation of the glands not unfre- qiiently terminates in abscess, especially in scrofulous subjects, with whom those situated in the neck seem more liable to suppurate than any others. Periosteal thickening and inflammation of bone are more commonly met with in the long bones of the extremities than elsewhere; the former so often forming rounded painful nodes on the shin-bone, the latter giving rise, by the deposit of fresh osseous matter, to enlargements of very irregular form and outline. The details of many of these subjects belong to surgery; the remainder, so far as diagnosis is concerned, must be considered with reference to the organs or re- gions in which they exist. § 2. Of the Locality of Tumours. — In the diagnosis of tumours, properly so called, there are two very distinct sets of symptoms, which are derived, the one from their local action as they interfere with function by mere size and pressure, the other from their gene- ral influence upon health; the former common to all, the latter be- longing especially to malignant tumours. It is therefore necessary first to inquire into the localities in which they are found, and the evidence of their presence there, although this cannot be wholly separated from a consideration of their nature. A tumour lying superficially with reference to any of the great cavities, or on any of the extremities, leaves no doubt as to its ex- istence ; one that is deep-seated in the abdomen, when its margins can be felt, or its resistance detected by firm pressure with the points of the fingers, may be recognised with equal certainty; on the other hand, if contained within the cranium, or deep in the tho- racic cavity, and, in some instances, when situated close to the lumbar vertebras, its existence can only be inferred from symptoms derived from the organs contained in the cavities, and must remain more or less uncertain. The indications are most indefinite in re- gard to the cranium ; they are more easily made out when the tu- mour is in the chest, and are seldom wholly unaccompanied by more direct evidence when situated in the abdominal cavity. They must each be discussed in considering the phenomena peculiar to various 8 114 DETRAVED CONSTITUTIONAL STATES. organs at a later period; and for the present we must assume that the tumour is palpable. It is of importance to study carefully the history of all such cases. In some it will be found that the symptoms detailed corre- spond with the commencement and development of the tumour; in others, they are only those of its later stages ; while, again, the history sometimes points to a totally different disease, and it is only while pursuing this investigation that a tumour is accidentally discovered. This division corresponds in some measure to real dif- ferences of character, and roughly points out those having an in- flammatory origin, those whose character has more or less of malig- nancy, and those which are slow in their growth, and comparatively harmless, except in their secondary results. To this, however, there are numerous exceptions. When the patient has already become conscious of its existence, we seek to ascertain its specific history so far as it is known to him, the progress of its development, and the symptoms which have been associated in his own mind with its presence ; as well as those bearing upon the general state of health and the affections of other and more distant organs which have been observed since it was first recognised. In a class so extensive as tumours it is vain to look for general symptoms which shall characterize the whole of them, but there are many which are of much value in discriminating the nature of the disease, and the special locality where it is situated. It is there- fore our next business to observe each of those circumstances care- full}'- which have been mentioned as indications of the general state of the patient. Thus, as we know that the history is very often faulty, it is important to consider whether there be febrile symp- toms, either such as usually accompany inflammatory action, or those more distinctly pointing to suppuration ; or whether there be only the quick pulse of debility or tubercular deposit. Again, we have to consider the appearance of the patient, calculating how much of the change reported is due to the presence of the tumour, and how much may be accounted for in other ways; and to note whatever strikes the eye as a deviation from the normal ideal standard. This part of the inquiry has perhaps to do more with the nature of the tumour than its locality. Rapidity of growth is a very decided indication in favour of ma- lignant disease; such are also the evidence of general derangement of health and itions of distant organs, other than can be accounted for by nervous sympathy and inter-communication; they show the existence of a taint of the blood different from what accompanies non-malignant growths. The local signs of greater or less derangement of function in contiguous structures have also an important bearing on the question. The aspect of the patient may be of service in so far as the physiognomy of disease enables us to discriminate between the tuber- cular and cancerous diathesis for example. Changes of colour, again, rather point to the organ in which the disease is located. These general considerations are also of value, as they afford evidence of obstruction to the nutrition, or the circulation, in different parts of the body. Not less important, sometimes, are the MORBID GROWTHS. 115 indications derived from position, as the patient is obliged by pain, or other un- easy sensations, to maintain a fixed posture, or to prefer one to another. We have next to note the relations and connexions of the tumour itself; with the skin, with muscles, with bone, with glands, or with internal organs; and it must be evident that very much will depend on the correctness of the antecedent knowledge of the observer. He must be familiar not only with the relations of deep-seated parts in health, but also with the changes of position that they are subject to in disease, inasmuch as the direction of the displacement may serve to point out the true origin or starting point of the tumour. Not less needful is a correct knowledge of structure and of function, in order that he may be able to distinguish alteration of form from change of position, and to recognise symptoms of dis- ease in particular viscera. The simplest form in which we can recognise the existence of tumour is when swelling is the result of inflammation, with effusion of lymph and serum, which terminates either in resolution or in suppuration. It can scarcely be mistaken for growth of any kind, because of the pain and superficial redness in its early sta°- e - it is very closely adherent to the skin and muscular structures, which cannot be made to move over it. In the iliac region, and over the surface of the chest, such swellings in their advanced stage are apt to be taken for growth from bone- the diagnosis, when the history fails to indicate the origin of the tumour, rests upon two points, viz., that inflammatory effusion is evenly spread out among the mus- cular structures, while morbid growth presents a more defined edge; and that the one adhering more to the skin can be made to move over the bone, while the other adhering directly to the bone, does not become attached to the skin till it has at- tained considerable magnitude. In the chest, we may be also guided by the cii- cumstance that more than one intercostal space is equally filled up by superficial inflammatory action, whereas the fulness is almost entirely limited to one, or st most two, when growth of any sort from the rib is its cause, until its size is such as to leave us in no doubt. Enlarged synovial bursa?, and lymphatic glands, give rise to tumours in various regions. The former have a very elastic feeling, and are generally somewhat ten- der, or rather, one might say, a cause of aching than of pain; the latter are hard very constantly tender, and often inflamed : they ean onlv exist in the situations in which anatomy teaches us these structures are to be found in health. This forms the first ground for diagnosis ; and in regard to the glands, we have the further knowledge of the ordinary causes of their enlargement,— the existence of some wound of skin or irritation at a distance, and the scrofulous diathesis. Scrofulous enlargements are much more frequent in the neck than elsewhere. Difficulty is most likely to be experienced in deciding whether a swelling in the groin be an enlarged gland or a small hernia. The history will verv generally serve to clear up auy doubt, because the descent of a hernia is sudden," commonly after a strain or muscular effort, and if it continue to enlarge it soon exceeds the magnitude of a gland. In addition to this, a hernia mav be almost always pushed back, and protrudes sensibly on forced expiration in coughing. Enlargement of the mammary gland is another form of superficial tumour: its consideration be- longs entirely to the domain of surgery, as also does that of fatty tumours. In reviewing the various regions, we find on the scalp encysted tumours, peri- osteal thickening, and fungoid growth; the former distinguished by their not beW adherent to the bone, the latter by their hardness and tenderness. The face is especially the seat of epithelial cancer. In the neck we encounter enlarged glands both lymphatics already mentioned, and salivary glands, which will be° noticed in speaking of affections of the mouth and throat. We also find occasionally a chro- nic enlargement of the thyroid gland, in the form of goitre. This is a tumour 116 DEPRAVED CONSTITUTIONAL STATES. soft and painless, ami generally very moveable, extending across the trachea, be- low the larynx, commonly more to one side than the other. There are no general symp onnected with its presence; it may indicate faulty nutrition, bat the health is unimpaired, and it is more a matter of inconvenience than actual dis- ease. The region of the neck is closely connected with the thoracic cavity, and deep- Beated tumours there, may come within reach of the finger as they rise in the neck. We are not now to enter upon the consideration of such as can only be recognised by auscultation ; our present purpose is only to speak of those which are superficial. Mention has already been made of tumours upon the ribs, and inflammation and suppuration of the wall of the chest. Where matter has already formed, a soft tumour is found on the surface of the chest: this may have its origin in a local collection of pus in the pleura making its way out. The history of internal in- flammation and superficial abscess is in general different, and if there be any doubt on the subject, recourse must be had to the evidence which the stethoscope affords of the state of the lung and pleura. Aneurism also gives rise to a soft tumour when it reaches the surface, but this commonly pulsates; a collection of pus can only do so under peculiar circum- stances. The pus generally tends to the lower part of the chest, aneurism more frequently shows itself at the upper. In both cases the lungs and heart must each be examined; and some trace of disease in the one or the other will serve to de- termine us whenever there is any obscurity about the symptoms. A firm elastic tumour protruding above the ribs, is generally an advanced stage of malignant growth in the chest. It is associated with general dulness on per- cussion either on one or both sides, and with indications of pressure on the bron- chi, the vessels, and the nerves; with local pains in the arms, local oedema, venous tortuosity, occlusion of arteries, &c. These symptoms will be taken in detail here- after. It is to be remembered that the sallow hue of malignant disease is gene- rally obscured by the obstruction to the circulation. Fungoid tumour, attached to the interior of the ribs, and pressing out between them, is not very easily distinguished from superficial swelling. It very often happens that the patient has first noticed it after unusual muscular effort, and its progress has caused such infiltration and even protrusion of the parietes, that it is liable to be regarded as having been caused by the strain, and to consist merely of an effusion of blood under the muscles. When close to the sternum, its cha- racters are more palpable, as a rounded, firm, and elastic swelling; it has not the softness of a collection of fluid, but it may pulsate, from its proximity to the heart. After a time the cachexia of cancer, or the appearance of a second tumour, may remove all doubts. In thoracic tumours recourse may sometimes be had to the introduction of a grooved needle. It must be admitted that this is only a refuge for ignorance; but ignorance is sometimes unavoidable .in such obscure cases. In the abdomen, a tumour may be simulated by mere muscular resistance. Knotted contraction of the rectus, or even of some portions of the transverse mus- cles, may give rise to doubt ; some patients cannot be brought, by any inducement, perfectly to relax the muscles, not only from unwillingness, but from some abdo- minal irritation. This feeling of hardness is less local than tumour; it is also per- ceived to move with the parietes, and cannot be pushed aside. A jerking move- ment with the tips of the fingers in making pressure over different parts, will often serve to determine whether there be any hardness behind the abdominal walls; or by slow, firm pressure, we may overcome the parietal resistance. It is also im- portant to ascertain whether there be dulness, on percussion, over the part, where the existence of a tumour is suspected. When a tumour is made out, its relation to the abdominal viscera must next be considered: if small, its present position; if of some size, its point of origin. But patients very often give the most extraordinarily inconsistent accounts of the ori- gin of these growths. In the right hypochondrium it is probably connected with the liver, and the symptoms of disease of this viscus must be studied. It may be simply enlarged, from congestion or inflammation; or from chronic disease; or it may be displaced MORBID GROWTHS. 117 from the pressure of a belt in men or of tightly-laced stays in women. Under such circumstances, the edge of the liver of nearly its natural form may be felt, some way below the margins of the ribs, with firm resistance above and duluess on per- cussion. Sometimes on the surface of this enlarged mass a rounded fulness is ob- served, giving a sense of obscure fluctuation. It is important to distinguish that it is on the surface, and not at the edge, where a distended gall-bladder may be felt in the same way. If the history and symptoms are those of acute disease, this will indicate suppuration; if they are chronic, it is more probably due tr> the pre- sence of hydatid cysts. In place of the regular form of an enlarged liver, several rounded masses may be felt in this region, extending more or less across the epi- gastrium. This is undoubtedly malignant, and the diagnosis of its connexion with the liver depends both on the general symptoms of disease of that organ, and on the circumstance that, by percussion and palpation, it is ascertained that they are continuous with it. This point must always be thoroughly investigated, because, of necessity, when enlarged, it extends into the epigastrium, as it is limited by the ribs in the opposite direction. One or even more hard masses in the centre of the epigastrium, or lower down towards the umbilicus, not connected with the liver, are most commonly caused by cancer of the stomach. The general symptoms are more especially referrible to that organ, and there is almost always vomiting, which at one period or other has been grumous or like "coffee grounds." The sallow, anaemic hue of malig- nant disease is especially marked, from the combination of cancerous growth and mal-nutrition. In the left hypochondrium, simple enlargement of the spleen produces a tumour of an oval figure, which is perfectly even on the surface. This mass has some- times been of such size as to reach quite down into the right iliac fossa. Its at- tachment is in the left hypochondrium, and the diagnosis will be more or less cer- tain, as this fact can be made out. Occasionally a firm, hard tumour may be felt to the left of the epigastrium, which cannot be traced into the hypochondrium, and which, though accompanied by mal-nutrition, has not been associated with symptoms distinctly traceable to disease of the stomach; such tumours have been found after death to be owing to scirrhus of the pancreas. The diagnosis is very difficult, and the position of the stomach is often such as to render it impossible to feel the hardened mass during life. In the lower part of the abdomen in females the conditions of the organs of ge- neration, the uterus, aud ovaries must be considered: these will be discussed in their proper place. Tumours connected with these organs all spring out of the pelvis. In the right iliac region accumulations of fasces may simulate a tumour: this, though their most common, is not their only locality; and I would take the opportunity of reminding my younger readers that, in all examinations of the ab- domen, care should be taken to obtain a full and free evacuation of the bowels before a diagnosis be pronounced. Similarly, in the centre of the hypogastrium, a hard, round tumour may be discovered, simply due to over-distentiou of the bladder. By careful manipulation, fluctuation can be discovered; but here, too, caution must be exercised, and, in cases of doubt, a catheter should be introduced, to ascertain its exact condition. Tumours below the level of the umbilicus, not traceable to these causes, gene- rally have their origin in diseased conditions of the omentum, or of the lymphatic glands of the abdomen, or in local peritonitis. The two former present more de- cided characters of tumour, defined and indurated; the latter is more diffuse, and very generally adherent to the parietes. They differ, too, in their history, as peri- tonitis is associated with pain and febrile disturbance, which are not essential to the others; and while the disease lasts, the symptoms are those of a partially acute disorder. It very often terminates in abscess ; it may be caused by a blow, or by inflammation or ulceration of some part of the bowel. In females, it may be con- fined to the structures round the uterus, and is best distinguished from the specific diseases of the generative organs, by their having become adherent to the sur- rounding parts, by the undefined character of the swelling itself, and by its ten- derness on pressure. US DEPRAVED CONSTITUTIONAL STATES. Disease of the omentum comes on gradually; it may be associated with irregu- larity of the bowels, sometimes marked by constipation, and not unfrequently by some form of hemorrhage, but not attended with fever. The general state of the nt is ana-mic and cachectic: the tumour itself is generally hard, and often nodulated, and may be made to move by turning the patient in bed from oue side to the other. It often gives rise to pain, but is not essentially tender. Disease of the glands very generally causes oedema of the feet and legs; and sometimes also ascites, which much obscures its diagnosis: in this case, its cha- racters are ill-defined, but the tumour is generally found firmly fixed, and deeply seated towards the spine. Tumours in the abdomen are very liable to pulsate; and the question will occur, whether it be aneurism. Abdominal pulsation is of comparatively little value, be- cause all the contents of the abdomen, lying as they do above the aorta and great vessels, are liable to succussion at each systole of the heart ; neither is the pre- sence of a "bruit" to be too much regarded, because, even in health, considerable pressure, and, in anaemic states, very slight pressure on a large vessel, is suilicient for its production. Enlargements of the liver and spleen are least likely to simu- late aneurism. (For further particulars the reader is referred to Chap. XXIII.) § 3. Of the Characters of Tumours. — After what has been said upon the localization of tumours, there is little to add on the sub- ject of their discrimination, as that can only he dealt with on cer- tain broad principles, when internal organs are concerned. To the surgeon it is all-important to be able to determine whether an external tumour belong to the class of malignant or non-malig- nant disease; whether the condition of the patient be such as to lead him to recommend its removal with the knife, or to abstain from so doing ; or whether the character of the tumour be such as gives him ground to hope for its diminution or disappearance by the employment of remedies of a less formidable character. To him, however, the question involves a great deal more than the consideration of the mere palpable characters of the tumour; he, too, has to consider its history, its mode of growth, and its effects, as well as the condition of his patient, both with reference to cir- cumstances connected with his previous life and his present state. To the physician these are the questions of real moment: many anomalous conditions are found after death which had, and could have no history during life; many which, while offering few analo- gies to the post-mortem inquirer, have histories scarcely distin- guishable the one from the other ; while, again, many of which the histories differ present lesions closely corresponding. The knowledge of these difficulties must not deter us from making the inquiry, so far as practicable, into the exact nature of the disease ; but it ought to lead us to embrace in our view the whole of the circumstances of each individual case. To these we especially look for guidance in determining the very important question, whether we have to do with the results of inflammation, or with a true or false hypertrophy of the organ, or with a malig- nant and necessarily fatal disease; and we must place in a subor- dinate rank the suggestions that may be received from the locality or the sensible qualities of the tumour. The forms which have been admitted into the table as being met CHARACTERS OF TUMOURS. 119 ■with in the medical -wards of the hospital are : (a) cystic growths, (b) fungoid or encephaloid cancer, (c) scirrhus, (d) colloid cancer, (e) growths from bone. a. In considering the relative frequency with which we encounter these several forms of morbid growth in different regions or organs, it may be remarked that cystic growths divide themselves into two classes, the acephalo-cyst, which is entirely adventitious, and the simple or compound cyst, which consists of an abnormal develop- ment of natural structure. We have already referred to the con- nexion between the acephalo-cyst, or simple hydatid, and the echino-coccus ; practically there is no advantage in discriminating cystic growths except in so far as the knowledge of the presence of fluid derived from its fluctuation leads to the evacuation of the con- tents. They all have this property in common, that their destruc- tive tendency is limited to the organ in which they are situated, and they affect the general health no further than as the function of that organ is of importance, or their size interferes with the in- tegrity and usefulness of surrounding structures. The hydatid is especially prone to infest the liver ; and there it is alone that its presence can be made out with the remotest degree of confidence during life: of the other forms of cyst those only claim any notice which are found in the mammae and in the ovaries. Pathological anatomy, indeed, teaches us that other organs are liable to become the site of cystic growth, but I know of no test by which they can be brought under the province of diagnosis. b. Fungoid or encephaloid cancer is the form of malignant dis- ease commonly found in the chest, whether it be attached to the pleura or the mediastinum (in both of which it is sometimes a mat- ter of doubt whether its first point of departure be not from bone,) or whether it be developed from the intra-thoracic glands, or, as happens in rare instances, from the glands in the axilla. In the abdomen, it is the character which cancerous growth generally pre- sents in the liver, it is that which is always developed when its ori- gin is in the deep-seated lumbar glands, and it forms the most numerous section of cancers of the uterus and vagina. c. Scirrhus, again, exists in the largest proportion of cases of cancer of the stomach; it attacks the rectum, and in rarer cases, other portions of the alimentary canal : in all of these we rest our diagnosis chiefly on that which is known to be its constant result, partial occlusion of the passage, which is not unfrequently com- bined w 7 ith subsequent ulceration ; evidence proving this event is therefore very confirmatory. Scirrhus of the uterus and vagina are often spoken of, and no doubt exist in many instances: most commonly, however, it is combined with fungoid disease, and very often cases are called scirrhus which ought to be called fungus. d. Colloid cancer seems most readily developed in the loose structure of the omentum and of the peritoneum generally; and its existence can only be inferred from the fact of abdominal en- 120 DEPRAVED CONSTITUTIONAL STATES. largement, which cannot otherwise be accounted for, coinciding with constitutional disturbance. This form of cancer, however, is the one in which cachexia is least marked; and I must again repeat that that is the most important point in medical diagnosis when wc speak of cancer. It is at least unwise to give an opinion implying the existence of cancer when the general indications do not point to something more than can be traced to local disorder; and while it is quite true that all internal growths are of serious import, because they are so little amenable to treatment, we must exercise great caution in attempting to analyze further, and say what is the exact character of the growth. e. Growths from bone seldom come under the physician's notice, except when developed in the mediastinum, on the ribs, or on the bones of the pelvis: in these localities they are usually of a malig- nant character; the slower growing enchondroma is less common in them than in the long bones of the extremities, and the same is true of the myeloid growths which have of late occupied the attention of surgeons. In history and physical characters, each of these forms of tumour presents differences which aid in their discrimination. Those con- nected with the ovaries will be discussed in a future chapter; and in speaking of the female generative organs, we shall have to treat of growths peculiar to the uterus, which are not here alluded to, because of their invariable local connexion. (See Chaps. XXXII. and XXXIII.) The diagnosis of cystic diseases of the mammas is essentially a question of surgery. Serous cysts in internal organs are distinguished by their even, rounded surface, and the sense of fluctuation given to the finger of the observer; from their history we learn that the development has been slow, while the condition of the patient proves that health is only interfered with so far as pressure impedes circulation, nutrition, or secretion. Encephaloid cancer is also rounded; but its surface is seldom even, it is nodu- lated and irregular, firm and elastic to the touch. Its history is of decidedly rapid growth, though it varies much in this respect; the patient suffers not only from the destruction of the organ which it affects, and the evils arising from interrupted function, but also labours under a cachexia which infects his whole system. Scirrhus feels very hard, and presents only one or two distinct nodules with more or less irregularity of surface. Its progress is slow; its history details disordered function long before any tumour has been noticed, and the cachexia of the patient derives increased intensity, from the interference with due nutrition, when the disease is situated in the alimentary canal ; pain is more constantly present in this than in any other morbid growth. Colloid cancer presents an unevenly rounded, highly elastic surface; it may give a sensation to the ringer nearly akin to fluctuation; the secondary nodules, which would serve very often as a pretty certain index of its nature, cannot be detected during life. Its growth is rapid; it does not CHARACTERS OF TUMOURS. 121 greatly impregnate the system at large, but its position is such as commonly interferes very considerably with the assimilative process. The malignant growths from bone belong to the more rapid-growing cancers, although generally firm and inelastic. This fact in their history serves to distinguish them from the non-malignant osseous growths, but their diagnosis need not go much beyond the question of the real or simulated connexion with bony structure; this is proved by their immobility and position. They take more or less the direction of the bone to which they are attached, and while some degree of movement can be made out between the superficial structure and the tumour, none can be obtained by any manipula- tion between that and the bone. Enlarged synovial bursas and fatty tumours are recognised by their general indolent character, their locality, and the sense of fluctuation and elasticity which each presents. 122 CHAPTER X. THE QUASI-NERVOUS DISEASES. § 1, Hysteria — Evidence almost entirely negative — Simulation of other Diseases — § 2, Chorea and Tetanus — The Muscular Symp- tom in each — Causes and Associations — § 3, Delirium Tremens — Condition of Patient — Alliance to Mental Disease. § 1. Hysteria. — The important distinction we have drawn be- tween objective and subjective phenomena, derives its fullest illus- tration from this protean malady. Here the sensations of pain and uneasiness are out of all due proportion to the derangement of function and of nutrition ; the feelings of the patient are the all- absorbing idea in her mind, and so completely do they take posses- sion of her faculties, of her very nature, that vital functions over which she has really no voluntary control, are swayed by the force which these feelings exercise when they become concentrated on any particular organ. Although most fully developed in the female sex, and originally deriving its name from a supposed excitement of the female generative organs, an analogous disease is not unfre- quently seen in men exhausted from any debilitating cause, or effeminate from over-care and nursing of themselves; extreme nervousness is the only term in common use to express such a state. There is no exact line of demarkation between this condition and one in which, the attention becoming fixed on some particular organ, sensations are supposed to arise there, of the non-existence of which we are satisfied by collateral evidence of their absurdity or impos- sibility: to this the name of hypochondriasis has been applied; it merges into insanity. The question of diagnosis then simply takes the form of an inquiry into the reality and importance of the complaints of the patient. When these stand alone, or are out of due proportion to other evidence of disease, we conclude that they are exaggerated, if not unreal; and when their intensity, as described in language, is not borne out by the actual effect upon the individual, we conclude that they are unimportant. The following remarks will apply to either sex, although especial reference must be had to the female in discussing the subject of hysteria. There is usually such a con- stant simulation of other diseases, that it is impossible to draw any general picture of it which would apply to every case, the only feature which they have in common, being the negative one of the absence of some important indication which is absolutely essential to the existence of the reality which is imitated by it: the function which ought to be deranged is unchanged; the sign or the symptom HYSTERIA. 123 which ought to be found is 'wanting; or we may even obtain direct evidence that the organ which is supposed to be the seat of disease is in a perfectly natural and normal condition, except that it is the point on which those morbid sympathies are concentrated. It has been already pointed out, how impossible it is to form any standard of comparison by which to measure expressions of pain. Other sensations admit of more analysis, and generally have a more definite range. Thus a sensation of numbness may be analyzed into actual deficiency of sensitive power, or into mere tingling, which produces a relative feeling of insensibility: a sensation of weight, whether in the head or at the epigastrium, is an explicit statement of what we can understand, and what we can generally refer to some co-existing morbid state. Of pain generally it is most important to remember that it does not imply inflammation: too frequently these words are regarded as almost synonymous, and complaint of severe pain calls forth all the energies of anti-phlogistic treatment: it is in reality nothing more than an expression of irri- tation of some nerve, and the cause of that irritation is to be sought for. The history often throws great light upon the nature of the case. Disorder of the uterine functions, often, very often, acts upon the imagination of the patient, leading her to pay attention to and exaggerate slight uneasy sensations. Long ailment without mate- rial loss of flesh, proves that the sensations are not indicative of serious disease. The commencement of the present attack has not been ushered in by the usual accompaniments of an acute or febrile disorder; in place of rigor or flushing, there has perhaps been a fainting fit, or an hysterical paroxysm, and the whole relation of symptoms betrays more or less of inconsistency in their sequence and their supposed causes and effects. At the time of examination the pulse may be either quiet or temporarily excited and quick, without heat or dryness of skin ; it is not hard or wiry, it is not firm nor is it often full, but generally weak, and varying with the least excitement. If the face be flushed, it is out of proportion to the condition of the rest of the skin. The tongue may be evenly coated, with projecting red pa- pilloe ; but there is no red edge, no thick brown streak in the centre, nor any patchy abrasion of epithelium ; it is not dry, nor is there accompanying thirst. The urine is pale, limpid, and copious; the bowels not altered from their usual state. There is no marked emaciation ; there is no pinching nor anxiety of features; sometimes a marked readiness to tears, or alternation from smiles to frowns. There is often alleged loss of power, in one or both legs, or in one arm. The best evidence of the reality of this state is obtained by rather rough handling, which will always bring out resistance; but it must be remembered that real loss of power is sometimes associated with spasm or reflex action, and to complete the evidence the limb should be placed in a constrained position, while the 12-1 THE QUA SI- NERVOUS DISEASES. attention of the patient is strongly directed to some other organ; if the mind be thoroughly pre-occupied, it will be supported for a moment or two by voluntary effort. On examining the region to which pain is referred, we very gene- rally find extreme tenderness; the slightest touch is represented as very painful, much more so than anything short of the most intense cutaneous inflammation could account for ; it is diffused over a large surface, and is not local or limited; and if the attention can be abstracted, very firm pressure is borne without apparent increase of suffering. Very good evidence of this fact may be obtained by varying the tactile manipulation with one hand and directing the patient's attention to that, while firm pressure is made with the other, or by referring to the condition of the uterine or any other functions in which the patient feels especially interested. • In females the globus hystericus, or rising in the throat, or the occurrence of a regular hysterical paroxysm, often materially aids the diagnosis. But all the ordinary evidences of hysteria must not cause us to forget the possible co-existence of some severe ailment in such a constitution ; and this so much the more that the very exaggeration of the symptoms may lead us to doubt the existence of actual disease in its early stage, when practical experience teaches us that it is not necessarily associated with such symptoms. It is often a very nice point to determine what is due to imagina- tion — perhaps associated with perverted volition, — what is simply due to exaggeration, and what there is of real disease in the condi- tion of the patient; and this can only be done by carefully weigh- ing the relation of disordered sensations, of perverted functions, and of abnormal or normal physical signs in each organ in succession. As the more frequent forms of hysteria are mere simulations of severe disease, so a regular hysterical paroxysm is, after its fashion, a simulation of epilepsy. The limbs are tossed about with the same violence, but more of method may be detected in the hyste- rical, more of regularity in the epileptic convulsions. The patient in epilepsy bites his tongue severely, hurts or wounds himself in falling ; the hysterical female never seriously injures herself, and is only bruised by the energy of her movements during the paroxysm. The expression of the features is often horribly distorted in epilepsy; is generally placid in hysteria, with a quivering tremulous move- ment of the closed eyelids. The epileptic fit ends in deep slumber, the hysterical paroxysm often in tears : in the one consciousness is suspended, in the other it is not so, except when fainting occurs; but of this it is sometimes extremely difficult to feel quite certain. § 2. Chorea and Tetanus. — This is perhaps the best place to notice two diseases which stand on the confines of general disorder of the whole system, and special derangement of the nervous element in it. They are marked by striking objective phenomena, which consist of acts of the muscular system not only involuntary, but CHOREA AND TETANUS. 125 uncontrollable. These acts may be associated 'with, a variety of other symptoms, as they may be with differing conditions of in- ternal organs ; but the muscular movement stands by itself as the sole indication by which the disease is recognised. Here diagnosis has but little to do. The element of the disease is quite unknown to us, and hence it is to the prominent symptom alone that we have as yet to look for the discrimination of each; to this symptom the name of the disease is applied, and by this is it characterized. The movements of chorea once seen can never be forgotten or mistaken ; nor can the fearful spasms of tetanus be taken for any- thing else. It is true that in severe lesions of the brain, when the patient is in a state of stupor, or of delirium, convulsive movements may be seen in some cases, spasms of muscles in others; but no one who has seen the diseases can ever mistake them for chorea or tetanus. It is quite foreign to the purpose of this work to draw pictures of disease, as our sole consideration is the gronnd upon which diagnosis is to be formed. In chorea we rely upon the restless jactitation, the tossing hither and thither in the most uncertain manner of one or more limbs, or of the whole body. In tetanus, on sudden and violent contraction of various sets of muscles, frequently alter- nating with as sudden relaxation. In chorea the system at large does not suffer much disturbance, except when other conditions of disease are associated with it: in its more severe forms the expression of the features is almost maniacal, and the patient becomes gradually exhausted from constant restlessness, inability to take food, and imsomnia, terminating in delirium, coma, and death. In te- tanus the system early indicates febrile disturbance of a low and adynamic charac- ter, and the disease is generally attended by rapid sinking and prostration. The spasm of tetanus is called clonic, from its sudden invasion, alternating with relaxa- tion: it can scarcely be confounded with tonic spasm or perpetual contraction of particular muscles, which is constantly associated with organic diseases of the nervous centres, especially with certain forms of pressure and with induration of the brain or cord. Both chorea and tetanus maybe simulated by hysteria; but the imitation is not such as can impose upon any one who has observed the true disease and is prepared for such a simulation. In hysterical movements there is necessarily more method than in those of chorea; in hysterical spasm there is seldom the exact correspondence in the condition of a whole set of muscles found in true tetanus. In either case, when the suspicion is awakened, the abstraction of the patient's attention will serve to interrupt the movements or relax the spasm. These diseases are generally found associated with some cause of irritation; it may be said, perhaps, that they are always so, although our means of analysis frequently fail to detect it. In chorea we have to seek for some shock to the nervous system in sudden fright, or some irritation in the digestive system ; loaded bowels, worms, &c: sometimes the vascular system is deranged, and there may be a condition of anasinia or disease of the heart; not unfrequently it is asso- ciated with that peculiar condition of blood that manifests itself in rheumatism ; sometimes there is disease in the nervous system, but it has been less uniformly traced to this than to the other conditions already enumerated. In tetanus we inquire whether it be dependent on the irritation of some par- ticular nerve, or on some obscure affection of the brain or spinal cord; whether it be eccentric or centric; traumatic, from the irritation of a wound, or idiopathic, without known cause: in the latter case the question whether it have arisen from the administration of poison is suggested by the fearful revelations of recent times. Our investigations can reach no further. o" § 3. Delirium Tremens. — We must also class this as a disease which involves something more than mere disorder of the nervous centres. It seems to be due to perverted nutrition of the brain 12G THE QUASI-NERVOUS DISEASES. consequent on the circulation through its mass of impure blood unsuited to develop healthy functions. Its relation to the nervous system is somewhat similar to that of mania : in classification nei- ther of them can be regarded as diseases of the nervous system, because in each there is an element extraneous to it ; but in their development they are so intimately associated with it that we cannot doubt that they are accompanied by hidden change of structure. "With reference to diagnosis, it will be more convenient to consider this disease, when speaking of delirium as a symptom of the con- dition of the brain, where its relations to other forms of delirium will be more easily exhibited. But there are certain general ob- jective phenomena by which it is marked; it is a delirium cum trcmore. Tremor is its essential characteristic, which every act of the patient betrays: the hand cannot be held still; but there is neither the jactitation of chorea, nor the regular shake of paralysis agitans ; the tongue quivers when protruded ; and these movements dTffcr from the ordinary tremulousness of pure nervous debility, in the rapidity and excitement with which each act is performed. The patient sits down and gets up in a hurry, he raises himself in bed with a spring, he turns suddenly round to the person who addresses him, he thrusts forward his hand for the pulse to be felt, and he puts out his tongue with the same quick unsteady movement, when directed to do so. All this may occur before any delirium has showed itself. From the patient himself, or his friends, it will be learned that he has either lately had a drinking bout, or that, being an habitual drunk- ard, he has been, under circumstances of privation, debarred from his accustomed stimulus ; perhaps that there has been some mental anxiety, and along with this, his last few nights have been sleep- less. He will say that he has been long ailing, that his present state has been supervening for weeks or months, and will often be exceedingly shy of telling that there has been any recent aggrava- tion of his symptoms, or that they have, as we may be well assured from other sources, all come on within a few days : this appears to arise from a consciousness of the real cause of his malady, which he vainly fancies he may conceal ; but it is worthy of noting, because it might lead to a mistaken diagnosis. The pulse is soft, often large, sometimes weak and quick. The tongue is evenly coated with a moist creamy fur. The skin is warm, frequently perspiring; but in the early stage itmaybe dry, and often exhaling somewhat of a rheumatic odour ; it has never the heat and pungency of fever. In former days, when delirium was regarded as evidence of inflammation, depletion was no less had recourse to in this than in the delirium of typhus fever, or of ma- nia: but in this practice essential symptoms were evidently over- looked — that of the pulse and the moist tongue; and just as in at- tempting to form a correct diagnosis, so for the purpose of adopting sound treatment, the totality of symptoms must be considered in place of the mind being fixed on one which is remarkably prominent. 127 CHAPTER XL GENERAL EXAMINATION OF REGIONS AND ORGANS. Diseases often a Compound Phenomenon — All Organs ought to he examined — Negative as luell as Positive Results stated — Exami- natien of Brain and Nerves — of Chest — of Digestive Organs — of Urinary Organs — of Uterine Functions — Appearance of shin. We come now to the consideration of particular organs, and it will be found that many of the more general indications sought for in the earlier part of the investigation have an especial bearing upon the diseased states to which each organ is liable. These the student has been advised to note as he proceeded in his inquiry, whether observed in the details of the history of the case ; or in the general symptoms pertaining to the skin, the pulse, the tongue, the bowels and kidneys ; or in the appearance and position of the patient. He has also been advised not to attempt to form a judgment on the case before each indication has been fully investigated, and the seat of any complaint of pain or uneasiness has been thoroughly ex- amined: but he must be further warned that, although the history of the case, the general symptoms and the particular disorder, cor- respond to each other and make up one intelligible whole, he has not done his duty to himself or his patient unless a survey, however rapid, have been taken of the condition of each particular organ. This course is absolutely necessary, not only because the discovery of some obscure change may throw fresh light upon the totality of the symptoms, and ultimately lead to a different and more cor- rect diagnosis ; but for the no less important end of ascertaining whether any distinct and superadded malady exist, which may most materially modify the treatment. As already stated, the order in which it is proposed to examine these organs follows the usual division into regions, — the head, the chest, the abdomen, and the extremities, taking the dependent struc- tures connected with the principal organs situated in each of these regions as they successively come before us. We commence with those of innervation, the brain, spinal cord, and nerves. We then take those of respiration and circulation, the lungs, the heart, and blood-vessels; next, those connected with digestion, beginning with the mouth, the stomach, and intestines, with their investing mem- brane, followed by the liver, spleen, and kidneys; and, lastly, the ovaries and uterus. After these will be noticed, the skin, cellular tissues, bones, and muscles. Throughout the inquiry the importance of system in every step of the investiga- tion has been pointed out, and I recommend to the student either to adopt the ar- 128 EXAMINATION OF REGIONS AND ORGANS. raogemenl just mentioned, or to form for himself some other plan more consonant with tin' theory of disease which he has been taught: in every case which presents itself tn him he ought to follow exactly the same course in examining the different ins, although occasionally he may find it advantageous first of all to examine thoroughly that organ which the history of the case, or the prominent symptoms, whether objective or subjective, point out as the probable seat of disease, provided he have not, from general indications, come to the conclusion that the disease is one of those having no local site, which have formed the subject of the preceding pages. His next care, in either case, should always be to examine in a definite c the various organs, with their local phenomena, and to note in his case-book the negative as well as positive results which he obtains. As a mere matter of detail, I would suggest that he should never enter in bis notes such vague expressions as "chest healthy," but state explicitly the extent of his examination and its results, which need not, however, occupy much more space. Thus, to take the case of the chest, he may state simply that there is "no com- plaint of pain, palpitation, cough, or shortness of breathing;" and this would im- ply that the chest had not been examined by percussion or auscultation, lie may go further, and record that "nothing abnormal has been discovered by percussion or by auscultation," or he may limit himself to some particular portion, "breath- ing natural under the clavicles, at the back of the chest," &c; in the one case, he is understood to have examined the whole, in the other, only a part. The chief use of all these suggestions is to establish habits of accuracy; but if he should ever wish to refer to these cases in after years, if it should be his lot to publish reports of them for the information of others, then the value of definite statements will more clearly appear. In looking for indications of the state of the brain, we direct our attention to the mental phenomena of consciousness and coherence: we have to observe whether there be any degree of slowness of ap- prehension, or inability to understand and reply to questions; whether there be any wandering of thought, as expressed by talk- ing, or muttering, or irrational acts; and the relations which these bear to each other. The appearance of the eye is closely connected with the state of the brain, as shown in strabismus, and dilatation or contraction of the pupil. Deafness is another important indica- tion, especially when associated with discharge from the ear: so is the manner of speech, slow, hesitating, or imperfect. These ob- jective phenomena are not all equally valuable; strabismus and deafness may have nothing to do with the present state of the brain ; incoherence may be simulated by hysteria: want of consciousness by obstinacy; the manner of speech may be a congenital defect; but they are each suggestive of further inquiry. In hysteria, we often meet with imitations of these various states, talking nonsense, singing, pretended sleep, cataleptic trance, &c. ; and if suspicion be aroused by the incongruity of these with the general state of the patient, or if the history indicate any previous symptoms of an hys- terical character, careful watching may trace consciousness when there is pretended stupor, or a method and artifice in the delirium, which disease never presents. Subjective phenomena consist of statements of headache and giddiness, double or distorted or indistinct vision, tinnitus aurium, perversions of smell or taste, insomnia, loss of memory, &c. The condition of the nervous system generally is indicated either EXAMINATION OF REGIONS AND ORGANS. 129 by the condition of muscles, in paralysis, convulsion, or spasm; or by sensations more purely nervous, pain, numbness, tingling, or anesthesia. Disease in the chest is shown by liviJity of face, hurry, labour, or difficulty in breathing; by a history of cough or sensations of pain and dyspnoea. These more probably point to the heart, if palpitation be complained of, with irregularity of pulse, and the dyspnoea be felt in mounting a hill or going up-stairs: they rather point to disease in the lungs, if cough be the more prominent symptom, accompanied by expectoration. Diseases of the digestive organs will have for their general signs, loss of appetite, or a sensation of craving; pain after food, or occasional vomiting; constipation; diarrhoea; disordered states of the tongue without corresponding indications of fever; pains in the epigastrium and in the abdomen; fulness, tympanitic distention, hardness, tenderness, or fluctuation. For the kidneys we have always the ready means of inspecting the urine, and, in cases of doubt, examining it chemically and mi- croscopically. Pains in the loins, in the groin, testicle, or urethra: excessive, scanty, frequent, or painful micturition ought always to lead to further inquiries. - In females, it is generally desirable to ascertain the condition of the menstrual flux; regular or irregular, scanty or excessive, the intervals being too long or too short, and its appearance being ac- companied by pain or uneasiness. We ought also to learn whether there be any other vaginal discharge. Eruptions on the skin, or distortions of bones and joints, do not readily escape observation; but, whenever pain on the surface is complained of, an inspection of the part is advisable, as it fre- quently solves a doubt or a difficulty which all the description in the world fails to unriddle. By such observations we determine whether further examination of any particular organ may be necessary, not only in the way of instituting a more minute inquiry into symptoms, but also of making, when possible, a physical examination. Those connected with states of innervation have a high importance in the phenomena of disease ; but here the physical aid is wanting, and too often we cannot get beyond a simple induction based upon the symptoms both general and special; and to them we now proceed. 130 CHAPTER XII. SEMEIOLOGY OF DISEASE OF THE BRAIN. Causes of Obscurity. — History imperfect. Div. I. — Sy?nptoms derived from Mental Functions. — § 1, Coma, or Insensibility — § 2, Stupor, or Unconsciousness, — § 3, Insomnia. — § 4, Delirium — of Fever — of Delirium Tremens, of Inflam- matory Fever — of Inflammation of Brain — of Insanity. Div. II. — Symptoms from Nervous Sensibility. — § 1, From General Alterations of Sensibility — § 2, From the Sense of Sight — § 3, From the Sense of Hearing — § 4, From Special Sensations. Div. III. — Alterations in Muscular Movement. — § 1, Spasmodic Action — § 2, Paralysis. In no department of medicine is diagnosis more obscure than in that upon which we now enter. Enclosed within its bony case, al- terations in brain structure corresponding to phenomena during life can never be discovered till after death, when it is much more difficult to trace their connexion; and numerous and diversified as are the functions of the organ as a whole, physiologists have yet failed to determine with any degree of accuracy, the particular regions in which its various powers are developed, or the special uses of many of its parts. The theories of Gall and Spurzheim, had they been based on any sufficient groundwork of fact, might have rendered essential service in discriminating the site of diseased action ; but experience has shown that perversions of those mental functions which form the basis of their system do not depend upon, or even correspond with, lesions of the brain in those regions to which the names of organs have been assigned; and it yet remains to be proved that special portions of matter are at all necessarily connected with particular actions of mind. In addition to these difficulties we find one set of head symptoms, which, from their transitory character, can scarcely be supposed to depend on change of structure; others which, though more persis- tent, leave no trace for the observation of the anatomist: both of these must as yet be considered simply as disturbances of function, though in their characters, they approach so nearly to the symptoms of structural disease, that it is often very difficult to distinguish them. On the other hand, the evidences of structural disease of very different kinds are so exactly analogous, that the physician is often at a loss in endeavouring to assign to each its exact cause: no less perplexing is the circumstance that the obscurity of the mental faculties in many of these conditions of disease deprives us of the aid which a true account of the patient's sensations might afford, CONDITION OF THE MENTAL FACULTIES. 131 as they are blunted, or perverted, or the power of analyzing and describing them is lost. For the same reason, it is not unfrequently impossible to obtain a history of the case at all available for the purposes of diagnosis; and yet no part of the inquiry is more important. Impracticable as the exact discrimination of symptoms may be at the time of ob- servation, each case is generally marked by successive features in its history which, if they have been properly noted and carefully studied, will throw most important light on its character and causes. The pathology of the brain is much less understood than it ought to be in the present day, in great measure, I believe, because the importance of the antecedent phenomena has been underrated, and the symptoms have been read apart from the history. Abercrombie is deservedly one of the great authorities on diseases of the brain ; but the principles of diagnosis cannot be learned from his work on this subject, because, in most instances, the previous history of his cases is so meagre. Let it be remembered, too, that in the present state of our knowledge this record of the symptoms during life is, in many instances, all that is really known of the disease, all that is really valuable in treatment: and thus, in thiPcase, diagnosis be- comes, as it ought to be, the hand-maid of practice. Mental alienation forms another element in the consideration of diseases of the brain, which is, as yet, very much beyond the reach of pathological research. Without speaking dogmatically, it may be affirmed that scarcely any lesion has been found in cases of in- sanity which has not also been present in instances in which the mind has been perfectly clear. We must be content to acknowledge our ignorance in this matter; and if we can trace our general resem- blances, and classify cases according to some well-known types, — more especially if we can discriminate the cases in which structural change exists from those in which it is not necessarily present, — we shall have done all that we are justified in attempting. It will probably simplify the study of the diseases of the brain if, before entering on their special diagnosis, this chapter be devoted to an exposition of the symptoms which are more directly derived from the powers of innervation, as they refer to the mental faculties, and the centripetal and centrifugal nervous actions — the sensations and the muscular movements of the patient. Division I. — The Condition of the Mental Faculties. The indications derived from this source may be referred to two principal heads — consciousness and coherence — perception and re- flection. These correspond to two very clearly defined features of disease expressed by the terms coma and delirium. Between the two extremes we find an almost endless variety of examples, in which they are, more or less, blended together, where it is scarcely possi- ble to tell whether the perceptive or the reflective powers be most in abeyance : in such instances there is partial loss of consciousness, 132 SEME 10 LOGY OF THE BRAIN. with a certain amount of insensibility to ordinary stimulus, and con- fusion of thought without active delirium : they may be only the transition stage from one state to the other, but are often distinct from cither. CSma is related to sleep, of which it presents the neatest possible exaggeration; while delirium is associated with in- somnia, which is its invariable attendant, and often appears as its precursor. § 1. Coma, or Insensibility. — Consciousness is entirely suspend- ed ; the mind is a perfect blank; the patient is alike deprived of the power of thought and expression, and of the knowledge of external things; voluntary action has altogether ceased; he makes no reply to any question ; he may be pinched or pulled about, and he gives no evidence of pain or annoyance; the muscular movements are only those of organic life, or such as may be excited by a sort of reflex action, or unconscious resistance. In such cases it is important to discover whether the absence of voluntary action depends merely on the state of the coma, or whether there be distinct paralysis of some of the muscles: a limb placed in a constrained position is moved in the one c™e by the counterpoise of flexion and extension, in the other it remains a lifeless object in the condition of rest. When paralysis is present, the extent of the lesion is measured in some degree by the number and variety of the parts implicated; but two conditions are chiefly observed, — hemiplegia, affecting one entire la- teral half of the body ; paraplegia, or general paralysis, involving both sides alike. (See Div. III. § 2, of this Chapter.) If any history can be obtained, we have to inquire how the pa- tient passed into his present state, whether it supervened suddenly, or whether gradually increasing stupor and somnolence have deep- ened into coma; and in the former case, if there were any convul- sive movement in the first onset of the attack. When no one was present to observe these circumstances, we may still learn much from the position in which the patient was found : as it points to the sei- zure having occurred when he was at rest, or having given him warning of its approach, or to its having overtaken him in the midst of action or exertion, or to its being the possible result of accidental injury. This condition is found in several different states, a. It may be the result of a fall or a blow, producing in the first place concussion, followed by extravasation, when fracture of the skull has occurred. The coma of concussion is not so deep, and there is never paralysis; hemiplegia points especially to extravasation. In their further progress these cases may pass into inflammation and serious disor- ganization of the brain. b. An apoplectic seizure, in which the patient has suddenly fallen down insen- sible, without convulsion, or with convulsive movements very slightly marked. When hemiplegia co-exists with coma, thus suddenly coming on. without any trace of injury, the diagnosis is certain. But apoplectic coma may exist without paralysis, and then its presence can only be determined negatively by the exclu- sion of all other possible causes. c. A comatose state may be caused by intoxication, or opium. In neither of PARTIAL CO II A. 133 these does it come on so rapidly; intoxication betrays itself by the odour of the breath; and in poisoning by opium the person may generally be recalled to some degree of consciousness, until near its last stage. In these cases the previous cir- cumstances, and the position in which the patient is found, may be of great service in guiding our opinion. d. Coma may also be the result of extensive effusion of serum into the ventricles of the brain. It is difficult to conceive how this can happen suddenly, and yet it is quite certain that patients are seized while walking along the street, or engaged in their usual avocations, with a fit, generally more or less convulsive in character, followed by coma, and not unfrequently attended with either paralysis or continued spasmodic action of one side of the body. The diagnosis rests chiefly on two points, the existence of convulsions in the primary seizure, and the extent of the coma, which is scarcely so complete as in apoplexy; in the latter, spasmodic movements are seldom met with. A history of previous bad health, with debility, would lead to the suspicion of effusion; a florid face and a full habit point more generally to sanguineous apoplexy. e. Coma supervenes gradually in the course of a variety of diseases, indicatino- either a morbid condition of blood circulating in the brain, or progressive disorgani- zation of the brain itself: cases of the last description are more readily recognised. § 2. Stupor, Unconsciousness, or Partial Coma. — A certain de- gree of unconsciousness always accompanies delirium: this circum- stance will be subsequently referred to. We have now to consider the cases in which stupor is the prominent symptom. When coma is incomplete, but attended by hemiplegia, or convul- sive movements, the same rules of diagnosis are applicable as to com- plete coma. The phenomena of partial unconsciousness with paraly- sis are sometimes very remarkable. The attention of the patient is attracted by objects about him, which he follows in their move- ments with his eye ; when spoken to, he turns toward the speaker, and seems to make an effort to reply, and it may be conceived that paralysis alone prevents his utterance: on closer investigation, how- ever, it may be found that, though the attention be aroused, the mind receives no impression, and the patient, though not insen- sible, is yet unconscious. When paralysis is not present, the patient seems to be asleep, breathing regularly and tranquilly, but he is found to be in a very deep sleep; he is roused with great difficulty, and, without appear- ing to awake, he resists any attempt to move him in bed; he strug- gles when he is undressed; he pulls up the clothes about him when he is uncovered; and even when thorous:hlv aroused, his mind is quite confused. Though unable to answer questions, or do as he is directed, he will make very distinct combined movements in changing his position in bed, and placing himself comfortably, as if he wished again to go to sleep. Here delirium, or rather incoherence of mind is evidently associated with partial unconsciousness. Of the conditions in which stupor is present, we find (") That it very often fol- lows upon a regular epileptic seizure: indeed, the sleep in which an epileptic fit almost always terminates may be said to be of this nature; and, though generally very transient, it may occasionally be prolonged even for days. (&.) It is also met with as the result of what has been termed transient apoplexy, or of concus- sion : the position the patient was found in, sometimes aids in determining whAer the fall was the cause of the subsequent state, or whether it happened from loss 134 SEMEIOLOGT OF THE BRAIN. of consciousness. Any appearance of blood about the mouth, showing the tongue bo have been bitten, would lead us to believe the attack had been one of epilepsy; but in diagnosis, the distinction between epileptiform and apoplectic serai-coma is unimportant, and only demands consideration from the probability of recurrence in the one and the smaller chance of it in the other, (e:) Semi-coma from intoxi- cation, of poisoning with opium, is not accompanied by t lie same degree of loss of eons* iousness. When the patient is thoroughly roused, he will indicate less vacuity of mind. ( are now considering as a symptom of acute mania. When this condition is superadded, all the ideas are thrown into confusion, the fixed delusion itself may for a time be lost, or be in abeyance, or may acquire greatly in- creased force; some other prominent idea may take possession of the mind; or there may be perfect incoherence. The delirium of insanity exactly corresponds, in these respects, to the delirium of disease, and is only more distinct and more exalted. It comes nearest to that of acute inflammation, with which it is often ex- actly identical, and the diagnosis must be based on the mode of incursion and the indications derived from other symptoms. "When the attack has been ushered in by perversion of the af- fections, alterations in temper or spirits, or by peculiarity of man- ner in acting or speaking, especially when these can be traced to some cause of anxiety, bad news, or sudden fright, it is probably mania. Now and then, if the reports of friends may be trusted, cases of delirium tremens commence in a similar manner; and we DELIRIUM OF INSANITY. 141 must guard against such a mistake by ascertaining whether there have been dissipation or excess prior to its occurrence. If due re- gard be had to those symptoms referrible to the "general state" of the patient, the skin, the pulse, and the tongue, faulty diagnosis, which cannot always be avoided in diseases of the brain, will not lead to errors in treatment; rational as opposed to empirical reme- dies, can alone give satisfactory results. So likewise, in discriminating the delirium of acute inflammation from that of acute mania, besides that light which is thrown on the case by the ascertained absence of peculiarity or perversion of ideas prior to its appearance, still more information may be gained by a strict examination of all the symptoms yet to be detailed, which point to inflammation of the brain as their cause. As we shall not have another opportunity for discussing the subject of insanity, a few remarks on its more general features may not be inappropriate in this place. Its forms are very varied : the patient may be morose, taciturn, or reserved ; or he may be loquacious, noisy, or unmanageable; any one or more of the faculties and affections may be the especial seat of the disease; his delusions may be fixed and invariable, or may comprehend a constantly changing series of fancies; and these, again, are usually accompanied by the presence of hallucinations and illusions, — mental impressions which seem to the patient to be produced by objects affecting his senses, when in truth they originate in the mind itself. These imaginings of the insane are very different from what may be more properly termed alterations in sensibility: in the latter the force of true impressions on the nerves is exagge- rated or diminished in intensity, or their character is confused and indistinct: in the former, the mental conception* is referred to the organs of sense, where im- pressions are felt exactly analogous to those which would be received if the cor- responding object had a real existence: in the one the sensations are vague and ill-defined, in the other they seem distinct and clear. In the strict application of terms, the word hallucination implies that no object is present to stimulate the organ to which the idea formed in the mind is referred; while in illusions, existing objects, which in the first instance produce the stimu- lus, are clothed by the mind in characters more or less foreign to their true na- ture, and these are so inextricably blended with the sensation originally produced, as to give rise to the belief that the resulting idea is wholly derived from an ex- ternal impression. Morbid fancies are not limited to insanity; but when the judgment is perverted or lost, they are not corrected by the force of true impressions opposed to them, and hence their permanence and domination in insanity and delirium. In mental affections the patient is usually out of health, but there are no gene- ral symptoms invariably present: the tongue is often foul, the bowels confined, and during the paroxysm of acute mania the pulse maybe somewhat accelerated, but we seek in vain for evidence of inflammation, for convulsion, or paralysis, ex- cept when imbecility succeeds epilepsy, or paralysis accompanies fatuity: the svmptoms referrible to the nervous system neither betray increased sensibility, nor loss of power, but consist of deceptions of the nerves of sense, and delus^ms regarding external objects, which may extend to the condition of the whole body, or only that of some particular organ. The most prominent exception to this ge- neral rule of diagnosis is found in the condition of puerperal mania, which seems to hold a place somewhat intermediate between mental alienation and the delirium of disease, being allied to the former in the perversion of the affections and the reason, and the absence of distiuct signs of disease, while it is assimilated to the latter in its coincidence with the peculiar state of health belonging to pregnancy and parturition. Its diagnosis cannot be based upon any peculiarity in the mani- festation of the mental phenomena, but simply on the fact of its occurring during the puerperal state, and occasionally after prolonged lactation, when perhaps it is 142 SEMEIOLOGY OF THE BRAIN. rather to l>e regarded as mania occurring in a condition of anrcmia, than mania cidted with pregnancy. In its commencement there is almost always deli- rium: after its subsidence the patient remains in a condition of temporary un- soundness of mind: undoubtedly faulty nutrition is one of the antecedent circum- stances, but there is something more — hereditary tendency, insanity in other mem- bers of the family, or individual predisposition, as indicated by repeated attacks in successive pregnancies; at all events, it is alike different from the blood-poison- ing of livers, inilammatious, &c, and from delirium depending ou change of struc- ture in the brain. Division II. — Alterations of Sensibility. Sensation may be morbidly keen, or it may be obtuse and even entirely lost, or it may be perverted; each of these conditions ex- tends, more or less, to the whole nervous system, or is limited to particular organs. With reference to all alterations of sensibility, a distinction must be made between pain and tenderness: the one denotes the existence of some unusual stimulus, the other indicates increased susceptibility to any impression; they are often present together in various conditions of disease (e. g., local inflammations,) and we are apt to consider them as only different expressions of the same nervous phenomena. When they are taken as symptoms of cerebral disease, and when no local cause exists in the part in which the phenomenon is present, it is still more important to re- member the exact idea which each conveys: the one is to be re- garded as perverted sensation ; the other as morbid sensibility. § 1. General Alterations of Sensibility. — General tenderness is not a symptom of much consequence when standing alone; it is then commonly the result of hysteria, or mere nervous excitability: if associated with causeless anxiety, depression, or dread, or with irascibility of temper or great elevation of spirits, it points to in- sanity. Sensibility generally diminished is probably never seen except as the result of mental alienation, or as combined with general para- lysis ; but it must be remembered that it is not by any means a necessary concomitant of paralysis. Perverted sensations affecting the whole system are similarly best seen in cases of mental delusion. Analogous phenomena are observed in the sensation of heat complained of by patients in Asiatic cholera, while the whole body is sensibly cold ; in the sen- sation of chilliness in fever, when the skin is morbidly hot to the touch; and in the extreme cold and shivering of ague, or of severe rigor. The tjngling and formication of jaundice, and similar sen- sations produced by the action of certain substances in peculiar idiosyncrasies, are scarcely to be regarded in the same light. The only one which really bears on our present subject is that general sensation of pain and malaise which cannot be localized by the pa- tient, and is not to be accounted for by the condition of the blood, as in fever: this symptom is not to be lightly disregarded, and is often the precursor of more serious lesions of the nervous system. ALTERATIONS OF SENSIBILITY. 143 § 2. Alterations in tfie Sense of Sigjit. — Of local conditions, none deserve more consideration than those presented by trie or- gans of vision, where the pupil so readily exhibits the increased or diminished sensibility of the retina, independent of the patient's volition. They consist of — a. Difference of size of the pupils on either side, which may with certainty be regarded as evidence of severe lesion of one-half of the brain: it usually results from partial or complete insensibility of one retina, and very rarely from increased susceptibility or irri- tability: in the majority of instances it is a dilatation of one pupil, and not a contraction of the other. b. Morbid contraction of both pupils ; associated either with (1) intolerance of light, pointing to inflammatory action; or (2) with insensibility more or less marked, especially seen in coma and narcotism; or (3) simply with increased irritability, the pupils dilating pretty freely when light is withdrawn, but contracting unduly on its admission. c. Morbid dilatation of both pupils : (1) with insensibility com- plete, indicating pressure equally affecting both hemispheres, and hence most commonly seen in effusion of fluid in the ventricles; (2) with oscillating movements when light is withdrawn, and again suddenly admitted — a condition most commonly found in the tran- sition stage from inflammation to exudation in the hydrocephalic forms of disease; (3) with sluggish movements, which only show an obtuseness in the perception of light, anil the excitement of reflex action, the pupil dilating largely, and contracting feebly, when light is withdrawn and again admitted — a common condition in fever; (4) a similar state of the pupil is also produced by belladonna. Diktatiou of the pupil, with insensibility of the retina, exists in amaurosis, and the distinction between blindness resulting from disease of the nerve, and that which is consequent, on disease of the brain, is to be sought in other symptoms of disordered innervation. The point to be studied is the effect of the sudden admission of light after its exclusion. When no change at all occurs, sight is lost, whether in contraction or dilatation; but the movement may be so slight as to escape observation. In contraction, intolerance of light, or a sense of pain on its admission, is to be carefully noted; in dilatation we have to watch for evidence of the existence of vision when the patient is unable to express his own sensations. Increased irritability, seen in rapid contraction and full dilatation on the admis- sion or exclusion of light, stands exactly opposed to sluggish action : the one in- dicates exalted, the other, depressed nervous energy. It is very remarkable how the presence of some object producing an unusual degree of attention in a patient who is listless and depressed, such, for instance, as the entrance of a friend or near relative, may immediately restore the pupils for a time to their normal ex- citability. In examining the condition of the pupil it is of the greatest impor- tance that light should be excluded from both eyes at the same time, in order to judge correctly of the effect of the stimulus upon either when it is again admit- ted. d. Perversions of the sense of vision have less definite relations to conditions of brain. The most important are — (1) double vision, especially when not associated with strabismus, which comes more Ill SEMEIOLOGyOFTIIEBRAIX. properly under the head of muscular movements; (2) dimness and haziness of vision, partial loss of sight when a portion of an object is lost, and seems to be cut off, muscsc volitantes, and ocular spectra; (3) hallucinations and illusions, in which unreal objects are seen, or natural objects arc clothed in unreal shapes, the con- stant accompaniments of delirium. The first division is that which demands the most attention, as being probably indicative of cere- bral disease: the whole of those classed in the second division are more commonly observed in sympathetic or functional disturbance; the third are the results of delirium or mental alienation ; ocular spectra are distinguished from them by their accompanying states of perfect consciousness and reason, when the evidence of the other senses proves to the individual the non-existence of the object. § 3. Indications derived from the Sense of Bearing. — These are much less numerous, and though often dependent on mere local causes, some of them are not without value. a. Deafness supervening in the course of a febrile attack, as indicating diminished sensibility of the brain, is almost certainly an evidence that the disease is fever and not inflammation. Ex- treme degrees of deafness are sometimes produced by pressure. b. Deafness of long standing in a person suddenly attacked by febrile disorder, should always lead to inquiries into the state of the ear. Disease located there is very apt to excite inflammation within the cranium*, it is commonly accompanied by pain and purulent or fetid discharge. For the same reason, when pain is present, we ought to inquire into the existence of deafness, or any other evidence of disease ; and thus a history of scarlatina, as ante- cedent to the deafness, is very instructive. c. Intolerance of sound or noise is a valuable symptom of great nervous irritability. d. Less importance is to be attached to the existence of tinnitus aurium, of unnatural sounds and noises, or voices. The former may exist along with disease of the brain ; the latter are more commonly referrible to a mental state ; but both are not unfre- quently the result of mere local affection. § 4. Special Alterations of Sensibility. — Perversion and loss of the senses of taste and smell are comparatively unimportant with reference to disease of the brain; they are generally dependent on some morbid condition of the nerve or the mucous membrane. Alterations of common sensation in other organs derive their chief significance from our being able to determine whether the affection bo limited to the filamentous extremities of the nerves, or be pro- duced by some cause acting upon their main trunks, or be con- nected with disease of the nervous centres. We have to consider the condition of the parts to which the nerve is distributed, and the relation of the affection to its ramifications. When the sensa- tion is referred to the terminations of one nerve, we have to ALTERATIONS OF SENSIBILITY. 145 observe whether any perceptible change of texture in the organ to which it is distributed can account for its existence; when no such cause exists, we have to inquire whether the sensation be limited to the branches of that nerve, or extend to others having a similar origin. Those which have especial reference to the central struc- tures, are such as affect the entire half of the body, or extend equally to either side: those limited to the nerves will again occupy our attention (see Chap. XVI. ;) but it may be here remarked, that local fixed pain often accompanies the early stages of chronic dis- ease of the brain, especially in organs not otherwise the subjects of common sensation. It may be quite impossible to show the cause of this connexion, and the fact cannot, therefore, be made available for the purpose of diagnosis; but it is well that it should be borne in mind, that its weight may not be lost in considering other symp- toms of disease. Pain of the head and giddiness are among the local alterations of sensibility which frequently accompany disease of the brain, and yet they are the least to be relied upon: not only do they con- tinually fail in giving notice of mischief going on within the cra- nium, but they are associated with so many other disorders, that in by far the greater number of instances they do not point to any serious lesion. Thus they are to be met with in dyspepsia and constipation, and in almost all the disorders of the digestive and assimilative processes; they constantly coexist with disorder of the circulation, disease of the heart, anemia, and plethora, whether the head be too freely or too scantily supplied with blood ; they are frequently associated with altered conditions of the blood itself, in fever, inflammation, chronic blood ailments, &c. These belong to what we call functional disturbance of the brain: if rightly considered, they ought not to give rise to any important misconception ; for in every instance the organ in which concomitant symptoms of disorder exist, ono-ht to be carefully examined. For example, we know that vomiting and constipatTon are very often secondary to inflammation of the brain; and if for a momeut this circumstance be forgotten, and the attention be directed only to the local derange- ment, we find nothing there sufficient to account for the inflammatory fever which is going on; the tenderness of abdominal inflammation is entirely wanting: on the other hand, in dyspeptic headache, however intense the pain, the evidenced in- flammation cannot be traced, but the liability to disorder of the stomach is a fact easily made out. Useful information may be obtained in cases in which there is a possible connexion between the head symptoms and disordered circulation or disease of blood, by inquiring whether the pain be relieved or aggravated by as- suming the horizontal posture. If the general symptoms be only" those of fever, we shall have more difficulty in determining whether the altered sensibility be caused by the fever, or whether it point to some more serious lesion, and ought to teach us that the fever itself is only symptomatic. It must not be forgotten that the pain is sometimes external to the skull ; rheu- matic, with tenderness of the skin and rheumatism in other parts; inflammation of the scalp, in commencing erysipelas or disease of bone, inflamed pericranium, &c. In all the functional disorders of the nervous system we must be careful neither too hastily to conclude that they are limited to the nerves to which the sensations are referred, nor be too ready to ascribe them to disease of the central organs • there are no such cases occurring in practice which are not occasionally associated with either condition. 10 140 SEMEIOLOGY OF THE BRAIN. Division III. — Alterations in Muscular Movement. Indications derived from the muscular system divide themselves into irregular or involuntary movements, and loss of power: Bpasms, convulsions, and palsy. Some of these conditions have been already enumerated, but they must be again cited, in order to contrast them with those which are essentially connected with dis- ease of the brain: they belong to objective phenomena, and are symptoms which can hardly escape observation. § 1. Spasmodic Action. — The slightest, but not the least impor- tant form of this affection is seen in the muscular twitchings of fever, as subsultus: it is at first only indicated by a tremulous movement in performing any voluntary act, caused by the irregular action of the muscles combined in its performance, and differing in some measure from the tremor of mere weakness by this irregu- larity: in a further stage of the fever it is more constant, and such movements of the muscles of the arm are almost always seen : at an advanced period it is combined with delirium, assuming the character of "floccitatio," a picking at the bed-clothes, performed in this tremulous and irregular manner. It does not prove that there is any peculiarity in the fever poison, but only that the brain and nerves are especially acted upon by it. Tremor also charac- terizes the muscular movement in delirium tremens : in this condi- tion there is less irregularity of action, and every motion is per- formed in a hurried manner, with marked energy and activity, while in fever they are all essentially slow and apathetic. AVhen the muscular twitchings are more spasmodic or convulsive in character, and there is delirium or loss of consciousness, we have reason to suspect more serious mischief; they are in such circum- stances often confined to one side of the body, or more marked on one than on the other; not unfrequently paralysis of one side is seen associated with spasmodic twitchings of the other. In such affections loss of control over the movements is associated with some irritation of nerve-fibre which stimulates the muscles to action. Loss of voluntary control is also a phenomenon of chorea, in the form of irregular jactitation of the whole body, of the various limbs, or only of one of them : the movements are more spasmodic than convulsive; the muscles act, not simultaneously, but severally, in opposition to, or uncontrolled by volition. The absence of de- lirium or stupor in this instance, proves that no serious lesion of the brain exists, and leaves it undecided in what part of the ner- vous tracts the irritation is seated. General convulsion is a more fearful form of spasm : the muscles of the whole body are thrown into violent and irresistible contraction, which produces contortions of the features and movements of the limbs; volition is lost, consciousness is suspended, contraction of one set of muscles is immediately followed by that of their antago- nists, in consequence of which the body may be thrown by an ALTERATIONS IN MUSCULAR MOVEMENT. 147 almost superhuman strength from one side to another; the feces, the urine, and the semen are often involuntarily evacuated. Gene- ral convulsions occur in various forms of brain disease, but attain their greatest severity in the distressing attacks of the regular epileptic: the great distinction between epilepsy and convulsion will be found in the context of symptoms: at its first incursion, the patient attacked with epilepsy seems to be in perfect health before his seizure; when it has passed, there is nothing beyond a feeling of languor for a day or two, or muscular soreness from violent action, to show that he has passed through the struggle; he once more appears to be free from disease : in its later stages the history of recurring attacks leaves no room for doubt. When dependent on other diseases, convulsions do not stand alone, but are found in connexion with a febrile state, with delirium, or with stupor (see Chap. XIIL, § 5.) Children are particularly liable to convulsions: irritation of the nervous system is with them very apt to produce the affection, and teething, disordered digestion, or intestinal worms are its common causes; but we must remember that it is not unfrequently the first symptom by which the attention of parents or nurses is drawn to the existence of insidious inflammation. In adults there is gene- rally some previous history when convulsion is a symptom of disease of the brain ; still it does occasionally occur as the first manifesta- tion of fatal effusion of serum in the ventricles, in consequence of the very same sort of inflammation as the hydrocephalus of child- hood. Convulsion is also a very usual symptom of blood-poison- ing, in cases of albuminuria. Spasm is the prominent feature of tetanus; muscular rigidity more frequently occurs 1 in connexion with disease of the brain : it sometimes supervenes on paralysis, causing permanent contraction, or it remains as a consequence of convulsion, especially in child- hood; in other instances it arises slowly and spontaneously in long-protracted disease, and in such circumstances it must be re- garded as a serious symptom. Strabismus occasionally exists as a condition of muscular spasm, but is more commonly due to paralysis. It is one of the incidents in general convulsion, and is transient, except when followed by paralysis of the antagonistic muscle. In inflammation within the cranium it is frequently produced by irritation of the origin of the motor nerves, and is then a very common cause of double vision. § 2. Paralysis, as a symptom of disease of the brain, must be studied especially with relation to its extent and duration, and also the mode of its incursion. It is one of those disorders which, in a truly scientific classification, could find no place except as a symp- tom of disease; but we are met by the impossibility of ascertaining' the exact condition of the nervous structures during life, and we also know that, while it is dependent on a great variety of causes,. 148 SEMEIOLOGY OF THE BRAIN. its features present characters which are constant and invariable; thus in some cases we cannot get beyond the fact of paralysis being present, while in others, the primary cause having been removed, the function of the muscles only remains in abeyance until they are roused by the repeated application of some local stimulus. It has therefore seemed necessary to assign to it a separate place in our classification (see Chap. XV.,) and then the question of its causes and extent will be more fully examined. "VYc may here remark that paralysis of cranial nerves must be more important than that of solitary nerves in any other part of the body, because the lesion is so much the more likely to be within the skull, and similarly, either hemiplegia or paraplegia, extending to the nerves origina- ting next to the foramen magnum, i3 more serious than when either disease is limited to the lower limbs. Again, hemiplegia is more important than paraplegia, because the two hemispheres of the brain are more distinct than the two halves of the spinal cord, and affec- tions of one side are therefore more likely to have a cranial than a spinal origin. The fact of the paralysis being complete or incomplete, does not go much affect the situation of the lesion as its character, and is chiefly of importance because the one is a reality about which there can be no question, while the other may either be overlooked or be simulated by diseased imagination or perverted will. It is to be remembered that we are only dealing now with one symptom, and if we are to attain to correct diagnosis we must compare it with the other evidence of cerebral disease, and not hastily conclude that, because the apparent paralysis is such as might have a cranial origin, this is any sufficient ground for assuming the existence of a particular form of disease. Ptosis is a symptom not readily to be passed over: difficulty in articulation, thickness of speech, stammering and stuttering or hesitation, in persons who have had no such previous affection, are also of much importance in relation to disease of the brain, indi- cating, as all these do, some affection of cranial nerves. Their anatomical relations may help us to trace the point at which dis- eased action is going on; and where two or more nerves issuing by different foramina are simultaneously affected, we have at least strong presumptive evidence that the cause of the paralysis lies within the cranium. Strabismus again comes under consideration, as it often is due to paralysis. We have to inquire whether it be recent or of old stand- ing: in its chronic state there is generally retraction of one muscle with elongation of its antagonist, which is of no moment as a symptom of disease now going on, as it is either the remnant of some convulsive attack in childhood, or the consequence of some defect of vision; in its recent state it is very frequently the evi- dence of irritation and muscular spasm, but is also occasionally seen along with paralysis of other cranial nerves, as the effect of pressure, e. g., along with dilatation of the corresponding pupil. 149 CHAPTER XIII. DISEASES OF THE BRAIN. History — Acute and Chronic — Antecedent States. — § 1, Scrofulous or Tubercular Inflammation — In Infancy — its Early Stage— its Advanced Stage — In Adults — its Association with Phthisis — Tubercles in the Brain — § 2, Simple Inflammation — its Causes and Characters — its Locality — § 3, Chronic Disease — Distin- guished by its History and Symptoms — § 4, Apoplexy — Charac- ters of the Fit — History — Partial Coma — Serous Apoplexy — Associations — § 5, Epilepsy — Convulsion — its Periodicity — Hys- terical Epilepsy — § 6, Functional Disturbance — its Characters- Associated with Disease in other Organs — with General Debility. In the preceding chapter a general outline has been given of the very large class of symptoms which must be investigated in inquiring into conditions of disease in the brain, and at first sight their num- ber and variety seem to present almost insurmountable difficulties; but in reality it is not so: in any given case, we are rather left in the dark by the absence of trustworthy evidence of the state of the brain, than bewildered by the number of objective and subjective phenomena: thus, when the mental functions are deranged, we lose all aid to be derived from the sensations of the patient ; in some cases one symptom (e.g., paralysis,) stands alone, in others there is scarcely anything to indicate the existence of disease beyond the presence of pain, which we know may be exaggerated, or may de- pend simply on disturbance of other organs. We cannot too often recur to these important principles — (1) to inquire in every possible way into the history of the case; (2) to examine most carefully the condition of other organs, and search for the existence of other diseases: if these two points be neglected, correct diagnosis is almost impossible ; if properly attended to, they not only lead us in the right direction when we fail to get at the exact truth, but they also enable us to avoid many errors. The next step is to consider the various important lesions of the brain, and ascertain whether the case under investigation adapt itself to any one of these, not overlooking the possibility of insanity and simple functional disturbance, which, with all their complex associations, belong distinctly to diseases of the brain. The primary division is into those with and those without a febrile state. Acute diseases of the encephalon in adults seldom arise spontaneously, or without previous derangement of health; hence the importance of the history of the case. We may thus be enabled to exclude "head symptoms" occurring in the course of some other 150 DISEASES OF THE BRAIN. acute disease ; it is only necessary to guard against being misled by a vague assertion of the existence of fever, when this was but the first step in the progress of inflammation. The history also conveys very, important information with reference to the recurrence of headache, to pain or discharge from the ear, to previous loss of power, or attacks of convulsions in genuine cases of disease of the brain, or to cough and emaciation as preceding tubercular menin- gitis: in either case inflammatory action, when present, is, as it were, engrafted on old standing disease, and this is its most com- mon course ; on the other hand, it is sometimes developed suddenly in a person who had previously enjoyed perfect health, with great febrile disturbance, severe pain in the head, vomiting, and consti- pation ; or it is announced in a more unmistakeable manner by the coexistence of convulsion. Here we shall learn that symptoms of affection of the brain were among the earliest phenomena of disease, and we are thus assured that this' organ has not become secondarily affected in the course of some other febrile disorder. The importance of the information obtained from this preliminary inquiry can hardly be overrated, in so far as it serves to point out the association of the tubercular diathesis, either by the previous condition of the patient himself, or his hereditary tendency to scrofula or consumption. It may also greatly assist us in forming a judgment as to the exact seat of the disease, whether in the membranes or in the substance of the brain, because we learn from experience that meningitis is apt to be produced by disease of bone in the internal ear and the sinuses of the nares; or by caries or fracture of some other portion of the skull ; by syphilitic nodes of the pericranium, or by injury of the scalp, especially when termi- nating in suppuration; on the other hand, inflammation of the substance of the brain, when not dependent on over-stimulation of the organ, or upon scrofulous deposit, is more commonly excited by the pressure of an old apoplectic clot, or by the progress of chronic disease, traces of which are to be found very often in the past his- tory of the individual. The symptoms in the acute diseases of the encephalon are not generally such as point with any distinctness to the exact site of the action, because, though doubtless commencing in different structures, and occasionally limited to them, inflammation involves so much the general functions of the brain, as the centre of in- nervation and the organ of mind, that we can scarcely assign to each part a distinct share in their production ; it rather concerns us to find out any really available mode of discriminating the two great practical divisions, — the scrofulous and the simple inflammation. . § 1. Scrofulous or Tubercular Inflammation.— This form of in- flammation is so much more common in infancy than at more advanced periods, that until recently it was hardly recognised as occurring after the age of puberty; and the name by which it was SCROFULOUS INFLAMMATION. 151 first known, "acute hydrocephalus," was limited to childhood: the records of St. George's Hospital prove that it is not uncommon up to the age of twenty-five or thirty. Its symptoms and progress have been much more studied in the earlier periods ; and the de- scription of these, in consequence of the modifications due to vital phenomena during the progress of development, will not always be found applicable to the disease as occurring in the adult. Patholo- gical research seems to prove that the disease is the same, at what- ever age it occurs: it is essentially connected with the strumous diathesis, which exerts some mysterious agency in its development, and hence it is numerically far more common than simple inflamma- tion: indeed, up to the age of twenty-five, the one is the rule, the other the exception ; so much so that, excluding infancy altogether, the number of cases occurring in connexion with the scrofulous diathesis, from eight or ten years of age onwards, is probably double that of cases of simple inflammation at all periods of life collec- tively: this fact is very important in diagnosis. The tendency of the inflammatory action is to the effusion of serum rather than of lymph or of pus; but both conditions fre- quently coexist, as well as varying degrees of softening of the ce- rebral structures. These different lesions probably correspond to different degrees of arterial action during life, as indicated by heat and pain of head, in opposition to dulness, heaviness, and delirium ; at present no certain rules can be laid down by which they may be discriminated: coma and unconsciousness are pretty certain evi- dences of effusion, but in prolonged cases the brain seems partly to recover its power and become tolerant of the pressure. The sus- ceptibility of the brain in the earlier periods of life is so much greater than in later years, that inflammation of the brain is then often the first indication of the tubercular diathesis, while afterwards tuber- cular deposit will have always been first formed in other organs. Much as has been written on the diagnosis of the early stage of this disease in infancy, it is practice alone that can give any readi- ness in its discrimination. A child belonging to a scrofulous family is attacked by slight febrile disorder, with irregularity of the bowels, especially tending to constipation, with vomiting and occasional fretfulness : in such a case it is necessary to observe very carefully all indications referring to the brain ; the mode of standing, walk- ing, sitting, lying, any aversion to light, or dislike to the erect posture, as shown by nestling its head on the mother's bosom, and turning away peevishly from any attempt to amuse or occupy its attention. These circumstances, again, must be compared with the amount of general disturbance: a child suffering from infantile fever shows much more weakness and prostration in comparison with the signs of cerebral affection: in hydrocephalus the heat of skin is most marked over the head, but is not in proportion to the quickness of the pulse ; the tongue is coated but not dry ; the stools are costive and often deficient in bile; thirst is not urgent; the 152 DISEASES OF THE BRAIN. vomiting Las no necessary connexion with the period of taking food: in infantile fever, the heat of skin is more general, there is dryness of tongue, thirst, and very often a tendency to diarrhoea; listlessness and indifference mark the expression of the features rather than the anxiety and knitting of the eyebrows so often seen in hydrocephalus. In simple gastric disorder, on the other hand, there is little or no quickness of pulse, no heat of skin or of head ; the tongue is much more coated ; the vomiting and constipation are less obstinate, yielding more readily to treatment; the countenance may be dull and inexpressive, but it is not anxious. In some few cases, and these are the most difficult of diagnosis, the tubercular disease has begun so decidedly in the abdominal viscera, that diarrhoea persists till the head affection has become unquestionable from the presence of coma or convulsion: in other instances an attack of convulsion is the first circumstance that awakens the attention of the mother or nurse to anything being wrong. The hopelessness of the disorder deprives diagnosis of much of its interest: yet it is well to be able to warn parents of approaching danger, and it is now and then a source of gratification when we can remove apprehension regarding a case which has been looked upon with distrust, and can feel confidence in a prospect of amelio- ration. In the advanced stages, extreme listlessness and unwillingness to be moved, frequent moaning, great aversion to light and noise, with marked inequality of pulse, followed by stupor, convulsion, para- lysis, strabismus, or insensibility of the retinre, and total blindness, sooner or later make the nature of the disease only too evident: their sequence is not always the same, and the more decided symp- toms may be postponed till within a day or two of the patient's death. When the disease has been making slow and insidious pro- gress for days before the child is first seen, and the bowels continue relaxed, while the history of the case is either imperfect or incor- rect, it is apt to be regarded as an advanced stage of fever: this is the disease with which in all circumstances it is most liable to be confounded, and therefore a few hints may be given for their dis- crimination. In doubtful cases it is always a favourable sign when the child is seen to watch the attendant as a stranger in the room, when, though listless and unwilling to be disturbed, he is not dis- tressed at being moved; it is also favourable when there is thirst and no refusal of fluid nourishment; and, I may add, what seems paradoxical, when delirium and muttering are observed at night. This is explicable enough from the consideration that, if delirium depended on serious lesion of the brain, the other symptoms would be such as to render the case perfectly clear ; it is only when doubt exists that delirium can be thus viewed. Deafness may be to a certain extent regarded among the favourable signs, as it is a com- SCROFULOUS INFLAMMATION. 153 mon circumstance in fever; but if it amount to total loss of hearing, it is most unquestionably of evil omen. Blindness is a constant effect of effusion, but it is sometimes difficult to make out whether the child be blind or simply indifferent to surrounding objects: mo- thers never admit the fact, and the mobility of the pupil can alone be taken as a certain guide. Heat of head, refusal of fluids, moaning, anxiety of expression, are all unfavourable: variableness of pulse is also a very hopeless circumstance ; its acceleration in acute hydrocephalus is constant, but not always great, often less than in fever, sometimes much greater; its occasional increase from slight causes, as "well as its unevenness under the finger, are of more value than its absolute frequency: during the period of effusion it is sometimes slow. Hydrocephalus must be carefully discriminated from the func- tional derangement following on exhaustion, which often so closely simulates it as to have received the name of the hydrencephaloicl disease: the proper place for its consideration is among functional disorders (§ 6;) the most useful diagnostic mark, in cases where it remains unclosed, is the condition of the fontanelle, which is full and tense in inflammation, hollow and flaccid in exhaustion. In adults the cases of tubercular inflammation of the brain may be divided into two classes: the one accompanying the early stages of tubercular deposit, when miliary tubercles are evenly distributed through the lungs; the other attending the advanced stages of phthisis, with vomicae in the lungs. In their general features there is considerable analogy, but in the early cases the symptoms are more acute, and correspond more closely to those seen in the same disease in childhood; in the advanced cases the inflammation is of lower type: the presence of disease in the follicular glands of the intestine renders constipation very rare; vomiting, on the other hand, is of common occurrence. The pulse, so often quick in phthisis, is always so in this affection of the brain ; the head is hot and painful; night-sweats, if they have previously occurred, have ceased; and, contrary to what is found in childhood, delirium is an early symptom. This subject has been already fully discussed under the head of delirium, to which the student is referred; its presence cannot fail to draw attention to the condition of the brain : it may be accompanied by strabismus, unequal action of the pupils, or aversion to light and noise, but such signs are more often want- ing among adults. Alterations of sensibility and mobility are rarely observed in the early stages. In advanced phthisis, emaciation naturally leads us to inquire into the previous history, especially with regard to chest symptoms, if none such have been detailed: emaciation unquestionably also attends chronic disease of the brain, but it ought to be enough that a suspicion of disease of the lungs is suggested; auscultation can- not fail to reveal its existence when a vomica is already formed. In early phthisis, with equal dissemination of tubercle through 154 DISEASES OF THE BRAIN. the lungs, the results of stethoscopic examination being less satis- factory, diagnosis is sometimes at fault. The disease to which it bears the closest resemblance is continued fever with pulmonary congestion. The differences in the auscultatory signs will after- wards be noticed in describing diseases of the chest, but sometimes they cannot wholly be relied on ; and even when they are well defined, the mind is so apt to be satisfied with the explanation which "fever" affords, that careful examination is forborne in the depressed and delirious condition of the patient. In such circumstances, a correct history serves as our best guide: the points which it indicates are the existence of cough before the commencement of the present attack, the occurrence of both headache and delirium at an early period, with relation to the fever and the wandering of the mind by day as well as by night. In conjunction with these we observe the more definite symptoms of heat of head, and vomiting with a tongue not very much coated, and a pulse not remarkably quick in the first instance, but often variable and unequal. As with the corresponding disease in infancy, the result of diagnosis is very unsatisfactory, revealing only the hopeless nature of the malady. Our apprehen- sions, grave at any time when the brain is seriously implicated, assume a more gloomy aspect when we have been able to determine that tubercular disease is present in other organs ; nevertheless, we obtain by its means not only a safer guide to treatment, but information most useful in the varying phases of the disease, and most important in venturing to give a prognosis to the friends of the patient. It has been stated that tubercular inflammation does not necessarily imply the presence of tubercles in the brain itself; and it is here only necessary to add. that their existence is not generally betrayed by any symptoms, even when found of considerable size after death, till inflammation occurs; and the course of the dis- ease is very much the same whether there be tubercular matter in the brain or not. Even when we have evidence of previous disease of the brain, and we may feel justified in believing that it is caused by tubercular deposit, because we can trace tubercle more or less clearly in other organs, still its 'absolute diagnosis is quite beyond human art. Its symptoms do not differ from those caused by the presence of any other morbid growth. It occasionally happens that, after an acute attack, the disease lapses into a chronic form, consciousness is nearly perfect, but paralysis of one or more cranial nerves remains, with less distinct evidence of general cerebral disturbance. In such cases the circumstance of previous febrile action, along with local lesion, points pretty definitely to the coincidence of inflammation and tumour; and the probability is very great, in the case of children, that it is scrofulous inflammation and scrofulous tubercle. § 2. Simple Inflammation. — Acute simple inflammation of the brain is exceedingly rare as an idiopathic disease; more frequently it is set up by injury or disease of bone, and now and then acute symptoms supervene in a case where there has been long-standing disease ; in all of these the general characters of the malady are the same, and the history can alone determine its cause and origin. The important antecedents may therefore be divided into two classes : (1,) those which have reference to injury or disease of bone, such, for example as a blow or fall, tumours or abscesses on the scalp, discharges from the ears and nose, or deafness from disease of the ear; and (2,) those which bear more especially on the condition of SIMPLE INFLAMMATION. 155 the brain itself — viz., the occurrence of fits, whether apoplectic or epileptic, the existence of any form of paralysis, impairment of vision, or deafness without disease of the ear. These circumstances also tend to show which portion of the encephalon is the precise seat of inflammation; but the determination of this is matter rather of curiosity than of practical importance in regard to treatment ; it is enough for our purpose if we can determine that acute inflamma- tion is going on within the cranium. When pronounced, the characters of the disease are quite un- mistakeable. There is pain of the head and restlessness, followed by quick, hard pulse, hot and dry skin, white tongue, heat of head, and flushing of face; the eyes are red and ferrety, and the pupils contracted; there is intolerance of light, and perhaps of noise; there are rigors, nausea, vomiting, and constipation, followed by convul- sions, delirium, coma. Delirium, strange to say, is often absent, or only slight and transient, until a semicomatose state follows on convulsion ; at other times it is furious and maniacal. Pain is a very constant symptom, and is generally referred to the forehead, but it may prove a very fallacious guide; intense headaches find their solution very often in simple gastric disorder: the pain of inflammation is sharp and darting, rather than aching, and when associated with intolerance of light and noise, we may be sure that it is something more than mere headache. Heat of head, flush- ing of face, pulsation in the branches of the external carotid, showing increased action there, lead to the belief that there is corresponding increased action of the internal carotid, caused by inflammation within the cranium. The nausea and vomiting are sometimes very striking; the smallest portion of food or drink being rejected, and sickness continuing even when nothing is taken into the stomach. That this is not caused by gastric inflammation is proved^ by the absence of pain and tenderness at the epigastrium : when accompanied, as it often is, by constipation, we have to bear in mind that this condition may of itself cause sickness and great cerebral disturbance in cases in which there is no inflam- mation present. The diagnostic value of such symptoms must therefore, in the first instance, depend on their being associated with others more distinctly referri- ble to the brain itself; their persistence after the action of a brisk purgative, of obstinate slowness of the bowels, in persons not habitually costive, are not to be lightly passed over. Rigor rarely accompanies the onset of the disease; it afterwards occurs fre- quently in its progress, and may assume such a character of periodicity as to re- semble intermittent fever, and lull the medical attendant into fatal security. Convulsions appear at very various periods: in young persons they sometimes usher in the attack, while in adults they are more generally delayed till the closing scene; whensoever they exist they are an important, and, at the same time, an alarming sign. The distinction between these and the true epileptic seizure, will be afterwards pointed out (see \ 5.) The symptoms of disease do not remit, after the convulsive seizure has passed, in true inflammation of the brain, as they do in epilepsy. Various alterations in sensibility and mobility succeed to the exaltation which first accompanies inflammatory action; and the progress of the case may be marked by spasm or loss of power; these indicate changes in cerebral structure, or pressure from effusion of lymph, serum, or pus, but have no direct bearing on the question of inflammation. Strabismus and double vision, it may be remarked, are generally the first in this sequence. The presence or absence of delirium seems in great measure to depend on the portion of the encephalon attacked by inflammation. It can scarcely fail to be preseut if the gray matter of the hemispheres be involved, but does not necessarily imply this particular lesion. In character it very much resembles an attack of 156 DISEASES OF THE BRAIN. acute mania, and the distinction is sometimes not easily made out. Regard must be especially bad to the relation the delirium bears to the signs of increased ac- tion, and the order of their occurrence: maniacal excitement necessarily produces flashing of the face and acceleration of the pulse, but to a much less degree than inflammation. Evidence may also perhaps be obtained of previous perversion of intellect when the disorder is linked with insanity. Constipation is common to both states, and there will be little chance of confounding the nausea and vomit- ing of inflammation with the refusal of food, so often manifested by the maniac. The alleged cause of the attack, whether physical or mental, may sometimes help our diagnosis, although it be quite true that a purely mental one may excite in- creased action and actual inflammation, as well as mania. The occurrence of convulsions along with the delirium render the diagnosis more certain. The extent to which these symptoms are present, and their number, must vary much in different cases. Without attempting to go too minutely into the diagnosis of the particular portion of the encephalon, which is the seat of disease, it may be observed that pain and the recurrence of rigor, seem rather referrible to inflammation of the membranes of the brain generally, while con- vulsions point to that more immediately investing the cerebral mass — the pia mater and the lining membrane of the ventricles; deli- rium chiefly accompanies inflammation of the gray matter, and alterations in sensibility and power of movement have especial reference to lesion of the central conducting fibres uniting the brain to the spinal system. Whether it be that the exciting cause acts simultaneously on more than one structure from the first, or that inflammation in one part is readily transmissible to the adjoining textures, certain it is that we seldom find local and circumscribed inflammatory action limited to any one tissue, and the symptoms are therefore necessarily more or less ambiguous; nay more, it is even true that those belonging more especially to one form of struc- ture may be excited by the simple proximity of inflammation in another. Xausea and vomiting are common to all the forms of in- flammation: they are to be more carefully noted in consequence of their occasional occurrence as premonitory symptoms, which must be viewed with great anxiety in persons who have been known to suffer from discharge from the ear, or to have had any other of the antecedents of cerebral disease: they are sufficient to cause us to be on the alert for the appearance of any other symptom of inflam- mation. Idiopathic inflammation of the membranes and particu- larly of the arachnoid and pia mater, is much more frequent in children and young persons than in adults; in them its first symp- tom is commonly an attack of convulsions: inflammation of the substance of the brain, again, is the more usual form in mature age, generally combined, however, with meningitis. From this combi- nation, no doubt, it happens that the course of the symptoms is seldom the same in any two individuals: thus, sudden alteration in manner may be observed passing at once into violent delirium, and followed by vomiting, while convulsion occurs only at a later period ; or vomiting and pain of the head may be the first in the order of sequence, and delirium only follow towards the close of the scene, CHRONIC DISEASE. 157 without any appearance of convulsion at all ; or again, convulsions may be the earliest symptom, but I believe this to be the rarest mode of attack, when the substance of the brain is the seat of the inflammation. In all of these cases it will be seen how little we can rely upon any one pathognomonic sign, and that if we would avoid dangerous or even fatal errors in diagnosis, regard must be had to all that can be learned of altered function or action in disease. § 3. Chronic Disease. — If the diagnosis of acute diseases of the encephalon be beset with difficulties, those encountered in investi- gating states of chronic disease are still greater, and in the majority of cases it must be confessed that we can scarcely form any certain opinion as to the actual lesion ; there we had to guard against being led by symptoms referable to the brain, to overlook acute diseases in other parts to which they were only secondary ; here we are very apt to mistake mere functional disturbance for chronic disease. In a practical point of view, and this is the most important one, the only question of real interest is, whether we can distinguish such as are dependent on states of chronic inflammation, and therefore remediable in a majority of cases, from those which depend upon other causes, when we must be content with treating symptoms; because, in the absence of inflammation, the same broad and ra- tional principles of treatment will be most efficacious, whether they depend upon functional disturbance or on serious disease. The first inquiry is necessarily the history of their origin and progress: the next must be into the condition of all the other organs of the body, because there are none, it may be said, which do not occasionally react upon the brain ; some, it is true, more constantly than others; indeed very distinct classes of symptoms seem to be pretty constantly associated with particular forms of disease, while the coincidence in other cases is rather accidental. If we fail to detect disease elsewhere, we must again revert to the brain itself, investigating more closely the relation of each phenomenon, and evidence of disease of bone must be sought for. The presence of inflammatory action is most clearly indicated when the commencement of the attack can be traced back to a fixed and not very distant period, and when the symptoms follow a definite course : uncertainty with reference to their development and their irregularity or incongruity are to be taken rather as indications of insidious disease, or of nervous, hysterical, or hypochondriacal dis- orders. As in the acute forms, careful inquiry must be made re- garding previous injuries or accidents, and the presence of syphi- litic nodes or tumours of the scalp ; caries and suppuration rather excite acute than chronic inflammation, and when associated with nervous symptoms of long standing, are more commonly found to have acted through the medium of the nerve-sheaths, than through the brain or its investing membranes. 158 DISEASES OF THE BRAIN. After careful investigation of the history of the case, the other attendant cir- camstanci 8 are to be considered. A cachectic state which is not dependent on discoverable disease in other organs is, to a certain extent, presumptive proof of organic disease; its absence is, on the contrary, an argument in favour of chronic inflammation where disease of the brain is believed to exist. To this many ex- ceptions are found; and encysted tumours, for example, frequently proceed to a fatal termination without any symptom of cachexia. Headache more or less accompanies all chronic diseases of the brain: much has been written on this subject, but little is known with certainty beyond the fact that cases resembling each other in their essence may differ very greatly in this respect, while those producing similar sensations of pain, weight, aching, or dizziness, may reveal alter death lesions very unlike one another. It is most difficult to discri- minate cases in which this symptom stands alone as evidence of disease of the brain, from those in which it is merely secondary on deranged digestion. When dyspepsia, vomiting, or constipation coexists with headache, the determination must rather rest on the absence or presence of concomitant signs than on its in- tensity or duration: perhaps, when dependent on disease of the brain, the pain re- curs more frequently, and without chylopoietic derangement; the intermissions are less frequent, the paroxysms of longer duration; it is aggravated by noise, motion, light, company, and is never dispelled, like a dyspeptic headache, by exercise or excitement. Very often, too, the recumbent posture aggravates the disorder; but its significance is greatest when it is accompanied by any disturbance of the mental faculties, or disorder, however slight, in the performance of muscular movements. The objective phenomena are much more trustworthy than the subjective. Al- terations in manner, in character, or in memory — partial paralysis, whether limit- ed to one or more of the cranial nerves, or extending in a modified manner to all the spinal nerves, or to those on one side of the body, as well as muscular irri- tability or spasm similarly distributed, are symptoms which can be more readily brought to the test of experiment than mere complaints of pain or uneasiness. Mental phenomena, in chronic cases, must be assumed to be dependent upon some cause of pretty general action, because we know that, in the absence of delirium, the intellectual faculties are frequently undisturbed by lesions of very consider- able extent, especially when they are limited to one hemisphere; we have also reason to believe that the gray matter of the convolutions is particularly involved in the production of such phenomena, and therefore we may be justified in re- garding them as evidence of chronic meningitis. When the cause of the affec- tion is central, and acting secondarily on the gray matter, we shall probably find as its accompaniments stupor or paralysis, which are more closely connected with disease of the fibrous element. Local paralysis, when slight, may be but the commencement of more general paralysis; when complete, it rather points to the pressure of a tumour, or to some other form of disease of local character. More extended paralysis, if caused by pressure, is generally accompanied by more or less stupor and confusion of thought; when standing alone, it is probably dependent on disorganization of the central structures and tubular nerve substance. In cases in which it is less pro- nounced, it would seem sometimes to be caused by chronic inflammation of the membranes, especially about the base of the brain. Paralysis, coma, and convul- sion, with reference to all forms of chronic disease of the brain, are symptoms of very unfavourable omen; spasm, or imperfect control of movement, hold out more hope of possible amelioration, as they rather show some inflammatory action or irritation of nerve matter. Convulsion is not often seen in chronic disease till to- wards its termination; it generally indicates some degree of inflammation extend- ing to the ventricles or the base of the brain. Not un frequently cases of long-standing disease put on, at some period of their history, the aspect of active inflammation. The acute symptoms in such circum- stances may be somewhat modified by the previous disease, but their diagnosis is much facilitated by a knowledge of the foregoing state. Unfortunately, the prog- nosis is almost hopeless, the chances of modifying the course of the inflammatory action being so much the smaller in proportion to the severity of the organic lesion out of which they have sprung. APOPLEXY. 159 Symptoms of chronic disease are sometimes due to degeneration of the coats of the arteries of the brain, and a hint of this possible contingency may be obtained from the presence of valvular disease of the heart which cannot be traced to an inflammatory origin. § 4. Apoplexy. — No condition of disease is probably more marked or more easily recognised than a pure case of apoplectic seizure. Suddenly, while to appearance in perfect health, the patient loses recollection, and falls to the ground in a state of unconsciousness; his face is turgid; his temples throb; his eyeballs turn upwards; his features are drawn to one side ; slight convulsive tremor agitates his frame, usually on one .side; and he lies dead to all around him. When examined, probably one side of his body, or even the whole of his limbs, have become flaccid and useless, remain in any posture in which they are placed, and drop as lifeless things when lifted from the couch ; his breathing is slow and laboured ; his pulse op- pressed, small, and yet resisting; if one side only be paralyzed, he makes meaningless, purposeless efforts, and struggles with the limbs of the other, when any attempt to move him is made; in course of time his breathing becomes stertorous; his urine is retained in the bladder, or dribbles away in the bed; his feces are passed involun- tarily. Without another conscious movement, without any know- ledge of what has transpired, the coma deepens, the breathing be- comes a succession of interrupted sighs, and he passes away with- out a struggle. Clear and unmistakeable as such a case is, we find in practice that all the symptoms may be so shaded off by imperceptible differ- ences, that at length scarcely any portion of the original picture remains, by which to give an exact definition of an attack of apo- plexy; and in common parlance, a "fit," followed by loss of con- sciousness, is called apoplexy. This is not the place to discuss whether anything be rightly called apoplexy which is not distinctly traceable to turgidity of vessels, with or without their rupture, and the consequent extravasation of blood; but, as a matter of diagnosis, it is essential to distinguish sanguineous apoplexy from all other sorts of "fit," whether these be followed by loss of consciousness or not. "When a history can be obtained in a case of apoplexy, it is not unusual to find that there have been, for some days or weeks, occa- sional warnings, which are spoken of as "tendency of blood to the head," consisting of headache, giddiness on sudden change of pos- ture, throbbing of the temples, &c. ; and the occasion of the fit it- self has been some strain or prolonged muscular effort, or some mental excitement. The fit itself may not be the first step in the actual progress of the malady, but may be preceded for some hours by an accession of violent pain, or by some form of paralysis of the cerebral or even of the spinal nerves. The occurrence of apoplexy is generally, to a certain extent, limited by age; a full habit of body, luxurious living, turgescence of the face, and the cessation of habi- 1G0 DISEASES OF THE BRAIN. tual dis charges, may each be found among the precursors, or, as tiny arc called, the predisposing causes of apoplexy. It has been already remarked, in speaking of semicoma, that it may be equally associated with apoplexy and with epilepsy; and in the broad outline of the former, just given, a drawing of the face to one side, and convulsive movements of the whole or part of the frame, have been mentioned as noticeable in an unquestionable case of apoplexy; and therefore it is evident that the "fit," and the semicoma following, may be symptomatic of either disease; in fact, it resolves itself into a question of degree, the amount of convul- sion, the depth of coma. Apoplectic convulsion is rather a faint tremor than convulsion, and is most marked when paralysis of one side of the face leads to more distinct deviation to the other. In epileptic convulsion, however slight, there is definite movement, forcible and almost irresistible, distinctly dragging the limb or, the head into unnatural contortions, and these are rarely limited to one side. The physician has no chance in general of seeing the move- ment and judging for himself, but any intelligent by-stander can comprehend the difference and say what he saw. Then, again, the coma differs in degree, and in the opposite direction: if the con- vulsion of apoplexy be slighter, the coma is deeper. The'difference can scarcely be made intelligible by words, but the loss of con- sciousness and usual sleep of epilepsy are quite distinct from the stupor of apoplexy: the one consists rather in confusion, the other, in suspension of the mental faculties. But there is another condition, which is called serous apoplexy. Here, too, there is a fit: there is loss of consciousness and paralysis, and yet there has been no turgidity, no rupture of vessels — mere effusion of serum. This fact has been alreadv referred to, and it is almost incredible that it should take place instantaneously. I think we must believe that a morbid process has been going on for some time; that at a certain point the brain becomes intolerant of pressure, this point being determined by momentary repletion of either arteries or veins, or of the capillary vessels, and that then the event occurs in a moment. This is not true apoplexy, and careful inquiry will always show that it is more nearly allied to epilepsy; that it is, in fact, analogous to the convulsive seizure which ushers in hydrocephalus, even in the adult; but the paralysis has proved the stumbling-block, and has been thought distinctive of apoplexy. The diagnosis is difficult, but I can affirm, from per- sonal experience, that it is not impossible, though perhaps nothing can teach it except watching such cases, with the knowledge that events of this nature do occur, and that they do manifest them- selves by special features. The condition of the pupils deserves consideration, although no very definite rules can be laid down. Contraction indicates irrita- tion ; dilatation, paralysis of the optic nerve. A want of corre- spondence between the two proves the existence of more severe APOPLEXY. 161 lesion on one side than the other; and would, therefore, at once exclude the idea of epilepsy. Be it remembered, that there is no one symptom by itself dis- tinctive of sanguineous apoplexy, and it is often only after several examinations that a diagnosis can with confidence be pronounced. There are two points which, in the subsecpient condition of the patient, serve very greatly to discriminate the cases ; these are, the recurrence of the "fits," and the relative consciousness on succeed- ing days. (1) When they recur at short intervals, and no paralysis follows, the case is certainly not sanguineous apoplexy; even if the convulsive movements be only slightly marked, they are probably epileptic, and after their cessation, convalescence from the condition of coma may be confidently looked for. When recurring at longer intervals, sometimes of days, more often of weeks, with paralysis enduring throughout, it is probably an instance of serous apoplexy ; true sanguineous apoplexy only recurs at very much longer inter- vals. (2) Alike in epilepsy and in serous apoplexy, consciousness is not so entirely suspended as in sanguineous apoplexy; at least, it is so for a much shorter time ; when serai-coma follows upon epi- lepsy, the subsequent state is one of prolonged sopor, from which, when the patient is roused, he manifests a certain degree of con- sciousness by placing himself comfortably in bed, drawing up the clothes, &c. ; but no regard is paid to surrounding objects. In serous apoplexy the sopor is less prolonged, and it is followed by a kind of vague, dreamy consciousness, which is attracted by sur- rounding objects, without recognising or understanding them, so that the impression made on the senses is not followed by any corresponding rational act. In apoplexy the patient wakes as from profound sleep, and the recollection is confused, the thoughts are collected with difficulty, and the reason used imperfectly; but there is distinct consciousness in the waking movements. The character of the pulse in cases of apoplexy is one which demands careful study on the part of the practitioner, because of its bearing on the all-important question of venesection : it has also its uses in diagnosis, inasmuch as a hard, wiry pulse, or a condition of vascular congestion about the head and throbbing of the temporal arteries, are so many indications of sanguineous apoplexy; but the converse does not by any means exclude the possibility of rupture of a blood- vessel. In all of these sudden invasions of the intellect, the heart and kidneys must be closely examined. Few cases of fatal sanguineous apoplexy occur in which both organs do not present evidence of disease, and probably in all cases one or other is at fault. Serous apoplexy is perhaps more frequently associated with the stru- mous diathesis; one form of convulsive seizure is directly connected with blood- poisoning in disease of the kidney, and it is perhaps conjoined with effusion of serum. To another condition attention has been drawn of late years — viz., the washing down in the current of the blood of some vegetation which has been gradually growing on the valves of the heart; this is suddenly arrested in some of the small arteries of the brain, stopping the supply of blood to the parts beyond, and interfering with their nutrition. In consequence of such an acci- dent, paralysis may either supervene rapidly when deficient supply is sufficient to produce it, or may come on gradually when imperfect nutrition has led to dis- 11 102 DISEASES OF TIIE ERAIN. nizatioo of ]>art of the brain-structure. Iu either case the menial phenomena ■ . &c, are generally wanting; and tins may .serve, along with physical evidence of valvular lesion, to lead to a pretty correct guess at its can 5. Epilepsy. — Epileptic convulsions have been frequently re- ferred to, yet something remains to be added to give consistency to its diagnosis. The term is somewhat indefinite in its application, because while on the one hand it is used to denominate a specific disease which has no analogue in, and receives no explanation from any of the disorders of function to which the brain is liable, yet on the other hand it is applied more or less indefinitely to any sudden seizure which is marked by convulsions and loss of consciousness. The grand distinction between epilepsy and convulsion is to be derived not from any peculiarity in the seizure, but from the context of symptoms. It resolves itself into the question, is there any dis- ease present in any organ, in the course of which convulsions may and do occur? On this question being answered in the negative depends the diagnosis of true epilepsy, imperfect as it must be confessed that such a distinction is. This point is quite unconnected with its curability: the prevailing theory at present is, that the eeizure consists in an excess of irritability and over-excitement of the nervous centres ; in curable cases, certain concomitant conditions, are regarded as sources of irritation, and these being removed, and the tone of the nerve-fibre itself restored, the disease ceases. The question proposed is not whether there be any such circumstance which determines the attack, but whether disease be present, which, either by being seated in the brain itself, or by establishing a cer- tain blood-crasis, tends directly to produce convulsions during its continuance. The most notable examples are inflammations of the cerebro-spinal axis, puerperal states, and albuminuria, or more pro- perly, perhaps, urajmia. In true epilepsy we fail to detect any s ich conditions during life, and although we do find, in certain cases after death, something within the cranium which may have acted a^ a permanent cause of irritation, its mode of action is unknown; it ^ symptoms are limited to the simple expression of irritability in the epileptic seizure. The convulsions of childhood may be said to form a class by themselves: more nearly allied to epilepsy than to the secondary convulsions of adults, they seem to depend on a species of excita- bility which is probably owing to the disproportionate development of the brain of infancy; as in epilepsy, too, the sources of irritation are various; with the exception of those connected with inflamma- tion, they do not lie within the cranium; but while one child never shows the slightest tendency to convulsion, another suffers repeated attacks from all the accidents of infancy; teething, worms, intes- tinal disorder, or mere exposure. Still they are not to be called epilepsy, except they return periodically, without the presence of the exciting cause; that in some children repeated convulsions terminate in confirmed epilepsy is too true, but in by far the greater number, fortunately, no such lamentable occurrence results. EPILEPSY. 163 One great element in epilepsy is its periodicity, whether regular or irregular ; but the first recurrence may be at so long an interval that the patient is lost sight of before a second fit occurs, and our diagnosis cannot wait for such an event for its confirmation. Its importance is such, however, that in all convulsive attacks it is de- sirable to ascertain from friends, or from the patient himself, as soon as consciousness is restored, whether he have ever been at all similarly afflicted. The severity and duration of the attack vary very greatly, from a transient loss of consciousness with the slightest possible muscular spasm, to the most violent and horrible convulsions. In the former case the patient is arrested for a moment or two in his usual avoca- tion, retains his position without falling, whether standing or sitting, and proceeds with his -work as if nothing had happened. In the latter, the mind remains confused when consciousness is restored, and the patient soon falls asleep, to wake up generally in a short time, stiff', or sore, or bruised, and perhaps complaining of head- ache, but not otherwise feeling ill. This confusion of mind and tendency to sleep is in rare instances prolonged for some days, the patient remaining, as has been already pointed out, in a semicoma- tose state. The diagnosis between true epilepsy and convulsions arising from other causes is not to be regarded as a matter of merely curious investigation, for upon its just appreciation depends the correct treatment of the case. I may cite an example in which the first epileptiform seizure was accompanied by some delirium, which differed materially from the mere confusion of epilepsy ; but the whole disorder seemed so transient, that its peculiarities were attributed to manifest bad manage- ment in the commencement of the attack; and with some misgiving it was re- garded as epilepsy. The patient was dismissed as having recovered ; but the next attack was distinctly one of serous apoplexy, at an interval, indeed, of nearly two years. After death there was found immense dilatation of one of the lateral ven- tricles. I cannot doubt that in this case a condition of chronic inflammation had existed throughout, and that judicious treatment might possibly have prevented the fatal termination. An epileptic seizure may be either feigned for the purposes of deception, or simu- lated by the hysterical paroxysm. One grand source of distinction in such cases is the circumstance of no corporeal injury being inflicted during the attack: not that this necessarily happens in true epilepsy; but while, on the one hand, a bitten and bleeding tongue or a bruised face may be taken as conclusive evidence of ge- nuine convulsion, its avoidance in circumstances which might naturally have given rise to it, leads to the suspicion that consciousness has not been entirely lost. The determination of its nature, indeed, turns mainly on the existence of consciousness, and various methods must sometimes be had recourse to for the purpose of ascertaining it. There is generally, too, a certain method and regu- larity in those movements which are either partially or wholly voluntary; and in the case of hysterical females, other characteristics may be observed from which the prevalence of hysteria may be predicated, and the consequent probability that the seizure, is only part of the same disorder. But this demands experience and attention rather than book-learning. Certain points must not be omitted in the investigation of convulsive attacks which are not immediately connected with diagnosis. In a first seizure, it has been shown how necessary is the incpiiry into the condition of other organs; but it is no less so even in cases where periodicity is clearly established. The possi- bility of success_in the treatment of all such disorders depends upon the correct- 164 DISEASES OF THE BRAIN. ness of this information, and in proportion to its accuracy will their management be removed from the realm of empiricism, and come under the domain of legiti- mate medicine. Not only do the physical condition of the cranium and all the relations of the brain to sensation, motion, and the intellectual faculties, demand particular study; but respiration, circulation, digestion, and elimination, have each been proved to have their influence, if not as causes of the disease, yet as special sources of irritation, and therefore must each be individually inquired into; and if last, not least, the reproductive organs, in their changes from disease to health, from imperfection to maturity, exercise a most unquestionable influence over its amelioration and its cure. § 6. Functional Disturbance. — Vague as this terra may be, it needs no argument to show the necessity for such a distinction in a classification of nervous diseases. Not only do our present means of investigation fail in pointing out that there is any disease in nerve- structure accompanying the delirium of fever, or puerperal mania; but there are numerous slighter and more transient alterations in the relations of the brain as the recipient of sensation, the origina- tor of motion, and the medium of intellectual operations, the nature of which, were our means of investigation never so perfect, we cannot by any possibility have the opportunity of ascertaining through the bony wall of the cranium; and to these last we espe- cially wish to limit the term functional, although it might very well include all those conditions which, so far as our knowledge extends, are unconnected with actual disease of nerve-structure. They divide themselves naturally into three main groups; (a) those connected with disturbances of the circulation, whether in excess or deficiency; (b) those connected with disorder in the pro- cess of digestion and assimilation; and (c) those which are more properly called nervous. Of the two former it is to be remarked, that while coincident, and bearing some relation to each other as cause and effect, the functional disturbance of the brain is not to be regarded simply as a symptom of disorder of the circulation, or of the digestion; for it is not a necessary or a constant effect. The same amount of disorder is not uniformly followed by similar dis- turbance in any two individuals, or in the same individual at dif- ferent times; while the identical symptoms may be noticed in the same person under very different states. Hence, the term nervous might be justly applied to all; but it is important to bear in mind that the connexion exists, and that the disorder of the circulation or of the stomach being removed, the functional disturbance of the brain for the time ceases. Insanity might, with some show of reason, be included in this section, as its relation to disease of the brain is so entirely unknown. We have already endeavoured to point out, in speaking of delirium, the means of its diagnosis, to which it is unnecessary again to allude. The symptoms of functional disturbance cannot be classified according to the disorders of other organs with w'hich they are asso- ciated; we shall, therefore, take them in the same order adopted in the previous chapter, considering them in their relations to intel- lectual faculties, to sensations, and to power of motion. FUNCTIONAL DISTURBANCE. 165 Here we meet with neither coma nor delirium ; their counter- parts, however, maybe traced; for we have the semi-stupor seen in what is called the hydrencephaloid disease of childhood, the mock hydrocephalus following on exhaustion, either from diarrhoea, from excessive depletion, or from want of nourishment. In care- fully following up the rational principles of diagnosis, which it is the object of these pages to elucidate, the error which this very name implies will be easily avoided, because on the one hand the history will teach us that the child has been exposed to depressing causes, while on the other its actual condition will be defective in some of those characters which are necessarily associated with in- flammation of the brain; as we find, for example, a cool scalp or a depressed fontanelle: when mistakes have been made they have arisen from limited inquiry, and from reasoning upon partial infor- mation. Another counterpart to the condition of coma in severe disease, is seen in the fainting-fit in the adult, which is sometimes simulated by hysteria, but is, in truth, merely an expression of want of blood in the brain. Then again, corresponding to hallucinations and illusions, we find ocular spectra and deceptive noises, as well as all the morbid fancies of the hysterical and hypochondriac. More common forms of disturbance are met with in the complaint of loss of power to carry out an ordinary train of thought, or tran- sient loss of memory. Among sensations may be reckoned as the most common, head- ache and giddiness; then partial blindness, tingling, ringing in the ears; to these, again, must be added the exaggeration of pain which is produced by constantly thinking of and directing4the attention to it. Muscular spasm and paralysis are not often seen as a consequence of functional disturbance, for, although we do not know that chorea is associated with any organic change in the condition of the brain and nerves, it has too much the characters of a distinct and definite disease to be classed along with those we are at present considering: both choreic movements and paralysis are simulated in hysteria. Convulsions, on the other hand, occur in infancy quite as often in consequence of functional disturbance as of organic disease: among adults we can scarcely include in this class those which are seen in cases of blood-poisoning, — uraemia, and puerperal convulsions, — although they be not directly connected with organic change in the brain. In the investigation of "head-symptoms" generally, the same rules must be followed as in the more severe diseases of the brain. We have to make out the history of the case, and the order of sequence of the various phenomena, remembering that, as the attention of the patient is fixed on what he considers the most important symptom, he generally dates the r commencement of his illness from the period of its first appearance, and it is only by close inquiry that he can be got to admit any previous derangement 166 DISEASES OF THE BR A IX. of health: indeed, it may have been so insidious as to escape his observation. Then diligent search must be made for other indica- tions referring to the brain or nerves, besides that of which the patient complains, lest, perchance, it should be discovered that it is but one link in a chain of symptoms which proves the existence of some severe disease of the enccphalon. In the order of examination we shall next be able to exclude febrile and inflammatory states; and then the appearance of the patient in regard to conditions of anrcmia or plethora naturally occupies our attention: not indeed in the more marked forms of blood changes, where hemorrhage, purpura, or chlorosis constitute distinct classes of disease, but in such minor deviations from health as perhaps are only testified by the circumstance that the symptoms are either relieved or aggravated by the recumbent posture. Along with this we naturally take the condition of the organs of circula- tion, when a slight cardiac murmur, unaccompanied by other evi- dence of disease, may be enough to explain uneasy sensations in the head, which are far more tormenting to the patient than the dyspnoea or palpitation which we might expect to find, and the very existence of which he utterly ignores. The lungs, too, must be carefully examined, but this rather for their negative than their positive results; for we are not now deal- ing with symptoms relating to severe disease, but with the little torments which invalids" frequently suffer; and, for their successful treatment, we are rather indebted to experience than to pathology. A step further brings us to the organs of digestion, which are moup often the apparent exciting cause of functional disturbance »than any other. But it is in their minor derangements only, that we can be justified in regarding the cerebral symptoms as functional. A bilious headache is a thing of every-day occurrence; but we must carefully analyze what -is meant when a person says he is bilious: we may employ such a phrase as a compendious expression of a certain state, but we must be careful how we listen to it from the mouth of a patient. Frequent vomiting, obstinate constipation, or severe diarrhoea must make us look further into the case; slight nausea, loss of appetite, discomfort during digestion, and irregularity in the action of the bowels may justify the conclusion that the uneasy sensations in the head are only functional. In addition to this, it will be found in practice that a patient seldom applies for relief at their first occurrence, when connected with derangement of the digestive organs. Dyspeptic symptoms arise by such slow degrees that few have reached the middle period of life without suffering from them; and it is only when they are more than ordi- narily severe that advice is sought: to some people they become the ordinary state of health, and immunity from them the exception; they have had their headaches over and over again, and begin to look upon them as necessary evils, till some strange sensation arouses suspicion of unknown mischief. The frequent recurrence of such head-symptoms, — their habitual association with attacks of FUNCTIONAL DISTURBANCE. 167 more severe indigestion or more than usual irregularity in the bowels, — their transitory character, and the circumstance that excitement and motion succeed in dispelling them after a little starvation, or a little purgation, — all this affords valuable assistance in discriminating these transient disturbances from the more severe forms of cerebral disease. The state of the urine, after all that has been said of the con- nexion of diseases of the brain with those of the kidney, will not fail to be investigated. The state of the sexual organs is chiefly related to that form of disorder which we have denominated the nervous. We have seen something of this mysterious connexion in hysteria, — a condition which tends greatly to heighten and augment the symptoms derived from this source, though they may have their existence quite inde- pendent of it; but all the disorders of these organs, and especially their undue excitement, must be borne in mind in relation to "nervous" disorders. Painful as the inquiry must be to every right-feeling man, we must not neglect the suggestions of the wan aspect and the shrinking eye of a young man in a state of nervous- ness bordering on insanity, who has brought upon himself, as the fruit of his vices, the penalty of a constant spermatorrhoea; duty commands us to endeavour to save him from himself, no less than from the clutches of the disgusting charlatan who only keeps up while he preys upon the disorder. But we tread upon delicate ground, and I must earnestly warn my younger readers against the scarcely less obnoxious and obscene familiarities of the legitimate specialist. This class of cases borders much more closely on the organic diseases which have been already discussed than either of the pre- ceding ; sometimes it is hard to be discriminated from mental alienation. The over-worked brain of the professional man who is labouring after eminence or wealth, and, still more, the over-excited brain of the stock-jobber or speculator, after a time becomes ex- hausted and unfit for the longer performance of duties beyond its strength; and apoplexy, paralysis, meningitis, or dementia put a sudden stop to his foolish schemes. It is vain to attempt any more correct classification of these symptoms; but, with reference to diagnosis, it is well to remember that they may be but the precur- sors of more serious mischief. On the other hand, it is always a state of depressed vitality which gives prominence to symptoms generally called "nervous." Over-anxiety and care, whether ac- companied by straitened circumstances, which deprive the individual of many of the comforts, perhaps of the necessaries of life, — or leading to irregular hours, when the system is alternately exhausted by long fasting, and taxed by subsequent repletion, — not less than a life marked by habits of gayety, dissipation, and excess, must in course of time undermine the strongest constitutions, and expose them to these attacks. By repairing the waste, giving tone to the system and relaxation to the brain, we can best hope to relieve present symptoms, and ward off more serious mischief. 1G8 CHAPTER XIV. DISEASES OF THE SPINAL CORD. I nil a mm at ion rare as an Idiopathic Disease — Its History and Symptoms — Connexion with Caries — Spinal Irritation — Chronic Disease. Inflammation of the spinal cord, except as a consequence of accident or injury, is confessedly so rare, that it demands but little notice in a work, the avowed object of which is to conduct the student to right principles of diagnosis. In its general character it ranks among acute diseases, and it is often accompanied by symptoms of cerebral inflammation: these may arise either from the sictual spread of the inflammatory action to the membranes of the brain, or they may be produced merely by the sympathy neces- sarily existing between parts whose functions are so closely con- nected: such symptoms have been found, both with and without sensible change within the cranium. The history of the case perhaps reveals the previous occurrence of some accident or strain, or casual exposure to cold, which may be reckoned among its more usual causes. In every instance it gives an account of a sudden seizure as the starting-point from Avhich to date the sequence of the phenomena, while the greater or less rapidity with which they succeed each other, enables us to judge of the relative severity of the attack. The early stages of the disease are liable to be confounded with rheumatism and neuralgia; but on closer investigation it will be found that there is more of general disturbance than the local and limited nature of the attack would warrant us in expecting, were the pain due to either of these diseases. It is always characterized by pain somewhere in the region of the spine, and generally pretty high up; of a fixed character, and notably increased by any quick change of posture. In well-marked cases this pain is accompanied by spasm, having somewhat of a tetanic character, especially in the muscles of the neck and upper part of the back; paralysis some- times comes on early. These are exactly the signs which, a priori, we should expect to meet with in inflammation of the cord, as they are due either to the irritation or the subsequent disorganization of the large bundles of nerve fibres. In many cases we are perplexed by the paucity and comparatively slight character of the symptoms directly traceable to the spine, and their very constant association, when they have attained a certain degree of severity, with others which are more distinctly cerebral. Paralysis, or loss of sensation, indicates a further advance: the inflammation is no longer limited DISEASES OF THE SPINAL CORD. 169 to the membranes, but, as in the chronic forms of the disease, some change has actually passed upon the nerve fibre. The condition of the bones should next occupy our attention, in so far as their regularity of position? capability of movement, and tenderness on pressure are concerned; and it may be laid down as a rule in diagnosis, that "when the cord is inflamed, and especially ■when spinal meningitis is present, any sudden twist or jarring movement gives more evidence of pain than mere pressure. Per- manent displacement, as a result of caries, may have proceeded to a very great degree without any distinct evidence of its impeding nervous action; and when paralysis at length occurs, it is often due to inflammatory action set up by the contiguity of diseased structure. Probably this cause operates even more frequently than the pressure dependent on increasing distortion: in such circum- stances the characters of an acute attack are generally wanting. As connected with this subject a few words must be said upon tbe somewhat fashionable ailment denominated spinal irritation. It is a great misfortune when a name is given to any affection which conveys an erroneous impression of its na- ture: irritation of a nerve produces either momentary spasm or transient sensa- tion, as the course of the nervous influence is centrifugal or centripetal: and a continuance or repetition of the irritation will produce the same phenomena in a more or less continued succession: in this view all pain and all sp^sm may be classed generally under nervous irritation, and so the true spinal irritation which characterizes the first stage of inflammation of the cord produces fixed local pain, and distinct local spasm. On the other hand, excessive tenderness or sensibility — hyperesthesia, as it is called, — such as occurs in inflamed states of organs, whether with or without actual pain, as well as the excessive mobility seen in chorea or delirium tremens, may be said to be due to irritability, but are certainly not the effect of irritation. Again, loss of sensation and loss of motion are not evidence of either irritability or irritation, but of interruption to the transmission of nervous influence, or loss of power in the brain to take cognizance of the one or originate the other. In what is called spinal irritation all these phenomena may be met with, and are mixed up together in the most incongruous manner. Some inquirers have deceived themselves into the belief tha*t the symptoms were capable of classifica- tion, and have even detailed examples of cases in which there was some pretension to scientific order and natural sequence; but in these instances they have, no doubt, been misled by their having put leading questions to persons in whom the promi- nent condition was a disordered fancy, and by their having readily obtained an- swers in the affirmative. Take the patient's own account of symptoms, or put the leading questions in such a form as to develop their incongruity, and no doubt need remain of the truth of what is here stated. There is often complaint of pain in the back, but its character, in place of being fixed, and local, and deep-seated, is diffused, superficial, and variable. Movement, at one time alleged to be impos- sible, is effected with perfect ease at another, when the attention is turned to some- thing else: the slightest touch, when the question is put, will be said to give pain, and yet firm pressure or a considerable jar at another moment is unheeded. This character alone is sufficient to distinguish such complaints of pain from those that are of real importance; the same remarks apply to the spasms and the paralysis which, each in turn, may form the principal feature of the disorder: they may, by a little dexterity on the part of the observer, be proved to have their existence only in the exuberant fancy of the patient. If the distinctions in the use of terms just pointed out had been clearly kept in view, we should probably never have had any doubts or confusion on this subject. Chronic disease of the cord is a subject on which little can be 170 DISEASES OF THE SPINAL CORD. said in a diagnostic point of view. The great evidence of its existence is to be derived from the paralysis which, sooner or later, always accompanies it; but this symptom alone can give little information regarding the effuses of its occurrence; because, as will be shown in the sequel (see Chap. XV. § 2,) one which really acts only on a small fragment of the medulla, produces symptoms such as we should imagine indicative of disease of a much more extensive form. The chief guide in determining the nature of the lesion is the order of sequence among the phenomena; thus, in a very general way, it may be stated that pressure on the cord gives rise to feel- ings of formication, tingling, heat and cold, &c, simultaneously with pain in the back ; whereas in inflammatory action, even of a chronic kind, the pain is more usually associated in the first in- stance with spasm, and the sensation of numbness comes on» at a later period. Both of these are again distinguished from the common cases of paraplegia dependent on atrophy of the cord by the absence of pain in the latter condition altogether. Another circumstance which may serve for our guidance in this, as it does in other organs, is the knowledge which pathology gives of the relative position and extent of diseased action; atrophy is confined to the lower end of the cord; inflammation is apt to diffuse itself widely; tumours are most commonly found towards its upper extremity; and each of these positions must of necessity be cha- racterized by phenomena of different kinds. I have said nothing of the means of distinguishing spinal arach- nitis from inflammation of the substance of the cord, nor, again, of the difference in symptoms between inflammatory softening and hardening; they are far too uncertain to be laid down for the guidance of the student, who may rest quite satisfied if he can dis- tinguish inflammation either of acute or chronic form from other lesions. 171 CHAPTER XV. PARALYSIS. Loss of Sensation — of Power of Motion — Incomplete Paralysis. — § 1, Hemiplegia — Its Mode of Incursion — Its Central Origin — Causes and Complications — § 2, Paraplegia — Its Causes and Varieties — Cfeneral Paralysis — Paralysis Agitans — § 3, Local Paralysis — Its Mean ing — Nervous — Muscular. By paralysis is meant the inability to transmit nervous influence, whether in a central or in a peripheral direction ; but the term is more usually applied to that manifestation of it which consists in loss of muscular power: loss of sensation has been called ansestliesia, and a corresponding term for muscular paralysis has recently been invented — acinesis : loss of power of motion without diminished sensibility is much more frequently met with than the converse, and when the two are coincident the diminution of mobility is generally much greater than that of sensibility. Taking into consideration the compound nature of most of the nervous tracts, it will rather appear surprising that the two conditions should ever be apart, than that they should frequently be found associated in the same individual; and in those exceptional cases in which the nerve fibres are wholly sensory, or wholly motor, we find that the very same circumstances which in the one lead to anaesthesia; in the other produce muscular palsy. In prosecuting the diagnosis of nervous diseases there would therefore seem to be no advantage in separating them in a pathological view; and in semeiology, as has been already observed, objective phenomena are generally more certain and con- clusive than subjective. The history of the incursion of paralysis and the symptoms which have preceded its development, give us the first clue to discover the cause on which it depends ; but it is also of use in enabling us to determine whether the complaint made by the patient of loss of power or numbness be based on a real alteration of the condition of the parts, or be entirely, or partly imaginary; a point which is often very difficult to decide when the paralysis of the nerve is not complete. In real paralysis we shall either find that at one time it has been more perfect than it now is, and that it commenced with a comparatively sudden seizure, or that it has come on gradually and has been slowly increasing: its amount, too, is the same at different times of observation. This may be best measured by power of resistance ; but it is necessary to bear in mind that spasm is sometimes associated with paralysis, and, while there is little or no voluntary power, the 172 PARALYSIS. muscle under the influence of spasm may offer great resistance to movement of the limb by another: such an occurrence can only mislead when the observation is very superficial; one set of muscles only is affected by the spasm, and that for but a short period, the limb under all other circumstances remaining in a powerless condi- tion : such spasm is only seen when the paralysis is complete: it is referrible to some sort of reflex action. The duration of the affection aids in determining the nature of the lesion; we discriminate cases according as we can trace an invasion of recent disease on old standing paralysis, or the latter supervening on illness of longer duration, or all the symptoms commencing together. Similarly its mode of incursion may throw light on its cause, as we find it occurring suddenly in apoplexy, or more slowlv in chronic disease; ushered in by a fit or loss of consciousness, or gradually spreading from muscle to muscle; attaining its maximum in a few hours, or advancing from week to week. Occasionally a fallacy presents itself in the circumstance that some slight paralysis of long standing is only first observed when febrile disturbance is present; such, for instance, as slight strabismus, of which the patient was quite unconscious. This is best corrected by ascertaining whether there be any recent change in function ; double vision necessarily attends recent strabismus, unless the sight of one eye be lost. In all forms of incomplete paralysis, whether the patient complain of inability to walk, of imperfect power of the hand and arm, or of mere feelings of numbness, while yet there is no muscle which cannot be brought to act when he is at rest and no resistance offered, we are beset with difficulties, because, on the one hand, the cause of the disease is exceedingly obscure, and on the other, its main features are often simulated by hysteria or hypochondriasis. It is not only during life that this obscurity prevails, but even after death it may be wholly impossible to point out the lesion on which it depended. Were other instances wanting, very forcible evidence of this fact is derived from instances of what is called the para- lysis of the insane. In such cases we have to seek for other evidence of disease of the brain or nerves, if any such can be traced, in actions which do not come under the power of voli- tion; to study the character of the patient, as it may evince nervousness, hvsteria, exalted imagination, unnatural excitement or depression, and to compare one day with another the increase or diminution of symptoms. In hysteria especially, va- riation is the ordinary rule; consistency, the exception. A patient will fail toshow any power of resistance, or will bear pretty severe pinching at one observation, and at the next the symptoms have undergone a complete change. But it is to be remembered that the different result may be due to the manner in which the in- vestigation has been made. It has happened in my own experience, that one phy- sician pronounced anaesthesia to be complete, while another obtained distinct evi- dence of sensation ; because, by the one, only a transient impression was made, which was not transmitted to the sensorium, while the other maintained the irri- tation for some time, and at length consciousness of pain became apparent. Where we have reason to suspect simulation or imaginary ailment, various de- vices must be had recourse to in abstracting the attention, in avoiding leading questions, or perhaps putting them in a wrong direction, so as to bring out a want of harmony and consistency in the tale; we must watch the action of those mus- cles which are less under the control of the will, employed in winking, in speech, and in deglutition; but, besides this, we may learn much from the gait and move- ments of the patient, as the real paralytic makes vain efforts, which end in partial or complete failure; the " malade imagiiutire''' evidently does not attempt to bring the muscles into play at all ; the will is paralyzed, and not the instruments which it employs. The test of resistance, which, when judiciously applied, generally serves to detect any exaggeration or imposture, is also of great value in discrimi- nating cases in which the practitioner is liable to be misled by a phrase employed by the patient that he has "lost the use of" a limb, when it is only motionless from stiffness or pain of the joint; just as, on the other hand, it may detect the ex- istence of paralysis when the patient speaks of it as rheumatism. HEMIPLEGIA. 173 "We have no such test to apply in regard to the degree of sensibility, which must rest wholly on the report of the individual; but it is well to remember that it sel- dom exists without loss of power at the same time. Loss of sensation, when stand- ing alone, except in the case of one or two special nerves, is most probably exag- gerated; but as a sense of numbness or partial insensibility, it may be the first in- dication of coming paralysis which excites the patient's notice. The next point is to determine the form and distribution of the affection, because a knowledge of the number of muscles para- lyzed, and their relations to the nervous system, is the principal element in forming a correct hypothesis regarding the seat and nature of the cause. The value of paralysis, as a symptom of dis- ease, depends entirely on our acquaintance with the origin and course of the nerves, and on our being able to determine the point at which the interruption to volition occurs, whether by failure of the brain as the organ of mind to receive the power of the will, or of the nerve-tubes to transmit that will; and whether the interrup- tion, when affecting its transmission only, can be referred to the tract of a single nerve, or must be traced hack to the common exit or origin of several. We recognise in practice three main divisions of paralysis, — hemiplegia, affecting one side of the body; paraple- gia, implicating both sides equally, or nearly to the same degree, up to a certain height; and local paralysis, which maybe either limited to a group of muscles supplied by one nerve, or one set of nerves, or to single muscles by themselves, — in the former the dis- ease is probably seated in the course of the nervous trunk; in the other, in the muscular structure. •? § 1. Hemiplegia. — This form of paralysis is distinguished by its limitation to the muscles on one side of the body: a line corre- sponding to the axis of the spinal column separates those which can no longer be called into exercise by volition, from those which re- tain their healthy action. In its most extended sense the one-half of the tongue, the face, the chest, and the abdomen, as well as the arm and leg of the affected side, are all implicated; but such a condition rarely exists. Some of the muscles are more easily affected, some more quickly regain the power of motion; and we seldom see a case in which hemiplegia is complete. It may, there- fore, become a question, when certain muscles of one side of the- body are paralyzed, whether the case should be considered as one of partial hemiplegia or of local paralysis. And this is not a mere question of names; the correctness of the term employed implies a correct judgment regarding the causes of the phenomena observed; because, if we regard it as hemiplegia, we attribute the palsy to a cause acting upon the nervous centres, and thus affecting the nerves derived from them on one side ; whereas local paralysis points to a cause affecting only the nerve itself, and having no necessary con- nexion with the central structures at all; ultimately it may impli- cate them, primarily it is independent. The answer to the question is, in fact, the diagnosis of the case. 174 PARALYSIS. The history divides cases of hemiplegia very naturally into those ushered in by a "fit," and those in which there has been no loss of M-ionsness. In the former class there is no doubt whatever it the character of the paralysis: its cause is manifestly central; I so far as observations have hitherto gone, its extent throws no light whatever upon the particular portion of the brain involved. Sometimes the progress of the case and the duration of the para- lysis are of some assistance in determining the nature of the changes which in the first instance caused the fit. In the latter class the symptoms may have come on gradually or suddenly ; depending, in the one case, on disorganization of the brain, softening, or abscess; in the other, on extravasation of blood. I am not aware that, in any case, serous effusion has pro- duced paralysis without preceding evidence of inflammation, or the occurrence of a fit either distinctly convulsive in character, or more nearly resembling apoplexy. When slowly developed, we seek for evidence of previous disease of the brain in headache, earache, dim- ness of sight in one eye, double vision, ptosis, deafness, or impair- ment of intellectual power, loss of memory, &c.^ Occasionally, while such changes point to some form of chronic disease of the brain, the paralysis itself comes on rapidly; in other instances it is the only symptom, and beginning with partial failure of the power of volition over certain muscles, it gradually increases both in ex- tent and in intensity. When dependent on extravasation of blood, the patient has enjoyed his usual state of health up to the period of seizure; suddenly he becomes conscious of numbness, or loss of power in one of his limbs, and the paralysis soon involves the greater part of that side of the body. Occasionally the occurrence of headache leads to a strong presumption in favour of extravasa- tion ; but this, probably, is not the rule in such cases. The diagnosis between hemiplegia and local paralysis, — between loss of power depending on changes occurring within the cranium, and those affecting the nerve or the muscle — in all cases in which the history fails to point out symptoms directly connected with the cncephalon, must rest entirely upon the distribution of the affection in its relation to the anatomy of the nervous system. If we find 'that the palsy includes muscles supplied by nerves which have different origins, and have no direct communication with each other at their exit, we may be certain that the disorder is central. Hemiplegia is very rarely indeed associated with disease of the spinal cord: the space in the canal is so limited, that pressure on one half is sure to affect the other, although, perhaps, in slighter degree; and the two halves are so intimately united, that inflammation of the one never fails also to attack the other: paralysis of one side of the body is therefore always found with a minor degree of the same affec- tion on the other, when the disease is situated in the cord, and the case must be considered as one of paraplegia. In some cases, hemiplegia may be traced to a tumour within the cranium: its presence may be first shown by the occurrence of local paralysis of one of the cranial nerves, produced simply by pressure on its tract; hence it was said that the cause of local paralysis had no necessary connexion with the nerve-centres. PARAPLEGIA.' 175 In such a case the effect of the tumour within the cranium is just the same as it would have been had it pressed on the nerve after it had emerged from the skull. "When it lias attained some size, it may destroy a portion of the brain in which seve- ral nerves take their origin, causing paralysis of each, and then we have a case of partial hemiplegia — no longer one of local paralysis. Supposing that more than one nerve were paralyzed by pressure, the case would in reality be one of com- pound local paralysis; yet we should not be wrong in assigning to it an intra- cranial cause which is all that diagnosis can assert with any degree of confidence. It does not appear that such tumours can by their mere size produce more gene- ral hemiplegia. When this occurs it almost, certainly depends on the coincidence of inflammation, which has led to softening of the brain or effusion of serum. The oulv possible exception is when the pressure is excited on a portion of the me- dulla oblongata, and then paraplegia is the usual if not the invariable result. By far the most common cause of hemiplegia is extravasation of blood in the hemisphere of the brain opposite to the side of the body affected; but why this event causes in one case both apoplexy and paralysis, in another apoplexy alone, and in a third only hemiplegia, we are not always able to determine. It is to be remembered that while, on the one hand, hemiplegia does not necessarily follow on apoplexy, so, on the other, its continuance after consciousness is restored must not be taken as proving that the fit has been of the nature of sanguineous apo- plexy : because it is sometimes dependent on effusion of serum, when one lateral ventricle is more distended than the other. Extravasation of blood in the brain is so often found associated with disease of the heart and arteries, that, apart from any consideration of causality, the discovery of valvular lesion, or hypertrophy, affords strong presumptive evidence, in cases of hemiplegia, that they belong to this class rather than to serous effusion or chronic disease, in connexion with this subject we must again refer^p the plugging up of an artery by a mass of fibrine detached from a diseased valve. In most cases the paralysis is produced ; ^organization of brain resulting from imperfect nutrition; but it also appears to be sometimes the immediate effect of the stoppage of the supply of blood, when the symptoms are necessarily more quickly developed than in the other instance: but neither present the character of rapidity belonging to extravasation, and in neither is there anything like an apoplectic attack. § 2. Paraplegia. — Rarely a sudden seizure except after injury of the spine, it is but seldom dependent on cerebral disease; in both respects it stands in complete contrast to hemiplegia. As in hemi- plegia, however, the power of movement is generally more affected than the sensibility; but loss of the one seldom exists without par- tial failure of the other. Its characteristic is that it affects both sides of the body symmetrically, although not necessarily to the same degree. Its history points out its more or less gradual de- velopment, the occurrence of some accident or injury to the back, or it may perhaps afford evidence of disease of the brain. It ought always to be ascertained whether there be any deviation from the normal condition of the bones of the spine, or any point at which a sudden jar or blow causes more pain than elsewhere; we have then to consider how high the condition of paralvsis extends. a. In its most common form, the disease has come on by slow degrees, observed first, perhaps, in one leg, and soon after in the other, and still exhibited to a greater degree in the limb in which it was first felt, but extending no higher than the loins; it has been preceded by no accident, is accompanied by no distortion, and is entirely without pain. The patient at first only feels some weak- ness in the knees, and very frequently in walking experiences a 176 ' PARALYSIS. sensation as if be were treading on soft wool ; the muscular sense is soon lost, and he needs to look at his feet to know where he Bteps; gradually the paralysis increases, and in the worst cases he is at length reduced to such a state that he has no power even to move his limbs in bed except with the assistance of his hands, and yet the upper half of the body is unaffected. This is dependent on a condition of simple atrophy of the lower part of the cord; there is no evidence of inflammation, acute or chronic, during life, no appearance of it after death: nor do the remedies which generally influence the progress of inflammation show any power over this disease. b. The form occurring next in frequency is that dependent on injury or disease of the spine — fracture or caries of the bone, and ulceration of the intervertebral cartilage. Displacement following on these causes may of itself give rise to paralysis; but in chronic cases it is seldom found unaccompanied by evidence of inflammatory action: we may, therefore, for all practical purposes, class along with those just mentioned, the paralysis consequent on concussion, which may result at once from the accident, and be perpetuated by inflammation, or may only supervene some time after the injury has been received. Here the diagnosis is generally facilitated by the history of an accident or by the evidence of the displacement which generally accompanies fracture, caries, and ulceration. But it sometimes happens that the ulceration of the intervertebral car- tilage sets up inflammation in the membranes of the cord before displacement occurs; and while the pain on movement, and stiffness of the back, are only supposed to be rheumatic, symptoms more or less distinct of this inflammation are developed, and paralysis speedily follows. In such cases accurate diagnosis depends upon the correct appreciation of these symptoms, especially with re- ference to the seat of previous pain and stiffness; but it must be confessed that the knowledge often comes too late to be of much service in practice. c. Idiopathic inflammation of the cord, of itself, as we have seen, a comparatively rare disease, may give rise to symptoms of para- lysis under three distinct conditions: they maybe only the evidence of further disintegration, and the immediate approach of death; they may remain for a lengthened period in consequence of chronic thickening after the acute symptoms have passed by; or they may arise without any previous acute symptoms — the inflammation from the first prcsentino: only the characters of a subacute or chronic form. An exposure to cold, the occurrence of pain in the back, and the comparative suddenness of the attack, point to a condition different from what has been recognised as the consequence of atrophy. The resulting paralysis is paraplegia, but there is very generally a considerable difference in the degree to which the limbs on each side are palsied. d. The pressure of a tumour on some portion of the cord may also PARAPLEGIA. 177 give rise to paraplegia: when occurring in the lower region of the back, with no external evidence of its presence, it i3 not to he dis- tinguished from cases of atrophy; but when the paralysis has conje on gradually, when no history of injury is obtained, and no evidence of distortion exists, when the patient is free from pain, and the up- per extremities are partially involved as well as the lower, good ground exists for suspecting the existence of this form of disease; when the breathing is also interfered with, its seat is probably at the base of the brain, and it may be expected soon to prove fatal. e. Spinal apoplexy is one of the rarest forms of disease of the cord. The symptoms are said to be very much what might have been anticipated from our knowledge of cerebral apoplexy: vio- lent pain in the region of the efftfsion, general convulsions, sud- den paralysis, which, in place of affecting one side of the body, occupies its lower half to an extent determined by the distance of the effusion from the top of the canal : it is generally unaccompanied by coma, and proves speedily fatal. /. General paralysis. This is the only form affecting both sides of the body which has its seat in the brain: seldom complete un- til towards its close, it. is marked by a general loss of muscular power, an occasional difficulty in articulation, tripping over or stut- tering and slurring of one's words, as in the early stages of intoxi- cation. It is seen in its most typical form in the paralysis of the insane, where along with the gradual abolition of the muscular pow- er, there is a correspondingly gradual loss of mental consciousness, ending in perfect fatuity; it is usually preceded by symptoms of alienation of mind having more or less the character of exaltation of ideas: the patient imagines that he has* acquired an enormous fortune; or the quiet, steady man of business becomes suddenly gay and extravagant; the delusion seems always to have the character of happiness and contentment. Pathological anatomy is not yet sufficiently advanced to point out in all such cases what are the actual changes in structure on which, the disease depends, the brain being found in very various states after death. A corresponding form of disease exists without the accompani- ment of insanity, in which it is also quite impossible to predict the actual lesion that will be discovered; and though in some rare cases no appreciable change of structure can be detected, yet their whole character warrants us in assigning disease of the brain as their cause. The consistency of the affection, its extension to one or other or both of the upper, as well as the lower extremities, makes it pro- bable that the seat of disease is above the spinal column ; and, having satisfied ourselves that the vertebrse of the neck are free from dis- ease or distortion, our next step is to analyze with care the condition of the cranial nerves: deafness, unequal action of the pupils, stra- bismus, &c, are to be taken as evidence of disease in the cranium. It is worthy of remark that, while these nerves are affected only on 12 178 PARALYSIS. one side, and one arm is perhaps decidedly weaker than the other, the legs are usually equally paralyzed. The paralysis is sometimes coincident with a condition of spasm which aftbrds pretty conclusive evidence that the disease is situated in the hrain itself. Its progress is generally very slow, and the failure in muscular power may vary greatly in intensity in different parts of the body, being generally most complete where its existence was first recog- nised. In the paralysis of the insane, the defect in speech is gene- rally that which is first observed; in other cases this is not so, but its existence is always very important in diagnosis. The absence of any other indication of disease besides loss of power, in some in- stances, has led to their being mistaken for cases of listeria or hypochondriasis. g. Paralysis agitans: although clearly not belonging to the class paraplegia, the few remarks to be made on this disorder will best follow the description of general paralysis. There is no evidence of brain disease ; the intellectual faculties are unimpaired, the cranial nerves are not liable to be implicated; indeed, it is not proved that its seat is in the nerves themselves, but, like chorea, it consists in pome disturbance of the relation between nervous influence and mus- cular movement; there is no anaesthesia. It is chiefly a disease of old age, comes on gradually with shaking of the head or of the ex- tremities; these are indeed its only diagnostic features: it is occa- sionally left as the result of convulsions in infancy. An analogous disease is seen in the tremor of those subjected to the constant action of mercurial vapour. The tremor, in this case, is only excited by voluntary muscular movement, the individual at other times being perfectly still; and its seat is most probably in the nervous system, as it sometimes presents the phenomena of wakefulness and delirium. It is one of the examples of slow poi- soning mentioned in an earlier part of this volume. In all the conditions just referred to we are very much at a loss in attempting to explain the relation of the phenomena to change of structure in the nervous system. This difficulty is much increased by the fact that, whatever be the form of lesion, and however local and limited in its nature, we have the same general result of paralysis affecting both sides of the body alike: and therefore practically the important considerations in paraplegia are limited to the recognition of acute and chronic disease, and caries or injury of bone. When any doubt is entertained with regard to the reality of partial paraplegia, it may be always solved by ob- serving with due care the mode in which the feet are set down in attempting to walk: there is an indescribable uncertainty about the gait of a paraplegic which imposture can never successfully imitate. § 3. Local Paralysis. — It has been already explained, in speak- ing of hemiplegia, that this appellation is, in strictness, confined to cases of paralysis not having a central origin; when it depends on loss of nervous influence, the affection of the nerve is located some- where after it has emerged from the cerebro-spinal axis. Due re- gard to the extent and special distribution of the affection, and know- ledge of the anatomy of the nervous system, form the groundwork LOCAL PARALYSIS. 179 for the diagnosis' of local paralysis; it is limited to the organ which some particular nerve supplies. The cranial nerves, issuing singly from the brain, afford the most frequent examples ; thus we have amaurosis, ptosis of one eyelid, anaesthesia, or palsy of one side of the face, &c. In all such cases we have to assure ourselves well that no other cranial nerve is similarly affected, because, when more than one is implicated, there is good ground for believing not only that the lesion is within the cranium, but that it probably also in- volves the brain itself. In the case of the fifth and seventh nairs, where contiguity or admixture of fibres of different kinds exists, the relations of paralysis of sensation and motion are sometimes such, that we can define the exact portion of the nerve in which the dis- ease is seated. Ambiguity is, to a certain extent, in many instances unavoidable; because while, on the one hand, some very slight disease within the cranium may produce local paralysis and nothing more, it is equally true, on the other, that this form of palsy may be the first manifestation of serums disorganization. Pressure of a tumour on the brachial plexus, or upon the crural nerve, may give rise to symptoms of palsy and anaesthesia more or less complete in the limbs to which they are distributed : a not unfre- quent instance of this condition is the numbness of the legs during pregnancy. Some forms of local paralysis are more directly connected with the muscular structure than with the nerve by which it is supplied. This condition is met with — especially affecting the extensors of the forearm — in lead palsy, but also involving to a less degree the flexors. The colic which usually precedes the affection of the fore- arm, is probably caused by corresponding paralysis of the muscular coat of the intestines. Drop-wrist is also occasionally met with in over-worked, half- starved tailors and needlewomen, without colic, without blue-line, or any evidence of lead poison, and would seem to be produced by the forced and long-continued action of ill-nourished muscles. Similarly, an over-strain of muscle, on perhaps only one occasion, J3 sometimes followed by loss of power. Paralysis of the bladder from distention affords a ready example. Another cause of local paralysis, which, in the end, becomes general, should be mentioned — viz., fatty degeneration. Its patho- logical relations are not understood; but weakness and wasting of one muscle after another, proceeding in a direction which does not necessarily follow the anatomical relations of the nervous system, may be suspected to be due to this change; it is not possible to give any definite rule for its diagnosis. The history of the case, as has been already remarked, serves to exclude instances in which local paralysis is the last remnant of a more general affection, or the only effect of an apoplectic attack; these evidently belong to hemiplegia. In other cases it points out, when the disease has come on suddenly, what has been the exciting 180 PARALYSIS. cause; or it indicates, by the slow supervention "of the affection, that it is due to some condition of long standing. Such, for ex- ample, is the history of colic. Local paralysis is not generally a disease of grave import: it is much more so when the cranial nerves are the seat of the affection than when spintil nerves only are implicated; and among these con- siderable differences exist. Facial paralysis, coming on after expo- sure to cold, is one of the least important. Amaurosis is a very distressing disease to the patient; but ptosis is a symptom of much more serious consequence in the mind of the physician. Strabismus in childhood, after eclampsia, is common, and not of much conse- quence ; while in the adult its presence is of evil augury, when of recent occurrence. But, as before remarked, the coexistence of affection of two distinct nerves (e. g., facial palsy with strabismus) gives most cause for serious apprehension; or the concurrence of any of them singly with symptoms, however obscure, which can be traced in any way to disease of the brain. Loss of power is more definite in its indications than loss of sensation, inasmuch as the one is an objective, the other a subjec- tive phenomenon; but yet even loss of power may, to a certain ex- tent, be exaggerated, if not wholly simulated, by the imaginings of the patient, when the paralysis is incomplete; and such cases are always more difficult of diagnosis than when the power of motion is entirely lost. Patients often speak of numbness when they do not mean anaesthesia at all; there is no loss of feeling, but perhaps a sensation of tingling, or formication, to which the name is ap- plied. Such cases are rather to be regarded as an indistinct form of neuralgia, than as local paralysis. The bearing of diagnosis on treatment in all cases of local para- lysis, may be summed up in the discovery of its cause, whether that be revealed by the history of the case, or can be gathered from a knowledge of the portion of the nerve which is the seat of lesion, and a consideration of the structures immediately surrounding it, in so far as they may interfere with the transmission of volition and sensation through the nerve fibre. 181 CHAPTER XVI. NEURALGIA. Its place in Classification — Distinguished from Pain — Inflamma- tion — General Pain — Local Pain — Irritation — Neuralgia 'pro- per. — § 1, Tic Douloureux — § 2, Hemicrania — § 3, Sciatica — § 4, Angina Pectoris — § 5, Spinal Neuralgia. The term neuralgia is one which only serves to remind us of the limited range of our knowledge: had we attained to a perfect pa- thology, it would find no place in a systematic classification of dis- ease, except as a symptom. In itself a mere sensation dependent on a variety of causes, we are yet forced very often to rest satisfied with the knowledge of its existence, without being able to trace it backward to its true source in the causality of disease; and at the same time its very vagueness too often serves as a cloak for igno- rance, or furnishes a ground for deception. It is exposed to all the difficulties in investigation which are inseparable from merely subjective phenomena, and there are few indications by which we can correct an opinion we are driven to form merely upon the pa- tient's own statement: even when convinced that there is no exag- geration or deception, we are still so ignorant of the changes in nervous structure, that if we be able to prove by post-mortem evi- dence that there has been no other cause for the pain, we must still rest satisfied with the fact that it has been felt, and with the expression that it was neuralgia. One point is perhaps not sufficiently attended to in the employ- ment of the term, that while in truth all pain is perceived by the nerves, and in that sense is seated in the nerve, yet all pain ought not to be called neuralgia. The true distinction between the two is that in the one instance the sensation is produced by some irrita- tion acting locally on the terminal filaments of the nerves which are the normal recipients of it, while in the other it was caused by something affecting the trunk of the nerve, — that bundle of fibres, large or small, lying within the neurilemma, which in a state of health does not receive, but transmit the sensation: consequently, neuralgia properly so-called affects all the sensitive branches uni- ting to form the trunk on which the irritation acts, and pain is felt sometimes distinctly to the terminal filaments, sometimes vaguely in the course of the ramifying fibres. As in paralysis, a know- ledge of the parts over which pain is distributed, and of the ana- tomical relations of the nerves, will best assist us in distinguishing between neuralgia and local pain. When two distinct parts of the body, having no nervous communication with each other, are both 182 NEURALGIA. the scat of pain, the presumption is very strong that they are not simultaneously affected with neuralgia; when all the structures supplied by one nerve are painful, it is highly improbable that each should be influenced by a local cause; when one form of structure only is affected, we are led to suspect that there must be some change in that to account for the suffering, rather than an affection of the nerve: these rules are well exemplified in the diagnosis between rheumatism and neuralgia. At the risk of repetition, I must again remark that if there be a distinction be- tween pain and neuralgia, it is still greater between all sorts of pain and inflam- mation. Pain is the expression of irritation of nerve matter, and nothing more: in different individuals it has a very different signification; some are intolerant of pain, and generally use big-sounding words to express it — it is terrible, dreadful, intense — when, in reality, there is little derangement; some are callous and indif- ferent, and will scarcely admit that they suffer pain, when such disorder is present as can scarcely exist without it. Perhaps the best criterion of the reality and amount of pain experienced by the patient, is when it produces an expression of anxiety and pinching of the features; this is something quite different from the eyebrows being knitted together in a frown, and is equally distinct from the sad- ness and tear-shedding aspect of hysteria: it is one of the points in the physiog- nomy of disease which has to be learned by the student. It may be stated generally that pain accompanying inflammatory action is lc--s noticed by the patient than that attending nervous disorders, whether functional or neuralgic. The pain of inflammation is described as acute, darting, or stab- bing, in opposition to dull, aching pain; and that of suppuration as a throbbing pain : but the whole vital functions are so deranged that the attention is less en- grossed by it, and it less frequently forms the chief subject of complaint: perhaps, too, it is not so coustant; and as it is aggravated by pressure, it is also in some measure dependent on movement, and is therefore less felt in perfect quietude. Inflammations of various organs differ very materially in the amount of pain they cause; the bones, joints, and ligaments, the skin, and the serous membranes, be- come the seat of much greater pain when inflamed than the mucous membranes and the viscera. For example, in peritonitis, acute rheumatism, gout, carbuncle, the pain is generally a prominent symptom; in inflammations of the liver, the bowels, and the bladder, it is much less noticeable: again, a dyspeptic headache is much more complained of than the pain of the most intense meningitis; in acute pleurisy, the patient dare not cough or draw a deep breath; and yet, till his atten- tion be drawn to it, the pain may be the last thing he speaks of. Corroding can- cer, again, affords an example of pain without inflammation, which is very severe and lancinating, and yet patients occasionally present themselves who suffer very little while labouring under that dreadful malady. In Chapter II. (p. 33) allusion was made to the lessons taught by the duration of pain ; when it was stated that its importance in cases of long-standing is to be measured by its effects, and that when of recent date, it is a symptom of but little consequence in persons who have been long ailing, while their general health is not seriously undermined. These considerations suffice to show the necessity of inquiring into the patient's previous history, and in doing so we shall often find that the precursory symptoms, or the circumstances which have seemed to give rise to it, throw great light on its causes. General pain, by which is meant pain or aching not limited to particular organs, but irregularly distributed over the body, is commonly an indication of general disorder; such NEURALGIA. 18 .-> as we have already studied in what are called blood-diseases, fevers, rheumatisms, even ansemia: it may be muscular, or confined to the joints, to the bones () When one side only bulges, and the interci ices obliterated, ili«' effect is usually produced by distention of the pleura with fluid or air. (1) Without any deviation in form, a remarkable stillness and want of movement may be observed in the early stage of inflammation of the pleura; and when the disease is very limited, this effect maybe quite local, (.">) A very Striking change may be noticed in the contraction of one side, when there is no distortion of the spiue, as a consequence of previously existing empyema, (6) The contrast between thoracic breathing, when the diaphragm is not moved, in peritonitis, and abdominal breathing when all the respiratory nerves, except the phrenic, are paralyzed by injury of the upper part of the spinal cord, is well worthy of observation; its miuor degrees ought also to be considered iu diagnosis. b. Percussion. — The operator elicits the sound by his own act, his object being to ascertain the relative amount and position of the solid or fluid and gaseous contents of the thorax. The stroke should be short and sharp, and not more forcible than is necessary to produce a distinct sound, except when the character of the reso- nance is doubtful, and then it may become needful to compare the sound produced by firmer percussion with that which results from a gentler tap. The finger used as a pleximeter to receive the stroke, should be level, and, when comparing diiferent parts, should occupy as nearly as possible the same position with reference to the ribs, whether parallel or transverse, upon the bone or in the interspace. The information percussion conveys is derived from two sources: the resonance or clearness of the sound produced, and the sense of greater or less resistance to the finger; and it is to be remembered that these vary, not only with the condition of the lung itself, but also with that of the parietes, being remarkably modified by the elasticity of the ribs. In order to obtain trustworthy results, it is essential to compare the sound produced at corresponding parts on either side; and also to contrast the difference between the upper and lower, regions on one side with that on the other. '£>' Percussion indicates either that there is an excess of solid and fluid compared with gaseous contents or the contrary, as the sound is dull and dead and the re- sistance great, or the sound clear and resonant and the resistance slight; and these conditions maybe either beyond what is consistent with perfect health under any circumstances, or merely different from that of the surrounding parts or the corresponding parts of the other side of the chest. It is quite true that various morbid states are associated with unusual sounds on percussion, which become sensible to an experienced ear; but, except in the extremes of tympanitic reso- nance and remarkable dulness, they are not such as can be well explained to the student, because there is no absolute standard from which their variations can be calculated. Percussion is not equally applicable over all parts of the chest. (1) In front its variations are readily perceived, but it is only over the upper third that the in- dications are of much value with reference to the lungs. In the middle third the heart on the leftside prevents a correct comparison with the right; and lower down, while enlargement of the liver may be the cause of dulness on the right . distention of the stomach with gas may give rise to unusual resonance on the Applied over the region of the heart, it teaches us whether a larger portion of lung-tissue than usual be displaced by disease of this organ, or, on the contrary, AUSCULTATION. 195 whether the lung have encroached on the ordinary space of precordial dulness. (!') At either side the upward pressure of the abdominal viscera tends to invali- date any results of percussion below, and those only are trustworthy which are ob- tained from the region bordering on the axillae; and even here stomach resonance in rare cases makes itself heard. (3) Over the back the thickness of the walls of the chest limits us in very great measure to the inner border and lower angle of the scapula, as it requires considerable tact to make the difference perceptible even in the supra-spinal region, where, notwithstanding, it is much more readily applica- ble than upon or just below the spine of the scapula. In a downward" and out- ward direction we are met by the same difficulties, which tend to invalidate the effects of percussion in front and on either side: for practical purposes, however, the information derived from the region on either side of the spine, when the sca- pulae are drawn aside by the arms being crossed in front, is quite sufficient. e. Auscultation. — In this term -\ve include all the sounds produced by the movement of the air; whether in ordinary breathing, in forced inspiration, in the act of coughing, or in the resonance of the voice. "We have to observe the sound caused by its simple mo- tion backwards and forwards in the air-tubes and vesicles, to take note of the force with which the voice formed at the larynx is transmitted through the tissue of the lung, and to listen for any- thing unusual or abnormal, which we may call superadded sounds. The vesicular murmur, as it is called, heard loudest and often alone in inspiration, is that which characterizes healthy lung: it is distinguished from unhealthy breath-sounds of all kinds by its great softness, but in loudness and distinctness, perhaps, no two chests are exactly alike. The resonance of the voice also differs extremely in different persons, and even in different parts' of the same lung in perfect health: in disease its chief value is derived from a want of correspondence between those in which its intensity is usually equal. The characters of superadded sounds will be discussed in Chapter XIX. I may here repeat that the most practical advice that can; be given to a student in entering the wards of a hospital, is to ex- amine the chest in every case when it can be done without sufferino- to the patient: if on first applying his ear to the stethoscope he should hear nothing, he may cause the patient to inspire deeply, to talk, or to cough, when some sound will be produced; and if that sound be peculiar, he ought to listen to it till it can be recollected and recognised again, and if possible he should get some more ex- perienced auscultator to explain it. By this means, in a wonderfully short time, he will find himself quite competent to say what is healthy and what unhealthy breathing, what is natural and what superadded sound. In the detailed treatises on auscultation descriptions of all possible sounds are given, and names are too often employed which have tended rather to perplex than to instruct. The nomenclature has unfortunately been derived from the morbid condition with which the sounds have been supposed to be associated ; and in well-marked examples, no doubt, the name and the association are correct; but as it necessarily happens that such morbid states are not separated from each other by any distinct line of demarkation, and that the actual character of the sound cannot be very clearly defined, it seems unwise to employ a name which suggests a theory of disease, while prosecuting an inquiry which is only ultimately to lead. ] i EXAMINATION OF THE CIIKST. rv. It is better, therefore, to confine ourselves as much as possible to tcnm which convey ideas of Bound rather than ideas of disease. jcultation is best performed in front, by means of the stethoscope. Over the the ear more readily takes cognizance of the condition of extensive tracts of hi 1 1 _ . when applied directly, with only the intervention of a fold of linen: sounds have to pass through much thicker parietA, and therefore it is unwise still further to deaden them by the intervention of an instrument: when it becomes important to localize a sound, the stethoscope may be used. In conditions of disease we meet with modifications of the breath and voice- sounds, and with superadded sounds. There can be no absolute standard of health to which the breath or voice-sound can be at all times r. ferred; and heme, as iu percussion, our judgment in regard to them must he in great measure formed by comparison of different parts of the same chest. The student must place no reli- ance on what he may consider deviations from the ideal standard, but confine himself to discovering a want of consistency between the two sides, and it will often require the exercise of his clearest judgment, and most correct reasoning, to deduce from this want of consistency the exact nature of the deviation. It is to be observed that difference in the intensity of the voice-sound is most liable to mis- lead, and is least to be relied on as indicating the condition of the lungs: differ- ence in the loudness and quality of breath-sound affords more direct and more satisfactory evidence: difference in the resonance on percussion is uumistakeable proof of different degrees of density of the lung, if the parietes be free from disease, while superadded sound is of necessity connected with something abnormal : and we have only to determine what that sound exactly is, and what physical elements can give rise to it. The combination of the evidence derived from these sources, with the history of the case, and the other symptoms of disease, forms the la-is upon which our judgment concerning the pathological condition of the lungs ought to rest: it is most important to remember that no one of these facts, taken singly, is sufficient to warrant any deduction regarding its nature; and that the larger the number of facts which coincide, the more will this deduction partake of the nature rtainty. The loudness of these sounds in the same individual, at different periods, or at different parts of the chest, depends on three circumstances — the size and form of the spaces over which we listen, the force with which the air moves or the voice is produced, and the power of conducting sound possessed by the superficial parts. We may exclude the second of those, as being iu great measure under our con- trol, with this remark, that now and then it happens that over an entire lung the breathing may be unnaturally loud in consequence of its having a vicarious duty to perform in supplying the defect of its fellow: the air simply moves faster and more freely — its sound is exaggerated, and not otherwise changed. In regard to the size and form of the spaces over which we listen, it must be remembered that not only are these changed by disease, increased or diminished in size, but at any given spot we encounter vesicles, small bronchi, and large bronchi, at different depths from the surface; and that if the breathing in the vesicles be stopped, we shall hear the sounds in the larger spaces more or less loudly, according to the conducting power of the lung-tissue and the degree of noise the air produces in them. For example, consolidation will produce all of these effects in varying de- grees: 1st, it gives rise to more or less difference in percussion resonance; 2nd, it impedes or suppresses vesicular breathing; 3rd, it increases the conducting power of the tissue; -1th, it makes the large tubes more rigid, and the breath- sound in them more noisy. Or, again, unnatural spaces or cavities, of varying size, existing along with more or less of consolidation, will give rise to a similar series of phenomena. On the other hand, unusual expansion of the lung, while it causes a stoppage of the vesicular breathing, is attended with opposite effects in increase of resonance, in diminution of the conducting power, and in lessening the noise of movement in the large tubes. Two further considerations must be borne in mind with relation to these changes in the breath and voice-sounds — viz., that the rhythm and quality of the breathing (the ratio of the inspiration to the expiration, and the softness or harshness of tlie breathing) vary with different sizes and forms of spaces, and consequently become the measure of their capa- AUSCULTATION. 197 city; while, by the power of the voice, we are best able to judge of the quality of the superficial structures as a medium for conducting sound, and consequently, of their degree of solidity. By some it has been alleged that when the tubes or pa- rietes of a cavity are more rigid, the air is more easily thrown into sonorous vi- brations, and that tli^s cause is more powerful in producing vocal resonance than the sound-conducting property: the conclusion is the same in either case. Some allowance, however, is to be made for the size of the space, as it would appear to have something to do with the intensity of the vocal vibration of the air. Superadded sounds have reference to the presence of some extraneous matter which, in consequence of the movement of the air, or that of the lung-tissue, gives rise to sounds which have no resemblance at all to those produced by healthy breathing. They may be cafPsed by the two surfaces of the pleura moving on each other with a rubbing sound, or by consolidation of the lung giving rise to crack- ling noises as it expands when air enters, or by air coming into contact with fluid, whether serous, purulent, or inspissated; and the sound in each of these cases may give very direct evidence of the physical facts which combine for its production; but standing alone, as a symptom of disease, it would be of comparatively small value in determining the condition of the patient. 198 CIIArTER XVIII. MODIFICATIONS OF NORMAL BREATH AND VOICE-SOUNDS, AND OF PERCUSSION RESONANCE. Div. I. — The Clavicular Region. — § 1. Breath and Voice-sounds with Dubiess under one Clavicle — § 2, with Excessive Resonance — § 3, with Difference on Percussion slightly marked — § 4, with no perceptible Difference. Div. II. — The Posterior and Lateral Regions. — § 1, Breath and Vuice-sounds, with Dulness on one Side — § 2, with Excessive Resonance — § 3, ivith Difference on Percussion slightly marked — § 4, ivith no perceptible Difference. SUMMARY. — § I, Condensation of Lung-tissue — Carnijication — Hepatization — Tuberculization — § 2, Expansion of Lung-tissue — Empliysema — § 3, Condition of the Pleura. Y\ r E now proceed to consider the method in -which auscultation and percussion are to be applied in endeavouring to ascertain the physical condition of the lungs; and in this chapter we shall con- fine our attention to the modifications of breath and voice-sounds and percussion resonance, comparing each with the other as we go along, and leaving for the present out of consideration any sounds which may be superadded. It is true that in practice we shall not often find them so disjoined, but in order to arrive at logical con- clusions from the premises submitted to us, it is absolutely necessary to compare the two simpler classes of phenomena together before taking into account the third and more complex series: it will also have the advantage of preventing the student from acquiring the pernicious habit of trusting to any sign as pathognomonic of a certain form of disease, — an error which superadded sound is much more liable to produce than mere modifications of natural sounds. Division I. — The Clavicular Region. The evidence derived from this region is by far the most valuable portion of that which serves to indicate disease of the upper lobe: changes of structure seldom exist on its posterior aspect of sufficient amount to give rise to distinct auscultatory phenomena through the scapula, without also causing perceptible change in front: corrobo- rative signs arc generally found behind, and, possibly, disease which seems of small extent when we examine in front, is far advanced in the scapular region. Still the first and the most correct knowledge of its existence usually comes from the clavicular region, and it is a good rule that it should be the first examined. AUSCULTATION AND PERCUSSION. 199 § 1. Percussion notes a marked difference between the two sides of the chest, and one has a dull, dead resonance, with a sense of resistance. A. The breathing is louder on the duller side; there is a very evident prolongation of the expiratory murmur; it has acquired an unnatural harshness and a blowing sound: the voice-sound is also louder, and probably changed in character as compared with the other side of the chest. There can be no doubt that the disease is on the duller side, and of some form associated with consolidation. In this region we meet with tubercular deposit, fibrinous deposit, and retraction of the lung consequent on effusion into the cavity of the pleura. B. .The breathing is weaker on the duller side. a. It is entirely superseded by superadded sound: the voice- sound is loud and harsh ; the sound of the breathing is manifestly obstructed by some extraneous fluid mixed with the air contained in the lung, and in addition to this we feel sure, from the deadness of the percussion-stroke and the loudness of the voice, that there is some form of consolidation present, generally the tubercular. (See next Chapter, Div. I., § 1, a.) b. The dulness and deadness of the percussion-stroke are most complete, and are evidently not confined to the clavicular region, but extend throughout every part of the chest on the affected side ; the rhythm of the breathing, if any can be heard at all, is altered by disproportionate length of the expiration, and the voice-sound has a loud ringing character. The chest is probably full of fluid on that side, but the existence of this condition is to be decided from a consideration of the signs appertaining to the remainder of the chest. c. The sound on percussion varies according to the force of the stroke: a gentle tap brings out imperfect superficial resonance, a firmer stroke distinct and decided dulness; the breathing is weak and not otherwise altered in rhythm or quality, but in addition to the vesicular murmur there may be heard a sound of distant blow- ing. This would point out some solid mass occupying a central position with reference to the lung. d. There is local swelling under the clavicle, and the breathing is entirely suppressed. Here we have no doubt of the existence of tumour, aneurism, or solid growth, as the case may be. § 2. Percussion notes a remarkable difference with exaggeration of resonance on one side of the chest. A. The breathing is louder on the more resonant side. a. The percussion sound is tympanitic, while there is a sensation of wooden resistance to the stroke: the breath-sound is heard as if one were blowing into a large empty jar; the voice-sOund has the same character, called amphoric. These signs may be caused either by air in the pleura (pneumo-thorax,) with an opening communi- 200 AUSCULTATION AND PERCUSSION. eating between the lung and the pleural sac. somewhere near the clavicle, or by a cavity of very large size: in the one case the tym- panitic resonance is general, in the other local. b. The percussion-sound is less distinctly tympanitic, and there is no resistance; the breath-sound has a blowing character; the voice-sound is ringing. This condition is often met with in the first stage of pleuritic effusion: its true nature is only revealed by ex- ploring the remainder of the chest. B. The breathing is weaker on the mpre resonant side, or absent. a. The resonance is not tympanitic, but is remarkably clear, with great elasticity: if any breathing be audible, it generally consists of a long, distant, blowing, expiratory sound; there is no voice- sound. Here Ave have decidedly emphysema of the upper lobe of the affected side. b. The resonance is tympanitic, and at the same time clear; the breath-sound is simply weak and distant, its rhythm not necessarily altered; the voice-sound varies. Such is the effect produced by a small portion of air confined in the pleura: a rare circumstance, which sometimes follows on paracentesis, and has even been alleged to be the result of spontaneous development. c. In some cases of pneumo-thorax, while the percussion resonance is tympanitic with a wooden tone, the amphoric breath and voice- sounds are not heard, or only heard at a distance; either because the opening is temporarily closed, or is situated at some other part of the lung : these cases can only be rightly judged of by compari- son with the remainder of the chest. § 3. There is little difference on percussion, and no resistance on either side. a. The breathing is loudest on the duller side. a. Its rhythm is altered, the expiratory sound is especially pro- longed, loud, and harsh ; the voice-sound is also louder than on the more resonant side, which seems to approximate to the healthy standard. We have here a less marked form of consolidation; most probably, from its situation, tubercular, but possibly due to other causes. I. Its rhythm is natural. On the opposite side the inspiratory sound is deficient, and the expiratory sound is prolonged, but with- out any degree of harshness, any change in quality being rather indicated by softness and weakness: the voice-sound is louder on the duller side, but not remarkably so, while on the other it is weak or almost absent. This is sufficient to prove that the disease is on the more resonant side, and that the condition is one of dilatation. b. The breathing is weakest on the duller side. Its rhythm is altered, it has a wavy or jerking character, and the expiration is prolonged: the voice-sound, in contrast to the preceding case, comes out much more loudly on that side on which the breathing is defi- cient. The condition is one of commencing consolidation. THE CLAVICULAR REGION. 201 § 4. Percussion fails in detecting any difference between the two sides of the chest. a. Both lungs may be in their natural condition at this part: the ratio of the inspiration and expiration corresponds on either side, as well as the loudness of the voice-sound, and all comes within the limits of health. B. The resonance on both sides may be exaggerated ; the chest remarkably rounded and resilient, and moving very little in respi- ration; the upper ribs not descending as far as they ought in expi- ration, while in inspiration the lower ribs are usually drawn inwards: the inspiratory sound is short and deficient, and the expi- ratory prolonged and distant; the voice-sound more or less abo- lished, as the disease affects chiefly the upper or lower part of the lung. Such are the physical characters of emphysema affecting both lungs. c. Both sides may be duller on percussion than in health. a. The deficient resonance may depend upon loss of elasticity of the ribs, and the breathing may still be natural and equal on both sides, or it may have undergone some modification and be accompa- nied by superadded sounds. The probability of such an explana- tion being correct must be judged of by the age of the patient; the exact condition of the lung can only be determined by the na- ture of the superadded sounds. b. The dulness may be caused by consolidation, and the charac- ters of the breath and voice-sounds are necessarily changed. When the disease is so decided that the dulness is quite unquestionable, I believe it is never equal on both sides : the case really fails under § 1, and other morbid sounds rarely fail to give indications of dis- ease: when the dulness is slight, the principles of diagnosis are the same as in the next subdivision. D. A slight difference may exist, but the ear may fail to detect it. On comparison of corresponding portions of the two lungs, somewhere or other a difference in rhythm or quality of breath- sound and in the intensity of the voice-sound is distinguished by auscultation ; and we will suppose that no corresponding changes are discovered in an examination of the rest of the chest. Fortu- nately there is very generally some superadded sound to guide our determination ; but when absent we have to decide what circum- stances justify us in assuming the existence of disease in the upper lobes. The question is a weighty one, because here it is that tuber- cle is generally first deposited; but we must not forget that general symptoms indicating the possibility ought to be present to justify the assumption. Reverting to § 3, and imagining the difference on percussion to be so slight as to be overlooked, we find that there may be local emphysema or consolidation, and that in either case the expiration may be prolonged, but that the inspiration in emphy- sema tends to softness, in consolidation to harshness ; further, that if the voice-sound differ, it is weaker with the prolonged expiration 202 AUSCULTATION AND PERCUSSION. of emphysema, louder with the prolonged expiration of consolida- tion, than at the corresponding portion of the opposite lung. One important fact simplifies the inquiry very much: it is this, that if there be no superadded sound in emphysema, we shall have little or no cough, and no general symptoms: we have therefore only to decide what difference in the results of auscultation is sufficient to determine that the general symptoms are due to commencing con- solidation. (1) The most certain indication is when on one side the inspiration is shorter and the expiration longer than on the other. (2) The next in order of distinctness is when the inspiratory sound is wavy or jerking in place of heing even and continuous. (3) 'When both sounds are longer and louder on one side, the indication is only trustworthy if they be also harsh and unnatural there, while on the other side they continue soft; or, when this exaggeration is confined to the left side, for on the right side they are often louder in perfect health. (4) The expiration heard only on one side with no other change is a suspicious sign. (5) The inspiration heard louder on the left side is also suspicious. (6) The voice-sound heard louder on the left side along with any of these changes is a much stronger confirmation than when heard louder on the right. When a difference is established by percussion, it is evident that the lungs are in different states, and yet neither may be absolutely healthy; the same condition may have commenced in one which is advanced in the other. Considerable ex- perience may bo requisite to justify the assertion that both are diseased, but the conclusion may be a correct one, -with very imperfect knowledge, in the cases re- ferred to in § 1, that there is consolidation on the duller side. The dulness is ab- solute as well as relative; the breath-sound is changed in rhythm and quality at the same time that it is louder, and the voice-sound points to the same conclusion. But let us be very careful how we take the next step and determine what that consolidation is. ft is of the utmost importance to leave the mind as much -un- biassed as possible by the facts elicited by percussion and auscultation in the cla- vicular region, because the conclusion must rest quite as much upon the history of the pase, and upon the evidence derived from other regions of the chest: and till these are compared together we are not in a position to form any opinion whe- ther the cause of consolidation be tubercles, pneumonia, or pleurisy. No distinction has been here made between the varieties of blowing sounds, whether diffuse or tubular, bronchial or cavernous. In so far as these names ex- press conditions of lung they are objectionable, and in so far as they express dif- ferences of sound they may be of value to us afterwards in deciding what is the actual cause of the consolidation; but at present it is quite immaterial to our in- quiry wlnther the sound be formed in a large bronchus or in a vomica. The dif- ference is one of degree, not of kind, and the fact is simply that a blowing sound is heard on that side which is dull on percussion, and we determine that these two circumstances taken together prove the existence of consolidation. ]>ulness on percussion would seem to be opposed to the idea of the lung being hollowed out by cavities; and the conclusion would appear to be not unnatural, that whin the breathing is louder from this cause, the resonance on pereus ought to be greater than on the opposite side. Such a condition certainly does occur in the ce of a large superficial cavity, when the percussion sound pre- sents a wooden hollowness (of this kind is the cracked-pot sound:) and an expert auscultator can by percussion alone feel pretty certain regarding the causes of such differences: 1 1 1 . - Btudenl must be content a1 first with the broad distinctions of in- crea sea" ami diminished resonance ami resistance. The long blowing breath-sound heard with a tumour on one side of the chest, is to be accounted for by its press- TI1E CLAVICULAR REGION. 203 ing on some large bronchus: on careful auscultation it will be noticed that this sound is heard in addition to, not instead of, the vesicular breathing; the latter, however, is weaker than on the healthy side. When remarkable resonance is heard, as referred to in \ 2, it is to be noted first whether this be general or local ; and next whether the sound represent merely a great exaggeration of the natural sound with complete resiliency, or have acquired any peculiar or tympanitic tone, and whether it be accompanied by a sense of re- sistance: the examination of the posterior part of the chest will readily clear up any doubt between a large cavity and a condition of pneumo-thorax : it will equally answer the question as to the presence of fluid in the pleura and of emphysema in the marked form to which this section refers : the possible contingency of a small portion of air occupying the upper part of the pleura is best solved by the history of the case. It is very rarely met with except after the operation of paracentesis; but it probably does sometimes occur from spontaneous decomposition of the purulent fluid of empyema. The cases ranged under \ 3 are those most likely to be confounded together by a learner: his ear is sufficiently educated to know that there is a difference on per- cussion, but he may mistake the sharpness of the tone of slight consolidation for an increase of resonance. It is a good plan to compare not only the opposite sides of the chest, but also the upper and lower parts on the same side, when it will at once be perceived that there is a greater difference between the resonance above and below on the duller side than on the more resonant one; for this indi- cation to be conclusive, the chest must be symmetrical. Still, the fact does not determine which lung is the seat of disease, and the first impression is very pro- bably that it must be on the duller side, when in reality it is perhaps on the more resonant one. The safest course to pursue in all possible cases of doubt is to com- pare the whole auscultatory phenomena, not only as heard at corresponding por- tions of opposite lungs, but as heard in different parts of the same one: we may conclude with pretty great certainty that if under either clavicle they deviate much from their general character throughout the rest of the chest, there disease of some sort exists: and whether that be of the form of consolidation or of dilatation is to be resolved by the fact that comparative dulness and increased voice-sound (which always to a certain extent go together) are found on the healthy side when the disease is emphysema, on the diseased side when it is tubercular. The presence of a dilated bronchus in the emphysematous lung, causing blowing breath-sound, cannot so readily mislead us in this as in the following section, where the result of percussion is negative: in this case the absence of dulness or want of resili- ency should be sufficient to guard against error. There is one source of fallacy which must be avoided. When emphysema ex- ists to a considerable extent throughout the chest, and has been accompanied by repeated attacks of bronchitis, it frequently happens that all the tubes are to a certain extent rigid and dilated. Now, if the emphysema be chiefly of the lower lobes, and one of the upper lobes be less affected than the other, the breathing may be almost entirely suspended throughout the chest, while the dilated bronchi of the least diseased structure give rise to sounds under one clavicle which have the character of being produced in larger spaces, and not in the vesicles; and on this side there is by comparison dulness on percussion. How do we know that this is not a case of consolidation? Simply by considering the condition of the rest of the lung: we may be tolerably certain that, in extensive emphysema, the existence of tubercular or other consolidation is not to be looked for. The cases comprised under \ 4 demand a little more consideration, because the information derived from percussion is unsatisfactory; and the last series repre- sents a most important class of cases, — early phthisis, in which no information can be obtained from the rest of the chest; superadded sounds, too, are often wanting; and unless we can establish a distinct relation between general symp- toms and auscultatory phenomena, our judgment must be held in suspense. In health there is no great difference in the intensity of the breath and voice- sounds under each clavicle in the same individual; except that they are very slightly more intense on the right side than on the left. Scarcely any two indi- viduals present sounds exactly alike, and what would be the effect of disease were 20-4 AUSCULTATION AND PERCUSSION. it heard in one. is the normal condition in another. Bat though these limits of Mi have a very wide range, they have r to a certain standard with Which the Btudent cannot too early make himself thoroughly familial-; and when in any particular ease he finds the clavicular region on each Bide alike deviating from it, he must institute a comparison with the other parts of the chest, A patient does not generally seek for relief from symptoms of emphys ie; it is a permanent condition of ill health which has been the growth of years, ami lias Keen increased by every cold; and it is only when bronchitis is Buperad that he thinks of asking for medical advice. The sounds of bronchitis are I lizard in addition, and hence it often happens with inexperienced auscultators that the mingled sounds of the mixed diseases are taken as those of emphysema itself, and tin- possibility of emphysema without bronchitis is forgotten. When partial dulness exists on both sides, from mere loss of resiliency of the ribs the main source of error is the existence of a dilated bronchus. An elderly person who has long suffered from chronic bronchitis presents very often rather a flattened chest; the loss of elasticity in the ribs causes resistance in percussion, and tends to give the stroke a dull sound; the large tubes become thickened and dilated, with loss of elasticity; the vesicles do not expand and contract with their usual freedom, may be closed by thickened mucous membrane, or, when super- added sounds are present, by inspissated mucus: under such circumstances, just as happens in emphysema, blowing breath-sound both with inspiration and expi- ration may be present, with locally increased voice-sound ; and inasmuch as the alteration in condition aud especially in form of these tubes is unequal, the changes detected by auscultation are also unequal. When, in addition to this, the signs of general bronchitis are present, it becomes almost impossible to determine whe- ther at the apex there may not be either tubercular consolidation or a number of small cavities, or whether there be only dilated bronchial tubes; and the final de- cision must rest more on correlative signs and symptoms than on those of percus- sion and auscultation ; and we shall have not unfrequently to wait till the general bronchitis be gone, before pronouncing a decided opinion. Should the case then be submitted to a fresh examination, and nothing remain but the ill-defined dul- ness on percussion, and a diffuse blowing-sound of expiration, nearly equal on both sides, without the local distinctness of amphoric breath and voice-sounds, we may conclude with great confidence that there never has been any tubercle. It rarely happens that consolidation is equally advanced in both lungs, and an expert auscultator can geuerally detect a difference in sbade between the dulness of the two sides; but 1 must confess that I have seen serious mistakes made in attempting to determine by percussion alone which of the two was the most solidi- fied lung. Prom the advanced stage in which the dulness on percussion is unquestionable, it gradually passes, in cases of tubercular deposit, into that in which percussion fiiils in detecting consolidation at all: our means of appreciation are not sufficiently accurate, and the two sides of the chest are not even in health shaped exactly alike: while the difficulty of course is increased when the deposit is deep-seated and healthy or nearly healthy structure intervenes between it and the parietes. But when auscultation is taken along with percussion, the difference between the two sides becomes more apparent, and the existence of morbid structure is proved by the changes in rhythm and quality of breathing and loudness of voice, as well as by the superadded sounds, which not only differ from what is heard in the rest of the chest, but are also unequal on its opposite sides. The expiration is ah. more audible and somewhat prolonged, while the inspiration is .sometimes loud and harsh, sometimes weak and defective; the exaggerated voice-sound, in the latter instance, forming a most striking and trustworthy contrast. Assuming that a difference on percussion is not clearly made out, superadded id may at once determine that local change of some sort has passed upon one lung; but in its absence, or for further confirmation of its cause when present, we pare carefully by auscultation correspnding portions of either lung. Jt may happen that on one side the breathing is stopped by a plug of mucus in one of the tubes: this may be removed by causing the patient to cough and dislodge the obstruction. In doubtful cases the act of coughing is of use in other ways, by THE CLAVICULAR REGION. 205 changing the character of superadded sounds, and also by causing the patient to take a deeper inspiration than we can get him to do by ordinary means. Such a slight condition of emphysema as may possibly exist with no relative difference in percussion resonance, is of no practical value, except as it modifies the superadded sounds of bronchitis when any such are present ; our chief concern is to be able to detect with some degree of certainty the early deposit of tubercle. Rational diagnosis alike seeks to avoid forming hasty conclusions from insufficient premises, and neglecting evidences which, however slight, are of real import; and with this view the indications of early deposit have been ranged in the last sub- division of this section pretty nearly in the order of their importance. It is to be remembered that alteration of rhythm, or quality of breath-sound, is much more im- portant than mere loudness or distinctness, ami that naturally both the breathing and the voice are louder on the right side of the chest than the left. A word must be said of other phenomena as evidence of consolidation, which are derived, not from the lungs themselves, but from the sounds produced in the heart and arteries, which are transmitted through the lung. When the heart- sounds are heard more loudly at the right apex than at the left, or a blowing arterial murmur is heard in the subclavian artery, generally on the left side, there is reason to suspect consolidation; but both are unquestionably only of value as confirmatory of other signs. Such is a general outline of the evidence as to the condition of the lungs derived from the combination of percussion resonance and alterations in the breath and voice-sounds in the clavicular re- gion. Many of the more obscure points require for their elucida- tion an examination of the other parts of the chest, and in all cases a diagnosis must neVer be attempted without making it : the superadded sounds have yet to be considered, and my object has been to place the changes already spoken of in such a simple point of view as to lead the student by logical analysis to form for him- self a correct opinion of the state of the patient. For this reason many of the more delicate modifications which find place in elabo- rate works on auscultation and percussion have been purposely omitted: to a practised ear such varieties may all be sufficiently intelligible, as indicating peculiar conditions of the subjacent tis- sue ; to the student they are only productive of confusion. Let us never for a moment forget, that these investigations as aids to diagnosis ought not to serve as an opportunity for a parade of skill on the part of the observer, but are to be instituted solely for the better determining the form of disease under which the patient labours. At the same time the student ought not to be deterred from making himself acquainted with all the more complex phe- nomena of auscultation; for in this, as in all other branches of knowledge, the man who is most familiar with the more abtsruse facts will most readily appreciate the simpler ones ; and the evils that have resulted from paying too great attention to physical diagnosis have arisen quite as much from imperfect knowledge of the facts it discloses, as from disregard to symptoms derived from other sources. In the exercise of a sound judgment, and with the view simply of ascertaining the condition of disease, and its most appropriate treatment, a practised ear will be of essential service: in following the paltry object of a display of skill in determining 20G AT SGULTATIOH AND PERCUSSION. the exact condition of an obscure case, the most dexterous is con- stantly misled: 1 would even add that the self-satisfying curiosity which seeks to investigate all the morbid phenomena. with reference only to post-mortem appearances is a less estimable quality than that which, while satisfied with a more limited knowledge, has its sole aim in alleviating suffering and curing disease. Division II. — Tiie Posterior and Lateral Regions of the Chest. In comparing together the amount of percussion resonance and the modification of breath and voice-sounds, we find ourselves much limited by the various circumstances already mentioned as inter- fering with the application of percussion at the lower portions of the chest, and the indistinctness of its results upon the scapula ; but here we have fortunately to deal less with disease of small amount and limited extent, more with general conditions of whole lobes or the entire side of the chest. The breathing differs in intensity most materially in different patients, and the student should first endea- vour to catch the sound about the inner edge and angle of the sca- pula on the healthy side if he suspect one to be diseased: then to compare this with the other: from thence he may trace it upwards and downwards and to either side, listening at the same time to the sound of the voice. It is a good plan to* get the patient to talk continuously on some subject; because, not only is the voice thus heard, but at the end of each sentence a deeper inspiration is made, w r hich thus becomes audible, when, as it sometimes happens, the na- tural murmur is so weak as scarcely to be heard at all: practically, I think this plan more convenient than causing 'him to count one, two, three, &c, as many auscultators do; the latter gives more equal intensity to the sound of the voice than general conversation, but minute differences in vocal resonance are not of much value: it is important, however, in all cases to hear the natural respiration if possible without the intermixture of the sound of the voice. § 1. Fercussion elicits a marked difference in resonance between the two sides, with much resistance on the duller side. A. There is no breathing at all to be heard at the base of the lung, on the dull side; at a higher level, varying in different cases, it first becomes audible; and at the upper part prolonged expiration is heard louder on the dull side posteriorly just as it is in the clavi- cular region (Div. I., § 1, A:) the voice-sound is exaggerated and ringing at the upper part, and at one particular elevation it has a peculiar tremor and shakiness, which has received the name of pegophony. These circumstances enable us to determine that the ab- sence of breath-sound is caused by the effusion of fluid and conse- quent compression of the lung. B. The breath-sound is nowhere wholly inaudible, or at all events is heard so low down that there must be a doubt whether it be any- THE POSTERIOR AND LATERAL REGIONS. 207 where abolished: it has a blowing sound, and is harsh and distinct, the expiration being especially prolonged: the voice-sound is heard low down in the chest, with a ringing brassy quality, which is con- stantly taken for tegophony, but it is diffuse and nowhere exhibits the true characteristic vibration of that sound. It is to be observed that the marked dulness and resistance are more than consolidation alone could produce, and yet the characters of the voice and breath- sound are such as have been already mentioned as indicative of in- creased conducting power of lung-tissue by which the sounds pro- duced in the larger tubes are conveyed to the ear; it is therefore reasonable to conclude that there is effusion of fluid along with con- solidation of lung. c. The percussion sound is superficially somewhat resonant, but very distinct dulness is observed when the stroke is firm and forci- ble: the breath and voice-sounds are not much changed, except that the vesicular breathing is generally weak on the affected side, and is combined with a sound of distant blowing. The phenomena are the same as those referred to in the clavicular region (Div. I., § 1, B. c. ;) and the diagnosis of deep-seated tumour, so far as aus- cultation is concerned, really rests simply on such a state of things being found pretty generally throughout one lung. § 2. Percussion indicates a marked difference between the two sides of the chest, one of them being unusually resonant. A. The breathing is heard with a loud blowing, amphoric sound ; the voice has a similar character; the percussion resonance while tympanitic, has commonly a hard wooden tone, in pneumo-thorax. b. The breathing may be inaudible while the other characters re- main the same. These, like the corresponding cases in Div. I., are also produced by the presence of air in the pleura; and it is when the evidence obtained from the posterior and lateral regions is ana- logous to that of the clavicular regions, that we can alone deter- mine its existence with certainty. C. Very rarely do we find the clear elastic resonance of emphy- sema on one side contrasting very strikingly with the percussion stroke on the other; most commonly the affection extends to both lungs; the inspiration is generally inaudible, and the expiration characterized by one or other of the signs of bronchitis, or heard as a distant blowing sound: the voice-sound is less distinct than usual. § 3. The dulness on percussion being less marked, — A. The expiration is prolonged, and the voice-sound exaggerated where the dulness is observed, just as we have already mentioned in similar consolidation under the clavicle. B. A slight amount of emphysema of one lung produces effects similar to those mentioned in Div. I. ; louder breath and voice-sound on the duller side, without any character of harshness or alteration 208 AUSCULTATION AND PERCUSSION. of rhythm: prolonged expiration is rather to be heard on the more iniit side; but, except it be accompanied by some form of su- peradded sound, this condition is not one of any importance. c. In inflammation attended with pain, the motion of the ribs is interfered with, and there is slight dulness and want of breathing, while the voice is generally exaggerated: if a forced inspiration be taken we perhaps obtain the friction-sound of pleurisy or the crack- ling of pneumonia. D. The breathing is sometimes weaker on one side below; as we ascend, it becomes more audible, but is harsh and unnatural; and above, loud blowing breath-sound is heard more distinctly at one apex than the other; the voice is always unnaturally loud. Both lungs are, in truth, partially affected, but in one the signs of disease are much more evident: this is the character of acute tuberculosis; it is always accompanied by corresponding changes in the clavicu- lar region. § 4. No difference is any where detected on percussion between the two sides. a. The resonance may be natural. a. The indications of disease derived from auscultation are limit- ed to the apex, where they confirm the conclusions already arrived at in examining the clavicular region. A delicate ear may make out dulness in the supra-scapular fossa ; but cases continually present themselves in which it is not possible for the majority of persons to do so. b. On one or both sides the superadded sounds of mucus in the smaller bronchi may be heard, when there is no change whatever in the density of the lung; this commonly happens in bronchitis. B. Both sides may be unusually resonant; the chest full and rounded, the scapulre far apart, and little movement comparatively observed in breathing; the breath and voice-sounds are both weak, or almost null, perhaps some distant blowing expiration is audible; very commonly superadded sounds are detected. If similar circum- stances have pointed to emphysema in the clavicular region, the diagnosis becomes certain. c. Both sides may be somewhat duller than natural: rarely, in- deed, equally so on both sides, but still such as not to be very dis- tinctly different. This may occur in oedema of the_ lungs, double pneumonia, and general tuberculosis; the difference is least in the first of these affections and greatest in the last, in which, over th*e scapula and under the clavicle, it can almost always be made out : when the lungs are ©edematous, the superadded sounds leave us in no kind of doubt; in pneumonia the dulness can often be determined by percussion in the axillary region when it cannot be made out posteriorly. In any of these cases the presence of superadded sound, or a contrast between the loudness and rhythm of the breath- ing, suffice to prove 4hat there is something wrong, and we must assume that they in reality belong to the next class. THE POSTERIOR AND LATERAL REGIONS. 209 D. The difference on percussion is not observed. This does not form such an important class as it did in Div. I., because the early detection of insidious disease can seldom be accomplished except in the clavicular region. With reference to changes in the breath and voice-sounds, when we cannot make out any difference on percus- sion, it is to be remembered (1) that at the upper part of the chest behind, too much importance must not be assigned to them, when they seem to be normal in the clavicular region, because of the distribution of the large tubes towards the back of the lungs: (2) that at the lower part of the chest the voice-sound is of compara- tively little value, because of the distance from the larynx ; but in deep-seated pneumonia this is sometimes the only sign we obtain confirmatory of the evidence of general symptoms: (3) the mere weakening of breath-sound by emphysema, when increased reso- nance is not perceived, is of very slight moment, except in so far as it accounts for bronchitis being limited to one side of the chest: it is also to be borne in mind as affording an explanation of defi- cient respiration ; because (4) in pleurisy, before dulness can exist, the breathing is suppressed, and the distinction between the two depends chiefly on the history, and the presence or absence of pain and fever. Of the cases mentioned under § 1, it is to be remarked that no condition of lung gives such a dull, dead percussion sound, with manifest resistance, as that which is due to pleuritic effusion; the multiplying of evidences of its existence is there- fore unnecessary, but its amount may be judged of by the bulging, more or less, of the intercostal spaces, the lateral displacement of the heart, ihe space over which breathing can be heard, and the downward displacement of the abdominal viscera. The term osgophony is one of the opprobria of auscultation ; and yet it has be- come so consecrated by use, that it is difficult to see how it can be got rid of: the name conveys no idea of the sound, but is so completely associated in the mind with the thought of pleuritic effusion, that it cannot be applied without suggest- ing a theory of the nature of the disease; it is therefore quite as objectionable as any other word which more explicitly asserts the condition of the iung (c. r/., ca- vernous.) It is quite true that when the sound has been fully learnt, it will be re- cognised in its perfect form, under no other circumstances; but the resonance of the voice is most commonly increased when there is dulness on percussion, and often acquires a ringing or even a shaky quality, which closely resembles ajgo- phony, and is constantly mistaken for it. In using the term it must be limited to those cases only in which, over a small extent of lung surface, a hollow, squeaking, tremulous voice-sound is heard, which above and below passes into something else. Sometimes, in consequence of the lung being fastened down to some part of the chest by old adhesion, the breath will be heard unusually low in cases of sim- ple effusion, especially near the spine : this source of fallacy must be borne in mind, and an examination of the lateral region will give sufficient evidence of the pre- sence of fluid. The condition of the lung is very different in consolidation and compression ; the one being a deposit within, the other a pressure from without; in both, the vesicles may be equally obliterated, and the mass equally solid and heavy; but in the one there is no loss of size, and all the tubes are patent ; in the other all the minor tubes at least are collapsed as well as the vesicles. This circumstance fully explains the inci'eased breath-sound as heard in consolidation compared with that heard in compression. In a case in which there is consolidation of the lower lobe along with effusiou 14 210 3CULTATION -VXD PERCUSSION. of fl aid, the upper lobe mast suffer compression to allow space for its presence, firm ;uigophony. In the second the breathing gives rise to a peculiar whiffing sound as it enters the small tubes, the sides of which have acquired hardness and increased vibratory power from the effusion of lymph around ; and it is readily trans- mitted to the ear through the dense elastic structure: the voice has at the same time a very loud, sonorous, and metallic or brassy sound, from the same circumstances, and is diffused over the whole hepatized portion of the lung. In the third the characters vary SUMMARY. 213 very much according to the amount and the state of the deposit: in the early stage the breathing is heard in smaller tubes than in carnification, and does not produce in them the whiffing sound of hepatization ; the voice is not ringing as in the one, nor metallic as in the other; there is indeed a period in tubercular deposit in which modified vesicular breathing is heard, while no marked change has passed on the voice at all; proceeding further, the vesicular breath- ing is more or less suppressed, and the lung acquires greater power of transmitting sound, so that the breathing and the voice, which properly belong to the bronchial tubes, are heard at the surface, and are therefore louder and harsher than in health: this gradually increases in intensity, till the tubes are encroached upon, when the breath-sound becomes more faint, and their elasticity being lost, the expiration is prolonged; at the same time consolidation has pro- ceeded to a greater extent, and the voice-sound is therefore louder: next, the foreign matter softens and is expelled, the air begins to vibrate in larger spaces, and the breath-sound becomes louder, harsher, and more blowing; till at length the large cavity, with un- yielding walls, gives out a long, loud, blowing inspiratory and expiratory sound: at the same time the voice-sound attains such loudness and distinctness that it seems as if it were produced at that very spot, and spoken up through the stethoscope to the ear. As might be anticipated, in the rarer cases in which tubercle is deposited in the same way as lymph, the auscultatory phenomena are also analogous. In each of these cases diagnosis is aided by several other cir- cumstances: in carnification by evidence of the presence of fluid or air in the pleura or of some solid substance which has pressed on the lung and expelled the air from its vesicles ; in hepatization by the lower and back parts being more commonly affected; in tuberculization by the upper lobe being first or most extensively diseased. The difficulties are chiefly connected with the revefting of the ordinaiy rule regarding situation and the combination of two conditions of condensation — carnification with hepatization, or with tubercles; tuberculization with hepatization; or even all three together. "We have also to consider the condition of the opposite lung: when the breathing is much obstructed on one side, it is usually exaggerated on the other — puerile as it is often miscalled; and if it be equable throughout, the disease is probably not tuber- cular: if the apex of the comparatively healthy side be affected, the opposite lung is almost certainly in a state of tuberculization ; if the sounds at its base be changed, the cause of disease in the other is probably inflammation. § 2. In cases in which the lung has become less dense than na- tural, it is immaterial whether the vesicles be distended, as in the common form of emphysema, or the air pass into the parenchyma of the lungs, as happens when its structure is torn : the natural elasticity which expels the air at each expiration is lost in either 214 AUSCULTATION AND TERCUSSION. case, the air stagnates, and the vesicular murmur is no longer aucli- ble: the sound of air moving in the large tubes would indeed be heard distinctly, were it not that the rarefied tissue has become a bad conductor; and hence it is only when superadded sounds indi- cate the motion of the air, or when the tubes, thickened, roughened, or dilated, cause unusual vibration, as it passes to and fro, that the distant sounds reach the ear at all plainly: the voice meets with the same obstacle to its transmission, and is only heard when the tubes are thickened or dilated. The superadded sounds therefore stand with many for the evidence of emphysema, while in reality they are so only secondarily: the thickening and dilatation of the tubes, and the increased voice and breath-sound which accompany them, are frequent sources of fallacy. § 3. No other condition of disease exactly simulates the dead, dull, inelastic sound of percussion, and the sense of resistance which is produced by the presence of fluid in the pleural cavity: occupying as it always does the inferior part, the intensity of the dulness gradually diminishes towards the apex, but of course it varies with the amount of fluid; and inasmuch as pleurisy does not necessarily imply the presence of fluid, the dulness may be caused by effusion of lymph only. ^Yhen this is the case, the dull sound is mixed up with a certain degree of resonance, which has been compared to that of striking on wood; one which in its greatest intensity is best heard when there is a thickened pleura with air in its cavity. If there be no accompaniment of pneumonia, the lung is simply carnified from pressure ; it is pushed upwards, and hence the sounds belonging to this condition are most distinctly to be made out under the clavicle; somewhere over the scapula regophony is met with. "When pneumonia is also present the tubes remain more generally permeable to air, and the voice-sound is diffuse, somewhat metallic or brassy, but modified by the superstratum of fluid, so as to ajfproach to jvgophony ; it differs from this essentially, however, in that it is diffuse and not local. The tympanitic percussion sound of air in the pleura is very rarely pure; there is almost always a thickened membrane, which gives a wooden tone to the resonance, and fluid usually exists at the base. Percussion over a large cavity has an amphoric or cracked- pot resonance, which is somewhat analogous, but no mistake need occur from this cause if any degree of care be used; because at the lower and back parts breathing, probably much altered and mixed with superadded sounds, can be detected where there is only a cavity at the apex, while none can be heard in pneumo- thorax, save where the air escaping from the lung causes the long amphoric blowing of expiration. 215 CHAPTER XIX. SUPERADDED SOUNDS IN THEIR RELATION TO ALTERED BREATH AND VOICE-SOUNDS. Classification. — § 1, Interrupted Sounds — § 2, Continuous Sounds. Div. I. — The Clavicular Region. — § 1, With marked Dulness on one side — § 2, xuith excessive Resonance — § 3, with less marked Difference on Percussion — § 4, with no perceptible Difference. Div. II. — The Posterior and Lateral Regions. — § 1, With marked Dulness on one side — § 2, with excessive Resonance — § 3, with less distinct Difference — § 4, with no perceptible Difference. Summary. The real Teaching and relative Value of superadded Sounds. We have next to consider what further light is afforded by su- peradded sounds as to the causes of that change of structure Avhich has been indicated by alterations in breath and voice-sound and in percussion resonance ; and also what they teach us concern- ing the state of the lungs, in cases in which we have been unable to detect any change of density. Various modes of classification have been adopted by different authors, but they have all been framed more or less on theories re- garding the mode of development, either with reference to the situ- ation in which the sound is supposed to be generated, or to the amount of fluid assumed to be necessary for its production. The names which authors have thus either fancifully or theoretically imposed upon these sounds have too often only served to mislead the student, by causing him to attach the idea of a particular con- dition of disease to the name of some given sound, or by rendering it impossible to understand the exact character of one upon which various names have been bestowed. We have endeavoured in the preceding chapter to limit the names used to terms expressing the character of the sound heard, and the same course will be followed with reference to this new class of phenomena, in so far as it can be done without roughly discarding customary terms. Perhaps there is no advantage in classification at all, but it may tend to simplify matters if the superadded sounds be divided into inter- rupted and continuous — including in the former those that consist of a series of distinct noises or minute explosions, and in the latter those that form only one prolonged sound. § 1. Interrupted Sounds. a. Crepitation consists of a succession of fine crackling sounds, commonly so minute and so close together that the ear can scarcely detect their distinctness. 216 AUSCULTATION — SUPERADDED SOUNDS. I. Moist Sounds; the least objectionable term which has been cra- ployed to designate a rattling noise in which the separation of the individual explosions is more distinct than in crepitation: they con- \r, the idea of air passing through a small quantity of fluid in minute bubbles. c. Gurgling Sounds are only a modification of moist sounds, but are yet easily recognised as a class by themselves, the air evidently gurgling or passing in large bells through a considerable amount of fluid. (/. Metallic Tinkling. — This might also be called amphoric drop- ping, conveying to the ear the idea of distinct drops falling with a plash in a large space, and producing a ringing metallic noise. c. Closely connected with the preceding is the plashing sound heard when the patient moves quickly, or is shaken, in cases of hydro-pneumo-thorax. It is called the sound of succussion. These sounds pass by insensible degrees into each other. Cre- pitation may be so very fine as to be mistaken for a continuous sound (of friction for example,) or it may be so very coarse as to be analogous to a moist sound; theoretically very distinct, the value of such sounds can only be estimated practically by the co- existence of other phenomena. Moist sounds may be divided into fine and coarse; they hold a position intermediate between crepi- tation and gurgling. Among these may be classed a sound which has been very inappropriately called dry crackling, which consists of single clicks recurring at longer or shorter intervals ; when speaking of it apart from moist sounds, of which it is, in certain circumstances, the precursor, it will be distinguished by this cha- racter. Another modification is the squeaking sound, which ap- proaches to gurgling, and conveys the idea of a large bubble, formed rather in consequence of the viscidity than of the quantity of fluid. Gurgling, again, sometimes consists of solitary bubbles, at very considerable intervals, exploding in a large empty cavity with a hollow metallic or amphoric ring, which is scarcely distin- guishable from metallic tinkling. § 2. Continuous Sounds. a. Sonorous and Sibilant Sounds. — These consist of a prolonged tone, grave or shrill, or simply of a continuous hissing noise, ac- companying the greater part of the act of inspiration or expiration, or both together, but chiefly the latter: it is that noise which, when loud enough to be heard without applying the ear to the chest, is called wheezing. The depth or shrillness of the note indicates, within certain limits, whether the sound be produced in larger or smaller tubes. b. Friction Sound, caused by the rubbing together of two roughened surfaces of pleura, which, in their healthy state, glide noix lessly over each other. It has been already noticed that crepitation is sometimes so fine that it can scarcely be distinguished THE CLAVICULAR REGION. 217 from friction, when the ear cannot discriminate the distinct explo- sions of which the sound is composed. In a similar manner, fric- tion may be so coarse as to be mistaken for crepitation. The chief differences are these: crepitation is more deep-seated, friction more superficial; fine crepitation accompanies the act of inspiration only, is quite rhythmical with it, and terminates with it: friction may occur at any period of the respiratory act, is very commonly heard both with inspiration and expiration, or is intermediate between them, and is not rhythmical with the inspiration. The one is evi- dently part of the sound produced by the movement of the air in the lung during inspiration ; the other has nothing to do with the respiratory sounds at all, but with the movements between the lung and the chest. Along with these distinctions must be taken the correlative evidence as to whether the affection be one of the lung or of the pleura. c. Crumpling Sound. — It most nearly resembles the crumpling together of tissue-paper; it is heard most frequently at the apex of a tuberculous lung. Believed by some to be caused by the stretching of old bands of lymph, its rationale is not well under- stood, and its value is not great. d. Creaking: a very similar sound heard on deep inspiration, when the air first begins to penetrate a previously carnified lung. It has no interest but as a matter of curiosity after the subsidence of an attack of pleurisy. Not unlike to this is the creaking pro- duced by old bands of lymph in the lower region of the thorax, or the rubbing together of roughened portions of pleura over tu- bercular deposit. No attempt has been made to give detailed descriptions of these sounds, because they can only be learned by experience: good ex- amples of each should be sought out, and carefully listened to, before making any attempt to discriminate them in obscure cases. Division I. — The Clavicular Region. § 1. With marked dulness on one side. a. When that dulness is due to interstitial deposit we may have any of the interrupted sounds, from fine crepitation to gurgling and metallic noises. In the greater number of cases, interstitial depo- sit at the apex is tubercular, and any superadded sound serves only to show the particular stage of the disease; but when its character is that of fine crepitation, when the breath-sound has a loud, diffuse, blowing character, and the voice a brassy resonance, we must look to the general symptoms to see whether we have not to deal with pneumonia: clicking and squeaking sounds, with sup- pressed or blowing breathing, ajid loud vocal resonance, exist from the commencement of tubercular softening; but with the marked dulness now under consideration we are more likely to meet with abundant coarse, moist sounds and gurgling, indicating the existence of cavities. The character of the breathing may scarcely be dis- 218 AUSCULTATION — SUPERADDED SOUNDS. tinguishablc, because it is thus superseded, but, when heard, it is harsh and blowing, and the voice is always loud. When the super- added sound has a metallic character, the cavity must be of some size, and then the breath-sound will have something of amphoric blowing, provided the fluid which causes the bubbling does not oppose the free ingress of air into the cavity: the voice-sound be- comes painfully loud under such circumstances. Friction-sound may accompany both forms of interstitial deposit, but in phthisis it is generally peculiarly creaking. B. With fluid in the pleura. The entire absence of superadded sound, when the breathing is blowing, and the voice ringing, is of itself a very important point in diagnosis, naturally suggesting the absence of deposit in the lung, and leading to an examination of its lower and back parts. Friction-sound is sometimes heard just under the clavicle, but more commonly, when audible, it is to be found somewhat lower down. c. In the case of deep-seated tumour, while the breathing is weak, and the voice probably unchanged, there are also generally no superadded sounds; at least, there are none which belong to it as a tumour, and those in the lung are only the result of bronchial irritation: if it be an aneurism, there will be others connected with the circulation. § 2. With marked resonance on one side. A. When the cause of this is the presence of air in the pleura, we shall have our diagnosis greatly confirmed by the absence of gurgling or metallic noises in the clavicular region; this fact, even when the metallic tinkling or plashing are not heard behind, assists in distinguishing the case from one in which a large cavity presents characters of breath and voice-sound, which equally deserves the name " amphoric." b. When the resonance is due to emphysema, we find that if severe bronchitis exist, moist sounds are audible in various parts of the chest, but rarely jander the clavicle : with any degree whatever of bronchitis, sonorous and sibilant sounds are heard there; with no bronchitis, emphysema gives rise to no superadded sound. § 3. When the dulness is not so marked. A. In cases of consolidation of the lung from pneumonia the dul- ness is generally distinct; but though this sign be wanting, the existence of fine crepitation with whiffing breathing, and brassy voice, is sufficient to cause further inquiry. The consolidation is more commonly tubercular; crepitation of a coarser kind, with prolonged expiration and diffuse exaggerated voice-sound, accom- panies the rapid development of tuberculosis; a certain amount of chronic pneumonia is probably coincident with it in these circum- stances, but the crepitation is not so fine, the breathing is not whiff- ing, and the voice is not brassy, as they are in the simple in- THE CLAVICULAR REGION. 219 flamniation of the upper lobe. In the more ordinary development of tubercles fine moist sounds often occur early with some suppres- sion of the breathing, but with increase of the voice-sound; when, towards the end of the first stage, the breathing becomes louder and more blowing, clicking or squeaking sounds are heard; the coarsest sounds are only found with decided dulness. Sonorous sounds, of a local character, sometimes exist along with the slighter dulness and exaggerated voice of early phthisis ; they greatly obscure the character of the breath-sound; and in con- trasting such a case with the next, it is of the utmost importance to observe that they are heard on that side which is relatively the least resonant. Friction and creaking are both occasionally heard; the former coexists with either form of consolidation, the latter always with tubercles: crumpling sound is generally regarded as a very certain token of tubercular deposit; but to give force to either of these signs, the breath and voice-sounds should also be conform- able to such an hypothesis. b. When the lung, over which dulness is observed, happens to be healthy, the other being emphysematous, the absence of any super- added sound on the duller side, and the existence of sonorous sounds on the other, are important aids to diagnosis; but the latter are only audible when there is also bronchitis. They are not entirely limited to the clavicular region when emphysema is present ; and this circumstance may be of use in judging of an obscure case, when a dilated bronchus produces auscultatory phenomena, resem- bling those of an empty cavity; moist sounds may be heard with very severe bronchitis, but they are never limited to the apex, and are generally audible there only at the very end of the expiration. § 4. No difference being detected in percussion resonance. a. If the lungs be healthy at their apices, there will be no super- added sound. When very extensive bronchitis exists, both moist and sonorous sounds may be audible, but especially the latter: if either be heard at one apex only, while posteriorly the superadded sound, of whatever character, prevails to about the same extent in both, or if heard at either apex after it has ceased in other parts of the chest, we have reason to suspect at least a tendency to phthisis, if not the actual presence of tubercle. b. When both sides of the chest equally indicate increased re- sonance on percussion, in the clavicular region, a similar condition is sure to be found in the rest of the chest. It very generally happens that a patient applying for relief in such circumstances is at the time also suffering from bronchitis, and sonorous, or sibilant, or even moist sounds, are to be heard on both sides ; and then their value in the clavicular region is chiefly negative, that they are heard less distinctly there than elsewhere. c. When both sides of the chest seem equally deficient in reso- nance, and superadded sounds heard in the clavicular region may also be detected elsewhere, they will consist of the varieties of moist 220 AUSCULTATION — SUPERADDED SOUNDS. sounds indicating bronchitis, or very generally distributed tuber- cular disease. The diagnosis between these states depends so much upon the contrast between the upper and lower portions of the lung, that their consideration must be postponed for the present. When the superadded sounds are confined to the apex, there must be in reality a difference in percussion, and the case belongs to the next subdivision. d. Some difference on percussion exists between the two clavi- cular regions, but the ear fails in detecting it. To the student this class is necessarily a larger one than to the experienced auscul- tator: it is one which requires more than any other the exercise of careful discrimination in pronouncing a judgment, and it is import- ant, because to it belong the instances of incipient disease. In no class of cases is superadded sound of more value in forming a diag- nosis, provided it be taken in connexion with the alteration of the breath and voice-sounds. Moist sounds, especially those which have a squeaking or clicking character when found along with jerking or wavy breathing, or prolonged expiration and increased vocal resonance, indicate most certainly the presence of tubercular de- posit, which perhaps never affects both lungs equally. Coarse moist sounds, or any thing approaching to gurgling, can scarcely exist without very decided dulness. Very fine moist sounds approach so near to crepitation that they are apt to be mistaken for it: if dul- ness be not pronounced, it is scarcely possible that such a pheno- menon should find its explanation in the existence of pneumonia; a more probable solution is that capillary bronchitis has been set up by the presence of tubercle. Sonorous or sibilant sounds, when only heard at one apex, are also evidence of local bronchitis; and whether the prolonged sonorous expiration be due to the distention of the tissue by emphysema, or its consolidation by tubercle, is a question that must be solved by the relative characters of the breath and voice-sounds detailed in the previous chapter. It is one of vast importance in diagnosis, which the character of the superadded sound alone cannot decide, and, in fact, any preconceived ideas of the association of sonorous sound with emphysema may very pos- sibly lead us into error. A creaking or friction-sound, with ex- aggeration of the voice and prolonged expiration, and still more decidedly, a crumpling sound at either apex, are of much value in determining early tubercular deposit before dulness on percussion becomes very perceptible. The presence of any strictly local morbid sound at either apex, as it points out the certainty of struc- tural change there, comes to have immense significance when other symptoms indicate the possibility of tubercular disease, and still more, when the other indications of percussion and auscultation give countenance to the idea of consolidation at the apex, where the lo- cal sound is heard. Of the cases included in | 1, with marked dulness on one side, it is to be re- marked that superadded sound, when it is of the interrupted kind, generally proves that the change in density is due to interstitial deposit: its fineness or coarse- THE CLAVICULAR REGION. " 221 ness being determined by the size of the tubes or spaces in wbieb it is formed, and the character of the exudation by which it is caused. When dulness is marked, and the sound fine, it may be pretty confidently assumed that the condition is one of hepatization, either with or without tubercle ; because miliary tubercles would not account for the dulness when existing only to such an extent as to produce irritation and exudation in the small tubes and vesicles. When the sound is coarser, and consequently formed in the larger tubes, or in a number of small cavities, the general symptoms and history must determine whether we have to do with the second stage of pneumonia or with phthisis; the latter being the ordi- nary, the former a very unusual cause. When large bubbling sounds are heard, we are sure that considerable hollow spaces exist, which can only be the result of tubercular cavities, or of the much rarer inflammatory disorganization of lung- tissue which is always accompanied by fetor of the breath and sputa. The continuous sounds are seldom heard with marked dulness. Friction is oc- casionally met with under the clavicle when the dulness is caused by pleurisy, but is more commonly absent. Sonorous sound, as indicating a minor degree of irri- tation of bronchial tubes, not extending to their minute ramifications, might be taken as confirmatory evidence that the dulness was caused by a tumour. Vi hen resonance is excessive on one side (§ 2,) the only sound which can be of much value in the clavicular region is the sonorous: by its presence the movement of the air in the large tubes becomes appreciable, when in consequence of the in- terposition of emphysematous lung, in which the air is all but stagnant, no breath- sound at all would be heard on the resonant side. Moist sounds, too, may some- times be detected on the resonant side when the bronchitis is severe, but these rather belong to the next section. Iu I 3 we find the very important coutrast between partial consolidation, which is generally tubercular, and partial emphysema. The very fine sound of irritation of the smallest tubes which sometimes accompanies miliary tubercle, comes very close upon the crepitation of pneumonia; sometimes, too, the tubercular deposit produces a real pneumonia of slight extent, with genuine crepitation : such cases must be regarded from a general point of view, which includes all the signs and symptoms, or else an error in diagnosis is very likely to be made; and while ad- mitting the high probability that the consolidation has a tubercular origin, we must still not forget the possibility of simple pneumonia. The clicking and squeaking sounds of softening tubercle are very decisive when the difference in percussion resonance on the two sides is not very great; and equally valuable is the sonorous sound of bronchitis with emphysema: the one heard on the duller and the other on the more resonant side. But sometimes the several explosions or bubbles are more numerous, and assume the form of moist sounds, and these, as well as the sonorous, may be heard either on the duller or on the more resonant side. It may happen, too, that the student, while recog- nising a difference, is mistaken in regard to the relative resonance of the percus- sion stroke, and his interpretation of the cause of the sounds, is utterly wrong : they mean, perhaps, only the presence of local bronchitis, but they do not show why it exists. Error in such cases is best guarded against by a careful consideration of the indications derived from the rest of the chest; if no moist sounds be heard elsewhere, or if no evidence of emphysema be obtained from other parts of the same lung, there will be a strong presumption in favour of the difference in per- cussion sound being due to tubercle: their general distribution must be considered subsequently. It need only be added that the presence of some obstruction in the bronchial tubes which gives rise to superadded sound, is very apt to interfere with the indications of consolidation so far as the breath-sound is concerned, thus de- priving us of one of the elements on which, in the former chapter, stress was laid as a means of coming to a correct judgment iu the matter. Creaking and crumpling sounds are less frequently met with in the cases referred to in this section than in the following one; but as they decidedly belong to those in which some form of consolidation has occurred, they at least serve to determine the question of percussion dulness, and to give great preponderance to an hypothesis of tubercle as its local cause. Iu § 4 we meet with the cases most important to the physician, most puzzling to the learner — the first stages of phthisis; with the exception of a few instances 222 'AUSCULTATION — SUPERADDED SOUNDS. in which tubercular Boftening has occurred in the lower lobes, there arc none con- nected with auscultation in which it is so difficult to come to a decided opinion. It is true that the patient cannot know whether we be right or wrong, and that it is a soft course to give a rather unfavourable prognosis in all cases of doubt : it is true that this course is pursued by many of the most popular ami most successful practitioners; but it is also true that this is the course of quackery and imposture, ami I believe that no earnest student will be satisfied with it, and that no ri minded physician (eels quite eomf'urtable in practising the little deception which such a method implies. Here it must be admitted that superadded sounds are sometimes extremely valuable, because when we cannot find any thing wrong elsewhere, they the existence of local disease, and that local disease may be tubercular. The crumpling sound, when heard, is, like the wavy or jerking breath-sound, that which is most constantly associated with tubercular deposit. Creaking only proves the previous existence of local pleurisy, which very frequently is set up by, and, perhaps, sometimes ends in, tubercle. The fine moist sounds and the sonorous sounds referring only to bronchial irritation, derive their whole value from being the exponents of local action, whether they be heard at the apex only, from the first, or linger there when they have ceased to be heard elsewhere. Division II. — The Posterior and Lateral Regions. § 1. When there is marked dulness on one side. A. In simple serous effusion the absence of superadded sound confirms the diagnosis, proving that there is no affection of the lung: when fibrin is also effused, friction may occasionally be heard, but not always. The point at which it is most frequently detected is near the axilla, and towards the front of the chest: and this is the necessary result of the circumstance, that the lung floats upon fluid, which cannot alter in volume during respiration; consequently its free edge at the point furthest from its attachments is that which will most readily partake of the movement of the fluid as it rises and falls with the decreased and increased capacity of the chest in breathing. b. When changes exist in the interior of the lung along with the effusion of fluid. a. We find, in certain cases, no superadded sound at all at the base ; higher up, coarse crepitation ; and still higher, perhaps to- wards the front of the chest, or under the axilla, fine crepitation, but its existence depends a good deal upon the stage of the disease. b. In other cases there are throughout very abundant moist sounds, diminishing in intensity and in degree of coarseness to- wards the upper and front parts of the chest. These two conditions are very dissimilar, and are to be recognised by the different character of the voice and breath-sounds; but they are still more marked by general symptoms, to which we shall subsequently refer: the one is pleuro-pneumonia, the other pulmo- nary oedema, with passive effusion into the pleura. C. When the fluid begins to be absorbed after pleuritic effusion with no change in lung-structure, a crumpling sound is heard, on deep inspiration, analogous to that observed at the apex in some cases of tubercular deposit. It is an auscultatory curiosity rather than a phenomenon of any real practical value. THE POSTERIOR AND LATERAL REGIONS. 223 § 2. "With marked resonance on one side. a. When pneumo-thorax is accompanied, as it very soon is, by effusion in the pleura, two sounds may be produed -which are very diagnostic ; the one a plash, if the patient be swayed somewhat quickly from side to side, technically called succussion, which ex- actly corresponds to the shaking of any liquid in a half-empty jar: the other, a dropping of the fluid in which the shrunken lung has been bathed, while the patient remained in the horizontal posture; it falls in successive drops from its lower border upon the surface of the fluid, when he sits up, with a peculiar ring, which is denomi- nated metallic tinkling. These phenomena are neither of them constant; and it is to be noted that, by various authors, the term metallic tinkling is often applied to any interrupted sound which has a metallic resonance. b. In emphysema it is necessary, as already mentioned, for the production of superadded sounds, that bronchitis be present. If moist sounds be the result, they are louder and more distinct in general bronchitis on the non-resonant side, and never exist to any great extent in a very emphysematous lung: when found only in the dilated lung, they are generally also few, and coarse, heard per- haps only towards the end of expiration, and very often super- seding all breath-sound whatsoever. The sonorous sounds, on the contrary, are more audible on the resonant side : a prolonged sono- rous expiration, with excessive resonance, is nearly certain evidence of emphysema. § 3. When the difference on percussion is less marked, especially in regard to resistance. A. Consolidation existing on the duller side: a. The coincidence of fine crepitation with loud blowing or whif- fing breathing, and exaggeration of voice, is very characteristic of pneumonia: it is usually local, and perhaps shades off into a coarser sound; it is generally found in the lower lobe, and seldom rises above the middle of the chest. b. When the dulness is more extensive, the blowing character of the breathing less peculiar, and the crepitation of a coarser kind, especially when this is audible over the upper part of the chest, we may suspect that the consolidation is tubercular. The hypothesis is confirmed if we find that the greatest amount of crepitation and the loudest breath-sound are heard above, and that both equally diminish as we descend, though occasionally fine crepitation may be heard at the base. Such are the indications of acute general tuberculosis of one lung; and though there be generally such differ- ences, on auscultation, as are quite sufficient to denote that it is not pneumonia, still we must chiefly look to other circumstances for correct diagnosis, because there is, in reality, often a certain de- gree of chronic pneumonia present at the same time. The condi- tion of the patient is very different from what it could possibly be 224 AUSCULTATION — SUPERADDED SOUNDS. if there were the same extent of sthenic inflammation: and the opposite lung very generally gives evidence of the development of tubercles at its apex. As soon as clicking or squeaking sounds at the apex take the place of crepitation, the apparent obscurity of the case is removed. c. Moist sounds may be heard very extensively in one lung, which is the seat of a certain amount of dulness, from the breaking up of tubercular deposit: when limited to the lower lobe very simi- lar phenomena are developed by the suppurative stage of pneumo- nia: the moist sounds are closely analogous, and the exaggeration of the voice and blowing breathing of tubercular cavities there do not differ from what is ordinarily heard in pneumonia. The deter- mination must rest chiefly on the history, either of long ailment or of a recent acute attack, the symptoms of which have been neces- sarily severe when it has terminated in suppuration; or we may obtain evidence of pyaemia, with its secondary abscesses; the dis- eases which afford an explanation of the condition referred to, are much more frequently acute than chronic. d. In the commencement of pleurisy, slight dulness is often accompanied by friction before fluid is effused. Occasionally, the exudation is wholly fibrinous, and the friction-sound so intense, as to resemble crepitation. e. If the evidence of consolidation be limited to the upper part of the chest, the same rules are applicable as those already detailed in the previous Division; with this difference only, that partial dul- ness over the scapula corresponds to marked dulness in the clavi- cular region. When the superadded sounds are found in both places they generally tend mutually to elucidate each other. B. When the difference in percussion is caused by excess of resonance on one side, the absence of any morbid sounds on the duller side, and their presence on the more resonant one, would decide that the case was one of emphysema. When moist sounds are to be heard on both sides, they will probably be most abundant on the duller one; and then the ques- tion must arise whether this be not the seat of disease. Assuming that the condition be one only affecting the lower and back part of the chest, we have to consider the phenomena connected with the breath and voice-sounds as indicating dilatation or consolidation, especially observing on which side they deviate most from those heard a little higher up ; we have also to consider the characters of the moist sounds themselves, whether large and coarse on the duller side, as they would be in the softening of tubercle and in suppura- tion of the lung, or whether, on the contrary, while finer and more numerous on that side, they are only found as a few coarse bubbles, where the greater resonance is observed, the air moving in the large tubes while it is stagnant in the vesicles. Prolonged sonorous expiration, so constantly heard in emphysema, would probably decide at once that the resonant side was that on THE POSTERIOR AND LATERAL REGIONS. 225 which the greatest amount of disease existed: and it is to be remembered that such evidence may often be obtained in the clavi- cular region, when the lung is emphysematous at its lower part, and the accompanying bronchitis is of such a character that nothing but moist sounds can be heard behind. c. The hypothesis of the existence of a tumour deeply-seated would derive great confirmation from the absence of any superadded sound. § 4. When no difference is perceived on percussion. a. The percussion being natural. a. The absence of superadded sound proves the lungs to be healthy, and taken in conjunction with the same evidence in front, leads us to look elsewhere for the cause of any cough that may be complained of. b. Both sonorous and moist sounds are to be heard in cases of bronchitis, the former usually in the early stage of an acute attack, or where the disease is subsiding, the latter being its more ordinary manifestation, and being usually most distinct at the lowest part of the lung. When moist sounds are very fine, and limited to one side, the affection has been often mistaken for pneumonia: we must carefully ascertain whether the localization can be accounted for by consolidation, of which evidence may be found in altered breath and voice-sounds. If this suspicion be negatived, we are justified in believing that the case is one of simple bronchitis. It is much more usual to find moist sounds on both sides; and it is my belief that when the percussion is really natural, healthy breathing will always be found at the upper part of the chest: in recent cases probably accompanied by some sonorous sounds from the scantiness of the secretion; in chronic cases, sometimes of rather a harsh character from loss of elasticity in the air-tubes. When the breath- ing is otherwise altered at the upper part, some further change has taken place in the lung, and there is in reality either increased resonance or dulness on percussion. Sonorous sounds at the com- mencement of the attack are more frequently limited to one side than moist sounds. B. The resonance is unusually great on both sides. This may vary very greatly in amount, and when bronchitis is present, emphysema gives rise to all sorts of moist and sonorous sounds. When the latter predominate, the diagnosis is plain enough : with the former, if the excess of resonance be small, the fact that moist sounds are heard above as well as below may lead to the suspicion that the case is one of very generally disseminated tubercle; this is especially to be remembered in the emphysema of early life. The doubt is best solved by a comparison with the clavicular region, considering whether the sounds heard there would be best explained by the hypothesis of general emphysema or early tubercular deposit. Then, again, the moist sounds of early phthisis are usually fine, 15 226 AUSCULTATION — SUPERADDED SOUNDS. those of emphysema are essentially coarse, ami bronchial effusion tends to accumulate in the lower or most dependent part of the chest. C. Both sides may be equally dull. it. When double pneumonia or double pleurisy is its cause, the extent of the disorder and the severity of the general symptoms are generally such as to leave no doubt on the mind of the observer: the signs enumerated in § 1 are then found equally on both sides. It is highly probable, if the dulness be but slight, and the other signs obscure, that any sound which might be taken for crepitation is in reality only a form of fine moist sound. h. Moist sounds limited to the base, while higher up the breath- ing is not otherwise modified, except in being rather harsh, are very common in chronic bronchitis, with some degree of induration or senile atrophy. The very same indications, however, may be present when tubercle is limited to the lower lobes, and it is just possible that such might be their true interpretation; but the pos- sibility is a rare one, because in general the alterations of sounds are much more extensive when tubercular disease attacks the lower and back parts of the lung. When moist sounds are heard on both sides throughout the whole of the poste- rior region, with some degree of dulness, they must be dependent on one of the following conditions: — oedema, engorgement, induration with atrophy, or tubercu- losis. The diagnosis of oedema of the lungs does not rest so much on any peculi- arity of the physical signs, as on the circumstance of our being able to discover some present obstruction to the circulation, such as produces oedema in other or- gans, especially disease of the heart or kidneys. Secondarily, it would derive con- firmation from the expectoration being watery in place of puriform. Engorgement, again, depends either upon obstruction to the circulation through the pulmonic veins, or upon gravitation of blood in fever, &c, when the patient is confined to bed. Superadded sounds are always present, which partake of the character of crepitation, or fine moist sounds, and these have no distinctive marks. That they are not the consequence of genuine pneumonia, we only know from their extent, while the evidence of much consolidation is wanting : that they are not caused by bronchitis must be proved by a consideration of the relative seventy of the symptoms. Tuberculosis of the lower lobes can scarcely be distinguished from induration, because in both there are usually present the signs of general bronchitis. Per- haps on more careful percussion we may be able to detect some difference in re- sonance between the two sides in this form of phthisis; perhaps, too, clicking or squeaking sounds maybe heard; if cavities have been formed, the voice-sound may be locally increased at those spots, or generally louder at the base than at the middle of the lung; information may also be gathered from observing that pro- longed expiration or vocal resonance is more distinct on one side than the other, especially when this occurs under the axilla at points furthest removed from the root of the lungs and the large tubes. But all these evidences may fail, and we turn to the clavicular region, and there perhaps we find proof of more distinct con- solidation on one side than the other, and we are satisfied that the disease is tuber- cular; on the contrary, we may find no great difference on percussion, each ap- pearing somewhat duil; auscultation may indeed reveal blowing expiration, and coarse moist sounds nearly allied to gurgling on one side, while the breathing is only harsh on the other, and yet this may be only caused by a dilated bronchus along with the induration, the apparent dulness being due to loss of elasticity of the ribs. It must be confessed that these cases give rise to very great difficulties in diagnosis: the constitutional symptoms, however, very generally point more THE POSTERIOR AND LATERAL REGIONS. 227 distinctly to one form of disease than the other, and if we follow this suggestion in a careful analysis of each of the signs just enumerated, we shall probably come to a correct conclusion. Certainly the most trustworthy evidence of tubercular disease at the posterior part of the chest is derived from the coincidence of signs in the clavicular region; fallacy there (e. g., a dilated bronchus mistaken for a ca- viry) only arises from taking one sign as sufficient to prove the existence of tu- bercle. Sound principles demand that when we assign to blowing breathing, or gurgling sounds this cause, we should also have distinct evidence of very advanced consolidation, because tubercular matter is not evacuated until the separate masses have been closely aggregated together. r These circumstances have been gone into with some minuteness, because the cases are very apt to be misunderstood : the moist sounds passing from fine to coarse, as we descend, is just what we expect to meet with in bronchitis, and the mind is very readily satisfied with the explanation of all the constitutional symp- toms which this disease affords when present in its chronic form, which we know is very capable of simulating phthisis; the important point is overlooked that phthisis may simulate bronchitis : to guard against such an error demands close scrutiny and careful reasoning, for it must be remembered that the prognosis in the two disorders is widely different. d. The difference on percussion may be unobserved because of the thickness of the walls of the chest. a. Commencing pneumonia in one lung may be indicated by fine crepitation with exaggeration of voice, or there may be only a few moist sounds from irritation of the bronchial tubes, or even this may be wanting, and nothing but exaggeration of the voice be found ; these differences merely depending upon the distance from the surface at which the fibrinous effusion is taking place, the over- lying lung tissue being resonant and but little implicated in the disease. Vocal resonance, therefore, taken along with general symptoms, occasionally becomes a valuable distinguishing sign between pneumonia and bronchitis of one lung, which no doubt has been often mistaken for it. Friction in the very early stage of pleurisy, before dulness can be detected, sometimes indicates the form which the inflammation is about to take, for undoubtedly the constitutional symptoms are very often pronounced before the physical signs give us any very definite information. b. Dulness at the apex posteriorly is very apt to be overlooked. The restriction of moist sounds to the apex is a very important sign, because of the natural tendency of the fluid in the bronchial tubes to gravitate to the base of the lungs. All the superadded sounds mentioned, as occasionally heard in the clavicular region, when dulness is only slightly marked (Div. I., § 3,) may be found over the scapula when no difference on percussion can be detected there ; and in the supra-spinal fossa the crumpling sound is more frequently met with than any where else. c. When the ordinary signs of bronchitis prevail throughout one lung, and are limited to the upper part of the other, we have great reason to suspect that the disease has a tubercular origin, even when we cannot make out any sign of consolidation at all. In proportion as the thickness of the walls of the chest interferes with the evi- dences of change of structure derived from alterations iu breath and voice-sounds 223 AUSCULTATION — SUPERADDED SOUNDS. am! nance, so do the superadded sounds acquire importance. The eluded under \ 1 are therefore less dependent for their diagnosis on the - than those in which the percussion Bound is less distinct; but they may be of so . as when, for example, with disease of the kidney, we arc anxious to know whether effusion into the pleura be merely passive, or the re- of inter-current pleurisy; the existence of friction would prove the | ;np!i. Still the right discrimination of all the cases mentioned in this depends more upon the correct interpretation of other signs : whiffing breath-sound, for instance, is much more valuable than crepitation. In $ 2 we meet with two very important sounds, — succussion and metallic tinkling. The first of these cannot exist under any other circumstances than when air and fluid are present together in the pleura : the second, although liable ■ mistaken for other sounds, is also, when pure, very distinct evidence of the same fact. But we must be able to assert the existence of pneumo-thorax when neither are heard, and we know that the effusion of fluid is a necessary conse- quence of the presence of air. It is unnecessary to explain why these sounds are sometimes absent; it is enough to be prepared for such an occurrence. It has happened to careless observers to mistake the gurgling sounds in the stomach lor succussion; and by the best authorities the name of metallic tinkling is used when there is no pneumo-thorax: it is well to remember that the sound is merely that of fluid dropping in a partially filled cavity of some size, whether that be in the lung or in the pleura. There is not any chance of a careful observer mistaking emphysema for pneumo-thorax. The coincidence of fine crepitation with the other signs of pneumonia, as men- tioned in \ 3, gives great certainty to the diagnosis; but this sign has been more than once alluded to as a very common source of fallacy. Cases of tuberculosis in which crepitation at the back of the chest is very distinct are rare ; but they are to be borne in mind, especially when the history does not correspond with the :istion which this sound gives of the existence of pneumonia. Tubercular de- t limited to the base, or more advanced there than at the apex, is that condi- tion which causes the greatest difficulty in diagnosis with reference to the poste- rior region: such cases may be mistaken for pneumonia, but are more commonly confounded with bronchitis, as explained in § 4. There is less chance of error when one lung is slightly emphysematous at its lower part, than when the same condition exists at the apex. If the sounds of bronchitis be limited to the resonant side, no mistake can be made, whether the ditference on percussion be rightly or wrongly interpreted; if they be heard on both sides, although more distinct on the duller one, the suspicion of consolidation there is not so apt to mislead as it is in the clavicular region: the possible vari- • are detailed in the preceding pages chiefly in order that the student may be able to give to himself a consistent explanation of what he hears. The cases of real difficulty are enumerated in \ 4, and though perhaps enough has been there stated to show the grounds upon which diagnosis is to be made, a recapitulation in a less formal method may serve to make them more intelligible. We may at once exclude those in which some faint stethoscopie indication ekes out general symptoms, and shows that pleurisy or pneumonia is impending, or is actually present in minor degree, or is deep seated. Auscultation can do no more than lend a feeble aid, and no great reliauce is to be placed upon it. We may also exclude those in which only imperfect information is derived from percussion, be- cause the walls are too thick and unequal {e.g. in the scapular region) to produce definite results, while the other auscultatory phenomena are well marked and dis- tinct. The cases to which we now refer are those in which the sounds of bron- chitis are taken for something else, or those dependent on other causes are sup- posed to indicate its presence. The sounds produced by bronchitis include two very distinct classes — the so- norous and moist sounds: the former are not apt to cause mistakes; and the only point to be remembered, is that when confined to one part of the chest, there is probably some cause for their localization, which must be sought for in consolida- tion, or dilatation, or may be more vaguely traced out in a history of previous in- flammation of the lung; and thus, while explicitly pointing to bronchitis, they may THE POSTERIOR AND LATERAL REGIONS. 229 be the means of detecting other and more permanent disease. Moist sounds, again, vary very much in character ; and the range of those which may be caused by bronchitis and nothing more, is a very wide one : it is true in a general sense, that very fine sounds, even when not quite what may be called crepitation, are most probably excited by fibrinous or tubercular deposit, and that very coarse or large bubbles are only heard when there is a cavity; but these limits cannot be strictly defined. One leading characteristic of the bronchial exudation is its tendency to accumulate in the lower part of the chest, and therefore it is there that we seek for it; and in a large proportion of cases moist sounds, heard there only, are distinc- tive of bronchitis. The exceptions are so few, that if heard equally on both sides, except there be something incongruous in the history of the case — hemoptysis, quick pulse, &c. — it does not demand any very close investigation: it is only when they are confined to one side that we have to inquire whether there be not some consolidation or dilatation of the lung-tissue existing at the same time; and when consolidation is found, the probabilities are very greatly in favour of past or pre- sent inflammation — very much against tubercle. When the superadded sounds are not limited to the base, there may be found in the clavicular region or over the scapula sounds which closely resemble crepita- tion ; but we may at once dismiss the idea that the whole of them can be caused by pneumonia, unless the constitutional disturbance be very great indeed, and we are reduced to the hypothesis of disseminated tubercle or of bronchitis: we have the same hypothesis to deal with when the sounds at the apex are either coarser or sonorous. If the deposits of tubercular matter be very wide apart, they may not produce any definite signs of consolidation — generally there is a difference be- tween the two apices, but not invariably : the more nearly the sounds at the apex approach to crepitation, the more distinct the evidence will be. The cases are naturally divided by their history into the acute and chronic ; those of recent date, with simply mucous expectoration or mixed niucilaginous- looking sputa; and those of long standing, in which the secretion is distinctly puru- lent, or muco-pus. In recent cases the mode of incursion very often indicates the character of the disease, and is really much more trustworthy than the physical signs: in childhood the sounds may be clicking or squeaking, such as in adults we seldom meet with but in phthisis, and yet the case may be simply bronchitis; it is at this age, too, that we most frequently find the equally disseminated tubercular deposit, which fails in giving evidence of consolidation. The true nature of such cases can only be determined by their history and general symptoms. Sonorous sounds at the apex are less likely than any other variety to have a tubercular source when moist sounds exist at the lower part of the chest: in adults, when tu- bercles are present, the sound, of whatever character, is generally as distinct in front as at the back of the chest, and very probably more so on one side than on the other. In chronic cases the history is often so similar, whether there be tubercle or not, that less aid is derived from this source; still, we may have a report of hasmopty- sis, or suspicion may be aroused by the extreme rapidity of the pulse, the fine thin skin or clubbed nails of phthisis; and so great is the importance of such correla- tive symptoms, that the stethoscopist may be wrong, and the man who never prac- tises auscultation, right, in the interpretation of tubercular disease of the lower lobes: all the physical signs are readily explained by the hypothesis of bronchitis, and the general symptoms are attributed to the same cause. Then, on the other hand, a more common error is to be guarded against, that differences of sound at the apices necessarily indicate tubercles: rigidity and dila- tation of tubes is so frequent in chronic bronchitis, producing a certain amount of blowing breathing, and giving a degree of coarseness to the moist sounds in one part of the lungs, while a slight amount of emphysema, or the closure of some tube with mucus, causes a suppression of all sound in another, that it is not diffi- cult to account, in a general way, for changes in breath-sound and varieties of moist sound met wdth when there is no tubercle; but they are apt to mislead the inexperienced. The difficulty of ascertaining the exact condition of the lower lobes, so far as tbe breath-sound is concerned, is very often increased by the closure of tubes just 230 AUSCULTATION — SUPERADDED SOUNDS. alluded to; and when the secretion is very abundant or much inspissated, no sound may reach the ear over a large portion of the posterior region, except a few large coarse bubbles. Summary. In reviewing the facts which superadded sounds really teach, we find, first, that their presence is a direct indication that some- thing is wrong, even when the comparison of breath and voice-sound with percussion resonance fails in pointing out that there is any change of density in the part; secondly, that in such circumstances the sound is probably due to bronchitis; thirdly, that when its cha- racter is quite local, we have reason to suspect that there is some localizing cause, but there is nothing in the sound itself which can warrant us in pronouncing decidedly upon the nature of that cause ; fourthly, that when combined with other physical signs they rather tend to show the stage of the disease than its real character. When the student has been well trained in the principles of diagnosis, he may after a time pronounce Avith comparative certainty on the condition of a patient from the simple evidence of superadded sounds in a large number of cases, especially when they are heard in the posterior and lateral regions: such a proceeding, however, at all times liable to error, ought to be carefully avoided by a learner, and even persons of great experience fall into mistakes when trusting to superadded sounds in the clavicular region, where their indications must be regarded as more uncertain. It is of great importance that this principle be kept steadily in view; the stethoscope, and medical diagnosis altogether, are constantly brought into discredit by conclusions regarding the state of the lungs being based on the evidence which these sounds afford, to the exclusion, not only of ge- neral symptoms, but even of the other physical signs, which are far more trustworthy in judging of change of structure. The presence of some superadded sound is, indeed, readily detected, and affords at once conclusive evidence that there is something wrong, vrhile the comparative estimate of changes in breath and voice-sound and in percussion resonance requires careful examination and logical rea- soning to ensure correctness ; and we are too prone to adopt the easier and shorter method: but this very facility in the one case is apt to lead to hasty generalizations and false deductions, which are more likely to be guarded against by the caution and accuracy required in the other. The interrupted sounds for the most part show that there is some obstruction to the entrance or exit of air, which is overcome in a suc- cession of jerks or explosions, varying in magnitude and frequency from the finest of crepitation to the coarsest of gurgling sounds: and, with certain qualifications, its fineness or coarseness is a mea- sure of the size of the tube or space in which the sound is formed. But if the cause be one of general operation, the obstruction in the larger tubes interferes with the entrance of air into the smaller, and hence in simple bronchitis the sounds are seldom of the finer SUMMARY. 231 kind; whereas in pneumonia and tuberculosis the irritation is limit- ed to the smallest tubes, and the finer sounds are developed: and this remark will be found true of the moist sounds heard in each disease, even if the hypothesis should be subsequently verified that true crepitation is produced by a wholly different mechanism, and is absolutely as well as relatively a dry sound. The interval occur- ring between the explosions, when they are few and coarse, or squeaking, varies chiefly with the relative viscidity of the fluid: bubbles of air passing through pure pus must of necessity be much larger than those passing through simple serum. The metallic tim- bre which interrupted sounds sometimes present, is only produced by echo in a large space, which contains little fluid; it is alike pre- sent when the noise is caused by the bursting of a bubble or the falling of a drop : the metallic bubbling is the commoner circum- stance in a large cavity, the metallic dropping in the pleura itself, but distinct dropping does also occur in large cavities. The continuous sounds have no character in common beyond that which their name implies. Sonorous sound teaches that the air is thrown into vibration by some minor obstruction to its passage ; there may be some plug" of mucus which, itself vibrating like the reed of a musical instrument, produces a corresponding sound in the air, and converts a bronchus into a hautboy ; or there may become constriction of the tube which causes the air to pass with a hissing noise. It is supposed that the graver sounds are always produced in the larger, and the shriller tones in the smaller tubes. Friction sound is rather a curiosity than one which is readily available in diagnosis ; pleurisy can be very well ascertained without it, and in the cases in which it might be expected to be of most value, when fibrin is poured out without serum, it is commonly so rough and coarse that it resembles crepitation rather than ordinary friction. Crump- lino- and creaking sounds indicate some hinderance to the expansion of the lung, and are therefore only of value when other abnormal sounds at the apex are wanting, or when at the base we find diffi- culty in explaining the meaning of dulness. No mistake is more frequently made in the interpretation of su- peradded sound than the assumption that when heard at the apex it is a certain indication of tubercle. The probabilities are, undoubt- edly, very greatly in favour of such a conclusion ; but it is precisely in the rare cases which are not tubercular that skill in correct dia- gnosis is most valuable in regard to treatment, and where its exercise requires the most careful consideration of all the circumstances. It were far better for their patients that medical men never took a stethoscope into their hands, and trusted solely to general indica- tions, than that they should stop short of the knowledge necessary to enable them to discriminate such cases. 232 CIIArTER XX. DISEASES OF THE RESPIRATORY ORGANS. § 1, Laryngitis — Acute and Chronic — (Edema of the Glottis — to be distinguished from Pressure on the Trachea — § 2, Tracheitis or Croup — Crowing Inspiration — § 3, Pneumonia — its History and Symptoms — its Auscultatory Phenomena — Inflammation of the upper Lobe — Abscess — Gangrene — Complications — § 4, Pleu- risy — its Eatly Stage — its Advanced Stage — Complication with Pneumonia — Passive Effusion — Causes and Complications — Pleurodynia — § 5, Pneumo-thorax — its History and Symptoms — the Presence of Fluid — § 6, Bronchitis — Acute and Chronic — Bronchorrhoea — § 7, Emphysema — its Complication with Bronchitis — §8, Asthma — distinguished from Emphysema — Say Asthma — § 9, Phthisis Pulmonalis — its History and Symptoms — Auscultatory Phenomena — their Rational Exposition — § 10, Tumours — § 11, Hooping Cough — § 12, Chest Diseases in Child- hood. Haying in the previous chapters attempted to analyze the vari- ous auscultatory phenomena which are to be met with in examining the chest, let us now take into consideration the diseases to which they owe their origin, in order that we may compare with the facts elicited by percussion and auscultation, the history and general symptoms, and ascertain what influence each of them ought to have upon' any hypothesis which may be suggested for their explanation. In this chapter will be included the subject of phthisis pulmonalis, although it be not properly a local disease, and claimed a passing notice in the earlier part of the volume as one of the depraved constitutional states: it was then found impossible to enter on a consideration of the indications which auscultation affords, and it has been thought better to place it in contrast with bronchitis, to which in many respects it bears a close resemblance. Here, too, we must refer to aneurism of the aorta and its subdivisions as one very common form of tumour in the chest, although diseases of blood-vessels belong to another division of the subject. Hooping- cough and croup, while they have each some claim to be regarded as epidemic, and popular belief runs strongly in favour of the in- fectious character of the former, arc yet neither of them sufficiently understood, in a scientific point of view, to enable us to classify them except as affections of the respiratory organs. § 1. Laryngitis. — This affection occurs in two very distinct forms, the acute and the chronic, which differ from each other very greatly DISEASES OF THE RESPIRATORY ORGANS. 233 in severity, and even in character, so that it is only "when some fresh accession of inflammation has occurred that the chronic dis- order assumes any practical importance. In most cases of acute laryngitis the attention is at once arrested by a hoarse, prolonged, rather laborious inspiration, interrupting the speech and causing the patient to stop to take breath, while the voice is hoarse, or there is complete aphonia. The history may generally be summed up in a few words; after some exposure the patient has "caught cold," sore throat being the prominent symp- tom, and difficulty of breathing having come on early. The sore throat, the painful deglutition which usually excites coughing, and the hoarseness in the early stage, are very important as indications of the serious malady impending, as well as valuable guides when it is more completely developed; because the amount of redness of the fauces bears no proportion to the pain and difficulty of swallow- ing which the patient complains of. We are thus at once enabled to exclude common quinsy, which gives rise to the same symptoms, unaccompanied, however, by either hoarseness or dyspnoea in any marked degree: the discoloration in laryngitis, too, has generally a livid hue. The progress of the disease is very characteristic: at intervals the difficulty of inspiration is much increased, and then a period of comparative quiet probably follows; but these spasmodic attacks rapidly increase in frequency and urgency, till each inspiratory effort assumes a convulsive character, the face grows dusky and is covered with clammy perspiration, the shoulders and clavicles are heaved upwards in laborious breathing, the larynx moves up and down in a tumultuous manner, and instant suffocation seems impend- ing; the patient can scarcely make the attempt to speak, or if he do, it is only in a short, hoarse whisper. At the commencement of the attack there is usually a good deal of febrile excitement, a hot skin, quick, firm pulse, and flushed face; as the insufficient aeration of the blood goes on, and begins to tell on the constitution, the pulse fails in power and increases in rapidity, the skin tends to coldness, the flush on the cheek is changed to a dusky tint. All this bears upon correct diagnosis, although what it teaches be simply that there is some obstruction to the entrance of air into the lungs : the consciousness of the pa- tient, indeed, points out that it is in the larynx ; but we know that any cause might have the same effect upon the breathing, which opposed a similar obstacle to the inflation of the lung: such circum- stances, we shall find, perplex the diagnosis of the chronic affection. As in many other diseases of the respiratory organs, the patient suffering from acute laryngitis usually assumes the sitting posture; he cannot lie down with ease, but shows more restlessness and anxiety than under any other affection : cough is never prominent, perhaps rarely present, for the patient cannot fill his lungs suffi- ciently to produce it. His sensations point simply to the larynx, 234 DISEASES OF THE RESPIRATORY ORGANS. except that now and then there may be pain at the lower end of the sternum, caused by the laboured inspiratory movements. The evidence derived from auscultation and percussion is entirely nega- tive: wherever the stridulous laryngeal noise does not prevent the breath-sound from being heard, the indications are those of health. Besides this form of laryngitis, which may be termed the idio- pathic, it is met with as a consequence of injury, such, for example, as the entrance of an irritant fluid or gas into the trachea: it super- venes, as already mentioned, on the chronic form: or it ascends from the inflamed trachea of croup, or descends from the inflamed fauces of quinsy. Its association with croup and.the means of discri- minating the two diseases will come under our notice in the next section : in each of the other cases, the history and symptoms are primarily those of the precedent affection ; and a knowledge of its existence prepares us for the correct interpretation of sudden dys- pnoea, raucous breathing, and symptoms of suffocation when the laryngitis supervenes. There is also what may be termed a bastard laryngitis occa- sionally met with, consisting of oedema of the glottis. It is prin- cipally associated with the sore throat of erysipelas, and with renal disease: and this would lead to the belief that it has the character of low phlegmonous inflammation rather than that of simple serous effusion. But the swelling of the vocal cords from this effusion is the dangerous circumstance, and that which brings it into associa- tion with laryngitis. The symptoms are less severe, and the inflam- matory .fever is absent; the dyspnoea, however, is sometimes equally urgent; the correct interpretation of the form of obstruction is chiefly inferential; the co-existence of the other forms of disease excludes the idea of acute or sthenic inflammation ; and when dis- ease of the kidney is present, even if unknown, there is generally external swelling of the throat, as well as internal oedema. The absence of auscultatory phenomena, indicative of disease of the lungs, is most important in regard to treatment. I have more than once seen the operation of tracheotomy performed without even a transient relief to the sufferer; with in- deed, in one case, manifest injury, from the excitement and alarm it produced. In these cases the diagnosis was based on insufficient premises : there were, it is true, the sudden invasion after exposure, the rapid progress, the inflammatory fever, and the extreme dyspnoea, with discoloration of the face ; but neither had there been sore throat nor aphonia, and unmistakeable signs in the lungs showed that if the larynx were implicated it was only secondarily; postmortem examination re- vealed what is not inaptly called broncho-pneumonia of the most extensive kind, in each of these patients. The propriety of the operation must entirely rest upon the correct interpretation of the causes which produce the suffocation which it is intended to relieve; but it is even more apt to be undertaken with a wrong im- pression when urgent symptoms supervene in chronic cases, than when the dis- ease is from the first acute. Aphonia is a very good measure of the extent of tbe inflammation, or rather of its progress, and of the effects it has produced. "When the hoarseness has passed rapidly into complete aphonia the affection is unquestionably a grave one. Feel- ing an inability to produce any laryngeal sound, the patient may be content to speak in a whisper; but it is to be remembered that this does not of necessity im- LARYNGITIS. 235 ply the existence of aphouia; and if no effort be made to produce articulate sound, we have at least the right to suspect that the patient may have the power to do so, but does not exercise it. This is one of the common manifestations of hysteria, but is not likely to be mistaken for acute laryngitis; it is rather the chronic af- fection which it simulates; and along with the aphonia there maybe an unnatural barking cough, which tends to make the counterfeit more complete: in such cir- cumstances tracheotomy has been performed without the very slightest necessity, in consequence of mistaken diagnosis. More commonly hysterical aphonia lasts for months or years, the patient all the time being able to speak aloud if she but made a real effort. In chronic laryngitis the disease is not only of much longer dura- tion, but of much less severity; and except when an acute attack supervenes, there is at no time urgent dyspnoea. The inspiratory act is sometimes noisy, and more laboured than natural; but gene- rally the voice is much more affected than the breathing: it becomes rough and harsh, or husky, or may be lost. Chronic laryngitis is connected especially with two other forms of disease, the tubercular and the syphilitic, and it is therefore important to make out from the history and symptoms whether either of these cachexies may exist as its cause. In some cases disease in the larynx and trachea has proceeded much further than in the lungs, where only a few miliary tubercles exist — phthisis laryngea it used to be called; and then its tubercular nature is not so readily made out : to one accustomed to watch all the indications of disease there is something very characteristic in the altered voice of phthisis, caused no doubt by the circumstance that such inflammation of the glottis tends to ulceration rather than to thickening of the cords. In the syphilitic form we trust more to the existence of secondary symptoms of any sort than to the history of infection, which the patient may have an object in denying. Besides these varieties, chronic laryngitis may be left after a more acute attack of the idiopathic kind has passed away; and there would also seem to be some tendency to a recurrence of the disease in a chronic form, after any exposure, in a person who has once suffered from the acute disorder. In other instances we find it associated with disease of bone or cartilage. The general symptoms depend more upon the condition of the patient in other respects than upon the severity of the local ailment, which is not such as materially to affect the health. There is fre- quently a feeling of soreness, or dryness of throat, with some diffi- culty in swallowing; occasionally the act of deglutition excites cough, which may end in retching: in many cases these symptoms are wholly wanting. There is usually tenderness on pressure over the larynx ; any alteration in form, or any degree of fulness, would lead us to suspect disease of bone or cartilage. Cough is very generally present, is harsh, and sometimes peculiar in tone; but less so, as a general rule, than in affections of the trachea. The disease most liable to be confounded with chronic laryngitis is aneurism of the aorta: any tumour in the same situation would DISEASES OF THE RESPIRATORY ORGANS. produce similar results; but practically this is the cause which most commonly originates them. By some physiologists it has been as- sumed that the symptoms are produced by pressure on the laryngeal nerves, especially the recurrent; but no doubt much is due to the irritation produced by its actual contact with the trachea itself. Tlic only conclusive evidence is the discovery of the tumour: a suspicion, indeed, that the dyspnoea and cough may not be the ef- fect of laryngitis, will probably be suggested by the absence of soreness in the throat, and the character of the voice, which is not absolutely hoarse, but has rather a cracked sound, and is wanting in power; the sound of the cough is not so rough, but generally more harsh and clanging. Such circumstances, however, only amount to bare suspicion: more value may be attached to the fact that while there is no soreness of the throat, there is often a pecu- liar dysphagia — a sensation of the food sticking fast in the gullet, which, like the changes in breathing and voice, may be partly due to interference with nerves, partly to pressure on the oesophagus. § 2. Tracheitis, or Croup. Crowing Inspiration. — Acute in- flammation of the entrance of the air-passages in childhood is an affection quite sui generis. It is not here our business to enter upon its pathology, but merely to point out that, while in the adult the inflammation is commonly limited to the larynx, or at least derives all its importance from the inflammation attaching itself to the opening of the glottis, in childhood the trachea is the chief seat of the inflammation: the larynx and the fauces are usually involved secondarily and to a less degree. The chief exception to this is found in the diphtheritis which often prevails epidemically on the Continent: it clearly commences in the upper part of the pharynx, and very often terminates in true croup. In the history of the case we either find that the child has been ailing for two or three days, with symptoms of cold attended by hoarseness, or that the antecedents have been so slight as to have escaped notice, and that the child has waked up in the night in a state of high fever, with considerable difficulty in breathing. The attendant phenomena always indicate very marked febrile disturb- ance; the skin is hot, the pulse quick, and the face flushed, and the progress of the symptoms is* closely analogous to those already mentioned in laryngitis. Hoarseness is an indication which de- serves a first place among the evidences of the disease, because it is one which so seldom attends the common colds of childhood: nex t — if considered along with other circumstances — the peculiar croupy inspiration which follows a fit of coughing, and the brassy or ringing noise of the cough itself; when taken alone, these signs have often led to mistaken diagnosis. As the disease proceeds, membranous shreds of lymph may be coughed up or expelled by vomiting, or patches of lymph may be seen on the fauces: this renders the diagnosis of the disease quite certain; but in some PNEUMONIA. 237* cases no membrane at all is found, the trachea and bronchi are simply inflamed and bathed in purulent secretion. Auscultation of the chest reveals noisy breathing, mixed with a variety of clacking or moist sounds, according to the character and extent of the secretion. In attempting to discriminate between croup and acute laryngitis, we have first the very broad distinction that the one is a disease of childhood, the other of adult life: a form of tracheitis is indeed sometimes found in young adults, in which fibrinous exudation lines all the tubes, even to their minute ramifications; but this is confessedly so rare that it may be left out of account. Next we have the cir- cumstance that, except when lymph is visible in the fauces, there is no sore throat or difficulty in swallowing; and lastly, the stethoscopic signs of affection of the tubes, which, though obscured by the noisy breathing, are nevertheless capable of being discriminated. These indications also bear upon the important question of tracheotomy. Powerful to save life, when the larynx only is involved, it is gene- rally absolutely useless when the bronchi are implicated, and not unattended with danger: the absence of stethoscopic evidence of bronchial inflammation, and the existence of sore throat, or lymph on the fauces, would justify our entertaining the proposition if it ever ought to be practised in croup; the more abundant the lymph about the fauces the less probability is there of its having passed to any consi- derable distance along the trachea. Both affections are alike liable to exacerba- tions and remissions, which are probably of spasmodic character; but in croup there are also violent fits of coughing, which are comparatively rare in laryngitis. Crowing inspiration, or false croup, is often mistaken for the true, especially by those who are content with solitary indications: the appearance of impending suffocation is even greater in the spas- modic disease, and the inspiration following the temporary closure of the glottis, from which it derives its name, sounds very similar to that following a fit of coughing in croup ; but in other respects the diseases differ very widely. The crowing inspiration rarely extends beyond the period of dentition, with the irritation of which it is closely connected: it comes on suddenly, without preliminary catarrh, cough, or hoarseness ; it is not accompanied by inflam- matory fever, and as soon as the paroxysm has passed, the breath- ing is completely free from obstruction. In all these respects it stands in complete antagonism to the true croup. It is evidently a paroxysmal disease, and more nearly related to the convulsions than the inflammations of childhood, as shown by spasm of the flexors of the thumbs and great toes, which is so frequently observed during the attack: it is especially associated with disorder of the primge viae, inflamed gums, and impetigo capitis leading to enlarged cervical glands. By some pathologists enlargement of glands has been supposed to be its ultimate cause ; that of the thymus gland, especially, tending to produce pressure on the laryngeal nerves; probably the two affections only stand to each other in the relation of common effects from the same cause: imperfect nutrition alike manifesting itself in convulsion, in cutaneous eruption, enlargement of glands, and faulty assimilation. § 3. Pneumonia. — Inflammation of the substance of the lung generally presents itself to our notice only in the acute form; • 238 DISEASES OF THE RESPIRATORY ORGANS. chronic pneumonia is sometimes the accompaniment of rapid tuber- culosis, and as- i 1 1 only occupy our attention as one of the compli- cations of that disease. Its history is, therefore, recent ; nor do we find that the patient has been liable to similar attacks at previous periods. We only learn that, after some sort of exposure, severe cold has been caught: in its commencement there may have been rigor, or pain in the side; but these phenomena are often absent. It is always attended with more or less inflammatory fever, as in- dicated by the heat of surface, coated tongue, quick pulse, fee., occasionally the combination of increased arterial action and in- sufficient aeration of the blood, together produce a peculiar dusky flush on the cheek, which is very striking. The breathing is hur- ried, and in severe cases, the number of inspirations in a given time exceeds the normal standard in a much higher ratio than the acceleration of pulse. The cough is hard and dry, especially in the earlier stages, the tough adhesive phlegm being brought np with difficulty and presenting very soon a rusty colour from an intimate admixture of blood: the expectoration is much more abundant, and more distinctly blood-tinged when the type of the inflammation is lower in degree. Pain is sometimes complained of, from the pre- sence probably of a slight complication of pleurisy, and the patient has a general sense of illness much more decidedly than in bron- chitis for example. The distinctness of the auscultatory signs depends very much upon the position of the inflammation, whether near the surface or deeply seated. It attacks the lower and back parts of the lungs very much more frequently than the upper and anterior portions, and we have, therefore, much more confidence in the diagnosis when observed somewhere behind or to either side: the percussion dulness is not complete, and generally not very extensive: in parts the breathing is suppressed, in parts much exaggerated, but nowhere entirely absent, even down to the very edge of the^ diaphragm; the expiratory sound is longer in proportion to the inspiratory than in health, and when much exaggerated it becomes very loud and blowing, with a whiffing metallic or brassy character, com- monly called tubular breathing. The voice-sound is increased, and becomes diffuse, ringing, or metallic; but it has neither the sharp- ness of that produced in a large cavity, nor the shakiness of that which accompanies the effusion of fluid. When fine crepitation is distinctly heard as accompanying the foregoing phenomena, the diagnosis may be pronounced with certainty : the sound is not heard over the whole of the hepatized portion of the lung, but more com- monly towards its edges, and sometimes only when a deep inspiration is made. The period of the disease during which really fine crepita- tion is audible— that form of it which consists of very fine crack- ling, heard only at the end of each inspiration, — is limited, and is soon succeeded either by its almost total cessation, or by its gradual transition through coarse crepitation into true moist sound. Sono- PNEUMONIA. 239$ rous sound is sometimes heard in consequence of the presence of bronchitis: and not only does acute bronchitis accompany pneu- monia, but it may precede it, and among the aged is very often its exciting cause. In such cases the history is a good deal modified, and the auscultatory phenomena are not so distinct. The condition just described is that of the fully-developed dis- ease ; but the practitioner may have to treat a case in an earlier stage, when the history is such as leads him to suspect inflamma- tion of the lung, while yet there is no evidence of consolidation. He only finds that on one side the breathing is weaker than on the other, and then undoubtedly fine crepitation is among the surest and the earliest indications of what is going to happen; but while he fails in no part of the treatment which the general condition of the patient and the probability of the invasion of pneumonia would indicate, it is wise to abstain from a positive diagnosis until the signs be more fully developed, in order that he may not be misled in his judgment of subsequent symptoms, which may prove the disease to be something else, bronchitis or pleurisy for example. It must be remembered, too, that when pneumonia is deep-seated, its presence will scarcely be marked by any physical signs at all ; but if sufficient regard be paid to the whole category of symptoms, we may be contented if the diagnosis derive confirmation from su- perficial weakness or deficiency of breathing, with local exaggera- tion of voice-sound, especially when these indications are met with at the side of the chest, at a distance from the large tubes, while percussion elicits no dulness, and auscultation detects no crepita- tion. In either of these cases the practitioner, by causing the pa- tient to cough, or even only to talk, and thus securing deep inspi- ration, may develop the absent phenomenon of crepitation. One form of pneumonia in particular belongs to this class ; it is that dependent on secondary suppurative fever with pyaemia. The small foci of purulent pneumonia are rarely to be discovered by ausculta- tion; and the supervention of cough, with any alteration in the breath-sound on one side of the chest, is enough to show that secondary suppuration has attacked the lung: but here the ques- tion of which organ is attacked is merged in the more important one of a general crasis of the blood, indicated by the symptoms of suppurative fever. The great error of physical diagnosis, in asserting that fine crepitation is patho- gnomonic of pneumonia, has been already mentioned. It may be quite true that there is one form of it which is never heard in any other condition of disease (yet even this may be exactly simulated by coarse-friction-sound ;) it may be also true that, if this form be clearly and distinctly heard, pneumonia is certainly pre- sent ; but if we take all the varieties of crepitation into account which we do hear in true pneumonia, they are clearly not confined to it. It is equally false to as- sume that crepitation is a certain indication of pneumonia, and that its absence proves the disease to be of some other kind. The real value of crepitation is only as it conforms or is opposed to other signs of disease ; when no other symptoms of pneumonia accompany its presence we 240 DISEASES OF THE RESPIRATORY ORGANS. must seek for some different explanation of the phenomenon; its entire absence may lead us to suspect thai we nave been wrong in attributing other symptoms to pneumonia; bul Li thai evidence be distinct, its degree of coarsen i not be ■ded; nay, even when the character of the sound is entirely altered, and ac- companies expiration as well as inspiration, it still does not stultify the diagnosis of pneumonia, but only shows that an unusual amount of serous exudation has B fact which the character of the expectoration will probably sutli- utly ratify. Pneumonia is most frequently found in the lower lobes, and we consequently place most reliance upon the auscultatory phenomena when observed in that situation ; we receive their evidence with more hesitation when confined to the upper lobe ; and when the whole lung presents the same character of dulness, blowing, breath- ing, and crepitation, we may be certain that, unless the general symptoms be very grave indeed, the disease is partly if not wholly tubercular. In distinguishing fibrinous from tubercular deposit in the upper lobe, we must remember that very fine crepitation is rarely met with at the upper part of the lung ; consequently, the more con- tinuous the sound appears, the more distinct its limitation to the inspiration alone, and the more equal its diffusion over a considera- ble space, the more probably is it caused by pneumonia. We have first to take into consideration the history of the case, the duration and general symptoms of the disease, and the character of the sputa ; and next, to remember that, in such a situation, if the pa- renchyma be infiltrated with lymph, dulness must necessarily be very marked ; the vesicles are occluded, and the vesicular murmur will therefore be annihilated; the tubes remain open, are inflamed and indurated, and the breathing will consequently be very loud and whiffing, and the voice-sound brassy, and much increased in intensity. It will also be remarked that these changes are pretty equally extended to the whole lobe of the lung, and its margin pretty clearly defined by their extent, because they are often more marked towards its lower part than quite at the apex. "But not unfrequently pneumonia of the upper lobe is only en- grafted on previous tubercular deposit, and then the crepitation is coarser, the breathing less whiffing, the voice not so brassy ; the spe- cial signs and the general symptoms each approximate to those of phthisis, of which we have yet to speak (§ 9.) One source of fallacy is when loud blowing breathing is heard in an empty vomica, and crepitation exists in its immediate neighbourhood: but if carefully examined, clicking or squeaking sounds will be found mingled with the crepitation, which is always coarse ; the expiration is more blowing, and less whiffing ; the voice-sound is less brassy, and more shrill; and careful percussion will detect a hollowness or wooden resonance over one particular point, which under certain circum- stances, presents what is called the cracked-pot sound: still more, these characters are strictly local, and limited to the immediate region of the cavity: above, below, and on either side, are heard PNEUMONIA. 241 the sounds belonging to tubercular consolidation; and, above all, the history and symptoms are of phthisis, not of pneumonia. Pneumonia sometimes runs on to the formation of abscess. Apart from those cases which are due to secondary suppuration, this is a very rare event, and inas- much as in its advanced stages the exudation becomes purulent, while the physi- cal signs of complete consolidation around large tubes differ but little from those of a cavity, mistakes have often been made in the interpretation of abundant puru- lent expectoration, with loud blowing breath-sound confined to some particular spot at the base of the lung. It is true that careful auscultation would prove this to be more diffuse than cavernous breathing ought to be; but this fact mav be overlooked: another consideration, however, forces itself on our attention; when pneumonia terminates in abscess, some poi - tion of the lung structure becomes dis- organized, and pus evacuated from an abscess of this sort has always a fetid odour, and it is not safe to diagnose abscess of the lung in such circumstances where this character is wanting. This rule does not apply to secondary deposits which pre- cede the pneumonia, gradually enlarging as the inflammation goes on. Such cases are very commonly called gangrene of the lung; but while there is undoubtedly destruction of some portion of the tissue, the primary condition is suppuration, and they may be readily distinguished from true gangrene by the appearance of the sputa: in the latter always brown or blackish, in the former chiefly purulent; the odour in both is that of sphacelus, which impregnates the breath of the unfortu- nate patient, and is diffused throughout the apartment. Gangrene is a much more fatal disease than fetid abscess, and is generally not immediately related to pneu- monia. Chronic pneumonia seldom exists independent of tubercles: sometimes in a case of long standing, when the period of fever and rusty expectoration has gone by, we find evidence of consolidation, with coarse crepitation and moist sounds at the base of one lung. In the absence of the tubercular diathesis we may hope, and if the patient get thoroughly well, we may believe, that it is a case of chronic simple pneumonia; but such are rare. Cases sometimes present themselves in which we find evidence of a low form of pneumonia coexisting with some other disease, and we must be careful that the diagnosis of pneumonia, however clearly made out, does not cause us to overlook the complication. Fever, for example, often presents such a combination, when it may require very nice diagnosis to say in how far the fever arises from the pneumonia, or the pneumonia from the fever. This is not merely an idle specu- lation, because important practical results in regard to treatment depend upon the decision. When properly considered, the treatment of one or other disease will not be blindly followed; but the educated practitioner will ever bear in mind the two very opposite diseases he has to treat together, and modify his remedies to meet the exigencies of the case — especially when an acute inflammatory disease supervenes on a chronic exhausting one. The combination with pleurisy will be subsequently referred to; its chief importance with regard to diagnosis comes from the manner in which it modifies the auscultatory phenomena : to its presence we must no doubt ascribe the circumstance, that sometimes the sound of crepitation, heard early in the disease, ceases, and instead of being replaced by blowing breath- ing, and other phenomena of advanced consolidation, the breath-sound itself be- comes inaudible: it seems impossible that fibrinous deposit beginning near the surface should of itself cause a stagnation of the air in the large tubes, which can never be closed by such means; neither is there any reason why the sound of its necessary movement should not be transmitted to the ear, unless the lung be pushed aside by fluid. The condition already referred to, in which the presence of vesicular breathing at the surface prevents our hearing the blowing sound of deep-seated pneumonia is of quite a different nature. The coexistence of delirium is not to be regarded as a separate disease, but as one of the phenomena attending on severe pneumonia. It is of much importance in treatment, and when appearing early may lead to a suspicion that fever of the continued type exists along with the pneumonia, but does not necessarily imply 16 DISEASES OP THE RESPIRATORY ORGANS. this tin' altered character of the blood is sufficient to account for the cerebral disturbance. § 4. Pleurisy. — In its proper sense, one of the acute inflamma- tions of the chest, it commonly sets in with pretty smart fever and stitch in the side. We find from the history, perhaps, that there been some exposure to cold, and that the attack commenced with rigor. The ordinary symptoms of inflammatory fever are present, with considerable dyspnoea, manifested in quick, shallow breathing, with little movement of the ribs: the patient especially abstains from taking a deep breath, or making any attempt to cough, because the friction of the inflamed surfaces, caused by either act, excites or aggravates the sensation of pain: the charac- ter of the pain is sharp and darting, and it is referred to a spot just below the nipple, on the affected side. The face is seldom flushed, and the colour is not dusky, because there is no obstruc- tion to the oxygenation of the blood as it passes through the lung. In the early stage the patient seldom lies on the affected side, as he, does at a more advanced period — probably he complains that such a posture increases his sufferings; at this time, too, the physi- cal signs are few and indistinct. They consist simply of impaired movement of the ribs over the whole side, or more particularly over that part where the inflammation has commenced. The breath- sound is more or less suppressed or jerking, in consequence of the pain attendant on full and perfect inspiration ; the expiration ap- pears prolonged. This suppression partially extends to the healthy side, and thus tends to diminish the contrast between the two. The voice-sound is generally exaggerated at an early period over the seat of inflammatory action. Friction is sometimes heard very soon after the disease has commenced, and then there is always attendant dulness on percussion. Here the disease may stop, and no effusion of fluid occur; and it does occasionally happen, particu- larly in cachectic states, that the inflammatory fever proves fatal, with delirium and copious effusion of lymph, without any exuda- tion of serum at all. In such cases the friction-sound may be very persistent and very grating, and heard over a large surface, imi- tating closely the crepitation of extensive low pneumonia. These, however, are exceptional cases; the friction is generally transient, and the patient either recovers rapidly, or the inflammation goes on to the effusion of fluid. The duration of the disease, however, may be very prolonged; and when the case first comes under observation, such a history must not exclude the possibility of pleurisy. It may happen that the early stage is scarcely marked, that there has been no pain, no febrile disturbance, nothing to denote what is going on, till dys- pnoea appears as the result of the pleura having become full of se- rum. The patient may have had pain in the affected side for weeks or months from some other cause — dyspepsia for instance; and it PLEURISY. 243 then becomes quite impossible to fix the date of the commencement of pleurisy. In the further progress of the case, dyspnoea becomes a more constant feature, ordinary breathing is interfered with, as •well as the more unusual respiratory efforts ; pain, if it have existed, sub- sides. The face is apt to be dusky or discoloured; and the patient very often seeks an erect posture, inclining to the affected side. Dulness on percussion is very manifest; at the base the sound is especially dead, inelastic, and resistant; higher up, while it acquires some degree of elasticity the resonance no where presents the cha- racter of health. The breath-sound is absent at the base; above it is blowing, and. the expiration prolonged. The only exception to this rule in simple pleurisy, arises from some part of the lung being tied down by old adhesion ; but as it cannot be so on all sides without its being so generally adherent that there is no room for fluid, the characters enumerated must be detected somewhere, if they be not general. Towards the upper part of the chest, gene- rally about the lower angle or spine of the scapula, the quivering or shakiness of the voice-sound, called regophony, is perceptible. When the pleura becomes quite full, the intercostal spaces bulge ; the dulness passes the median line in consequence of the mediasti- num being pushed over, and along with it the heart is displaced: this circumstance is to be observed earlier, and is always more palpable w r hen the fluid is on the left side. The breath-sound is almost entirely suppressed: now and then the sound of friction may be caught, its position depending on the amount of fluid, the laws of gravitation, and the circumstance of air entering at all into the lungs, and leading to relative change of position between it and the parietes. After pleurisy has lasted some time, the recur- rence of rigor, followed by copious sweating, generally indicates the conversion of the serous effusion into pus; empyema as it is called. The pleura and the subjacent lung, being so closely connected, are very often simultaneously attacked by inflammation; perhaps the exposure to cold, which causes the pleurisy, at the same time gives rise to pneumonia, or to bronchitis. In the latter case the superadded sounds due to bronchial secretion accompany the changes in breath-sound more properly belonging to pleurisy: in other respects the physical signs are the same. But it is different with pneumonia: here the consolidation of the lung prevents its yielding so much to compression, and the fluid rises all around it; the upper lobe, which is not inflamed, yields to compression, and the evidences of pneumonia are confined to the central regions of the chest; necessarily modified by a stratum of fluid being interposed, and giving rise to unusual dulness. "While this dulness indicates pretty plainly the presence of fluid, the observer is surprised by the sound of breathing extending so far down, and for a moment doubts whether there can be effusion after all. In others of these HAl DISEASES OF THE RESPIRATORY ORGANS. complicated cases the signs of pneumonia may have been detected early, but the consolidation may not have proceeded far, or may have been limited to the outer part of the lung, -which is then pushed so far away from the side of the chest by effusion, that the crepitation and blowing-sound cannot reach the ear, and the con- clusion may be arrived at that very severe pneumonia exists when, in truth, it is very slight. In all of these cases we derive some in- struction from the characters of the expectoration. Simple pleurisy shows nothing more than the ordinary secretion of mucus, which is brought up with difficulty, or not at all ; more abundant expectora- tion indicates pretty surely the existence of some degree of bron- chitis; rusty expectoration most certainly that of pneumonia. It is well to limit the term hydro-thorax to those cases of passive effusion in which the existence of fluid iu the pleura is only one form of local dropsy; not forget- ting, however, that a low form of inflammation of serous membranes generally is one of the most common occurrences in dropsy connected with Bright's disease. Such cases, besides presenting the ordinary evidence of fluid in the pleura, are marked by the comparative rarity of true regophony, and the constant presence of the moist sounds of bronchitis, or rather bronchorrhoea, as the necessary result of an cedematous state of the lung. The amount of fluid is never extreme when there is no inflammation, and very commonly it is found in both pleurae, which is very uncommon in pleurisy. By the general statement that dulness extends in greater or less intensity throughout the whole side of the chest in which pleurisy with effusion is present, it is not meant to deny the existence of a sort of tympanitic sound at the apex, to which attention has been called by some auscultalors. To my mind the name seems misapplied, and is apt to convey to students a wrong notion of what they are likely to hear. It somewhat approaches to the "cracked pot" sound; and it is important to remember that this kind of wooden hollow resonance may be heard when the only change in structure in the lung is condensation from -the pressure of fluid below: it has been mistaken for the resonance of a cavity. It may sometimes be of use to the student to observe whether the relations of dulness and want of breathing to the rest of the chest be at all altered by change of posture: the gravitation of the fluid, and floating of the lung upon its surface, bringing the breath-sound to a locality where before it was absent, would be strong confirmatory evidence of pleuritic effusion. In the early stage obscurity is chiefly owing to the circumstances that there is no change of structure, and that the only evidence which a physical examination can afford is suppression of breathing, from imperfect action of the lung: but this stage cannot last long; and pain of some days' standing, without effusion of Ivmph or serum, cannot be pleurisy. In the more advanced stages, the difficulties are caused either by consolidation of lung-structure preventing its being floated up by the liquid, or old adhesions fixing it firmly in its place. It is impossible to point out all the variations in auscultatory phenomena which the latter may pro- duce; but it is worthy of remark that the fact of a previous attack ought to have been ascertained in obtaining the history of the case, and the observer prepared to look for unusual effects in making his examination. "When the adhesions arc very extensive, there is a permanent deficiency of resonance which, though of no it amount in the majority of cases, may yet be perplexing, especially in chil- dren, where the parietes are thin, and changes of resonance consequently great. The most important feature of passive effusion is that it has occurred during the continuance of a disease which tends to cause dropsical accumulations: and probability that such is its true explanation may be shown by the presence of anasarca in the lower limbs, or of disease of the heart or kidneys, even when there is no dropsy elsewhere. On the other hand, if hydro-thorax be the first fact that is brought to our notice, its insidious progress, and the absence of pain PNEUMO-THORAX. 245 or fever in the commencement, ought to lead us to look further into the case, in order to ascertain if there be any other condition of disease with which it may be associated. There is still greater reason for such a suspicion, if the effusion be on both sides. We also meet with other rarer causes of effusion, in pressure on, or occlusion of vessels; but in them hydro-thorax is very subordinate. Still more constant is the association of all other forms of disease of the chest with pleurisy: pneumonia is perhaps the most constant; then phthisis, which especially develops a local and asthenic pleurisy without serous exudation ; less frequently bronchitis, which seems to be more distinct and independent, only ac- knowledging the same cause, and developed simultaneously. Pleurisy is also met with as the result of accident, — fracture of the ribs, with local injury of the serous membrane. This fact is one that ought not to have been passed over in obtaining the history of the case, and it can scarcely be so, because the patient knows of the injury and feels the pain, while he knows nothing of the pleurisy; he therefore talks of his accident as the cause of his sufferings. It is the business of his medical attendant to find out the pleurisy, remembering that the signs will be a good deal modified by the cause; for the same suppression of breathing on the painful side will occur as in pleurisy, because of the aggrava- tion of the pain by breathing: but when the movement of the fractured rib is prevented by the support of a bandage, the breathing is again at once in great measure restored, if pleurisy have not supervened. Spitting of blood may have attended the accident, the lung structure having been torn; and we may find emphysema or pneumo-thorax, as the result, to complicate the diagnosis. Pleurodynia is sometimes in all probability only a very limited form of pleurisy, which speedily contracts adhesions, and gives rise to no positive auscultatory phenomena: such we may feel sure is its meaning when it occurs in a case of tubercular disease. But the name is more properly applied to muscular rheumatism affecting the intercostal and other respiratory muscles: it occurs as a sudden attack of pain in the side, which interferes with the breathing, catches the patient in attempting to cough or inspire deeply, and may even give rise to the motionless condition of the ribs and want of breath-sound which have been spoken of as accompanying the early stage of pleurisy. The diagnosis rests on the absence of febrile disturbance, the extent over which pain is felt, the existence of superficial tenderness, and the character of the pain, which is rather a diffuse soreness, as if the side had been bruised, than a sharp stitch, like that of pleurisy: the presence of rheumatism in anjr other organ would give great assurance of its nature, and this may often be further proved by its being excited by any muscular movement, such as raising the arm, or bending the body from side to side. § 5. Pneumo-thorax. — This seems the most proper place for introducing a few remarks upon this disease, because it presents some relations to pleurisy. Its history is necessarily one of previous ailment: if the patient be known to have had phthisis, we conclude that the air has made its way by ulceration from within outwards; if he be known to have had pleurisy, we suspect empyema has existed with suppuration and abscess of the lung. It may also occur as the sequel of an accident causing rupture of the lung, or of a natural or artificial opening through the parietes for the exit 240 DISEASES OF THE HE S PI R ATO 11 Y ORGANS. of pus or scrum from the pleura: in such cases the amount of air is commonly less than •when an ulcerated opening into the lung exists. In cases of phthisis the event has probably happened with a sensation of something having given way in a fit of coughing or in some unusual strain; in empyema the first event is the discharge of a large quantity of pus by expectoration: the latter is, however, a very rare occurrence. In either case there is excessive dyspnoea; sometimes with, sometimes "without pain on the affected side: and fluid, if not previously present, is very soon secreted. The febrile symptoms are generally evident enough, but not severe ; and they necessarily present a low type in consequence of the previous condition of the patient. His aspect is generally expressive of anxiety and depression, with more or less dusky dis- coloration of the face. He very commonly seeks a semi-erect pos- ture, inclining to the side of the disease; but not unfrequently there is no urgent dyspnoea till an attempt at movement be made, when it immediately becomes very marked. The affected side of the chest is rounded and motionless, has a loud tympanitic resonance, with a wooden hollowness if pleurisy exist; and then there must also be dulness at the base, in propor- tion to the amount of fluid. Throughout the whole of that side there is entire absence of the vesicular murmur: at the upper part some of those sounds may be heard which accompany consolidation, when such a condition has prevented the lung from completely col- lapsing. Amphoric breathing is heard more or less loudly as we chance to listen near to or at a distance from the opening into the lung, or it may be suspended by temporary closure of the aperture: when present it is accompanied by amphoric voice-sound, which is usually more general. When these signs exist, taken in conjunc- tion with the history, and with the tympanitic resonance, pneumo- thorax cannot be mistaken for anything else; the possible error of mistaking a large cavity for a case of this disease will be discussed along with the evidence of vomicee in phthisis. If the aperture be closed, the stillness throughout the chest is such as no extreme of emphysema ever simulates: if there be any doubt, we observe that on the affected side there is none of the heaving movement of the upper ribs, and the drawing inward of the lower, so remarkable in extensive emphysema; while on the opposite side there is no pro- longed or sonorous expiration; we only discover exaggerated natural breathing (puerile as it is called,) so far as the lung is healthy: and this is most evident about the centre of the chest, where we escape alike from the signs of tubercle and of bronchitis or partial pleurisy on that side. But the history of the case ought to set us free from any doubt between emphysema and pneumo- thorax; and if the signs of phthisis be met with in the clavicular region, they would only tend to confirm the diagnosis, because tubercular ulceration is one of the causes of the disease: but they are not often present; for, unless the apex be fixed by adhesion, it BRONCHITIS. 247 is certain to be displaced inwards, and adhesion acts as a safeguard against the escape of air into the pleura. But there are other signs which are still more easily recognised, when fluid is present as well as air. In the erect posture, if the lung have shrunk so that its base does not reach the level of the fluid, we hear, on listening at the back of the chest, when the patient first rises up, a dropping of the fluid, in which its posterior portion was floating when the patient lav on his back : it has a metallic sound, and is known as metallic tinkling. At first the drops fall in rapid succession, gradually becoming fewer, until they cease altogether. This sound is very characteristic; and when observed along with the other signs of pneumo-thorax, the' diagnosis amounts to a certainty. But it is not always heard, because the lung may touch the fluid even when the patient is erect. We may then move the upper part of the patient's body backwards and for- wards as he sits, while the ear is applied to the chest, to catch the plashing sound of succussion. Doubt has been expressed whether the stomach-sounds might not be mistaken for those produced in the pleura; but they can only be so by one who has never heard true succussion : when heard and recognised, it affords as perfect confirmation of the other signs as metallic tinkling. Air may be generated in the pleura by decomposition of fluid, or may be admitted by paracentesis: in such cases there must always have been previous pleurisy. The air rises to the top, causes a local tympanitic sound, and deadens the sound of breathing, because it is a bad conductor when interposed between two solid substances — the lung and the parietes. The fact is a mere curiosity, and has really no practical bearings. It might be mistaken for a cavity with unusual resonance, and so might lead a hasty person to say that there was phthisis coexistent with pleurisy. Such a diagnosis is always hazardous ; for what are supposed to be the most common signs of phthisis may be exactly simulated by those of pleurisy with accompanying bronchitis, while there is no tubercular deposit whatever in the lung. On careful consideration of the condition referred to, it will not be difficult to perceive that the resonance is too great for any thing but air in the cavity of the pleura, and that the auscultatory sounds are only deficient in distinctness: we may also generally cause this tympanitic resonance to change its place by altering the position of the patient. § 6. Bronchitis. — The two forms of this disease, the acute and the chronic, may be recognised by their history: the auscultatory phenomena are sometimes exactly the same in each, and when they differ, they derive their distinctive characters rather from the quali- ties of the secretion than from the fact that the membrane is in a state of recent or of long standing inflammation, except in so far as dilatation or rigidity of the tubes has been produced by repeated attacks. 248 DISEASES OF THE RESPIRATORY ORGANS. In the acute form we obtain simply the history of cold followed by catarrh, which may have been, in the first instance, attended by a good deal of heat of skin and chilliness, by pain diffused over the front of the chest, and a tearing, or painful sense of tickling after coughing: there is, at first, no expectoration; but the secretion gradually increases in amount, generally becomes glairy and trans- parent for some days, and subsequently yellowish and partly opaque. The cough commonly causes headache during the febrile state, and there is some thirst and loss of appetite, without much acceleration of pulse. An attack of influenza differs in no respect from this form of bronchitis, except in the severity of the concomitant fever; there is decided quickness of pulse, coating of tongue, and heat of skin, with more intense headache, general lassi- tude and depression, complete loss of appetite, &c. But, after all, the two ases merge so completely into each other, that a case must be called influenza or bronchitis very often solely from the circumstance that the disorder is or is not epidemic. The same depression will attend severe bronchitis in a feeble person that marks influenza in the robust; and hence the inquiry into the patient's pre- vious health, unimportant as regards diagnosis, is of value in determining on treat- ment; and although it be a most dangerous error to treat the nomenclature of disease in place of the patient, the name of influenza sometimes serves to remind us of depression, and prevent unnecessary depletion. The chest is perfectly resonant on percussion so far as the bron- chitis is concerned. The breathing is at first accompanied by sonorous sounds, which are believed to be graver when formed in the largo tubes, shriller when in the small: moist sounds are next heard ; which begin by accompanying the sonorous, and gradually supersede them altogether, until the declension of the disease, when they are again heard: the breathing first becomes natural at the apices, and the moist sounds linger longest at the bases: the voice- sound remains as in health. There may be some difference in degree, but these phenomena are usually met with on both sides alike in simple bronchitis. If the moist sounds be confined to one side, the case may be mistaken for pneu- monia, especially when they are fine and limited to the base of the lung: the pre- sence of sonorous sounds would be sufficient to prevent such an error; but when these have ceased, the determination must rest on the absence of all dulness, and of exaggeration of voice at any part, as well as on the character of the expectora- tion, which is less adhesive and never rusty. Where it has been decided that the case is one of bronchitis and not of pneumonia, we have still to account for the circumstance of one lung only being affected; and this we may perhaps learn from the history, as it either indicates an attack of inflammation at some former period, or tells of gradual emaciation, haemoptysis or some Other symptom of com- tubercular disease. It is often impossible to detect the signs of early phthisis while the bronchitis lasts ; but the circumstance of the morbid sounds being most distinct, and lingering longest at either apex, is quite enough to excite suspicion. Chronic bronchitis, when it occurs for the first time in any given case, is probably merely an unusual prolongation of an acute attack which has been neglected, or has found the patient in a condition of general debility; the history is merely that cough has continued BRONCHITIS. 249 after the symptoms of febrile disturbance, pain, &c, have subsided; the expectoration is more or less purulent; the auscultatory signs give no evidences of consolidation ; nothing is discovered beyond the persistence of moist sounds. In such cases, however, careful search must be made for signs of early phthisis. More generally there is a history of previous coughs and colds, and the present attack is either an aggravation of a constant con- dition of ill-health, or has come on insidiously without acute symp- toms : there seems to be a permanent liability to chronic inflamma- tion of the mucous membrane, and this is sometimes coupled with a condition of emphysema. The patient is not feverish; the pulse is sometimes quick and weak, and the tongue may be accidentally foul; but it is not dry, and there is no heat of skin: the condition of the bowels is important, because occasional diarrhoea would lead to the suspicion of phthisis. If emaciation exist, the peculiar thinness of skin, and clubbed nails of tubercle, are not found in simple bronchitis; the face is often discoloured, dusky, or muddy, when the disease is severe, becoming remarkably so when emphysema is present, and having a more distinctly blue or purple colour when it is associated with disease of the heart. The gait is stooping in such cases, from the shoulders being elevated, and in bed the patient cannot lie down; orthopnoea is commonly associated either with emphysema or disease of the heart. The breathing is laboured, but not hurried : the cough is generally frequent, and loose ; the expectoration usually easy, but sometimes only possible after a good deal of coughing: it is muco-purulent, or almost wholly pus, in simple chronic bronchitis; it is watery, frothy, and abundant when the bronchial secretion is secondary on disease of the heart or kidneys. Percussion either detects no difference between the two sides, or excessive resonance is especially observed on one. Sonorous sounds seldom exist in chronic cases, except when emphysema is present: moist sounds are heard loudest at the back of the chest, and in the most depending positions, where they are louder and coarser than elsewhere, except when the movement of the air in the small tubes and vesicles is impeded ; and then scarcely any sound is heard, or at most a few large bubbles: sometimes local absence of breathing, in consequence of one of the larger tubes being temporarily plugged up, may perplex the observer. In chronic bronchitis it is to be remembered, that both voice and breath sounds may be locally exaggerated by the thickening, dilatation, and rigidity of the tubes, but it seldom happens that such changes are of very unequal extent on the oppo- site sides. A single dilated tube at one apex may cause some difficulty in dia- gnosis; but if there be dulness on both sides, it is nearly equal, and depends only on want of resiliency of the ribs; if there be dulness on that side on which the large tube is found, its real interpretation is, that there is excessive resonance on the other, where want of breathing indicates emphysema; if resonance be more marked over the dilated tube, it has none of the hardness and hollowness, or local characters of a cavity, but is accompanied by elasticity and resilience. This is the only case of real difficulty in chronic bronchitis, when by many of its concur- rent symptoms it simulates phthisis : the converse case, in which phthisis simu- 250 DISEASES OF THE RESPIRATORY ORGANS. latea chronic bronchitis, will be referred to in \ 9 of this chapter. In a few words we may say, that all changes of percussion resonance, as well as most of those connected with breath and voice-sounds, indicate something besides bronchitis; :■ tubercles, or emphysema, or pleuritic effusion, or inflammatory consolidation, ma: and the correct explanation of the phenomena depends on consi- derations belonging to each of those states, not on any thing specially connected with the moist sounds themselves, which only arise from the coincident bronchitis. Bronchorrhcea is probably the best name for that condition of the Jungs in which the secretion from the mucous membrane is due, not to inflammation, chronic or acute, but to secondary congestion induced by disease of the heart, or more pro- perly to oedema of the lung associated both with disease of the heart and of the kidneys. Except when partial dulness is produced by pleuritic effusion, there is nothing in the physical signs to indicate that this is not simple bronchitis: there is usually a difference in the expectoration, when there is no inflammatory condition of the membrane, and there is the still more important fact of disease existing in other organs. In other cases bronchitis is engrafted upon persistent disease of the heart or kidneys, and its symptoms are greatly aggravated in consequence. Complications in either of these organs are the most common, and ought espe- cially to be sought for in chronic cases; after all that has been said it is scarcely necessary to repeat that the existence of emphysema and tubercular deposit are each to be inquired into: in the acute form we find bronchitis complicating pleu- risy and pneumonia or even pericarditis, and often present as a result of conges- tion in cases of fever. § 7. Emphysema has been so often alluded to in 'the preceding pages, that a short restwii of the more important points connected with it must suffice. Its great and prominent feature is dyspnoea — laborious, in contra-distinction to hurried breathing; the respi- ration is generally slow, and yet the patient is conscious of dyspnoea, and makes complaint of it: there is no difficulty of articulation; but yet he may stop in the narration of his symptoms to take breath. In its most aggravated form, the elevated shoulders, the rounded back, or the full, highly-resonant chest, the peculiar weak, power- less cough and voice, and the dusky, somewhat earthy or muddy aspect, are all so striking that we need scarcely institute a physical examination to satisfy us of the existence of emphysema. Whether confined to one lung, or extending to both, the phenomena of a well-marked case consist of slight descent of the upper ribs in expiration ; their heaving movement, with but little expansion of the chest in inspiration, while the lower ribs are. drawn inwards; excessive resonance, and absence of breath-sound, or the substitution of prolonged (\istant expiration for vesicular breathing. It is^ of most importance as a complication of chronic bronchitis, aggravating all its evils, and permitting sometimes such an accumulation of secretion, that scarcely a bubble reaches the ear, although the tubes be quite full. In its minor degrees it is often an unexpected cause as well as complication of bronchitis: the obscurity of the symptoms some- times leads to its being mistaken for early phthisis; while it not unfrequently affords an explanation of the existence of asthma. When the upper lobes are chiefly implicated, absence of voice-sound is a great help in diagnosis; but this is far from being constant: prolonged sonorous expiration is a more reliable sign, when some ASTHMA. 251 degree of bronchitis is present. It is unnecessary to repeat here the circumstances detailed in a former chapter (Chap. XVIII., Div. I., § 3,) by which we decide 'whether relative dulness on per- cussion be due to consolidation of a portion of one lung, or to dilatation of the corresponding part of the other. Slight general emphysema, in the absence of bronchitis, gives rise to few symptoms by which it may be detected. The patient perlpips suffers from repeated attacks of asthma, or any little cold is attended with much dyspnoea: in the intervals we find that the inspiratory sound is generally weak or deficient, or a rumbling noise only is heard, which cannot be classed as inspiration at all ; but on deeper breathing some little sound becomes perceptible, which is followed by a prolonged distant blowing expiration. These cases are difficult to discriminate from those in which the breath- sound is naturally weak, and where the ear may be applied over any part of the chest without hearing any thing in ordinary respiration. This is not to be regarded as an unnecessary refinement ; for where emphysema is present, there is to a certain extent less chance of the lungs becoming tubercu- lous than when the breathing is naturally weak. Sometimes, while the inspiration does not differ from that generally found in health, the expiration is universally prolonged. Are such cases at all emphysematous? This is a point apparently somewhat uncertain ; but I conceive that one of the elements of emphysema is a suppression of the sound of inspiration, and that its distinctness is to be regarded as exceptional and local, and that it only occurs in consequence of dila- tation or rigidity of some tube near the surface. As the emphysema becomes more extensive, so do the attacks of breathlessness become more frequent and more severe; and in addition to the ordinary compli- cation of bronchitis, we have two others of much importance — hypertrophy and dilatation of the right side of the heart, as a sequel of the disease of the lung, and dyspeptic symptoms, which, while they have no immediate connexion with the condition of the chest, interfere very seriously with the action of the diaphragm. Both tend to aggravate the dyspnoea: the one by sending into the lungs a larger quantity of blood than they can supply with air, the other by preventing the al- ready distended lungs from receiving the limited supply, which each inspiration might otherwise introduce: the former is permanent, the latter only temporary in its effects upon the respiration. The constancy of the prolonged sonorous expiration is easily explained by the loss of elasticity of the air vesicles, which deprives the lung of the power to expel any secretion existing in the tubes: hence it is that sonorous sounds are so charac- teristic of the disease, though in truth they depend upon bronchitis. The same circumstauce explains why, with a larger amount of secretion, the moist sounds are almost suppressed; because the air is stagnant in the smaller tubes, and the fluid accumulates till but a few bubbles of air can pass through, and very coarse sounds only are heard at the end of inspiration, and more especially at the be- ginning of expiration. § 8. Asthma. — In speaking of the descriptions given by patients of the disease under which they are labouring, the necessity was shown of excluding any theory which the name given to the com- plaint might imply, when this name comprises not only the facts of the case, but the notions acquired of their causation. This is especially true of asthma; and when a patient calls himself asth- matic, it must be our first object to ascertain whether the dyspnoea 252 DISEASES OF THE RESPIRATORY ORGANS. be habitual, and of long continuance, or -whether there be any paroxysmal character in the attack. We restrict the term to those s in which the difficulty of breathing occurs distinctly in pa- roxysms, of longer or shorter duration, which at their -worst cannot exceed a couple of days, and more generally last only a few hours. In such instances the malady comes on gradually. At first it is only during a catarrh that any shortness of breathing is experienced ; by and by it recurs more frequently, and with greater sev<#ity, cither without the presence of catarrh or terminating in it; and de- pends on such a variety of causes, that it is almost impossible to assign the true one. The paroxysm may be excited by local or at- mospheric causes, or by derangement of stomach: it is unattended with fever, the skin generally being cold, and often covered with moisture: the prominent fact is inability to fill the chest with air, as manifested by the gasping for breath, and by the want of breath- sound in the lungs, while there is no permanent cause of obstruction at the larynx or in the trachea, the patient having been quite free from dyspnoea before the paroxysm began, and knowing full well that he will be free from it as soon as it is over. In a very large number of these cases there is some degree of emphysema; and the more the lungs are thus altered the more easily is the asthma excited, the more severe is it while it lasts, and the longer its continuance. But there are cases in which we can trace no emphysema, and we are cognizant of nothing but the spasm by which the air is prevented from entering the lungs with its ordinary freedom. The paroxysms are most apt to occur at night; and, be- sides the immediate object of shortening their duration, we have to consider their relation to local causes, or disordered stomach, with a view to their prevention. Hay-asthma is really a catarrh, and has nothing of the parox- ysmal character. It cannot be distinguished.from ordinary catarrh, except by its recurring at the same season of the year, by its being excited in the immediate proximity of its known cause, or by its surprising and almost immediate cessation on removal from such proximity: these discoveries are more frequently due to accident than to skilful diagnosis. All other so-called asthmatic cases maybe resolved into changes in the permanent condition of the lungs, or diseases of the heart and blood-vessels. § 9. Phthisis Pulmonalis. — The existence of tubercles in the lungs is only the local expression of a general disease called by some a blood-crasis, by others a diathesis. Allied to scrofula, it is placed in the table of diseases among the chronic blood ailments, but its most constant manifestation is in disease of the lungs ; and it was therefore thought better to defer its consideration until we had reviewed the other diseases of these organs. In its characteristic form and advanced stage, both general symp- PHTIIISIS PULMONALIS. 253 toms and local phenomena are so distinct that no disease is more readily or more surely recognised: in exceptional cases it is not un- frequently mistaken for other diseases, while they in their turn are liable to simulate phthisis: in its early manifestation it is, very im- portant to be able to recognise it while yet latent, and before its symptoms are fully developed. Its sadly fatal course makes the conscientious practitioner view these early phenomena with great anxiety, and study their relations with the greatest care; as the dread in which it is universally held serves as a never-failing resource for the fraudulent and the avaricious, who pretend to detect phthisis when it does not exist, and promise a cure alike to those whom they thus deceive as to the true nature of their malady, and to those whom they delude with false hopes as to the powers of art when their case is already past recovery. The history comprises several points of considerable value in dia- gnosis: loss of relatives from diseases of the chest under whatever name, especially those occurring at the period of adolescence ; ac- counts of previous illnesses and ailments of the patient himself; and the mode in which his present attack has commenced. It must be regarded as unfavourable when cough has begun without preceding catarrh or coryza, but has been from the first dry and hacking; when during its continuance, or at its beginning there has been haemopty- sis of the amount of a teaspoonful or more; and when in the pro- gress of the case the dry cough has been changed for one accompa- nied by thin mucilaginous rice-water sputa, and that form of expec- toration has been followed by thick yellow phlegm. The general symptoms very often indicate the presence of hectic ; the skin, especially that on the palms of the hands, being at times dry and hot, while at others it is bedewed with excess of moisture ; there are also night-sweats, the pulse is quick and weak, the tongue frequently patchy, and sometimes preternaturally red, shining, or smooth. Along with this we have the particular indications of re- markable thinness of the skin, which can be pinched up, as if it were detached from the subcutaneous structure, and clubbing of the nails, with the occasional presence of diarrhoea: any signs of emaciation are of value when not traceable distinctly to disease of the chylopoietic viscera. The patient's appearance sometimes be- trays weakness with a mixture of languor and excitability; the eye brilliant, the cheek pale, with a hectic flush, and the whole aspect delicate. The respiration is observed to be quick, while the patient has no feeling of dyspnoea, and does not seek by posture to relieve his breathing. No complaint of cough, perhaps, is made till it be inquired after ; there may be mention of wandering pains in the chest, of a feeling of tightness, or perhaps of local pain from inter- current pleurisy. The voice is very often characterized by a slight degree of hoarseness, which, as the disease proceeds, may ultimately terminate in complete aphonia. None of these symptoms are always present, and some are 254 DISEASES OF THE RESPIRATORY ORGANS. very liable to be found in other diseases, but one or two have more value than the rest. Among these we reckon family history; hae- moptysis, when there is no disease of the heart, no r|Jaxed throat or spongy gums; quick pulse and night-sweats, thin skin, clubbed nails and emaciation: especially when these are found about the pe- riod of puberty, and from that onward to the age of thirty. He- moptysis is studiously concealed by some patients, in whom it has really existed, is much talked of by others in whom it has been only simulated, especially the hysterical and hypochondriac. The quick- ness of the pulse is generally an index of the severity of the dis- ease ; and a natural pulse, when the evidence of phthisis is distinct, is always a favourable indication as to the progress of the case. Clubbed nails seem to have some direct relation to the condition of the lungs and heart, and though most commonly seen in phthisis, yet attain even higher degrees of development in rare cases of disease of the chest, when not a tubercle exists. The auscultatory phenomena vary according to the site of the deposit and the progress it has already made. An important fact in their elucidation is, that tubercle has a remarkable tendency to be located in the apex of the lung; and that however disseminated through other parts of the organ, it is very generally found there too ; this law is all but universal : the converse is also true to a less extent; that in other diseases of the lungs the signs are more fully developed in other parts: we shall therefore consider the symp- toms of tubercles at the apex first. The facts of which auscultation and percussion in this region give evidence are the original deposit of tubercle in solitary small masses, their gradual increase in size, the excavation of the lung which follows on their softening and ex- pulsion ; and incidentally inflammation and irritation of the bronchial tubes, of the pleura, or even of the parenchyma of the lung, which may be excited by their presence. If the previous chapters have been carefully studied, the pheno- mena necessarily resulting from such causes will be known a priori. A very small amount of deposit can only affect the breathing in the way of making the expiration a little longer, and the inspiration a little shorter, and harsher or louder, or perhaps weaker, than on the opposite side, or by giving it a wavy or jerking character: the voice-sound will be a little louder : the percussion-sound can only be very slightly if at all altered; but it must not be forgotten that both voice and breath-sounds have a tendency to be louder on the right than on the left side in health. Sometimes a confirmation of the existence of tubercle in this early stage may be _ obtained from the heart's sounds being heard more loudly at the fight apex than the left, which is impossible in health ; a bruit in the subclavian artery, when it cannot be heard in the carotid or at the heart, is also of value, although the rationale of its development is not under- stood. These are, after all, very uncertain grounds on which to determine that so serious a disease as phthisis has begun, and yet PHTHISIS PULtaONALIS. 255 they are sometimes all that auscultation and percussion afford. An opinion ought not to be pronounced on such insufficient data, if standing alone ; but we may feel very safe in the deduction, if the history and general symptoms point to the probability of phthisis, and if the physical signs be only taken in conjunction with the whole evidence which the case supplies. Above all, let me warn, the student against supposing that he is reasoning accurately in taking them in conjunction with only one of the more general symptoms; such, for example, as a weak and quick pulse, or lueuioptysis : this is the most common cause of error. As the disease proceeds, the evidence of consolidation becomes more distinct, and along with it we have signs of irritation of the bronchial tubes (sonorous and moist sounds,) of inflammation of the pleura (friction and creaking sounds,) sometimes of inflammation of the parenchyma (true crepitation,) or of the progress of the tuber- cular disease itself (clicking or crumpling sounds;) and we admit the great probability that these signs are caused by the presence of tubercle: yet we cannot dispense with the evidence derived from the history of the case, because they only prove local consolidation, and no more, and this may be inflammatory. Still further in the progress of the case, the evidence of local consolidation is accompanied by louder blowing breath-sound from commencing excavation when the cavities are empty; and at a more advanced stage, the dull percussion stroke may be converted into something approaching to tympanitic hollowness ; the breath- sound is still more blowing, and the voice-sound is sometimes pain- fully loud, as if some one were speaking into the other end of the stethoscope ; this cavernous sound, as it is called, is Tsven more clearly brought out occasionally when the patient whispers. The necessary result of air entering these cavities when fluid is present is, that the superadded sounds become bubbling, gurgling, or even metallic. An important fact in relation to this stage of the disease especially, is flattening or sinking of the ribs, and deficient move- ment in inspiration ; without this our signs of excavation are pro- bably altogether wrong, and we must look for some other explana- tion. The general symptoms, too, are necessarily more pronounced, and the history of the disease extends over a longer period. The principal fallacy in the first stage is when the healthy lung is supposed to be tubercular because the opposite one is emphysema- tous: in the second, when pneumonia of the upper lobe is mistaken for tubercular consolidation: in the third, when a large tube is mis- taken for a cavity, or a large cavity is mistaken for pneumo-thorax. In chronic pleurisy with empyema, attended by symptoms of hectic, sounds exactly resembling those produced by tubercular deposit may be heard under the clavicle: the practitioner must be thrown much off his guard by some unusual circumstance, who confounds these two conditions ; but what has happened more than once within my own personal knowledge, may happen again. 256 DISEASES OF TOE ©ESPIRATOKY OBGANS. p For the sake of the student we tnaj point OUl more in detail the relations which superadded sounds present to the different modifications of breath and voice-sound xved in the progress of the disease. The voice-smiml steadily increases in intensity from the beginning of consolida- tion to its ultimate termination in the largest possible cavity. Not so the breath- sound: this is first commonly harsh and i rated, or wavy and jerking: then the inspiration becomes diminished in intensity while the expiration is prolonged; anl subsequently, when cavities begin to form, each increases in loudness, but expiration more especially becomes remarkably blowing. With the first i dition BQperadded sound is usually absent; sometimes a crumpling sound may be heard on deep inspiration, but if the presence of tubercular matter give rise to any inflammation, fine and coarse crepitation or moist and sonorous sounds are developed; the variations probably depending upon whether the vesicular structure or the tabes be more particularly the seat of the inflammatory action. Proceeding a little further, the sonorous sound is entirely replaced by moist sound, when the secretion from the tubes becomes more abundant; but in the same proportion does tin- air find difficulty in entrance, and the breath-sound becomes partially suppressed: this condition is not necessarily permanent, and the lung may return to one in which the breathing is simply harsh and exaggerated. At this stage tin' presence of crumpling or of friction-sound or of one or two clicks is often of gre;r • in giving certainty to the diagnosis, when bronchial irritation has passed away. In the second period the difference in resonance becomes quite distinct: but the student may feel uncertain which of the two is the diseased lung, unless he compare the sound of the percussion stroke above and below on each side of the chest. The moist clicks now become more frequent, and are often mixed up with squeaking sounds; coarse crepitation and sonorous sounds are more rare, or are heard only in the vicinity of where the softening has begun; moist sounds are common. There are two circumstances which tend to produce these effects, the partial softening of small tuberculous masses, and the presence of local bronchitis; and though clicks and squeaking sounds be more distinctive of the former, and moist sounds of the latter, yet they are by no means to be taken as their di- rect exponents, because each may be found in either circumstance. Another cause of the presence of moist sounds with deficient breathing is the recent oc- currence of hemoptysis : dulness is commonly present, but it is slightly marked: the circumstance of hemorrhage having existed sufficiently explains the pheno- menon, and, when heard only at the apex, moist sounds are pretty conclusive evidence that its cause is the previous deposition of tubercular matter, because we know of none other which can give rise to hemorrhage at the upper part of the lung only. As a necessary consequence of the presence of the fluid, whatever it may be, that produces these sounds, the entrance of air is impeded and the breathing is deficient. Advancing still further, the dulness becomes unmistakable: indeed, the wooden or tympanitic sound over a cavity would always be called dull by any but an expert auscultator. The moist sounds become coarse, abundant, and mixed with larger bubbling, until a cavity of some size has formed, and then nothing but gurgling sounds are heard, when the stethoscope is applied over it: in its immediate neigh- bourhood the signs are those of less advanced disease. "When numerous smaller cavities exist, the condition is one of more general coarse or bubbling moist sounds. But besides the size of the cavity, the proportion of air and fluid which it contains greatly modifies the sounds it gives out, and we may have no super- d sound at all from the absence of either one or other. An empty cavity produces a loud blowing sound in breathing, but no gurgling; a full cavity gives neither one nor other, but only dulness on percussion; a cavity communicating freely with the bronchial tubes by an opening situated below the level of the fluid produces loud gurgling; one in which a small opening is similarly situated may give rise to only one or two resonant explosions: when the cavity is large and nearly empty, every sound produced within it has a metallic resonance; in a small cavity or one nearly full no such effect occurs. There need be no practical difficulty in distinguishing this metallic clang from PHTHISIS PULMONALIS. 257 that produced by a similar cause on a much larger scale, viz., the presence of air and fluid together in the pleura: the great and constant distinction is simply that in the one case, if we turn to the back of the chest, we find the indications of lung tissue, however diseased, occupying its natural position; in the other we have the tympanitic resonance produced by its absence; and if any breathing be heard, it is only a loud blowing sound resounding through the empty cavity, while at the base there is complete dulness, from the presence of fluid, and no breathing at all. In additiou to this there are two minor sources of information: the metallic sound is seldom produced by dropping when heard in a cavity, but is more commonly the result of solitary bubbles of air passing through the fluid ; it therefore keeps time with the breathing — dropping does not : the voice is less like that produced by speaking into an empty jar, and seems rather to be spoken into the stethoscope. The student must be reminded, too, of the possibility of a portion of air spon- taneously developed, £>r admitted by paracentesis, rising to the apex when the lung is not shrunken as it is in true pneumo-thorax, and when there is no commu- nication between the bronchi and the pleura. He has only to think of the fact that, if there be at the. apex a cavity capable of causing tympanitic resonance, there must be blowing breath-sound and loud voice; when there is air in the pleura just the opposite effect is produced, and both sounds are less loud than on the oppo- site side. Another general pathological fact may be turned to account in diagnosis — viz., that if tubercles be at all advanced in one lung, they are almost certain to exist in minor degree in the other; and when their presence is equally distinct in both lungs, they are still seldom found in exactly the same stage, or giving rise to the same modifications of sound. This is especially to be borne in mind when any one auscultatory phenomenon stands alone at either apex in a very marked degree, which would indicate an advanced stage of the disease, if it were found in conjunction with other corresponding signs and symptoms ; alone, we must be content to regard it as an anomaly to be hereafter cleared up as the disease proceeds ; but Ave may consider the possibility of morbid growth, — such, for instance, as encephaloid disease disseminated at the apex. (See § 10.) Tubercular disease is sometimes found solely or chiefly at the base of the lung: such cases are very apt to be misunderstood simply from the fact that they are so rare. When dulness on percussion is perceptible, and the morbid sounds are li- mited to one side of the chest, the phenomena may be caused either by chronic pneumonia, or by old thickening of the pleura with bronchitis confined to that lung. Gurgling or clicking sounds, showing that softening was going on and ca- vities were forming, would negative both of these hypotheses, because abscess without tubercle is attended with fetor: more reliance, however, is to be placed on the history of the case; long duration, gradual progress, and the absence of any distinct acute attack, all point more directly to tubercle, and when found in con- junction with general symptoms of phthisis, must be held, if not as conclusive, yet as affording grounds for very grave suspicion. Still more decidedly would this view ot the case be the correct one if with the dulness the morbid sounds were to be heard on both sides of the chest, but more loudly on the duller side. In other instances phthisis of this particular form closely simulates bronchitis; and this is the more common case, because the difference on percussion, when both lungs are more or less affected, is not readily made out, and there is, in truth, some amount of coincident bronchitis caused by the tubercular deposit. This subject has been already fully considered, and it is one which requires very nice discrimination. (See Chap. XIX., Div. II., § 4 d.) The existence of haemoptysis, beyond what mere straining might cause, of emaciation, quick pulse, thin skin, clubbed nails, or any of the more important symptoms of phthisis, ought to put us on our guard against pronouncing too favourable a diagnosis iu such cases. 17 Dl OF THE RESPIRATORY ORGANS. [| a 1 rare occurrence to meet with tubercles equally disseminated through the lung: Buch cases arc almost always recent, and this fact alone tends greatly to ie diagnosis. Still the history wants something of the severity of an lack; it is insidious; there is not immediate prostration, but gradual de- cline; there is often hasr j the B hrile symptoms are commonly of mild cha- racter, but the pulse is quicker than the other symptoms would lead us to ex] emaciation cannot have proceeded far, nor can there he hectic fever till softening have commenced; commonly there is a general blue discoloration of the t which most nearly resembles th: in severe bronchitis; it differs from the ash of pneumonia, as well as from the bloeness of diseased heart, and the dirty hue of emphysema; it is rather a flush or suffusion of face which, if the 1:, were healthy, would be florid, and is dark-coloured only because the vesicles obstructed. The physical signs at first resemble pneumonia, but of such an ex- t"iisive character that they cannot possibly be caused by acute inflammation where the general symptoms are so moderate: indeed, the sounds, when more carefully studi not exactly those of pneumonia; the crepitation is coarser and more ■ ■initiated, the breathing and vocal resonance are both free from any brassy t ;ie, till the phenomena are more distinct at the upper part, and, unlike pneumo- nia, they are not strictly confined to one lobe, but gradually decrease towards the ■ of the lung: the expiration is simply harsh and prolonged, and the voice ex- rated. At a later stage the signs resemble those of bronchitis, but the moist Bounds are fewer and more squeaking, with prolonged expiration, especially at the apex, which is not the case in bronchitis. Some difference on percussion between ;wo sides of the chest is generally distinct, but the same characters in slighter ree are found on the opposite side. If one lung present such signs of disease, while in the other consolidation is commencing at the apex, most unquestionably the whole is due to tubercular deposit. In early phthisis, when the signs are still obscure, considerable difficulty in making a correct diagnosis may arise from the coexist- ence of bronchitis: on the one hand, we may recognise the bron- chitis, and reason correctly regarding that, and yet be quite wrong in prognosis, because of overlooking the presence of tubercles ; on the other, we may recognise the phthisis, and come to very false conclusions regarding its progress, because of attributing to it signs which are in reality due to bronchitis. When along with an attack of bronchitis we observe general symptoms leading to a suspicion of phthisis, it is wise to wait before giving an opinion as to the tuber- cular or non-tubercular character of the disease until the former have disappeared; it is a very suspicious circumstance when the morbid sounds linger at the apices after they have ceased in other parts of the chest: and this is still more true of bronchitis limited to one lung; the very fact of the limitation offers a presumption that there is something abnormal in the lung so affected. Another common complication of phthisis is partial pleurisy near the apex of the lung: but the attack is not always so limited, and sometimes general pleurisy occurs when the lungs are already tu- bercular. It has been already mentioned that the sounds heard in the clavicular region, when the lung is condensed by pleuritic effu- sion, are exactly those of consolidation with a cavity subjacent: the percussion sound, while dull, has often a sort of tympanitic re- sonance; the breath-sound is remarkably blowing, with prolonged expiration; the voice loud and ringing; and if bronchitis be pre- sent, moist sounds are also heard; but with moderate care such a TUMOURS. 259 condition ought not to be mistaken for phthisis. During the exist- ence of pleurisy it is very unwise to give an opinion regarding the presence of tubercle. It is alleged by authors that double pleurisy is a suspicious circumstance ; probably indicating a complication of phthisis, and the hint should not be lost sight of; but it amounts to no more than a mere suggestion. Chronic pneumonia, if the term be used at all, may be applied to the condition of the lungs met with at one stage of tubercular deposit, particularly when the dis- ease is widely disseminated: a more active form may be excited by its rapid development in the upper lobe, which during its existence obscures any evidence of phthisis; but in a decided attack of sthenic pneumonia, we may feel great confidence that there is no . tubercle: such at least has been the rule in cases coming under my own observation, and the nature of the two diseases is so distinct, that it is exactly what a priori we have reason to expect. Severe and commonly fatal meningitis, in the form of acute hy- drocephalus, is frequently found in the tubercular diathesis; and when inflammation of tbe brain occurs about the period of adoles- cence, it will often be possible to determine its nature by an exami- nation of the lungs. Chronic peritonitis at the same age is another disease which very commonly has a tubercular origin, and calls for a similar examination. Diarrhoea may be rather regarded as a direct symptom than as a complication of phthisis. § 10. Tumours. — These have been referred to in speaking of the causes of dulness on percussion ; and while certain phenomena have been pointed out as possibly explicable on the hypothesis of their existence, no signs have been mentioned as direct proofs of it: more true wisdom is often shown in a confession of ignorance than in an assumption of knowledge ; and though a man of large expe- rience and pathological knowledge may sometimes give a shrewd guess at the true solution of the difficulty, there are points which render it almost impossible to reason correctly, because the facts are not only wanting, but to a certain extent unattainable. In such circumstances we must be content with the sort of empirical know- ledge which amounts to no more than this — " I have seen such and such a case, and it turned out so and so, and I think it highly probable that this case will have a similar termination." Such knowledge is the reward of careful observation, and is one of the most valuable acquisitions of the accomplished physician. Tumours in the chest are either aneurism or morbid growth. The latter is found sometimes disseminated through the lung, sometimes developed from the glandular structure at its root, or attached to the parietes ; and the indications will necessarily vary according to its site: the former, from the situation of the great vessels, presents symptoms somewhat analogous to that of growths from the root of the lung. The history of these cases is so far alike, that there is never 260 DISEASES OF THE RESPIRATORY ORGANS. aiiv thing to fix a correct date for their commencement, because in instances the patient has only become conscious of inconve- nience when some other disease has supervened. Neither do parti- cular classes or forms of growth produce any constant series of effects, the phenomena being commonly casual or accidental, and not essential. The patient generally complains of cough anj dys- pnoea, and sometimes of pain: difficulty of breathing is most per- ceptible when the tumour presses on some of the large tubes. The discovery of cancer or of aneurism elsewhere, in situations where their nature is more easily recognised, or signs of disease of the heart, would give significance to symptoms otherwise anomalous: no reliance can be placed on the absence of what is called the "malignant aspect," because the colour of the face is so liable to be altered by the condition of the lungs; interference with the pro- per aeration of the blood necessarily produces a dusky hue. Nodules of encephaloid disease may cause modifications in per- cussion resonance, and in the character of the breath-sound, or they may give rise to bronchial secretion and moist-sound; and most frequently the latter is the only evidence of disease. "We can do no more than satisfy ourselves that the balance of evidence is against the existence of phthisis as its cause. Scirrhus perhaps gives rise to more important changes in the breathing and vocal resonance, and the physical signs are very like those caused by a vomica, while the condition of the opposite lung is unlike that which is produced by tubercular deposit, and the general symptoms do not point to such an advanced condition of phthisis as implies the formation of a cavity. Sometimes the appearance of peculiar expectoration, which has been compared to thin currant-jelly, gives an assurance of the true character of the disease; but it must be confessed that very little can be done in making out the diagnosis of such cases. Tumours at the root of the lungs are more easily recognised when the disease has made some progress ; in their early stage there is nothing to point out their existence. As soon as they are of sufficient size to produce pressure on the bronchi, there will be irri- tation, probably secretion, and fits of dyspnoea, closely resembling asthma: of still larger size, they are apt to cause dysphagia, or to interrupt the current of the circulation; and now the patient begins to find out that in one posture he is more liable to suffer than in another. When the tumour has attained a certain magnitude there is dulness, not perceptible on gentle percussion, but brought out by a firm stroke, most marked near the sternum, and not to be detected in the axilla, or towards the side of the chest. The breathing is generally weaker, with prolonged expiration, heard at a distance ; the sounds of the heart are transmitted loudly over the seat of the tumour, and even beyond it. The patient perhaps breathes in a wheezing manner with considerable labour, or the respiration may be obstructed to nearly the same extent as it is in laryngitis; the TUMOURS. 261 cough is often weak and powerless, like that of emphysema, but has more of a paroxysmal character, and sometimes a loud brassy clang: a fit of coughing very generally terminates with a raucous inspira- tion. In many of these respects the analogy to laryngitis is very striking, and the most marked difference between the two is, that when the obstruction is in the larynx itself, the voice is either hoarse or destroyed, while when it is lower down in the trachea, the voice is scarcely altered in tone; it is only deficient in force. The interruption to the circulation caused by the tumour may at once lead us to infer its existence: it presses upon, or even sur- rounds and encloses the superior vena cava, in consequence of which, tortuous veins begin to develop themselves over the chest and abdomen, and the blood finds its way by a backward current into some pervious channel; sooner or later this venous obstruction gives rise to oedema, which is theaJimited, in a remarkable manner, to the upper half of the body. This happens both with malignant growth and with aneurism ; in the latter case additional signs are sometimes derived from the arterial circulation: the force of the current is diminished in some one or more of the arteries, causing perhaps a notable difference between the two radials at the wrist; or both alike to be almost imperceptible, while the heart's action is very generally, but not always, increased: a bruit may be heard in some unusual part of the chest, while there is none at the heart, or it may be heard loudly at both, and be almost inaudible at interme- diate points. Sometimes, again, the ordinary systole of the heart is heard unusually loud at some particular point, and this may be regarded as the effect of aneurism, because the sound has a knock- ing or jogging character, which is only preliminary to a similar impulse being felt, when the disease has approached nearer to the surface. Sooner or later aneurism shows itself externally by wearing away the ribs, and forming a pulsating tumour on the front of the chest, or by pulsation, which can be felt when the finger is pressed deeply behind the sternum or clavicle, except in the case of the descending aorta, when it sometimes produces no symptoms upon which reliance can be placed: slight dysphagia or dyspnoea, with pain in the back, caused by pressure and wasting of the vertebrae, sometimes leading to paralysis, maybe the only symptoms: no bruit is usually audible in this situation ; but would be of considerable significance if heard in an adult; in the child, cardiac murmurs are often very loud over the back. Solid tumours in the chest do not often pulsate, but the possibility of pulsation being only communicated should be borne in mind in attempting to discriminate their character. Tumours in connexion with the bones of the chest seldom give rise to any symptoms likely to call for examination, until there is swelling externally: those forming in the anterior mediastinum, which cannot find exit from the chest, and press inwards on the heart, the arteries, the veins, and the bronchi, do however produce 262 DISEASES OF THE RESPIRATORY ORGANS. symptoms more or less resembling those of pressure on the root of tne lnng. The very marked dulncss which they cause on percussing the sternum leads at once to the recognition of their presence; and tlic question is then only between enlarged heart or aneurism, and growth from bone. The coexistence of active pleurisy, or of passive effusion into either pleura, sometimes greatly complicates the diagnosis of tho- racio tumours. § 11. Hooping-cough. As in many other diseases in -which the group of symptoms is better known than the nature of the internal lesion, hooping-cough, when well marked, cannot be mistaken; and diagnosis has only to do with those cases which are obscure, because the whoop is imperfectly developed, or because the disease is si- mulated by or complicated with iher affections. Simple catarrh of childhood may very readily pass into hooping-cough if it be at the time prevailing epidemically; and this is the more probable when the cough is at all paroxysmal, or is an urgent or an early symptom, and when the fever is slight, and there is but little derangement of health, and especially when auscultation fails in detecting bronchial irritation proportionate to the severity of the cough. — When the disease is fully formed, if a paroxysm occur in our presence the case can scarcely be mistaken ; but we must often trust to the report of others; and there is a tendency to error in listening to the state- ments of mothers and nurses, who usually anticipate us in the con- jecture of its possible presence, and are disposed at once to attribute any peculiarity in the child's cough to this cause. A very good indication is obtained in cases where the account of the paroxysm is defective, from the occurrence of vomiting: a child with this dis- ease often vomits after a fit of coughing, while in other affections of the chest such an occurrence is purely accidental; in the one it is brought on simply by the cough, without sickness or loss of appetite, and the child will take his food directly afterwards: in the other, the stomach and bowels are disordered, and the relation to the cough is far less evident. In the early period of an attack of alleged hooping-cough, the pre- sence of much bronchial secretion should make us cautious in ac- cepting the statement of the friends as to the nature of the disorder ; similar caution is necessary when the disease is said to have attacked a child who has been long suffering from cough before any thing like a whoop was observed. In its latter stages there is usually much bronchial secretion, and the disease is frequently complicated by inflammation of the lung or effusion into the ventricles of the brain ; in very protracted cases it may terminate in the development of tubercle: diagnosis must then take account not only of the present symptoms, but of the history at a time when the characters of the affection were simple and unmixed with those of subsequent com- plications. An ill-developed child in whom an attack of bronchitis DISEASES OF THE LUNGS IN CHILDHOOD. 263 is attended with, excessive secretion, or one whose lungs are be- coming stuffed with tubercles, when the secretion is scanty and adhesive, are each of them very liable to fits of coughing, in which, while there is no real whoop, the struggle for breath is very ana- logous to the abortive paroxysms which occur before hooping- cough is fully developed. § 12. Diseases of the Lungs in Childhood. — This chapter would be "incomplete if a few words were not said upon the differences in diagnosis between the diseases of- children and those of adults. In the^first place, the resiliency of the chest makes the indications from percussion much more obscure and uncertain; at one time dulness seems to be well marked, which, after all, is only due to congestion ; at another, real consolidation produces only a difference in tone, which cannot properly be called dull. Secondly, the re- spiratory sound is so much louder and shriller,, that changes in character, except in its relative suppression, cannot be predicated of it with anything like the same certainty as in adults. Thirdly, the loudness of the voice does not assist us much in determining the sound-conducting power, and hence the degree of consolidation of the lung. And fourthly, the remark in regard to superadded spunds in adults, that no one is pathognomonic of any certain condition of lung, is infinitely more true of children. Crepitation in its true sense is not heard in pneumonia, clicking and squeaking sounds are heard when there are no tubercles, and gurgling noises are heard without cavitfes. The explanation of all these circumstances is simply that in the lungs of the child evejy sound generated any where throughout the lungs is heard with almost equal distinctness at any part of the surface ; and, therefore, whatever the affection may be the bronchial sounds prevail: at the same time the mucousmem- brane is more easily irritated, and secretion excited by slighter causes ; and hence it happens that sonorous sounds are very seldom present. In the diagnosis of the diseases of childhood we are therefore very dependent upon the history of the case and the amount of febrile disturbance ; but it must be remembered that the quick cir- culation of childhood is much more readily excited than that of the adult, and the comparison must not be made between the pulse of infancy and that of age, in coming to the conclusion that a child is suffering from inflammation of the lungs. That this is constantly done there can be no doubt, from the frequency with which mothers report that children have had such attacks, and that they have been told so by their medical attendant. Inflammation of the chest, whether as pleurisy or pneumonia, is not by any means a frequent ailment of childhood — pleurisy is especially rare in the first years of life, and when pneumonia is present its symptoms are invariably urgent. If any thing be needed in the way of auscultation to con- firm the diagnosis (and it is always wise to practise it,) we find per- 2G4 DISEASES OF TIIE RESPIRATORY ORGANS. haps some difference in tone on percussion between the two sides of the chest, or it may be, absolute dulness; the breathing probably differs on the two sides, and we may be able to say that one is harsher than the other, — more commonly, however, it is only less distinct on the affected side, and then, in place of crepitation, we find moist sounds; or at all events very coarse crepitation, — never the fine sound heard in the adult. Along with this there may be very considerable bronchial irritation of the other lung, so that all the signs of disease may be suspected to be due to bronchitis, and in fact the cases are quite exceptional in which unaided auscultation could determine the nature of the affection. Bronchitis occurs either as acute or chronic. In the former the sonorous sounds are very rarely heard ; there is a good deal of fever, but it is not so severe as that of pneumonia, the skin is not so pun- gent, and the signs of imperfect aeration of the blood are not pre- sent: the breathing is louder or weaker, according to the amount of secretion present, and this often differs on the two sides. The principal indication derived from auscultation is the very general distribution of the morbid sounds ; the absence of any difference in percussion would confirm the impression that the disease was simply bronchitis, but dulness on one side behind must not be taken as a proof that pneumonia is present; not only may an appearance of dulness be produced by mere congestion, but the existence of tuber- cular glands at the root of one lung which may have tended to excite the bronchitis may also be the cause of absolute dulness. Chronic bronchitis, which so often simulates, or is simulated by phthisis in the adult, is often quite undistinguishable from tuber- cular disease in infancy. Here dissemination of tubercle is the rule ; its aggregation in masses, except in the bronchial glands, the exception. It is from the aspect of the child and the history of the case alone that we can judge, aided probably in some measure by the general symptoms, and occasionally by the character of the sputa. When we learn that the patient has had an attack of measles, or has suffered much during dentition — that the constitu- tion has not rallied, but cough has gradually supervened; when there is a pallid, transparent skin, with long eyelashes and brilliant eyes, and the child is peevish and irritable, or languid and unex- citable, or remarkably quick and intelligent — suspicions of tubercle are naturally excited: and if in addition to this we find emaciation, debility, heat of skin, followed by perspiration and diarrhoea, the probabilities are greatly increased. If, on the contrary, we learn that the first attack was feverish, or that after hooping-cough, some years before, there has been great liability to coughs and colds; if the face be dusky, or the lips discoloured, and, except from dread of an impending cough, the child's temper be not materially altered; if, in addition to this, we learn that the cough ends in copious ex- pectoration, even though that should be tinged with blood, — the diagnosis and the prognosis are considerably more favourable: has- DISEASES OP THE LUNGS IN CHILDHOOD. 265 moptysis in childhood is by no means a sign of phthisis. The ste- thoscope can scarcely afford any assistance in discriminating these affections: and it must be added that, when judicious treatment is employed in cases -which have all the aspect of tubercle, the chil- dren so completely recover from the attack of bronchial irritation accompanying it, and are so often lost sight of subsequently, that no person of any experience will venture to give a decided opinion except in very clearly marked examples of each disease. It is to be remembered that when the bronchial affection has passed, the sio-ns of remaining consolidation at the apex are never found in childhood ; if any localization of tubercle prevail at this period of life, it is only in the glands at the root of the lungs. 2GG CHAPTER XXI. EXAMINATION OF TIIE HEART. History and General Symptoms — Changes independent of Disease — Special Signs. Div. I. — Evidence of Alteration in Size — Increased Impulse — Irre- gular Action — Extended Dulness — their Mutual Relations. Div. II. — Auscultatory Phenomena. — § 1, Modifications of Normal Sounds — in Intensity — in Distinctness — in Rhythm — § 2, J Hon — its Characters — its Indications — § 3, Endocardial Mur- murs — their general Characters (a) Diastolic — Aortic — Mitral — (b) Systolic — (1) at the Apex — Mitral — Tricuspid — (2) at the Base — Aortic — Pulmonic — Blood-sounds in general. In Chapter XVII., when considering the history and general symptoms of disease of the chest, it was remarked that dyspnoea and palpitation are the chief subjects of complaint with patients suffering from disturbance of the circulation, and that the history of the attack is usually obscure and imperfect. It may be added that these symptoms are much more frequently mentioned when their cause is merely functional than when organic lesion exists. Pain is an almost constant attendant on pericardial inflammation: it is also occasionally met with in old structural changes, presenting itself sometimes under the form of angina. A history of rheumatic fever, any indications of a tendency to dropsy, or the presence of chronic lung affection, and especially of bronchorrhoea, are each of them more or less valuable in estimating the probability of disease of the heart. In most instances, however, its presence may be very conclusively shown by the action of the pulse, the discoloration of the face, the impulse against the ribs which accompanies the movement of the organ, and the characters of the sounds produced, as they are changed by specific forms of disease. Errors in diag- nosis chiefly arise from confounding the signs of the functional with those of the structural maladies. We must presume that the student is familiar with the position and average force of the impulse which each stroke of the heart conveys to the fingers placed between the fifth and sixth rib; with the usual extent of dulness on percussion observed in the precordial region, when it is of normal size; and with the sounds which accom- pany its systole and diastole in a state of health, hence called sys- tolic and diastolic, or first and second sounds. In each of these particulars, changes may be perceived which are quite independent of disease of the heart: its position may be altered by effusion into the pleura or peritoneum: its impulse may be rendered more evi- EXAMINATION OF THE HEART. 267 dent by emaciation, or by consolidation of the lung, or may be les- sened by opposite states: the sharpness and force of the shock may be greatly increased by mere nervous excitement: and the precor- dial dulness may be diminished or increased in extent, as it hap- pens to be more or less covered by resonant pulmonary tissue. Nervous palpitation without increase of size of the heart itself, will be observed to vary much in intensity from time to time, and this especially according to the mental condition, whether of ex- citement or of depression. Attention directed to the organ greatly influences it, and not unfrequently the fact of making the exami- nation is of itself sufficient to excite or increase the palpitation, which again gradually subsides : this condition is one which attracts the patient's notice much more than palpitation depending on real disease. Division I. — Evidence of Alteration in Size. Those deviations from the normal conditions which afford the most certain indications of changes in the dimensions of the heart, and ought therefore to be especially studied by the learner, are the following: — When the heart beats lower down than in health ; when the usual shock of its impinging on the parietes becomes diffuse, heaving, undulatory, or irregular; when the dulness on percussion is extended in an inward or an upward direction; and when the stethoscope reveals sounds which are not heard under ordinary cir- cumstances. "With the exception of the stethoscopic signs, all of these derive their value from their affording the most conclusive evidence which we possess of changes of size in the organ; and this consideration ouo-ht always to be taken into account in making a diagnosis of disease of the heart. For no important deviation from health can long persist without affecting the muscular structure; and altera- tions in thickness, in capacity, and in power are those which are really efficient in developing the secondary affections accompanying the advanced stages of disease. 1. Its impulse being felt at a lower point than usual, is almost a certain sign of enlargement. 2. W T hen the action is heaving and powerful, lifting up the stetho- scope, or even the head of the listener, at each impulse, the walls must necessarily be thickened: in such cases the sharpness of the stroke is lost, and its duration prolonged. In other instances the impulse is much more diffuse, and less forcible, the heart coming in contact with different portions of the chest at successive intervals during the prolonged systole, with an undulatory movement, in which no distinct stroke is felt: we have then reason to believe that the enlargement depends more on increased size of the cavi- ties than on thickening of its walls. 3. Irregularity of action is very important, although of some- what indefinite signification. It must not be confounded with in- 208 EXAMINATION OF THE HEART. termission when a single beat is occasionally omitted or abortive, or a short pause occurs at certain intervals. Continued irregularity must be regarded as a positive sign of disease, but it may co-exist with almost any form of lesion. It is probably most frequently met with in disease of the mitral valve. •1. The extension of dulness towards the sternum derives its value from the circumstance that there the heart is uncovered by lung, and the liability to inaccuracy is not so great as when an at- tempt is made to measure it outwards. In enlargement of the heart the percussion dulness is, no doubt, extended in every direc- tion, and a practitioner well versed in the physical aids to diagnosis would be able to detect the exact dimensions of the organ, in spite of the interposition of resonant lung-tissue: the student cannot expect to do so with accuracy. In an upward direction diminished resonance may be distinguished with tolerable readiness; but when the sound is clear over the sternum it is probably due to some other cause than hypertrophy: it is, for example, especially marked in distention of the pericardial sac after pericarditis. 5. In connexion with the preceding indications, the stethoscopic signs are most valuable in explaining the causes of increased or irregular action, because the abnormal sounds are produced by ac- tual changes in the relation of solids and fluids, and enable us to assert more or less positively what is the nature of that change. _ The altered position of the impulse may possibly be clue to an adherent pericar- dium; but in this case there is very generally also hypertrophy, and the idea of enlargement is probably correct. If it can be shown that there is no enlargement, this alteration of the impulse affords the most reliable evidence of pericardial ad- hesion, which after all can only be guessed at. There ought to be no difficulty in distinguishing the heaving impulse of hyper- trophy from the short, sharp stroke of nervous palpitation; and yet in very many instances people are told that they have disease of the heart in consequence of the one being mistaken for the other. ^ Undulatory movement, in strict language, is only produced when the pericar- dium is full of serum; a largely dilated heart merely simulates it: in the one a wave is transmitted from the apex towards the distended upper extremity of the sac, at each systole; in the other, different portions of the organ come in contact with the chest in succession, but the definite course of a wave cannot be traced; the one occurs during an acute attack, the other is seen in chronic disease. Irregularity is best recognised by the action of the pulse: by it the meaning of the term intermission is also more readily understood; the abortive contraction of the heart produces no pulsation at the wrist, and a beat is lost just as much as if the heart stood still. The word "uneven" is used to signify a pulse of unequal force: an irregular pulse implies inequality in the duration as well as in the force of successive beats. Irregular action may subside under treatment, but during its existence it is a permanent, not a temporary condition; hence we speak of con- tinued irregularity as a sign of disease. The extension of dulness towards the sternum can only deceive when there is a morbid growth in the anterior mediastinum: the dulness in such a case does not usually terminate on a level with the base of the heart. It is of importance to observe whether the apex continue to beat in its usual position, lest displacement* be mistaken for enlargement. In endeavouring to establish correct rules for diagnosis, it has ALTERATION IN SIZE. 269 • been our constant aim to avoid taking solitary indications, however definite in themselves, as specific signs of any one form of disease. This rule must be applied to the varieties of pulse observed in dis- ease of the heart, which will be enumerated as they present them- selves to our notice in considering the sum of the evidence in each case. It is also applicable to the suggestion of adherent pericar- dium above referred to, and to the angular or pear-shape which we may find the precordial dulness to have assumed when dependent on hydro-pericardium; no one who studies diagnosis aright will suppose the existence of such a condition, unless acute symptoms have preceded it; passive effusion is never sufficiently extensive to produce the effect. If we commence with irregularity of action as one of the most evident signs of disease, we find in practice that it may coincide with the other phenomena already enumerated in very varying de- grees, and from a consideration of these associations the following conclusions may be drawn as probable explanations of the condition of the heart. a. With increased heaving impulse, we may assume the existence of hypertrophy with or without valvular lesion. b. Without increased impulse, but with extended dulness, enlarge- ment consisting especially in dilatation of the cavities, while the walls are not much thickened, or may be even thinner than natu- ral; and again either with or without valvular lesion. c. When abnormal sound is heard, we may be pretty certain that there is valvular insufficiency along with either hypertrophy or dila- tation, as the other indications tend to show. d. A very feeble pulse, with signs of hypertrophy, would afford very clear evidence of imperfect closure of the mitral valve. e. When none of these conditions accompany the irregularity, we may be led to believe that it is due to thinning of the walls or fatty degeneration without dilatation to any extent : it may possibly be also caused by adherent pericardium. Irregular action seldom accompanies hypertrophy without valvular lesion ; whereas it is most commonly present in dilatation and thinning of the walls, whe- ther the valves be healthy or not. The character of the pulse varies with the pe- culiar form of the valvular lesion, but in most instances the morbid sound heard on auscultation is more trustworthy : it now and then happens, however, that when the mitral orifice does not close during the systole, no bruit can be detected; and then the extreme feebleness of the pulse contrasting with the force of the heart's action, serves as a very useful guide. When valvular lesion has not led to altera- tion in size, it is not accompanied by irregularity of action. It must also be borne in mind that very considerable hypertrophy may be al- most completely concealed by over-lapping of the lung, and therefore great cau- tion must be exercised in deciding that irregular action depends on simple atrophy or fatty degeneration. Each of these subjects will be again referred to more in detail. When there is no irregularity the only trustworthy indications of enlargement are — a. If increased action be associated either with extension of 270 EXAMINATION OF THE HEART. • dulness in an inward direction or with an apex-bea? lower than in health ; b. If with the increased action or the extended dulness there be any thing of an undulatory movement, and especially if this be ac- companied by some unusual sound on auscultation. Division II. — Auscultatory ^Phenomena. In very many instances these alone are sufficient to determine the existence of disease in an early stage, before any change has oc- curred in the actual dimensions of the organ; in other instances they explain the cause of the change. They may be divided into modifications of normal sounds, and morbid sounds — "bruits" or "murmurs," as it seems better to call them to distinguish them from those which, par excellence, are called the sowids of the heart. These bruits, again, comprise those formed in the pericardium and those formed within the heart, sometimes classed as exocardial, and endo- cardial: the only pericardial bruit is friction; the endocardial, on the other hand, are divisible into the systolic and diastolic. We shall attempt to show what deductions may be drawn from their presence, and how the student may best refer the sound heard to one or other of these classes. Much confusion is created by unnecessarily increasing the nomenclature of va- rious sounds. It is quite allowable to employ a particular name to designate any unusual bruit, such as "purring," or "musical," but its exact character is now known to be of far less importance than its position and time of occurrence with reference to the rhythm of the heart's action. It seems quite unnecessary to in- troduce such a name as exocardial: if it mean to include sounds formed in the pleura, and not in the pericardium, the classification is objectionable : if it be re- stricted to the pericardial bruit, we need employ no other name than friction ; creaking is but a form of friction, and the name "to and fro" sound which has been sometimes used, is only applicable to certain cases, a majority, truly, but not all. With regard to endocardial murmurs, again, the introduction of the word re- gurgitant perplexes the student: either a systolic or a diastolic bruit may be re- gurgitant; and regurgitation may take place at any of the sets of valves; it merely expresses the fact of the ordinary current being reversed, — a fact which is quite as explicitly stated when the bruit is named according to its time and place. If during the diastole the left ventricle be filled from the aorta as well as from the auricle, there is regurgitation; if during the systole the blood pass out into the auricle as well as iuto the aorta, there is also regurgitation; but any one who un- derstands the mechanism of the heart's action knows that the expressions diastolic aortic, and systolic mitral murmurs imply these facts, and have the great advan- tage of being definite statements regarding disease. § 1. Modifications of Normal Sounds. a. They may have a ringing distinctness in consequence of ner- vous excitement: this is no indication of disease; it is transient, and when the palpitation subsides, the sounds resume their ordinary characters. b. The 1st sound especially tends to become short and sharp in thinning of the walls of the heart: the chief distinction between this and the preceding condition is its permanence, and its inde- pendence of excitement and palpitation. CHANGES IN NORMAL SOUNDS. 271 c. They become dull and indistinct, though loud, in hypertrophy. The prolongation and indistinctness of the 1st sound in particular, is the reason why they are often spoken of as being weaker than the sharp flapping sound of dilatation. d. Distance and obscurity of sound is produced by the interpo- sition of fluid in the pe/icardiuin or overlapping of the lung, espe- cially in emphysema. e. The rhythm, or proportionate duration of each sound, is very liable to be altered in the commencement of an inflammatory at- tack: this condition is very generally the precursor of some more definite evidence of change of structure; but it is associated with other forms of disease, and is also occasionally casual and transi- tory, the sounds returning to those of health. /. Either 1st or 2nd sound may be reduplicated. Each stroke of the pulse is represented by three or even four sounds heard in the precordial region. It is generally the 2nd sound which is redupli- cated, the 3rd following close upon it, and occupying the pause which in health intervenes between the end of the 2nd and the commencement of the 1st sound. When the 1st sound is redupli- cated, it causes of necessity reduplication of the 2nd. This modi- fication does not always imply disease: it seems to be due to irre- gular muscular action, and we can only decide from other circum- stances whether the defect be in the muscle itself, in the nervous system, or in the mechanism of the circulation. The most important of the modifications just enumerated is that in -which the rhvthm of the sounds materially deviates from that in health. The relative dura- tion of each sound and of each pause is in the normal state so constant, that it may be assumed with, great confidence that disease is present when this relation is broken through. It is therefore of very great value in leading us either to dis- cover past changes in structure, of which the evidence is imperfect, or to prepare for impending inflammation: it may thus lead to the discovery of an endocardial murmur which was not suspected, or may be the only proof left that pericarditis has preceded when friction is already abolished; while in cases of acute rheuma- tism, or inflammation in the chest, it prepares us for an attack of peri- or endo- carditis; and in those cases in which it passes off without any furtherevidence of disease, we are left to conclude that our remedies have aided in warding off very serious mischief. The loudness of the sounds depends so much more upon the proximity of the heart to the chest-wall than upon the intensity of the sound itself, that but little reliance is to be placed on it as an indication: and perhaps in no case is it so marked as' in the palpitation of nervous excitement. The very same circumstance which most frequently serves to conceal the dulness, and increased impulse in hypertrophy, serves also to diminish the loudness of the sound; and therefore, when much overlapped by the lung, the one source of information does not help to correct the other. Its intensity is of most service in cases of nervous palpita- tion, and in thinning of the walls of the heart without palpitation; in the one the shrillness of the sound is opposed to the idea of hypertrophy, in the other it leads to the suspicion of change of structure, which is not revealed by any other sign. Reduplication, like intermission, suggests some imperfection in the relation of nervous force and muscular contraction, in so far as one serves to regulate the other: but while we were able to draw a distinction between intermission and ir- regularity, as indications of disease, we are not able to lay down the same certain rules in reduplication. We may be very confident that when both sounds are re- ■J.~-2 EXAMINATION OF T1IE HEART. duplicated there ia some form of disease present: reduplication of the 2nd sound is very often caused by imperfect closure of the auriculo-ventricular aperture ou one side, which causes the systole of one ventricle to terminate more quickly than the other; but it is also heard, like intermission, in what we call mere functional disturbance. It will be readily understood that when either sound becomes pro- longed by the presence of a murmur, the reduplication is lost in the continuous bruit, li is wise in practice to restrict the term reduplication to cases in which no bruit is detected: for example, when there is a slight diastolic aortic murmur, the 2nd sound of the heart, formed at the pulmonic valves, may be heard quite distinct and separate from the aortic bruit, which replaces the 2nd sound there; but the two do not consist of a reduplicated 2nd sound, but of the sound and the bruit, which are heard separately, the one short and terminating at its usual time, the other prolonged. § 2. Friction. — The distinctive character of this sound is to be sought less in its peculiar acoustic properties than in the time of its occurrence with reference to the natural sounds of the heart. It has no further relation to them than that it is caused by the move- ment of the organ consequent on its alternate contraction and dilatation ; hence it forms no part of the natural sounds, does not occur at the same instant, does not follow the same rhythm, but is usually heard somewhere between and distinct from them. The natural sounds may be inaudible either because eifusion renders them indistinct, or because the friction is so loud as to overpower them, but it neither takes their place nor alters their character. Though called a "to-and-fro" sound, it is not necessarily double, but it certainly is so in a great majority of cases. Among its dis- tinguishing features the following may be regarded as the chief: — a. It may be heard any where over the precordial space, and frequently only at one point distinctly : when thus circumscribed, it is especially to be sought either where the membrane is reflected at the base of the heart, or where the apex impinges against the ribs. b. The sound is usually rough and grating, and seems to be su- perficial and close to the ear of the listener. c. A double friction-sound is more easily recognised than when it is single : endocardial bruits are also sometimes double, but in the to-and-fro friction the duration of each is more equal and shorter. d. The time of its occurrence with reference to the natural sounds forms our best guide in determining its nature. It com- mences distinctly after the 1st sound and impulse of the heart; the to-and-fro friction-bruits follow each other rapidly with a very short interval, which corresponds with the beginning of the 2nd sound of the heart; then comes a longer pause, during which the 1st sound is again heard, followed up by the recurrence of friction. During the existence of pericarditis, many circumstances occur to conceal the ordinary sounds of the heart ; and when there is any difficulty in distinguishing them in the precordial space, they should be listened for above the base of the heart, in the 2d intercostal space. There are two circumstances which chiefly tend to render friction-sound liable to be confounded with other bruits: viz., a scanty secretion of lymph, and an abundant secretion of serum. The friction may in either case be single; in the FRICTION. 273 former it is almost always limited to the reflexion of the pericardial membrane at the origin of the great vessels, and might therefore be taken for an aortic murmur; but in addition to the indications derived from the other characters enumerated, it is especially to be noted that its position and point of greatest distinctness are below and not above the base; the very opposite is true of an aortic systolic mur- mur, and an aortic diastolic murmur presents other features which are very dis- tinctive. If friction be obscured by the presence of serum, the point where it is most likely to be met with is the apex: here too in position it is much below the ordinary situation of a mitral murmur ; but it is further to be recognised by the circumstance that it is much louder when the ribs are depressed at the end of ex- piration, and may be very often rendered temporarily so by simple pressure. Friction differs from endocardial murmur in its acoustic properties very deci- dedly, when a well-marked example is compared with the pure bellows-sound : and the student ought to make his ear familiar with their respective characters; but in many cases he must be prepared to find each approximate so closely to the other that the character of the sound is not sufficient to denote whether it be formed in the heart or pericardium. The best mode of determining whether the rhythm of a double bruit heard in the precordial space differ from or coincide with that of the systole and diastole, is to listen above the base of the heart, where pericardial friction always becomes inaudible: when the ear is fully accustomed to the rhythm of 1st and 2nd sounds as there heard, the stethoscope should be immediately passed to the point of which the bruit is most distinct; if it be pericardial, the ear will at once detect the dif- ference in duration, and the want of harmony with that just listened to. The discovery of friction may be taken as unmistakable evidence of the presence of pericarditis, and hence the importance of being able clearly to determine its true character. In speaking of peri- carditis (Chapter XXII. § 1,) the ordinary correlative symptoms will be pointed out; and while on the one hand, these may be so striking as to leave no doubt in the mind of the observer that changes in percussion resonance, or in the rhythm and intensity of the heart's action, are due to pericarditis when friction cannot be detected, yet on the other, they may have been so slight that but for the pre- sence of friction we should not know of the existence of the inflamma- tion at all. The change of friction into creaking is far less common in the pericardium than in the pleura: when such a sound is heard, the principles of its dia'gnosis are the same as those already given for a single friction-bruit, and it will be all the easier because of its creak- ing character, which is so unlike an endocardial murmur. There is only one further question in regard to friction which the observer has to determine in order that his diagnosis of pericarditis may be quite certain; it is that the friction is really in the pericardium, and not in the adjacent pleura. Now, the only chance of its being in the pleura is, when it is local — to one side and not in the front of the heart ; and if the doubt be suggested to the mind, its validity can readily be tested by making the patient hold his breath: but it must be remembered that pericardial friction becomes more distinct, or may be only audible when the ribs are depressed, and therefore the patient should be taught to hold his breath after an expiration, not after an inspiration. § 3. Endocardial Murmurs. — Either sound of the heart may be prolonged beyond its ordinary duration, and lose its usual distinct- 18 l274 EXAMINATION OF THE IIEART. ncss when the sound is commonly called rough: they may be entirely superseded by a lengthened bruit, which has either a character of extreme softness (the true bellows-murmur, or bruit de souffle,) or that of a very harsh grating noise, or even approaches to a musical tone. From the slightest degree of roughness or prolongation, to the loudest possible bruit, every link is filled up by murmurs which glide by insensible gradations into each other, and unite the ex- tremes together under one common denomination. The essential element in their production is an altered relation of the blood to the solid structures, whether by change in the one or in the other; and they are only heard when the blood is in motion. They there- fore correspond exactly to the systole or diastole of the ventricle as the blood is passing out of, or into those cavities: they may com- mence a little before, or a little after the true time of the natural sound ; they may be carried on through the interval of pause, but they cease directly when the opposite action comes into play, either to be followed by the natural sound to which that gives rise in health or by a bruit corresponding in time to it. Their character, as caught by the ear, is always more or less blow- ing, the passage of fluid in this respect offering very close analogies to that of air through a constricted aperture. We are not sufficiently familiar with the laws of its production to be able to deduce from an analysis of the character of the sound the exact changes in which it originates, but in general terms it may be assumed that when the murmur is very soft the solid parts are not very greatly altered, and that when very rough, grating, or musical, there is either very con- siderable constriction, or a semi-detached mass floating down the cur- rent thrown into vibration as the blood passes. It is a point of some difficulty to determine when roughness and prolongation ought to be set down as only a modification of normal sound — when they ought to be regarded as something additional or superadded taking its place; the booming first sound of hypertrophy, and the redupli- cated second sound of unequal contraction, ought never to be called bruit. The readiest mode of determining whether the murmur be systolic or diastolic is to place the finger where the heart can be felt striking on the chest. If the sound commence at a period equally distant from each of two impulses, and intermediate between them, the sound is diastolic, it ends just before the heart strikes on the chest. If, on the contrary, it be nearly coincident with the stroke, it is systolic — it commences about the same time as the impulse, and ends long before the next stroke is felt. When the murmur is systolic, the sound produced by the moving of the blood may be either due to alterations in the orifices through which it passes, or to changes in the character of the blood itself, or to a combination of both. But if a bruit be recognised to be diastolic, it may be decided at once that there is valvular imperfection ; and in the majority of instances there is disease of the aortic valves, by which blood is allowed to return into the left ventricle. DIASTOLIC MURMURS. 275 If we inquire into the mechanism of the circulation, we find that the force with ■which the blood passes from the auricle into the ventricle is much feebler than that by which it is propelled into the arteries, and also that the power of the left ven- tricle is very much greater than that of the right; and inasmuch as the circulation through the arteries is carried on during the interval between one systole and the next by the resiliency or contractile force of the vessels, the rebound in the aorta and in the pulmonic artery, in cases of imperfect valves, are each in proportion to the muscular power of their respective ventricles. In addition to this, we have the pathological fact that disease of the aortic valves is a common occurrence, while disease of the pulmonic valves is very rare. During the systole the ventri- cles empty themselves of blood with a force equal to the contractile power of each muscular wall; and the vibration of the particles of blood thus produced, when its relative proportions deviate from those of health, become audible, even when there is no unusual obstruction to the current. During the diastole, again, the ventri- cles are filled; and when there is no alteration of texture in the cardiac apertures, no change of quality in the blood is ever sufficient to develop audible vibrations since the movement is caused only by the feeble contraction of the auricles. When the auriculo-ventricular aperture is very much altered by disease, especially if the vibratory power of the blood be at the same time increased by anaemia, a diastolic bruit is sometimes produced on the left side of the heart; on the right side it has never been recognised. When, again, the aortic valves close imperfectly during the diastole, the ventricle is partly filled from this source also; and the force with which the resiliency of the artery drives it back against the roughened or imper- fect valves, and still more the circumstance of its meeting with the current from the mitral valve in an opposite direction, is quite sufficient to produce audible vi- bration. The very same circumstance might happen on the right side of the heart, but I am not aware that it has ever been recorded; and the smaller amount of con- tractile force in the pulmonary artery, as well as the rarity of disease of the pul- monic valves, would lead us to suspect that the event should be a very rare one. A. Diastolic 3furmurs. — When a diastolic murmur is recognised, we have really in practice only to determine whether it be aortic or mitral. a. The probabilities are much in favour of the former, consider- ing the relative frequency of each. b. Mitral diastolic murmur, as it presupposes very considerable change in texture in the valve, cannot, one would imagine, exist with- out a mitral murmur also accompanying the systole : this is not ne- cessarily the case in patency of the aortic valves. c. The position at which each is heard in its greatest intensity, and the direction in which it is prolonged, are distinct though not differing so greatly as to form such a ready means of diagnosis as might be a priori expected. d. Further evidence of insufficiency of the aortic valves, if this be presumed to be the cause of murmur, is to be obtained from the character of the pulse which seems to be left almost empty by the blood falling back upon the heart after each stroke, and fills a^ain with a jerk. The one of these is, in fact, a murmur of regurgitation, while the other is not- and this would of itself, apart from the consideration of force, explain the differ- ent frequency of each : for it is not necessary that there be any roughness or con- striction of the aortic valves : a smooth aperture left by tearing or ulceration of a valve which permits regurgitation, when the recoil of the blood follows the systole of necessity causes a diastolic murmur. Hence a systolic bruit at the aortic valves is not always to be heard when a diastolic one is present, as I believe is unavoid- 276 EXAMINATION OF THE HEART. able at the mitral orifice. With this, too, is closely connected the fact that the '.on at which the Bound is heard in i; t intensity is not so different as it be supposed. In BOmi . no doubt, the blond is Bet into vibration as it hened or constricted valves in its backward course; but in other vibration only begins when it meets the opposing current from the auricle: in the one case it can be traced for several inches in a slanting direction, from the root of the aorta towards the apex, of pretty nearly equal intensity throughout; in the other, while the direction remains the same, the length may be tished to about an inch near the centre of the heart. The mitral diastolic murmur reaches to about the same point, and it will be readily understood how cult it must be to determine a difference in direction, although nearly at right anghs io each other, when the whole extent in each case does notexceed.an inch. There is, however, one point characteristic of the mitral diastolic murmur: the vi- bration is produced a1 the valve itself, and the sound is always heard in greatest ..sitv there, and diminishes in distinctness as it passes across towards the sternum to meet the line of the aortic diastolic murmur: such a circumstance, without the hammering pulse, would be to my mind sufficient for the diagnosis. On the other hand, a hammering pulse would very probably decide in favour of insufficiency of the aortic valves, even when the loudest sound seemed to be nearest to the apex. e. Systolic Murmurs. — The first question for consideration with regard to a murmur of this class is ■whether it be formed at the apex or at the base of the heart; and this is to be determined by the relation of its point of greatest intensity to the outline of the organ given by percussion, and the position of the apex-beat. 1. Systolie Murmurs at the Apex. — Commencing at the centre of the heart, we listen to the quality and rhythm of the sounds heard there, and move the stethoscope gradually downwards and outwards: the 1st sound will have lost its distinctness, and will present a character of roughness at the centre, which becomes a decided bruit at the apex. a. When the bruit is dependent on imperfect closure of a valve, the ear generally detects a spot of limited dimensions at which the murmur is much more distinct than elsewhere — the roughness of the 1st sound passes suddenly into loud bruit. b. This point of greatest intensity varies somewhat from unknown causes. In insufficiency of the mitral valve, it is to be found most commonly on a level with the apex, about an inch nearer to the sternum; and next in frequency, about an inch above the apex- beat, near to the nipple ; less commonly somewhere between those points. c. When the murmur is heard in greatest intensity considerably to the right of the apex-beat, or at the end of the ensiform cartilage, we may suspect that it is due to imperfection of the tricuspid valve; but this sound is less local, and therefore less certain. d. If the murmur, though decidedly more distinct towards the apex than at the centre of the heart, present no local point of greatest intensity, we may still conclude that it is a valvular sound if the heart be increased in size, and, in all probability, a mitral murmur. SYSTOLIC MURMURS. 277 e. Occasionally, mere changes in the quality of the blood produce a murmur which is audible over the centre of the heart, and becomes more distinct towards the apex. It is therefore necessary, in such cases, to study the history and symptoms with care, in order that our diagnosis may not be at variance with some particular indica- tion which has been overlooked. 2. Systolic Murmurs at the Base. — Proceeding in the same manner from the centre of the heart, the murmur becomes louder and more distinct as we travel upwards ; but the ear seldom comes upon a point where its intensity is so suddenly increased as at the apex. Here it is that bruits dependent solely on blood-changes are most commonly found ; and it is sometimes a matter of great diffi- culty to determine whether there be any structural alteration or not. a. When a diastolic bruit is also heard, there is necessarily val- vular disease, and, as we have already mentioned, probably disease of the aortic valves. b. If there be evidence of enlargement of the heart, the bruit is also almost certainly dependent on disease of the aortic valves, or root of the aorta. It must be clearly made out that the increased action of the organ is not merely produced by nervous excitement. c. A murmur which can be distinctly localized at the base of the heart, and is only faintly audible, or cannot be heard at all above the 3rd rib, is probably due to disease of the valves ; one which is diffuse and cannot be readily localized within the limits of the prsecordial dulness, is more likely to be caused by altered blood. d. A murmur which can be traced from below the 3rd cartilage on the left side to the 2nd interspace on the right, is generated in the aorta; one heard most distinctly in the 2nd interspace on the left side, is probably produced in the pulmonary artery. In the one case there may be disease of the valve, in the other there is probably only change in the character of the blood. e. When there is any suspicion of disease, the history and general symptoms must be carefully inquired into: an anaemic state may account for the existence of a murmur, and, under all circumstances, necessarily increases its intensity. Some authors distinguish pre-systolic and post-systolic murmurs from such as may more properly be called systolic. The names are ill chosen, and apt to con- vey a wrong impression, and the division is too minute to be followed by the stu- dent; but the possibility of some variation in the time of their commencement should be remembered, so as not to confound a systolic murmur, which does not exactly coincide with the apex-beat, with a diastolic one. The one ends at or near to the time of the beat, the other begins then, and ends long before the heart can be again felt impinging on the ribs. As a general rule, blood-sounds are characterized by great softness; and a whiz- zing, grating, or musical noise may be safely concluded to depend on some val- vular defect. Local distinctness is one of the best distinguishing features of mitral insuffi- ciency. It is to be traced when no hypertrophy of the organ is present, and very commonly coincides with a history of rheumatic fever. Irregular action, feeble- ness of pulse, congestion of the lungs, &c, leave no doubt as to the regurgitation 278 EXAMINATION OF THE HEART. of the blood through the mitral orifice -when the position of the murmur is doubt- ful, and may even be sufficient to prove this condition when no murmur can be I 1 at all. It is not necessary to go into the further question whether the im- losure of the valve depend upon alteration in its own texture preventing the edges from accurately adapting themselves to each other, or upon changes in relation between the size of the cavity aud aperture, and of the membranous valve, or of the length of the chordiu tendiucaa; though each of these causes may give rise to mitral insufficiency. An anaemic murmur is very seldom to be traced in greater intensity towards the* apex, but that it is so occasionally is quite certain; and the fact must not be for- gotten. The general indications which would confirm the opinion that it was due to blood-change only, are that the patient is young, and has never had rheumatic fever, and that the aspect is decidedly anaemic, — blood passing backwards through the mitral valve tends to produce blueness of skin, from obstruction to the circu- lation in the lungs: a bruit in the carotid artery or in the jugular vein, when none can be traced at the base of the heart, is also a valuable indication: the pulse in such circumstances is not at all deficient in power, but it may not be perceptibly so, even with decided mitral insufficiency, when regurgitation takes place only to a small extent. It may be suggested, in explanation of this form of blood-murmur, that the vibration is excited by the friction of the particles against the eolumnee carnese when the blood is in such a condition that it can be readily produced, aud that it is heard with greater iutensity towards the apex [only because the base of the heart and the great vessels are deeply covered by lung-tissue, while the apex is comparatively exposed in the particular instances in which it has been noticed; and this is the more probable, because it very generally varies in position and in- tensity from day to day. Tricuspid regurgitation seems to be a very common condition, and is very rarely indicated by the presence of a bruit. This is to be explained, no doubt, by the minor force of the right ventricle; aud it is therefore only in conditions of very decided disease that a tricuspid systolic murmur is met with: such cases, patholo- - know to be very much rarer than corresponding disease of the mitral valve. At the base of the heart bruits are so often dependent on blood-changes, that the diagnosis can rarely be made with any approach to certainty from the charac- ter and position of the murmur itself; and we therefore look in the first instance to the aspect of the patient, the history of the case, and the evidence of disease of the heart from diastolic murmur or hypertrophy, to aid in the determination. In no case perhaps is error more liable to be committed than in mistaking nervous excitement for hypertrophy, and deciding that therefore the bruit heard is an in- dication of valvular disease. In speaking of chronic blood-ailments (Chap. YIIL, \ 4) those circumstances were mentioned in detail in which an ana?mic bruit is probably to be heard; and it was there stated that, as the cause of the production of sound is in the blood itself, the motion among its particles caused by its passage through the healthy heart is sufficient to excite the vibration, and that the point at which the bruit is heard in its greatest intensity is only that which is most superficial; but that, as a general rule, it tends to be diffuse, and is audible over a large surface. In the majority of cases, systolic murmur at the base heard relatively louder over the 2d interspace on the right side of the sternum, indicates disease of the aortic valves, while one relatively louder in the same interspace on the left side, directly over the base of the heart, or, extending towards the left shoulder, is only a blood- eound: a local bruit in the 3d interspace on the left side, which is not propagated in cither direction, is most commonly caused by valvular disease. As the rationale of these rules, the following considerations may be suggested. Bruits are all heard more loudly over an interspace than over the rib immediately above or below ; the 3d interspace on the left side is that in which the sound ac- tually produced at the valve is best heard; and for all practical purposes we may for the present disregard disease of the pulmonic valves altogether, and assume that the question lies between disease of the aortic valves and ana?mia. True val- vular sound is therefore necessarily heard best, unless the heart be much enlarged upwards, in the 3d interspace; and it may possibly not be propagated to any dis- tance beyond, but heard there only: if, on the other hand, any anosmia be present BLOOD MURMURS. 279 as well as disease of the valve, the sound will be propagated along the aorta, not along the pulmonary artery; and therefore it will be relatively loudest on the right side above the 3d rib, though not so loud there as where it is actually produced. The case of a simple anaemic bruit is - quite different: there is no distinct point in the course of its passage through the heart where the blood is thrown into vibra- tion, but wherever vibration occurs, the sound is produced: practically the pul- monary artery is most superficial, and therefore, though it can be heard in the . aorta, the bruit is relatively louder iu the pulmonary artery, and consequently at that interspace where in very thin persons this artery may be often felt pulsating; the 2d on the left side. In consequence of the statement here made, it will be seen that proof of the nc- tual existence of ansemia, whiffing sounds in the arteries, "bruit de diable" in the jugular veins, &c, although it throw some doubt over the probability of true val- vular murmur, must not be assumed to disprove it altogether. It is probable that when a valvular bruit is distinctly propagated along the artery, there is almost always some degree of anamia to account for it; and that the really valuable in- dication is that there is a point at which the vibration commences, while its pro- pagation along one vessel or the other is of minor importance; because, although it be true that a pulmonic valve murmur is exceedingly rare, the principles of dia- gnosis must recognise its possibility, and endeavour to prove its presence or ab- sence. Such a murmur is very likely to be propagated along the pulmonary ar- tery ; and here, again, the only valuable indication would be the existence of a point somewhere below the 3d rib, probably very close to or under the sternum, from whence the vibration commences. If any one will take the trouble to listen to the sound heard in the carotid arteries in a few instances of acknowledged dis- ease of the aortic valves, he will very quickly find that the propagation of the bruit depends on something else than the diseased valve which produces it: the subject has been mentioned at some length, because the direction which the sound takes is often alluded to as the great indication in diagnosis. This inquiry into the means of distinguishing between a blood- sound and a valvular murmur is necessarily somewhat complicated; and yet it may become of very considerable importance when, for example, in watching a case of acute rheumatism, we have to deter- mine whether a bruit of some sort indicate the supervention of endocarditis. The rules which may be laid down as the most valuable for the guidance of the student in such a case are the following : — 1. To observe the point of its greatest intensity with reference to the three principal positions referred to, (a) the apex, (b) the base at the 3rd left interspace, (c) above the base at the 2nd left interspace. 2. To ascertain in how far at the points (a) and (5) it is capable of distinct localization. 3. If its character be, on the contrary, at all diffuse, to observe whether it can be traced towards or across the sternum or towards the shoulder. 4. To watch, from day to day, whether there be any variation in intensity at different points. In addition to these considerations, account must be taken of the past history of the case, as it may show the possibility of previous disease; and of the present condition of the circulation, as it may indicate such an amount of excitement as must of necessity exist when endocardial inflammation is going on, or such a state of quies- cence as is incompatible with it. Nor is it to be forgotten that bruit is produced in many cases of thoracic aneurism, and that these have to be separated by their position before the sound is taken as an indication of disease of the valves. 280 CHAPTER XXII. DISEASES OP THE HEART. History and Symptoms — Acute and Chronic Disease — their Com- mencement often Obscure. — § 1, Pericarditis — its Signs and Symptoms — § 2, Endocarditis — its Signs and Symptoms — Sources of Fallacy — the Origin of Cardiac Inflammation in Rheumatic Fever — § 3, Hypertrophy — its Indications — its Causes — § 4, Dilatation — the Flabby or Fatty Heart — Association with Hypertrophy — § 5, Valvular Lesion — with and ivithout Bruit — Mechanism of the Circulation — Production of Murmurs — other Indications — Obscure Cases — Causes of Disease of the Heart — Associations. The history of tlie various conditions of disease of the heart must of necessity present extreme contrasts, as they are calculated to interfere very greatly or not at all with the general comfort and well-being of the patient. Commencing as some do in the most gradual and imperceptible manner, a long period elapses in their history during which they are utterly unsuspected by the patient, and may only be casually discovered by the physician: by-and-by they begin to interfere with the circulation, and consequently with the breathing, and the patient becomes short-winded, or, as he supposes, asthmatic; and then an educated practitioner readily traces the true cause of the symptoms. In another set of cases a sudden strain is put upon the diseased organ, which overpowers its imperfect action, hitherto unrecognised, and irregular contraction, laboured movement, and impeded circulation at once develop themselves, and are assumed to be the commencement of disease in the narrative of the patient. Not unlike these last are a few rare cases, in which the strain has been so great as to rupture some part of the delicate mechanism in states of perfect health, and to have been in reality the beginning of the disease. In yet another class we are able to trace the history of inflammatory action by pain and dyspnoea in recent cases, or by the account of circumstances likely to have excited it, in those of long standing, and by the continuance of disordered function since the primary ailment. "We thus divide the cases naturally into the acute and chronic diseases of the heart; the one forming only a very small section, exceedingly limited as to the causes of their existence; the other embracing by far the larger number of cases, which can be traced back either to partial recovery from an acute attack, or to a variety of other causes, some of which are very vague and ill-defined. Among the acute cases we find pain or dyspnoea not unfrequently DISEASES OF THE HEART. 281 present; among the chronic they are unusual, at least as a perma- nent condition, and 'when met with, sometimes assume the charac- ters which have been ascribed to angina pectoris. (Chap. XVI. § 4.) The dyspnoea of inflammation may be spoken of rather as a catching in the breathing, or feeling of anxiety connected with it; that of chronic disease is more decidedly what patients call "short- ness of breath," felt in running, in going up-stairs, &c. The cha- racter of the pulse of course very often offers direct evidence of disease of the heart: and, in addition to this, the presence or his- tory of rheumatic fever, of inflammation of the pleura, of disease of the kidney and of dropsy, as the more constant associations of acute or chronic disease of the heart, are each to be viewed in the light of symptoms, or at least indications of its presence. Among them all, that which leads most frequently to the detection of cardiac inflammation is the presence of acute rheumatism. § 1. Pericarditis. — If any of .the signs of those diseases just mentioned as being associated with cardiac inflammation be pre- sented to our observation, and if on examination of the heart, peri- cardial friction be made out, there can be no doubt that pericardi- tis exists: other indications of inflammatory action will not be wanting, but here there is less need for the evidence of correlative symptoms than in other cases. When friction- sound is absent, it may be annulled either by the presence of fluid, or by universal adhesion : in either case, the general symptoms must be decided be- fore we can be warranted in pronouncing such a diagnosis, and along with these, not in opposition to them, we shall find in the former very extended dulness, especially in an upward direction, and, as usually described, assuming somewhat of a pear-shaped form; undulatory movement may sometimes be visible over the precordial space, while the heart's action is excited, laboured, or irregular, and the apex-beat somewhat elevated; the ordinary sounds of the heart are distant and indistinct over the position of percussion dulness, becoming louder and more natural above the space occupied by the fluid ; tenderness over the precordial space, pain, and dyspnoea, and great distress from any sudden movement, are also met with in such cases. On the other hand, when the sur- faces are agglutinated together, the evidence is more obscure ; per- haps the most important points, when taken in connexion with the general symptoms, are persistently perverted rhythm with nothing else to account for it, and a certain degree of obscurity of sounds, accompanied by increased and excited action. Taken along with the presence of precordial pain, distress or anxiety, and dyspnoea, the diagnosis may be pretty certain in a case of acute rheumatism or severe pleurisy, where pericarditis is to be looked for, but can never be relied on when there is nothing else to guide us to it. In the early stage, excited action, altered rhythm, and creaking noise before friction is established, should prepare us for its appear- DISEASES OF THE HEART. ance, especially if pain occur in the course of rheumatism, pleurisy, or albuminuria. In the latter disease, the plastic exudation i3 generally much less, the tendency to pour out fluid much greater. In the course of pericarditis we must be prepared for the occur- rence of pleurisy, and in inflammation of the pleura for its attack- ing the pericardium. When the friction occurs in the immediate vicinity of the heart, it may be difficult to say by which membrane the sound is produced ; because even when the breath is held, the impulse of the heart may cause pleuritic friction. Generally the diagnosis is not difficult, and, besides, it is not of very great im- portance. The Btndent must refer to the last chapter for the distinguishing characters of friction. His attention must, however, be specially called to two points in regard, to the diagnosis of pericarditis, a. All double bruits are not friction, b. Friction may exist as a single sound. Independently of such considerations as its loud- ness, distinctness, rubbing character, superficial position, &c, which can only be learnt by the habit of constant observation, and are never thoroughly trust- worthy, the best and safest indication is to be obtained from comparing the rhythm of the sounds heard over the arch of the aorta, beyond the pericardial sac, with that of the bruit wherever heard most distinctly. An endocardial murmur when double, corresponds in time to the first and second sounds 'heard over the arch, while friction does not: a single murmur, when anomalous in time, is most likely to be pericardial; if endocardial, it would correspond either to the systole or the diastole. § 2. Endocarditis. — The presence of an endocardial murmur is not decisive of endocarditis ; for it may be of long standing, or it may be merely functional. Excitement of the heart's action, per- sistent and not arising from some temporary cause, as well as fe- brile disturbance and cardiac anxiety, must be present to render the diagnosis certain ; indeed, in affection of the mitral valve, these symptoms may for some days precede the development of the mur- mur. And in old standing disease, where a murmur already exists, their occurrence may lead to a well-grounded suspicion of fresh in- flammatory action and exudation, especially during the existence of rheumatism. Of murmurs developed under observation, the most important is that indicative of mitral disease, and next, that already described as found at the base of the heart, of local cha- racter, and inclining towards the right side of the sternum. When general symptoms are wanting, and the heart is quiet, a systolic murmur at the base, diffuse in character, or one heard best above the 3rd rib, may be generally disregarded ; in cases of doubt it is, however, safer to act on the suspicion of endocarditis. Its incur- sion has been most frequently recognised while watching the heart in cases of rheumatic fever, but its existence must not be supposed to be limited to that disease, and in a large number of instances I doubt not endocarditis has been assumed when, in fact, the valvular disease had been developed in a previous attack. The murmur at the base, at first developed by the presence of a few adhering vegetations, is of course very local, and indeed amounts to little more than a rough- ness of the 1st sound at the 3rd interspace. The murmur at the apex, again, can- ENDOCARDITIS. 283 not be produced until the deposit is of considerable amount; for, as we have al- ready seen, the contraction of the auricle has not sufficient force to develop a mur- mur during the ventricular diastole, except in rare instances, while a systolic mitral murmur necessarily implies mitral insufficiency; it is consequently pre- ceded by no changes, but appears suddenly, as soon as the lymph on the valves prevents their perfect adaptation. In neither case, therefore, does the stethoscope afford us very sure means of diagnosis in the early stage of endocarditis: the modification of sound at the base is the earliest when the aortic valves suffer; but it is in some measure obscure and uncertain, from the possibility of blood-change in rheumatism, and practically the aortic valves are not involved so soon as the mitral. Hence it is important to view general symptoms, and to anticipate the appearance of the physical signs, which come too late to be of much service. In the progress of rheumatic fever it' is the duty of the medical attendant to examine the condition of the heart at every visit. No fact is better established than the association of cardiac inflamma- tion with this disease ; and if remedies caD avail, the time for their employment is at the first inroad of the inflammatory action ; the organ once spoiled is seldom restored to a perfectly healthy state: it is perhaps therefore not out of place to say a few words upon the subject of the precursory or premonitory phenomena, as they may be called. It would appear that when the perspiration is less abundant, and less sour-smelling, when the skin is dry and the odour rancid, the liability to cardiac complication is greater. The pulse is sharper and firmer, the heart itself becomes excited, its systole is sharp and shrill, and its impulse against the chest more perceptible, when there is any tendency to inflammation of that organ: but this excitement may be calmed, and no further change observed. Next we find that there is some alteration in rhythm; the 1st sound seems to be shorter, and the 1st interval longer than in health ; at least there is a notable change in the proportionate duration of the 1st and 2nd sounds and the 1st and 2nd intervals: this, too, may subside, but is very liable to be followed by more de- cided evidence of inflammation. Pain or dyspnoea may occur be- fore friction or bruit of any kind, but they seldom precede the other indications, and ought not to be the first suggestion of cardiac complication. If after the changes just spoken of a slight creaking be heard, we may be sure pericardial friction is just about to show itself; if a slight roughness of the 1st sound at the base, that endo- cardial murmur will soon be detected. ^ Not unfrequently the cardiac affection, and the consequent changes in the sounds of the heart, have been developed before the patient comes under observation ; and it is important to be able to deter- mine what is the exact condition of the organ at the time of ex- amination. The following rules may be laid down for the guidance of the student: — a. "When pericardial friction exists, the case is clearly one of pericarditis. b. When an endocardial murmur is present, it is well to inquire whether the patient have ever previously suffered from rheumatism. 2S4 DISEASES OF THE HEART. or have had any symptoms of disease of the heart before his present attack. e. A systolic aortic, or mitral murmur, as already described, found in a first attack of acute rheumatism, with no evidence of enlargement or irregular action, is very probably the result of re- cent endocarditis. J. A murmur heard on the first examination of the heart in a second or third attack of acute rheumatism, or along with enlarge- ment and irregular action, or when there is a history of previous palpitation, dyspnoea, or dropsy, is not to be regarded as evidence of endocarditis, which can only be inferred from concomitant symptoms. e. When pain and dyspnoea are complained of, and yet no morbid sound can be detected, the pericardium may be full of fluid. In such circumstances it will be observed that the natural sounds of the heart are obscure and distant in the precordial region, but be- come clear and distinct above the base of the heart; the dulness is manifestly extended, especially upwards, and its pyriform shape may perhaps be made out, or undulatory movement may be seen. The action of the heart is excited and increased, or irregular ; and this forms a striking contrast to the weakness of the sounds. /. In rare cases, universal adhesion of the pericardium may have annulled the friction-sound. This circumstance is to be borne in mind when the evidence of previous inflammation is distinct and the sounds of the heart are modified in a way that we cannot other- wise account for, especially when there is persistent alteration in, rhythm. There is probably no combination of signs especially dia- gnostic of the condition here referred to. The distinction between endocarditis and old valvular murmur is very constantly lost sight of; without any further question, a bruit is at once held to be conclusive evidence of inflammation. This is a very grave error in diagnosis, because, as we regard pericarditis and endocarditis as something different from tbe blood-change of rheumatic fever, and as of much more serious import to the patient's health and life, we are justified in disregarding the rheumatism, and trying at all hazards to save the central organ from damage; but such treatment is never to be adopted without reason, and is calculated to be injurious when based on a mistaken view of the case. At the same time it is to be borne in mind that a valve once thick- ened by inflammatory action shows a remarkable proclivity to future attacks, and at a post mortem examination often exhibits fringes of fresh lymph, when the symptoms during life were scarcely such as would have justified, even if they had suggested, the diagnosis of endocarditis. The harmony of general symptoms and physical signs has been much insisted on in the preceding pages, because the blood-change that occurs in association with what we call rheumatic fever is unquestionably one that tends towards ane- mia, as is proved by the development of blood-sounds during its continuance, which were not heard previously, — a circumstance not observed in true inflammations, as the term is generally understood. To apply depletory nieasures when an anaemic murmur is heard, is surely what no experience would justify or recommend. The most trustworthy indications of the liability to inflammation, or of its actual existence, are to be found in altered rhythm and persistent excitement, if by this term we understand something different from increased action. It is that which is found in its simplest form in nervous palpitation ; and the student should make HYPERTROPHY. 285 himself familiar as soon as possible with the difference, which is by no means dif- ficult to recognise, between the character of the sounds as they are heard in the excitement of nervous palpitation, the increased action of hypertrophy, and the quickened movement of fevers and inflammations of other organs. Not less important are pain and dyspnoea ; but they are often absent, and may be both dependent simply on rheumatism of the intercostal muscles, or even per- haps of the diaphragm. Tenderness between the ribs, pain aggravated by move- ment, or felt over an extensive surface, and the absence of signs of cardiac inflam- mation, are the evidences on which we base our conclusion that intercostal rheu- matism is the cause of the difficult or painful respiration. On the other hand, we must be careful to observe that the tenderness is not really in the pericardium, when it is increased by pressure. It may seem scarcely possible that enlargement of the heart should be mistaken for pericardial effusion ; but there is a certain similarity when the cavities are greatly dilated without thickening of the walls. The simulation of undulatory movement has been already mentioned, and the error has been due to this circum- stance, attended as it necessarily is with increased dulness on percussion. The difficulty can only arise when along with the dilatation the sounds are obscured by the existence of valvular murmur, and especially when heard both at base and apex: in such a case, when pain is complained of, or dyspnoea has been recently increased, and any of those conditions are present which may act as causes of pericarditis, the doubt will occur to every observant mind. The quasi-undulatory movement, however, will not long deceive any one of much experience, — though analogous, it is in reality different : but, in addition to this, a very safe guide is to be found in the circumstance that the presence of fluid diminishes the distinctness with which sounds are transmitted to the ear, and that above the region of the dulness the sounds of the heart, whether marked by bruit or not, are heard with much greater distinctness than any where in the pracordial space ; and this i3 something quite distinct from the difference between the intensity of a bruit as ordinarily made out in the one or in the other situation. For it is to be remem- bered that we are supposing an advanced stage of pericarditis, and that if there be not much fluid, there must be friction : if there be much effusion, the bruit or the natural sound are only heard as distant and obscure. § 3. Hypertrophy. — Increased dulness on percussion, heaving impulse, sounds muffled and indistinct though usually loud, a full firm pulse, and general throbbing of the arteries, indicate simple hypertrophy: the heart's action is not irregular. Such a condition, however, is one of comparative rarity: the increase of muscular power only results from the preservative action of nature, because some extraordinary demand has been made upon it; and the cause usually resolves itself into some obstruction to the circulation, and the evidence of this condition tends to obscure that of the hyper- trophy: the sounds may be altered by the presence of a bruit, the pulse maybe weak from mitral insufficiency, and the action may be irregular from accompanying dilatation. It is only when the heart has attained considerable size that this lesion becomes of much im- portance ; and it is then chiefly to be regarded as an index, more or less distinct, of the severity of those conditions with which it is associated. On the left side of the heart it is much more common than on the right, and this as a necessary result of the primary diseases from which it is derived. Its simplest form is produced by degeneration of the coats of the artery, and by Bright's disease of the kidney; and it is very constantly found after inflammation and atheromatous disease of the valves, or partial adhesions of the pericardium : 280 DISEASES OF THE HEART. all of those especially affect the left side. On the right, the chief cause of hyper- trophy a the impediment offered to the pulmonary circulation by an emphysematous condition of lung. § 4. Dilatation. — Increased dulness without heaving impulse, a quasi-undulatory movement, and irregular action; sharp, shrill, or feeble, and flapping sounds; a soft, weak pulse, with general dys- pnoea and depression, indicate a dilated heart. Its signs and symp- toms are those of enfeebled power, and hence they have close analogy with those produced by what used to be called a flabby, now very generally believed to be a fatty heart; the increased dulness and the undulatory movement are, of course, absent when there is no dilatation. These are the conditions most commonly associated with the pain and distress of angina pectoris, and its allied spasms. The diagnosis of fatty heart derives much confirmation from observing a pre- mature development of the arcus senilis, because the tendency to fatty degenera- tion in one tissue is not improbably associated with the same tendency in others ; but it is rather to be inferred from the pathological fact that simple dilatation is exceedingly rare, and consequently when we cannot discover any cause for the symptoms of enfeebled power, we suspect fatty degeneration. Dilatation without defeneration belongs especially to aortiG regurgitation, mitral insufficiency, and completely adherent pericardium. The valvular lesions produce complications which have yet to be noticed; the pericardial adhesion tends to increase the ap- pearance of undulatory movement. In a large number of cases more or less hy- pertrophy accompanies the dilatation, and thus the physical signs become infi- nitely varied. 1 believe that irregularity of action, accompanying evidence of en- largement, may be almost always taken as an indication of the presence of some degree of dilatation. § 5. Valvular Lesion. — This form of disease is that which is essentially associated with endocardial murmur: but as, in speaking of the murmur, it has been shown how it may be produced without alteration of the structure of the valves, so here it is to be remem- bered that valvular lesion may be found after death, which has not been discovered by the presence of a bruit during life. Our inquiry must, therefore, not be limited to the use of the stethoscope; we must ascertain the previous existence of rheumatism, or the coinci- dence of ailments with which we know that disease of the heart is more or less constantly associated: among these one of the most frequent is dropsy, and, as a general rule, it may be said that, when not produced by albuminuria, it is seldom found with any disease of the heart of which valvular imperfection is not a prominent feature. Probably, in the first instance, valvular lesion always gives rise to bruit: it is when the circulation becomes laborious and irregular that the murmur is lost or indistinct, and then the evidence of dis- ease is so clear that it is quite unnecessary as a confirmation, and its value only consists in its giving an explanation of the circum- stances which have led to the advanced changes of which other indications have rendered us cognizant. In diagnosis we have, therefore, to do with the fact of imperfect VALVULAR LESION. 287 closure of the valves under two aspects. In its first appearance, prior to other changes, when we may be called upon to determine how it is likely to affect the duration of life or the enjoyment of health, when the presence of the bruit is the only evidence of dis- ease ; and, at a later period, when very considerable alteration of muscular structure has taken place, and the imperfection of the valve, though in truth the cause of these changes, may or may not be revealed by any actual murmur: in the latter, as in the former, there are many important questions with reference to the prognosis and treatment, with which diagnosis has not any thing further to do than in establishing the fact. With reference to the first class of cases, the student has to re- member the three forms of endocardial murmur which we found to afford the most trustworthy evidence of disease; (1) a diastolic bruit; (2) a systolic bruit at the apex, of very local character; (3) a systolic bruit at the base, heard loudest below the 3rd rib, and relatively louder towards the right side of the sternum than towards the left shoulder. With reference to the second class, the existence of a bruit is a pretty certain indication of valvular imperfection ; but this may be due not so much to change in the structure of the valve, as to enlargement of the cavities of the heart, which has altered the relation naturally existing between the size and position of the aperture and that of the valve which is designed to close it. When no bruit is present, we must be guided by the general symp- toms of the case: venous congestion and a weak pulse, while the heart is acting powerfully, must, for example, be taken as conclusive proof of valvular lesion, whether we hear a bruit or not. At the risk of some repetition, let us for a moment consider the progress of the blood through the central organ. It passes onward through the mitral valve during the diastole, beginning its movement directly after the shock of the apex against the rib; it is performed slowly and silently, with but little force; and for a diastolic bruit to be produced, there must be very considerable roughness or change in the form of the orifice, to throw the blood into vibration. An anremic condition is never sufficient to develop sonorous vibrations with a healthy mitral valve. As soon as the systole begins, the valve-flaps ought to come together, to prevent any blood from escaping in that direction; and a systolic bruit can only be pro- duced by their imperfect closure: but as the force with which the ventricle con- tracts is considerable, a very slight defect is sufficient to produce this regurgita- tion, which for some reason or other very easily produces a bruit. It is not the roughness that occasions the murmur in this case, because it is just as distinct when the valves cannot close perfectly from any other cause, such as dilatation of the heart when the flaps are too small for the aperture, shortening or rupture of any of the chordae tendinece, &'c. Its position is remarkably local, most commonly between the same ribs where the apex beat is felt, and somewhat nearer the ster- num; sometimes in the interspace above: and though localized to a certain extent, by the sound being more readily heard through the interspace, still it has a dis- tinctness at one spot which no other endocardial murmur presents. From the latter point it is that the diastolic mitral murmur also proceeds; but it can be traced onwards towards the centre of the heart. Following the course of the blood, we find it passing through the ventricle; and now commence the vibrations in anasmic subjects which are heard in the precor- dial space or in the aorta: next it passes the portal of the aorta, and if the valves 288 'diseases of the heart. be roughened or stiff, even healthy blood is thrown into vibration, and a bruit is developi d which has for its point of greatest intensity the 3rd interspace, com- mencing before the apex impinges against the thorax, and terminating after it: if the blood be at all altered by aiuumia, this bruit crosses the sternum, and can be heard on its right side. As soon as the systole is completed, the aortic valves fall backwards and close in health: in disease the adaptation may still be perfect, and the 2nd sound of the heart distinct, though a systolic aortic bruit exist; but their adaptation may be imperfect, or a perforation may exist; and then the blood, in place of being held back by the valves, repasses into the ventricle, in conse- quence of the pressure exerted by the resiliency or contractility of the aorta. It may have to pass over stiff and rough valves, and be thrown into vibration as it passes, or it may pass through a smooth opening and no bruit be developed at the valve; but it very soon encounters the current entering in the opposite direction from the auricle, and vibration must result, and a bruit be formed. A diastolic aortic murmur is therefore always audible at the centre, and even onwards to near the apex of the heart, increasing in distinctness as we descend; but it may also be traced from the 3rd interspace. The blood on its return from the veins next presents exactly similar relations to the tricuspid valve on entering the right ventricle and the pulmonic valves as it leaves it; but bruits are very seldom developed on this side of the heart, except when caused by blood-change; and then they are heard much more loudly in the pulmonary artery than elsewhere, because at the 2nd interspace is found the most superficial portion of the circuit. We know that tricuspid regurgitation often take3 place, for we see the pulsation of the jugulars corresponding in time to the systole and apex-beat, but it occurs without bruit ; and though this result be no doubt partly due to the more feeble contractions of the right side, it also depends, in all probability, on the construction of the valve being such as to permit this regurgi- tation for the relief of the circulation: bruits at the pulmonic valves, independent of blood-change, are necessarily rare, from the comparative infrequency of disease at the root of the pulmonary artery. AVe have learnt, then, that a diastolic murmur from the apex towards the centre of the heart, indicates very decided mitral dis- ease ; one from the base towards the centre, imperfect closure of the aortic valves. We have learnt, too, that a systolic murmur, of local character and distinctness towards the apex, may be presumed to be dependent on disease of the mitral valve in the majority of instances, and that a murmur heard between the 3rd and 4th carti- lages on the left, traceable over the sternum to the interspace be- tween the 2nd and 3rd cartilages on the right side of the chest, may probably be dependent on disease about the root of the aorta, or the aortic valves; and the more defined and distinct it is, the more likely is this conclusion to be true ; the more diffuse and indistinct, the more care must be taken before coming to any judgment on the subject. For the purpose of diagnosis, the sound is only one element in the investigation, which has to be compared with all the others, and has to be reconciled with them on rational principles, not by forced and overstrained hypotheses. The points to be considered are, — a. The pulse. (1) It is essentially weak, often irregular, and sometimes almost imperceptible in mitral insufficiency. (2) It is jerky, thrilling, and hammering in aortic insufficiency. (3) It is weak in cases of diastolic murmur produced at the mitral valve, because such a condition is necessarily connected with mitral in- VALVULAR LESION. 289 sufficiency. (4) If it have at all a thrilling character, "while also firm and resisting, in cases of systolic murmur at the base, the pro- bability of aortic disease is much increased. b. The existence of hypertrophy renders the diagnosis of valvular lesion more certain. But we sometimes find that dilatation, without corresponding increase in size of the valve-flaps, renders them in- adequate to close the aperture. When regurgitation, therefore, occurs, it is more correct to speak of insufficiency than lesion of the valve, although practically that insufficiency depends in by far the larger number of instances on actual disease of the valve-structure, and is the result of the lesion, whether that have originated sud- denly in rupture, more slowly in the changes consequent on inflam- mation, or still more slowly in chronic degeneration. Shortening of the chordae tendineae sometimes seems to produce an insufficiency of the mitral valve, which may last only for a short time. This explanation has been offered of the mitral murmur of chorea, when it has disappeared as the spas- modic muscular movements have ceased. I have observed a similar effect follow on rheumatic pericarditis. An intense mitral murmur with evident regurgitation was heard, when the friction sound had ceased for some weeks, while the patient continued under observation; but at the end of three or four months, during which no treatment was pursued, it had entirely disappeared; the heart's sounds were then found perfectly normal, and only a suspicion of an adherent pericardium could be entertained. c. The general aspect and history of the patient serve to indicate the probability of heart-disease on the one hand by capillary con- gestion, or blood-changes on the other, by an appearance of anocmia. The indications from the venous circulation are also not less valua- ble than the capillary — jugular pulsation as caused by the blood being thrown back at each systole into the veins — venous hum as proving the existence of blood-change. When the systolic murmur is heard towards the apex, a weak pulse confirms the diagnosis of mitral disease: a well-filled pulse, though perhaps a very soft one, must lead to grave doubt as to whether the sound depend on mitral insufficiency; and if it be diffuse, and the aspect anaemic, the rational explanation would seem to be that the sound is heard there, only because of some accidental relation be- tween the chest and the organs of circulation, by which the sound of vibration of blood is conveyed to the ear better from the interior of one of the ventricles than from either of the great vessels. Again, if there be no anaemia, but, on the con- trary, venous and capillary congestion, with jugular pulsation, indicating that the blood is thrown back from the right side of the heart, a full pulse might lead us to suspect that the sound was not improbably due to disease of the tricuspid valve. In the systolic murmur at the base, the history of previous rheumatic fever, or of nervous or hysterical symptoms; the complaint of palpitation, or of cough and dyspnoea; and the aspect, whether pallid or florid, — help in the determination of what is the value of the bruit. Only it must be remembered that, begun by actual alteration of the valve, it may be exaggerated by changes in the condition of the blood. We should be mistaken in looking always for a thrill in the pulse, though this be not unfrequent; because, in place of its being firm, as it generally becomes in consequence of hypertrophy in very marked aortic disease, it may be rendered weak by dilatation or fatty degeneration : the coexistence of arcus senilis, as al- ready observed, affords some confirmation to the latter hypothesis. In decided anaemia we are apt to overlook the actual coexistence of valvular 19 290 DISEASES OF THE HEART. lesion. Tn hvpertrophy and dilatation we are apt to assume its presence when there is merelj imperfect closure and no positive disease: but the latter is of much less moment as an error in diagnosis than the former. The absence or presence of a hammering pulse may at once decide the question whether B diastolic murmur be produced in the mitral or in the aortic valves. When a double Bonnd is heard, the history, the pulse, and the aspect of the pa- tient oupht never to permit the existence of a doubt whether it be endocardial or exocardial even in cases in which the character of the sound is not sufficient to determine the question; and here, again, as between a double sound produced in the aortic and a double sound produced in the mitral aperture, the pulse is one of the best aids to forming a correct opinion. When all has been done that can be done towards forming an accurate diagnosis, many cases will remain in which the judgment is perplexed and the decision uncertain, many in which the conclu- sion has been absolutely false: but the mind best trained to ex- amining and weighing the facts of each case, and the ear most ac- customed to discriminate and individualize the sounds, will be least frequently in error in obscure cases — will also be most often right in those of every-day experience, which even in their simplest form present to the careful physician so perplexing a problem. We need only here allude to some of those loud musical sounds heard at times some distance from the patient, which from their very inten- sity cannot be localized at all: for them the stethoscope need not exist — they must be judged of solely by general symptoms. Cases, on the other hand, occasionally present themselves which are too few to be made the basis of any diagnostic rules, and yet too curi- ous to be passed over: these are cases in which the arterial and venous currents get mixed through some congenital malformation, the circulation of the foetus being to a certain extent continued after birth. The blueness of the skin, without appreciable obstruction to the respiration, and the long continuance of the symptom — its persistence, in fact, from birth, or at least childhood — serve suffi- ciently to mark them off as a set of cases standing alone. Disease of the mitral valve may be traced in a large number of cases to rheumatic fever. This seems to be the point on which endocarditis, accompanying that disease, most readily fastens in the first instance; when the first seizure is severe, or subsequent attacks occur, the aortic valves are usually also implicated. The systolic mur- mur is so readily produced, that very slight changes in the form of the mitral valve are indicated, though the pulse be for a long time scarcely affected, and the circulation undisturbed: when the change is originally greater, or repeated attacks of inflammation have seri- ously damaged the valve, the circulation is impeded, because the whole contents of the ventricle are not propelled through the aorta; and the current is, consequently, both smaller and weaker; but, besides this, the blood which escapes through the mitral orifice is driven back upon the lungs, producing congestion, and giving rise to imperfect oxygenation: hence we have the two symptoms of feeble pulse and dusky complexion. VALYULAR LESION. 291 In the further progress of disease the left side of the heart be- comes dilated, and its walls hypertrophied; sometimes the one, and sometimes the other condition prevailing, but, as a general rule, the dilatation exceeding the hypertrophy. The diastolic mitral murmur is usually developed when the hypertrophy is greater than the dilatation. The heart's action becomes irregular when the dilatation is in excess; and ultimately tumultuous action is brought on by some sudden strain, when the imperfect contractions of the ventricle, and the distended condition of the auricle, are such that no bruit is produced at all. In these cases the mitral disease may be entirely overlooked; and if the heart should happen to be much overlapped by the lung, so that its increase in size is not observed, the irregular action and feeble pulse may be set down as the result of degeneration, and the imminent danger of the patient unfore- seen. Disease of the aortic valves is very frequently a slow process, analogous to the atheromatous disease of the root of the aorta; the two conditions being, in fact, very often found together: but it is also the result of endocardial inflammation, especially when asso- ciated with mitral disease. Simple roughening, or thickening of the valves, such as does not prevent tolerably perfect closure, with- out regurgitation, is not of itself a disease of much moment; but the bruit heard over these valves during the contraction of the heart is of much importance from its being an early index of the tendency to atheroma: by destroying the elasticity of the aorta, this form of degeneration produces hypertrophy, and, when affect- ing the arteries of the brain, leads to disturbed circulation within the cranium, and ultimately to apoplexy. The valvular disease comes to be of real importance when regur- gitation is permitted: a permanent obstacle to the completeness of the circulation is established by a portion of the blood propelled during each systole returning into the cavity; and to counteract this defect hypertrophy is soon established: but the constant and excessive distention during the diastole also produces dilatation, and it is in cases of double aortic murmur that the largest hearts are usually found. The effect of the afflux and reflux of the blood upon the character of the pulse in these cases is most striking. Patency of the valve, while very generally dependent on rigidity or irregular form of the flaps interfering with their mutual adapta- tion, is also known as a result of accident when one of the valves is torn, or of ulceration: the absence of systolic murmur might lead to a suspicion that these last were the causes of the diastolic mur- mur. It very seldom happens that we know that the heart was free from disease before some unusual strain, and it is dangerous to conclude from the patient's statement that rupture has taken place on such an occasion ; in very severe disease of the heart, of long standing, the patient is often utterly unconscious of its existence till some such event call his attention to it. Imperfect closure of 202 DISEASES OF THE IIEART. the aortic valves is not unfrequently caused by dilatation of the vessel, while the valves themselves are free from disease. The same dilatation at a more distant part of the vessel occurs as aneu- rism of the arch, which is invariably attended with hypertrophy, and, to an inexperienced observer, may present many of the phe- nomena of valvular lesion. Among the associations of cardiac disease some may be traced to it as their cause, more or less remote: of these dropsy is perhaps the most frequent, both in its generic form as anasarca, and as pas- sive effusion into various cavities. Bronchitis, or rather bronchor- rhoea, results from the obstruction to the pulmonic circulation, giving rise to congestion and oedema of the lungs; and, for the same rea- son, simple bronchitis from exposure is more severe in persons with disease of the heart. Haemoptysis occurs in consequence of more decided congestion or plethora of the pulmonary vessels. Epistaxis is perhaps also excited by cardiac disease. Disordered cerebral circulation produces those affections which we have denominated functional disturbance of the brain, or may lead to epileptic, and especially to apoplectic seizures. Congestion of the liver is often manifested in jaundice; the same condition of kidney leads to the transient presence of albumen in the urine. Other associations are rather to be regarded as causes of disease of the heart; such as rheumatism, pleurisy, albuminuria, and that form of mal-nutrition which produces atheroma: in the former we expect to find inflammatory changes, in the latter, diseases of chronic form; the one more frequent in early life, the other found at later periods. Similarly, each of the forms of cardiac disease tend mutu- ally to develop each other. Not only does the valvular lesion lead to hypertrophy and dilatation, but these, in their turn, serve to in- crease the valvular imperfection. Partial adhesions of the pericar- dium become very often a cause of hypertrophy, while its complete adhesion is more commonly followed by dilatation or atrophy. Permanent albuminuria is associated alike with hypertrophy or di- latation, and with degeneration of the valves ; but while it seems to be a direct cause of the hypertrophy, its association with the other forms, is rather secondary and concomitant; it bears, how- ever, some very close relations to the inflammatory lesion, pericar- ditis especially being frequently found in the course of Bright's dis- ease. Inflammation of the pleura, is liable to spread to the peri- cardium, but seldom affects the lining membrane or valves of the heart. 293 CHAPTER XXIIL DISEASES OF THE BLOOD-VESSELS. DiV. I. — Diseases of Arteries — Aneurism — § 1, Superficial Aneu- rism — § 2, Thoracic Aneurism — § 3, Abdominal Aneurism. Div. II. — Diseases of Veins — Phlebitis — § 1, Pysemia — § 2, Phleg- masia Dolens — § 3, Capillary Phlebitis. Division I. — Diseases of Arteries. In pathology we become acquainted with inflammation vf the lining membrane of the arteries, but, as yet, it has received no clinical history: its occurrence is, indeed, so rare, that the obser- vation which may associate the history with the post mortem ap- pearances must be rather a matter of accident than one which can be fairly regarded as a subject of study. It is certainly very re- markable that the inflammatory action so often observed on the valves of the heart, and not unfrequently associated with patches of inflammation on the endocardial membrane, should so rarely ex- tend to the arteries. Aneurism is, in its early beginnings, also unknown to us in a clini- cal point of view; there is nothing in the history of its development characterizing the disease in such a manner as to be of avail in diagnosis. There is little to be learned regarding it beyond the fact that a swelling has been, at some period, discovered by the patient, or that symptoms have occurred which might be explained by the hypothesis of aneurism, when no swelling has been observed. Its diagnosis resolves itself into a consideration of the circum- stances proving the existence of a tumour, of the evidence of its pulsation, and of the disturbances produced in the circulation, especially in the development of an arterial bruit. When these points can be made out distinctly there is no difficulty in forming a correct opinion of the case. In many instances, however, from the position of the diseased artery, the information is obtained with difficulty, or is very imperfect; and then careful examination and correct reasoning can alone conduct us to a trustworthy explanation of the phenomena: a hasty observer is liable either to overlook the disease altogether, or to misinterpret the meaning of the symptoms which he has discovered. § 1. Superficial Aneurism. — When occurring in a tolerably superficial artery, the disease commonly falls under the care of the surgeon. Mistakes are less likely to occur than when it is deep- seated: the pulsation and the bruit are both pretty readily made out; and when by pressure on the artery, at the proximal side of 204 DISEASES OF THE BLOOD-VESSELS. the tumour, it collapses, and is rendered flaccid by the sac becoming partially emptied, the diagnosis is simple and distinct. In a more advanced stage, when from large deposits in its interior the sac has become hard and firm, it is especially important to note that the pulsation is felt when a finger is placed on each side, because an clastic tumour lying over an artery very generally pulsates out- wards, but not so as to be felt transversely across the course of the vessel. The arterial bruit may also be simulated by the pressure of a tumour on a perfectly healthy vessel, especially in those con- ditions of blood which embarrass the diagnosis of diseases of the heart, by producing cardiac murmurs. A tumour lying over an artery must, from its very position, be, to a certain extent, move- able, or at least its point of attachment to the deeper tissues does not correspond with the known course of the artery; and this serves as a further guide in diagnosis. In superficial aneurism we may sometimes be guided by the history of sudden appearance after a strain, and the mode in which it first revealed itself to the patient's consciousness; but to these much importance cannot attach. It seems scarcely possible that cellular inflammation and abscess lying over an artery should be mistaken for aneurism. § 2. Thoracic Aneurism. — It is unnecessary to repeat the indi- cations by which we may arrive at the conclusion that a tumour of some sort exists in the cavity of the chest (see Chapter XX., § 10;) we have only to consider here by what circumstances we may be led to believe that it is of the nature of aneurism. And in forming this judgment the pathological facts connected with the disease are not to be forgotten: such as its relative frequency at the commence- ment and arch of the aorta, and the consequent probability of its being found at the upper and front part of the chest, its tendency to cause absorption or erosion of tissues by pressure, and hence the frequency with which it is attended by pain; hence, too, its termi- nation by hemorrhage before it has attained any such dimensions as are seen in cases of malignant growth: nor may we forget the necessary disturbance of the circulation, and the constant accom- paniment of hypertrophy of the heart. In the dysphagia or dyspnoea caused by its pressure, which serves in many instances first to call our attention to its presence, it does not differ from other forms of tumour : but from the position of the aorta they are perhaps more common and earlier in their appear- ance, the cough in particular having a remarkable metallic clang. Aneurism is much more liable to interfere with the arterial circula- tion, morbid growth with the venous; in the one a difference can frequently be observed between the pulse at the two wrists, in the other we are more likely to find tortuous veins over the neck and thorax: but it may be worth mentioning that oedema of the arms, when the circulation is obstructed, sometimes renders the observa- THORACIC ANEURISM. 295 tion of the pulse fallacious. It would seem, too, that relief from the pressure, by change of posture, is more decided in the case of aneurism than of other thoracic tumours; but in all cases it is usually found at some period of their history that a prone position is preferred to any other. The situation in which aneurism is commonly found, towards the upper and front part of the chest, may lead to its being detected by percussion and auscultation; the dulness is limited, and is not complete; and though greater on one side than the other, unlike the consolidation of tubercle, it is most distinct close to the sternum. Solid growth in the anterior mediastinum is not limited to the upper part of the sternum, but the dulness extends all the way down; it is also more complete. The earliest auscultatory phenomenon is a jogging sound, which can be heard, and seems to be felt, when listening over the site of the tumour: it is probably produced by its actually impinging on the parietes. In other instances an arte- rial bruit or whiz is heard there much more distinctly than else- where: it is notunfrequently audible also in the precordial region; and hence, with the natural accompaniment of hypertrophy, may be wrongly attributed to valvular disease of the heart. In its further progress the aneurism causes absorption of the in- tervening tissues, becoming gradually more superficial: the bony structures soften, and the pulsation is readily observed externally. Pain is necessarily excited by this action, and has a gnawing cha- racter: the whizzing sound is rarely wanting. It is not easy to determine what circumstances give rise to the production of bruit in some cases and not in others ; probably they are connected with the form of the tumour and the condition of its interior. An ar- tery pretty evenly dilated will only give rise to the jogging sound already spoken of in consequence of its contact with the ribs ; while one in which a distinct pouch has formed, or which is lined in its interior by uneven layers of lymph, will throw the blood into sono- rous vibrations as it enters or leaves the enlarged portion. § 3. Abdominal Aneurism. — Abdominal pulsation has a very vague significance, and the student cannot be too careful to avoid the mistake of supposing it to be constantly or even frequently an evidence of aneurism. It is of common occurrence among nervous, hysterical, and dyspeptic patients, and means nothing generally, when unaccompanied by the evidence of disturbed circulation which is afforded by the existence of hypertrophy of the heart. On the other hand, simple hypertrophy very often communicates its pulsa- tion through the diaphragm to the abdominal viscera, when there is no enlargement of the descending aorta : and in such cases if anae- mia lead to the development of bellows-murmur, the mistake of sup- posing both pulsation and bruit to be dependent on aneurism is very likely to be made. The decided indications of abdominal aneurism are the follow- 29G DISEASES OF THE BLOOD-VESSELS. i n ^ : — The tumour corresponds in position and direction to the known course of the aorta or iliacs ; its attachments are firm, and it is but slightly movable; pulsation is felt in a lateral direction as the patient lies on his back, and this pulsation does not disappear on change of posture; a local bruit is audible, which cannot be heard over the precordial region. Any tumour lying upon arteries of the size of the aorta and iliacs must necessarily convey a sense of pulsation in an upward direc- tion, — from the artery, through the tumour, to the finger placed op- posite to it; but it does not pulsate laterally, and when a finger is placed on each side the difference is unmistakable. It is also to be remarked that in change of posture the altered relations of the tu- mour and the vessel will cause the pulsation to disappear in the one case, while it remains unaffected in the other. The arterial bruit cannot be much relied on, especially if there be concomitant ansemia. Division II. — Diseases of Veins. As in the diseases of arteries, we meet with inflammation and dilatation of the veins; but in this part of the vascular apparatus the inflammatory action is a very common and very serious disor- der ; the enlargement is of very secondary importance. Varicose veins, indeed, even if they were not entirely regarded as a surgical disease, could hardly claim any place in a treatise on diagnosis, and we shall therefore confine our attention to phlebitis. The lining membrane of the veins would seem to take on inflam- matory action in connexion with two very distinct conditions of the contained blood, and it cannot be doubted that the inflammation is itself of a different kind in each. In the one there is a tendency to the formation of pus, in the other fibrinous clots are formed, which more or less plug up and obstruct the veins. This subject has of late years been very closely investigated, and opinions are yet much divided on the sequence of events. With reference to diagnosis we have only to do with the conditions as seen at the bedside, and the facts elicited in the history of each: the first^ be- comes known to us by the existence of a form of blood-poisoning; the second is familiar to us in phlegmasia dolens. § 1. Pi/cemia, or purulent contamination of the blood, has already formed the subject of a previous section. (Chap. VIII., § 5.) When occurring in a patient who has an open suppurating wound, it might be alleged that the pus has actually entered into the open mouths of vessels: unphilosophical as this view must appear, it is evidently wholly inapplicable to those cases in which suppuration has been going on in a closed cavity, whether serous or synovial, or even in one formed by the artificial walls of an abscess: and it is equally untrue of pynemia supervening upon diffuse cellular inflammation. In such cases we cannot doubt that the disease has commenced by PHLEBITIS. 297 inflammation of a suppurative kind attacking the lining membrane of the vessel, whence the pus mingling with the blood is carried forward into the current of the circulation. With an open wound its advent is marked by shivering, followed by perspiration; and we may justly conclude that in the other instances the same phenome- na do attend it, but here they are obscured by the previous existence of rigor, and the liability to its recurrence when suppuration has commenced: hence it is not till the prolonged sweating of pyaemia, and the secondary inflammation of internal organs have declared themselves, that we can have any certain evidence of suppurative phlebitis having taken place. One point deserves attention, that the fact of empyema having followed pleurisy, of suppuration having occurred in synovitis, of a large suppurating abscess having formed, or of the existence of diffuse cellular inflammation, all alike point to a certain crasis in the blood which predisposes to suppurative phlebitis, and that this is only a further development of the same tendency to the trans- formation of effused plasma into pus. § 2. Phlegmasia Dolens is seen in its most characteristic form in women after delivery ; but it also occurs not unfrequently in anae- mic or chlorotic females: if it ever exist in males, it is certainly very rare. It is marked by pain and swelling of some portion of the leg, or even of the entire limb, which has a blanched, bloodless aspect; it is firm and elastic, and except in the absence of redness, much resembles the condition of erythema; it has not the hardness of erysipelas, nor the doughy feeling of anasarca. At the lower part of the limb, beyond the limits of tension and tenderness, oedema may be readily recognised by pitting on pressure ; and in- deed there is a certain amount of serous effusion throughout, which is caused by the obstruction offered to the return of the blood through the inflamed vein: this combination of inflammation and oedema is that which gives its peculiar features to the disease. Occasionally its characters are much more local, only affecting for example the calf of the leg; and then the collateral circulation prevents the serous exudation from being so distinct. Above the seat of swelling, pain may be traced for some distance in the course of the emergent vein ; and when superficial, as in the ham or the groin, a distinct hard knotted cord may be readily felt with the finger, which persists long after the acute symptoms have subsided. The seizure is always a sudden one, and has no history beyond that of its being found in the associations indicated above. Its common name of "white leg" sufficiently discriminates it from erythema nodosum or diffuse cellular inflammation, and its hardness and tension cannot lead to the mistake of supposing it to be mere muscular rheumatism. In some in- stances oedema with much tension, especially when one leg only is affected, presents characters of superficial tenderness not unlike phlegmasia dolens ; but it is always readily to be discriminated, by its commencing at the ankle, gradually extending upwards, and being always associated with venous congestion ; while the swelling 298 DISEASES OF THE BLOOD-VESSELS. of phlebitis begins in the fleshy part of the limb, and is never discoloured by tur- gid blood-vessels. A condition precisely similar maybe sometimes seen in the arm as a conse- quence of blood-letting when the lining membrane of the vein is irritated by the lancet, but it is usually associated with more or less of diffuse inflammation. § 3. Capillary Phlebitis. — At post-mortem examinations some of the internal organs occasionally present appearances which have led to their being said to be the seat of capillary phlebitis. The name sufficiently indicates the nature of the lesion ; an exudative inflam- mation attacking the interior of the capillary vessels, and plugging them up with fibrin. It seldom passes to vessels of large size. Its clinical history is unknown, and it is even difficult to conceive how, in the majority of instances, it could be discriminated by any signs during life from other inflammations of the same organ. Phlebitis ending in occlusion of vessels will for a time interfere with the circu- lation through the organs in which the veins originate; but their anastomosis throughout the body is so extensive, that the obstacle is very soon overcome by the blood being conveyed through some other channel. The only case in which I have seen very serious or rather fatal results, was one in which the inferior cava was obstructed, and nature was unable perfectly to establish the circulation through the tortuous vessels, which, however, carried a very large portion of the blood from the lower extremities into the superior cava. 299 CHAPTER XXIV. DISEASES OF THE MOUTH AND PHARYNX. Tlieir Association with Diseases of the Larynx — § 1, Of the Mouth — Glossitis — Ulcers and Aphthae — Oancrum Oris — § 2, Of the Fauces — Quinsy — Enlarged Tonsils — Ulcerations — § 3, Of the Glands — Mumps. The diseases of the mouth and pharynx do not present many questions of interest in a diagnostic point of view. The parts are readily examined, and simple inspection is generally sufficient to determine the seat of the affection and the nature of the disease. It is not our object to give a history of pathological states; but merely to point out the distinctive signs and symptoms by which these states may be recognised. The complaint of the patient is of soreness in the mouth or throat, and of difficulty in taking food. Conjoined with this there may or may not be symptoms referrible to the entrance of the windpipe, hoarseness or aphonia, harsh sound or difficulty in breathing. The continuity of surface, as already mentioned in speaking of diseases of the respiratory organs, often leads to an extension of inflam- matory-action from the one set of organs to the other; and to this fact very often the affections of the pharynx owe their importance and significance. In complex cases it is very desirable to make out, if possible, whether the difficulty in swallowing were preceded or even accom- panied from the very first, by cough or difficulty in breathing; as the disease is always of graver import, which, commencing in the larynx, produces a difficulty in swallowing, merely as a subsidiary affection, than one which has its original seat in the pharynx. In simpler cases little is learnt from the history beyond its duration and the occurrence of a febrile attack in its commencement; points which may serve to correct a faulty diagnosis, but are rarely es- sential to its accuracy. The difficulty in swallowing may be referred to a point below the inlet of the pharynx, and may be due to disease situated lower down, such as stricture of the oesophagus or pressure: but inspection of the fauces should never be omitted, as it may reveal deep-seated ulceration of the pharynx as the cause of this sensation. Thickness of speech will always result from obstruction about the fauces ; but it is very different from the hoarseness or aphonia of laryngitis: the mistake is only important inasmuch as it gives rise to false alarm, and to treatment unnecessarily active and severe. It is unnecessary here to revert to the means of distinguishing laryngitis from pressure on the trachea. (See Chap. XX., $ 1 and \ 10.) The appearances divide themselves into redness, swelling, ulce- ration, and aphthse; each of which may be recognised singly or in groups over different portions of the mouth and fauces. 300 DISEASES OF THE MOUTH AND PHARYNX. § 1. As affecting the Mouth. — Redness and swelling of the tongue indicate glossitis; at all times a rare disease, and now al- most unknown, since the absurdities of mercurial ptyalism have been abandoned. When such symptoms are present, this must not fail to be inquired into; but it is to be remembered that the quan- tity of mercury taken is no criterion of its effect, for, in peculiar constitutions or conditions of the system, they are by no means pro- portional to each other, and there are even cases of spontaneous ptyalism. We find a pretty safe indication in the fetor of the breath accompanying mercurial salivation. Yet even such a point as this requires both experience and accuracy of observation. I have known the odour of sloughing ulceration mistaken for mer- curial fetor. The tongue is also often affected with simple ulceration, or co- vered with aphthae. Both of these ought to be regarded as con- stitutional states: even when ulceration seems to be directly caused by the edge of a broken tooth, its real history is probably a con- dition of depraved nutrition ; and this is confirmed by the occasional appearance of ulceration along the edge, when no such exciting cause is present. Aphthae of the tongue are much more numerous than points of ulceration; they have an appearance of elevation rather than depression, look whiter and more solid, while ulcers are hollow, and filled with fluid secretion: spots of ulceration are apt to follow on aphthae when the white crust is detached, but the ge- neral aphthous state is still sufficiently marked. Both occur much more commonly in childhood than in adult life: ulceration is evi- dently allied to that condition which gives rise to cutaneous dis- orders, especially impetigo ; aphthae, on the other hand, point more directly to the mucous membrane. In infants the disease is known as " thrush," and is always associated with intestinal disorder; in adults it is most frequently met with in the last stages of ulceration of the bowels, preceded by a red and glazed tongue, or when diar- rhoea occurs as one of the signs of general exhaustion. Ulceration is at times met with on the lips and the gums, or the inside of the cheek ; in which situations aphthae are less common. On the gums it is important to distinguish simple ulceration from that which is produced by mercury ; the correspondence of ulcers on the lips and cheeks would tend to prove that its origin was not of this specific character. One form of ulceration of the cheek is seen in childhood, which in its milder form may be called sloughing ulcer, in its more severe form has obtained the name of cancrum oris. It is characterized by foul, unhealthy secretion, and rapid tendency to spread: in the worst cases destroying the cheek and side of the face, and, in all, producing a large unhealthy sore. There is no doubt that this, too, is constitutional. § 2. M the Entrance of the Fauces. — The morbid appearances which present themselves in this locality are those indicating in- DISEASES OF THE MOUTH AND PHARYNX. 301 flammatory and ulcerative action: the redness and swelling occur under two very distinct forms — the acute and the chronic. a. With some febrile disturbance, which rarely runs very high, we have general redness and swelling of all the adjacent structures; sometimes involving the root of the tongue, and not unfrequently the submaxillary region, accompanied by great difficulty of swal- lowing, especially when liquids are taken, nothing perhaps causing greater pain than the patient's own saliva, which for this reason he commonly spits out ; the tongue is much coated, and acquires after a time a sodden buff-leather aspect. When we can get a view of the throat, its aperture seems encroached on from all sides, and the uvula is long and large ; the mucous membrane is remarkably red and injected. These circumstances are quite sufficient to charac- terize quinsy: its course is usually rapid, ending in a few days by suppuration, and occasionally by resolution. The liability to its re- currence is so great, that any history of a similar attack is of value in considering the probable termination of sore throat in any given case. The occurrence of sore throat is so common, while in certain circumstances it is an indication of such importance, that a few words must be said on its general bearings as a symptom of disease. In its simplest form, as a result of exposure to cold, it is the same affection which in one portion of the mucous membrane causes coryza, in another catarrh: in the pharynx slight redness is seen on inspec- tion, very little difficulty in swallowing is experienced, and the feeling of soreness soon subsides : there is from the first very little fever, and its severity is rather pro- portioned to the catarrhal symptoms than to those of sore throat. A very differ- ent state of things exists when, instead of general irritation of the mucous mem- brane, inflammation attacks the larynx ; the soreness of throat and difficulty of swallowing are very much more pronounced, pyrexia is distinct, and yet on in- spectign little redness is seen, and that redness has a livid aspect. In scarlatina, again, the fever generally runs high ; but the cause of the soreness is at once dis- covered on inspection, in very extensive redness, spots of an aphthous or ulcerated appearance, or even sloughing ; in milder cases its true character is exhibited by the appearance of the cutaneous eruption ; in severer cases, the existence of an epidemic coupled with the occurrence of intense fever, considerable prostration, great lividity of the throat and ulceration, without much swelling, enable us to assign to them their true character even when redness of skin does not exist, or has receded. From all of these quinsy is distinguished by its local nature, by the swelling which goes along with it, and by the fever being only in proportion to the local action going on. And although the name be commonly restricted to those cases in which matter forms, all are to be regarded as belonging to the same class, which present such symptoms, even if the inflammation end without suppuration. I. In the chronic form the same strictures may be implicated in a less degree, a generally dusky redness prevailing with no great amount of swelling; or there may be chronic enlargement of the tonsils only, or a permanently elongated condition of the uvula, which are both by no means uncommon as sequelae of acute attacks. Not only do these appearances differ greatly from those presented by quinsy, but the history is also totally dissimilar: if there have been some aggravation of the symptoms within a few days, to which the attention of the patient is especially directed, still the evidence 302 DISEASES OF TIIE MOUTn AND PHARYNX. of old standing disease is not wanting if the case have been pro- perly investigated. It can scarcely be necessary to add a caution against being deceived by the ab- sence of any appearance of active congestion, into the belief thai the sure throat •is of old standing and of small moment, when fever is present: such an error would show entire ignorance of all right principles of diagnosis. Enlarged tonsils are very often the effect of the scrofulous taint, and occur in early life: symptoms of cough and dyspnoea, by which attention is first called to the case, may lead to a suspmion, of phthisis, from the want of evidence of any other affection by which they might be accounted for, till an inspection of the throat at once explains the mystery? An elongated uvula is similarly a cause of cough; and both may tend to excite and keep up bronchial irritation to an unusual extent. The observant practitioner will in all such cases notice peculiarities which serve to call his attention to the throat; thickness of speech, liability to sore throat,«pc- casional difficulty in deglutition, even when pain is not spoken of, such as fluids returning by the nose sometimes; deafness, and especially the sound of the cough which may be described as a throat-cough: but whenever the symptoms are not fully explained by the stethoscope, an inspection of the throat is a wise precau- tionary measure before pronouncing a diagnosis. e. Ulceration of the fauces occurs in three distinct forms: (1) As the residue of an acute attack ; (2) as a primary disorder in scro- fulous and cachectic states ; (3) as a consequence of syphilitic poi- soning. After quinsy the ulcer is generally pretty far forward, after scarlatina the tonsil is the usual site of ulceration ; the scrofu- lous ulcer is very often in the velum, the syphilitic usually reaches towards the back of the pharynx. That resulting from an acute attack is generally superficial ; the scrofulous is deep, but has flabby, perhaps jagged edges, which do not project; it often exists as a complete perforation of the velum: the syphilitic, again, is deep and rounded, with elevated serpiginous and defined borders. So far as diagnosis is concerned, these conditions might be accurately deter- mined by a correct history. In regard to treatment, the division of most import- ance is into the syphilitic and non-syphilitic ulceration. Both the other forms are, in great measure, constitutional, and must be met rather by such remedies as are suited to the general condition of the patient, than by those which have merely a local effect. In the female sex there is both greater difficulty in making out the previous existence of primary syphilis, and greater unwillingness to confess that such may have been its cause, than in males ; to say nothing of the reluctance felt by the medical man in even hinting such a possibility. AVhen the ulcer is rounded and excavated, with elevated margins, we must endeavour, by seeking in other di- rections for evidence of syphilitic'poisoning, to obtain some indication that may aid in solving the doubt which such a condition will naturally raise in the mind. True aphthae are less common on the fauces than on the tongue and lips; but a somewhat analogous formation is frequently ob- served there, which may be either a true exudative process, or merely the inspissated secretion of some of the follicles. These spots may be mistaken for ulceration, and it is only necessary to warn the student of this possibility ; though, probably, the mistake is not a very important one. When there is distinctly a deposit upon the surface, its significance is somewhat different from that of aphthae on the tongue ; it is only in childhood that its presence is of importance, because in them it sometimes exists to a great extent: DISEASES OF THE MOUTH AND PHARYNX. 303 the disease is known as diphtheritis, and indicates a constitutional tendency to that form of plastic exudation which is of so much mo- ment when it invades the trachea in croup. § 3. The Glandular Structures. — The inflammation of the fauces sometimes extends to the submaxillary region, and subsequently excites inflammation of the salivary glands: but these glands are also liable to be primarily affected. The swelling, though accom- panied with difficulty in swallowing, is chiefly external: the parotid, as the largest gland, gives the principal feature to the disease, which has hence been called parotitis — better known by its familiar epi- thet, "mumps." It is chiefly a disease of childhood and youth, and is not characterized by much febrile disturbance: it is of impor- tance as causing the disfiguring abscesses which are apt to occur under the jaw in scrofulous subjects, when the surrounding textures become involved in the inflammation which primarily attacks the salivary glands. This disorder furnishes us with the most marked examples of metastasis; the testicle and the mamma being each liable to inflammation during its continuance. Chronic enlargements of the cervical glands occur from a variety of causes in scrofulous constitutions; and these are ever apt, on the occasion of any little excitement or inflammatory action, to ter- minate in abscess. In almost every case of suppurative cutaneous affection of the face or scalp, they exist in greater or less degree ; but when the individual is free from constitutional taint, they are of no importance; the cause being removed, the effect of neces- sity ceases in a healthy person. 304 CHAPTER XXV. t EXAMINATION OF TIIE ABDOMEN. History of Abdominal Disease — General Symptoms — Effects upon the Health — Sensations often referred to other Regions — Actual Examination — of Outlets — of Excreta — of Abdomen itself — by Inspection — by Palpation — by Percussion. Before entering upon the consideration of the various organs contained in the abdomen, and their special maladies, it may be well to advert to a few general facts connected with the diagnosis of diseases of nutrition. Regarding the brain as the centre of in- nervation, the thorax as that of the circulation, the abdomen is especially the region in which the processes of assimilation and ex- cretion are performed. It is not meant that this definition is abso- lutely accurate; but, as an approximation to the truth, it points out in what direction we are to look for the signs and symptoms of disease there, as connected with the ingestion of food, the pre- paration of proper elements for absorption, their transmission into the circulation, the rejection of useless materials, and the removal of waste or effete particles, as well as the necessity for the perfect integrity of the organs by which these processes are carried on. That the deviations from healthy action should manifest themselves in altered condition of blood, in imperfect nourishment of tissues, and in functional disturbance of distant organs, to which the blood is carried, can cause no surprise; and the difficulties of the diag- nosis are only that while, on the one hand, the deteriorated condition of the blood may not be simply due to defective assimilation and excretion by abdominal viscera ; on the other, important changes in the circulation and innervation must react upon the abdominal organs, as it is by these two great physiological functions that their integrity and power are supplied and sustained. With reference to history, we must admit that it is often not re- liable, nor perhaps very material: no one entirely escapes occa- sional derangement of stomach and bowels, and it is impossible to say where healthy reaction against improper food ceases, and un- healthy action begins; hence, in chronic diseases, there are always a number of antecedent phenomena, and it requires skill to select those which are really valuable as facts in the history, and greater impartiality than is possessed by most medical men, to avoid putting the necessary questions in such a form as to elicit the answers which we expect to receive, from the general tenor of the symptoms. In cases of acute disease there is less difficulty in obtaining correct information regarding the sensations and experiences of the patient EXAMINATION OP THE ABDOMEN. 305 since the severe symptoms arose; but here again we are encountered by the difficulties that the sensations in the abdomen are, at no time, very defined, and that some prior illness, the historical evidence of which is very defective, may have very considerably altered the organic constitution or functional power of the viscus. The totality of the general symptoms marking inflammatory fever has the same value here as in other acute attacks: sometimes we derive secondary aids to diagnosis from the skin having a feeling of remarkable dryness, the pulse being small and wiry, or intermit- ting, &c. : the tongue always presents an unnatural appearance in derangements of digestion, and the bowels are seldom regular in their action, or the feces healthy in character; besides this, we find changes in the appetite, in the character of the urine, &c. Each of these symptoms has therefore a twofold meaning; first, as it forms one of a group which proves whether the attack be acute and inflammatory, or chronic ; second, as it stands for one of the signs of disorder in the particular organ; it is very important to bear in mind this double application, and to consider how far each is to be taken as evidence of the general condition which the whole group tends to prove, or derives its importance from mere local circum- stances ; e. g., how far a coated tongue is to be taken as evidence of inflammatory action or of disordered bowels. With reference to the appearance of the patient: any degree of emaciation points out a possible defect in assimilation ; even if it amount to no more than that the usual degree of obesity observed at advancing periods of life is absent, we may still be not far wrong in assuming that the individual is the subject of weak or faulty di- gestion; but extreme emaciation is a very constant consequence of severe abdominal disease. The aspect of the face and the colour of the skin are each of them, again, valuable sources of informa- tion in specific forms of disease. The sensations are not confined to the abdomen: very many of the functional disturbances of the brain (see Chap. XIII.) are only to be accounted for as results of irregularity in the digestive pro- cesses; dyspnoea and palpitation, pains in the sternum or between the shoulders, that pain in the right shoulder stated to be sympa- thetic of disease of the liver especially, are all of them attributable in like manner to abdominal disturbance. In the abdomen itself uneasy sensations are produced by unusual enlargements of organs, by increased irritability in congestive states, and by irritating properties of the contents of the hollow viscera; as also by any 'unusual character of the secretions which prevents the normal changes, or excites others which are abnormal, or renders them un- suited to the membrane which they traverse in their passage. As we proceed with the inquiry we shall find many of the symp- toms thus cursorily alluded to come more distinctly forward as evi- dence of disease of the various organs contained in the abdomen ; 20 306 EXAMINATION OF THE ABDOMEN. but we must first consider what aid may be derived from the appli- cation of physical investigation to diagnosis. First, we obtain very certain information from the exploration of tho outlets, the mouth, the rectum and the vagina; but with the exception of that derived from the state of the tongue, the extent of its application is extremely local and limited. Secondly, the excretions, by their changes in appearance and characters, afford very valuable instruction. The aid of chemical analysis has been brought to bear very fully on the condition of the urine, and in fact our whole knowledge of diseases of the kid- ney may be said to rest upon the chemistry of the secretion; but the same progress has not yet been made in regard to the feculent discharges, and any knowledge that has been gained is inapplicable for the purpose of diagnosis. Thirdly, the most valuable physical signs are derived from (a) inspection, (b) palpation, (c) percussion, on each of which a few words must be said. Auscultation is rarely applicable: in health no regular sounds are heard, which by their irregularity might in- dicate disease ; its employment in abdominal aneurism we have already noticed, and it is also useful in detecting the placental bruit, and the pulsations of the foetal heart in pregnancy. a. Inspection indicates deviations from the natural contour pro- duced by general fulness or local enlargements, serving both to suggest and to correct other modes of investigation. We observe a uniform and equable distention in peritonitis, which contrasts alike with the shrunken and retracted condition sometimes seen in colic and during the pain accompanying the passage of gall-stones, and with the irregular forms of distention of an analogous kind which are noticed in enteritis and obstruction. Similarly the simple inspection of the abdomen points out in many cases a very marked difference between the distended peritoneal sac of ascites pushing out the ribs as well as the abdomen, and the prominent rounded belly of ovarian dropsy, which very frequently evidently projects more on one side than the other. No less different is the aspect of general fulness in pregnancy from local swelling in disease. In the epigastrium the outline of a full stomach, and still more of an enlarged one, may be distinctly defined, and thus afford valuable assistance in the diagnosis of its actual condition. The uplifted ribs on the right side by enlarged liver, on the left by enlarged spleen, each point out the direction in which inves- tigation ought to proceed. b. As a necessary adjunct to inspection, and as a means of ascer- taining the cause of any deviation in form, palpation affords more information than any other means of exploring the abdominal cavity. It often indeed serves to detect deviations from health, which would otherwise escape observation altogether; and very many of the more important characters of disease in the abdominal viscera depend on its correct application. It embraces the sense of resistance or immobility of parts, their hardness and tenderness, and their relative size; it determines the value of pulsation; it in- dicates fluctuation. We might here go over almost all the important diseases of the abdomen, and point out the various lessons which palpation teaches; but they are so important, EXAMINATION OF THE ABDOMEN. 307 that they must be again mentioned in each particular case, and the reader is re- ferred to the section on morbid growths (Chap. IX., Div. II., § 2) for the details of the evidence which it affords in the varieties of abdominal tumour. In making the examination, the student has to consider whether what is felt as a deviation from natural form, consist simply of enlargement of parts, or be absolutely a new growth in so far as this is indicated by outline; next its form, whether smooth and rounded, or nodulated and irregular; and then its attachments, natural and ac- quired. c. Percussion may be said to be almost essential to a correct ap- preciation of the results of both the preceding sets of observations. It gives us the very valuable information whether any visible altera- tion in form be wholly caused by the presence of solid or fluid matter, or chiefly by the presence of the gaseous contents of the intestine; while the degree of dulness heard on percussion where a tumour is felt, determines to a certain extent its depth and thick- ness: it is still more useful in tracing out the origin and connexion of tumours when distention^prevents our being able to reach their attachments with the finger, or where they take their rise under the solid covering of the ribs. It is no less important as it aids in mapping out the extent and form of organs and tumours, as, for example, the shrunken liver, the enlarged uterus, or the distended bladder. When considered in detail, there is no question of diagnosis which the percus- sion of the abdomen tends so much to elucidate as that of ascites and ovarian dropsy. (See Chap. XXXII.) Remarkable resonance forms the chief charac- teristic of tympanites. The absence of dulness on percussion serves to discrimi- nate cases of chronic peritonitis without fluid, from those in which ascites is pre- sent; but the student must be reminded that when the patient is upon his back, a considerable amount of fluid may accumulate in the lower and posterior parts of the cavity, without manifestly altering the resonance on percussion. 308 CHAPTER XXVI. DISEASES OF THE (ESOPHAGUS AND STOMACH. Uncertainty of Symptoms — Sympathetic Affections of other Organs — Diagnosis a Process of Exclusion — § 1, The (Esophagus and Cardiac End of the Stomach — § 2, Organic Lesions of the Sto- mach — Stricture of Pylorus — Ulceration — Gastritis — Dilata- tion — § 3, Functional Disorders of the Stomach — Irritability — Distention — Faulty Secretion — Associations of Dyspepsia. No longer guided by the objective phenomena which serve for such clear indications in the affections, of the mouth and pharynx, we now come to a class of diseases which for their complete inves- tigation require, more than all other perhaps, the exercise of sound judgment and careful discrimination. Making up, as they do, the largest portion of the sum of minor ailments which medicine is called on to remedy, individually, their importance, with one or two exceptions, is not great; and consequently the opportunity of stu- dying them in hospital practice is but small, while that little is too often neglected, from the necessity the student feels of giving his short period of study to the graver or more acute diseases pre- sented to him. The common disorders of the digestive canal may be said to be but three, dyspepsia, constipation, diarrhoea. And yet in each of these conditions how much remains behind — how much to guide our practice, if we but knew it — how much that is as yet obscure, if not quite inexplicable! It is quite beyond the scope of our present plan to enter into all the details connected with so complex a subject as dyspepsia; it must suffice to point out the leading features by which symptoms may be referred to the stomach, and the general characters by means of which one form may be discriminated from another, and so that class of remedies be selected which may reasonably be deemed most suitable. It will probably be advantageous to consider the more severe diseases before inquiring into those which .are less im- portant. Much of the uncertainty that attends our knowledge of disorders of the stomach is caused by the necessity of relying so much on the sensations of the patient, since in many cases no anatomical lesions have been clearly associated with the symptoms detailed. The practitioner is consequently obliged to theorize as best he may on the h priori effects which he would expect from faulty secretion, de- ficient muscular action, and nervous irritability, to contrast these inferences with sensations, the real import of which he can only guess at, because the descriptions of the patient are generally so faulty, that in asking questions he often suggests the very answers he receives. A dyspeptic physician is very likely thus to mislead DISEASES OF THE (ESOPHAGUS AND STOMACH. 309 both himself and his patient, by rendering their sensations into the language of his own ailments. The information we derive is obtained from three distinct sources, the sympa- thetic affections of the head and those of the chest, and the symptoms more di- rectly obtained from the stomach and abdomen. In the head, pain, vertigo, par- tial blindness, temporary derangement of function, &c. In the chest, cough, and especially palpitation, local pain, &c. For the grounds of distinction, by which these functional disturbances may be recognised, reference must be made to the chapters on the diseases of those organs; here suffice it to say that the symptom generally stands alone; there is no other traceable to the same region, such as there certainly would be were the single symptom a sign of disease there; more es- pecially, it is transient, and generally of frequent recurrence, so that a patient per- haps complains of palpitation, when heart and pulse are alike quiet and normal at the time of examination, to be again excited by the same sympathy which had previously caused it. But, in addition, some other symptom, or rather train of symptoms, will be found in connexion with the stomach; loss of appetite or vomiting, sense of weight, distention or pain, either referred directly to the stomach or distinctly aggravated by the opposite states of either fasting or repletion, combined generally with ir- regularity of the bowels, constipation, or relaxation, or an alternation of both con- ditions. The seat of the pain or uneasiness varies a little within certain limits; but there will generally be no difficulty in assigning it to its proper source, by in- vestigating the conditions and signs of disease in adjoining organs, which might by possibility give rise to similar symptoms. f In dyspepsia, as in hysteria, when the pathology of the distur- bance is so little understood, the only safe principle of diagnosis is that of exclusion. The possible conditions of the brain, of the lungs, and of the heart must be duly weighed, and attention must also be paid to the condition of other abdominal viscera. § 1. The (Esophagus presents only one form of disease, — a cer- tain degree of closure either from stricture or from spasm. The complaint of the patient is of difficulty in swallowing, a sensation of the food stopping somewhere in its course, and its being, again brought up. The distinctive feature of this state is, that the re- turn of the food is immediate ; very few mouthfuls can be swallowed, perhaps no more than one before the pain and discomfort become such that the patient cannot proceed till that has been rejected; and the difficulty is always proportioned to the solidity of the food, fluids continuing to pass when no solid matter is received into the stomach at all. The rejected matter is simply masticated food, and has no smell of acidity, nor does the patient perceive any taste of bile. True stricture comes on very gradually and insidiously, is ac- companied by marked emaciation, and generally attended with a sense of hunger which cannot be relieved in consequence of the impossibility of filling the stomach with food: if necessary, the diagnosis may be made still more clear by introducing the probang. The closure from spasm is generally more suddenly developed, and is not attended by the same constitutional effects. In stricture the condition is permanent, and the only perceptible difference in the power of swallowing is due to the quality of the food; in spasm 310 DISEASES OF THE (ESOPHAGUS AND STOMACH. the difficulty varies in consequence of circumstances for the most part inappreciable. The remote cause of spasm would appear Sometimes to be mere nervous irritability; in other cases it is clue to local irritation of some portion of the mucous membrane, or to the pressure of a tumour on the oesophagus. In spasmodic stric- ture the probang can be passed, although it meets with some resist- ance, when any local cause of irritation exists. The circumstances here referred to apply equally to disease of the cardiac opening of the stomach, which produces an exactly analogous effect in regard to the introduction of food, as that of closure of the oesophagus, and therefore need not be considered separately. In seeking for characters by which these diseases may be distinguished, we ob- serve that any evidence of "exaltation" or of nervous irritability in other organs. prepares us for the existence of a similar condition in the oesophagus : if we learn that any thing liable to irritate the membrane has been swallowed, or if we find any redness or spots of ulceration on the fauces, we suspect the coexistence of spasm with local irritation: if a tumour exist, we should have concomitant evidence of pressure on the trachea. It further deserves notice, that occasionally ulceration of the epiglottis and im- perfect closure of the entrance of the windpipe excite coughing, so immediately upon the act of swallowing, that great part of each mouthful is returned before it can pass the irritable spot. Here there is not necessarily any spasm of the oeso- phagus; and, if along with the known existence of cough, and probably also of hoarseness or raucous breathing, the act of deglutition be watched, its cause will be at once revealed. § 2. Organic Diseases of the Stomach. — The two most important lesions found in the stomach are stricture of the pylorus, which is very often cancerous, and simple ulceration of the mucous mem- brane. Gastritis is a disease of very rare occurrence in its acute form ; dilatation is most commonly the result of partial closure of the pylorus, but possibly also commences as an idiopathic disorder. a. 'Stricture of the Pylorus, in its earlier stage, cannot be dis- tinguished from mere functional derangement; and when, as very commonly happens, dyspepsia is conjoined with it, the patient may appear to recover under treatment while yet the disease proceeds unchecked. The most constant symptom of stricture of the pylo- rus is vomiting: but I have seen the disease run on to a fatal ter- mination, in which, during a long period, that symptom was absent in consequence of an ulcerated opening communicating with the duodenum. When accompanied by ulceration, there is usually, at some period or other, grumous vomiting, which owes its appearance to a small quantity of blood, altered by the secretion of the sto- mach; sometimes there is more copious hemorrhage. The stomach may become enormously distended: indeed dilatation probably always exists, more or less; but it is much greater in simple thick- ening than in scirrhus of the pylorus, when the stomach is more irritable, and its contents more speedily rejected. Several meals, or even the food of three or four days, may be, in great part, ac- cumulated before it is rejected, or, on the other hand, the vomiting ORGANIC DISEASES OF THE STOMACH. 311 may occur after every meal: the longer interval proves the exist- ence of dilatation, if any thing like the whole quantity of food be rejected; the constant recurrence of the vomiting after food shows that there is a condition of irritability. The absence of signs of dilatation, when the vomiting occurs at longer intervals, and the return of the food after every meal, are each of them more favourable than a certain degree of dilatation with vomiting once or twice in the day, or at intervals of two days. The progress of the case is usually rapid when the disease is of a malignant character; the symptoms are unrelieved, or recur with greater severity; the aspect of the patient becomes wan and sal- low, with increasing emaciation: there is often lowness of spirits and despondency; and sooner or later, in most cases, the presence of a hard mass in the region of the epigastrium, towards the right side, leaves no doubt of the presence of scirrhus. Though analogous in the fact of partial closure of the pylorus, the two diseases run a very different course; the difference being caused chiefly by two circum- stances: the one, that along with the stricture there is a morbid condition of the mucous membrane in cancer, giving rise to irritability, ulceration, grumous vo- miting, &c; the other, that when the disease is constitutional, the altered condi- tion of blood, which attends its progress, necessarily renders it more rapidly fatal than mere thickening of the pylorus. The non-malignant form of stricture may be recognised by its frequent occurrence among spirit drinkers; by the accom- panying dilatation, the absence of hemorrhage, the circumstance that no tumour can be felt, and most especially by its slow progress: if the symptoms have existed for years, or even for many months, without a cachexia being established, the pro- babilities are greatly against cancer. The occurrence of hemorrhage in any large quantity in cancerous disease is the exception. At first, the blood only appears as small black or brownish flakes in the vomit, but, at a later period, assumes the character of what is called coffee- ground vomiting, the amount of blood in which may be considerable ; distinct he- morrhage is more probably the result of simple ulceration. We look with great distrust upon symptoms of uneasiness after food, eructations, occasional vomiting, and depression occurring in persons of temperate habits, unrelieved by treatment, or progressively getting worse, and attended with any degree of emaciation and sallowness. It does not seem possible generally to distinguish different forms of cancerous growth during life. It is only known that medullary cancer grows much more ra- pidly; that colloid, even if present in the stomach, is more abundant in its usual site, the mesentery; and that scirrhus is commonly the most painful of the three. Scirrhus is the most local ; encephaloid and colloid spread more rapidly, the former usually coexisting in the liver ; in cases in which scirrhus has spread, it is also to the liver. While we are taught much by the aspect of the patient, we learn little from the state of the pulse, tongue, bowels, &c. : there is generally constipation, in conse- quence of the small quantity of food which passes downward, and the tongue is often coated at the back; the pulse is for the most part weak, but seldom accele- rated. b. Ulceration. — But little is known of this disease in its clinical history; the symptoms seldom present any degree of uniformity in the cases which have been watched to a fatal termination ; they often fail to suggest the idea of ulceration at all, and at best the con- clusion regarding its existence can only be hypothetical. Extreme 312 DISEASES OF THE (ESOPHAGUS AND STOMACH. pain commences immediately after food is taken, and before di- gestion can possibly have begun, especially if excited by water or bland fluid, a pain which is localized in a particular spot, and always recurs at tbe same place, affords perhaps the most conclusive indica- tions. Ilrcinatemesis in an otherwise healthy individual is often due to the same cause: but either may be wanting, and there is nothing to be recognised beyond ordinary dyspeptic symptoms. In some few 7 instances the tongue looks red and raw, or spots of ulceration may be seen on it, or on the lips, indicating a generally depraved con- dition of the mucous membrane, one manifestation of which may be ulceration of the stomach: much more frequently, however, this state of the mouth is associated with ulceration, or irritation of the bowels. It must not be overlooked that simple ulceration of the stomach is not a com- mon pathological state in the bodies of persons dying of other diseases, and there- fore we must not hastily predicate it of a person suffering from dyspeptic disorder. Besides the simple ulcer, with the origin of which we are unacquainted, we meet with ulceration associated with malignant disease, at parts distant from the py- lorus. The same obscurity of symptoms attends this as the other forms of ulcera- tion, unless grumous vomiting occur to point more directly to its cause, or a tu- mour be felt somewhere in the epigastrium; and we may then be puzzled to ex- plain the absence of obstruction. We also find destruction of the mucous mem- brane, and consequent ulceration remaining as a permanent result of the corro- sion and inflammation caused by irritant poisons, especially the mineral acids and alkalies. The history of recovery from the acute attack, with abiding tenderness of the stomach and inability to take food without great distress, would point out the true nature of such a case. In speaking of hajmatemesis (Chap. VII., Div. II., \ 3,) the different forms of hemorrhage were enumerated; and it may be here added that, when preceded by local symptoms referrible to the stomach, that which occurs early in life, and is abundant and more florid, is probably caused by simple ulceration; that which is seen in advanced life, and is small in quantity and grumous in appearance, is pro- bably connected with malignant disease. If the blood have been brought up at some previous period, and the symptoms continue stationary, we may feel consi- derable confidence that the disease is not cancerous. c. Gastritis. — The occurrence of idiopathic gastritis is so rare in clinical medicine that practically it need scarcely be referred to. It is, indeed, only known as the consequence of the ingestion of some irritant, probably of the nature of an acrid poison; but in rare in- stances it has followed the taking a draught of cold water when the body was much heated by exercise, or has been caused by indi- gestible food. Both the simple ulcer and the thickening of the pylorus without malignant growth have been referred by some pathologists to chro- nic gastritis; but they have been unable to point out any characters by which the gradual changes can be recognised, before they have reached the points at which we have attempted, though so ineffectu- ally, to make them subjects of diagnosis. The symptoms of acute gastritis may be seen as part of more general inflammation of the peritoneum, when the stomach is in- tolerant of the least portion of food or drink; these again may be closely simulated by sympathetic irritation of the stomach in in- flammation of the brain. FUNCTIONAL DISORDERS. 313 d. Dilatation must be noticed, as it is found in cases in which, from the duration of the disease, there must always be some doubt as to the existence of organic lesion. It is probably connected, when of great extent, with some degree of obstruction to the pylo- rus, but may, likewise, be a consequence of habitual distention and loss of muscular power. In its minor form it gives rise to extraor- dinary tympanitic resonance over the whole of the lower part of the left side of the chest as high as the axilla ; in its more^ggravated condition it forms a sac which almost fills the abdomen, and has even given rise to the idea that the patient was labouring under ascites. In the former case, the complaint of pain on the left side will na- turally lead to percussing the chest; and the tympanitic sound ex- tending below the edges of the ribs, as well as above, taken in con- junction with the slow progress of the ailment, can leave no doubt as to its true character. In the latter there is generally a history of occasional vomiting, when very considerable quantities of fluid have been brought up ; and if this have occurred recently, extensive tympanitic resonance will be observed extending over the epigas- trium and left side generally; if for some days there have been no vomiting, we find distinct fulness below the epigastrium, of a rounded form, extending in the direction of the umbilicus, and passing thence towards the left hypogastric or lumbar region, superficially tympani- tic, but accompanied by deep fluctuation, with gurgling noise on movement, which has been mistaken for succussion. Latterly, a valuable aid to diagnosis has been obtained from the discovery of the microscopical sarcina ventriculi in the vomited mat- ter, which always betrays a great tendency to ferment. This ap- pears at present to indicate no more than a retardation of the food in the stomach, with a want of power completely to empty its con- tents; and we are consequently led to associate its existence with the probability of a condition of dilatation, especially that which ac- knowledges thickening of the pylorus as its cause. § 3. Functional Disorders of the Stomach. — Dyspepsia proper, accompanied by its multifarious symptoms, can only be safely pre- dicated when, after careful weighing of other possible states of sys- tem, we find a remaining amount of disturbance which we have failed to account for in any other way. And hence it is a rational conclusion that dyspepsia does coexist with different states which, while sufficient to account for some of the symptoms, leave others unexplained. It stands in close relation to most diseases of the ab- dominal viscera, either as their cause or their effect; and it may be associated with almost every chronic ailment, so as to make it diffi- cult to determine, when we are satisfied of the coexistence, what their exact relations are to one another. Such, for example, is its combination with anaemia and hysteria; in both quite as frequently the cause as the consequence of the general state; in both alike de- manding distinct recognition and separate treatment. OU DISEASES OF THE (ESOPHAGUS AND STOMACH. It is very important to remember, with reference to the stomach and its dis- orders, ill it almost every patient, no matter how ignorant or ill-informed, frames to himself, according to his amount of knowledge or prejudice, a theory of his ail- me attribute-! to indigestion all his sufferings, another constantly alleges that he is bilious, a third is not satisfied unless he is well purged, and a fourth, who relishes the pleasures of the table, is slow to admit that his stomach is over- taxed or unequal to the demands made upon it. No cause more frequently leads to wrong diagnosis than forgetting to separate between the true narration of symp- toms and sensations, which are our only guide in this class of disorders, and the constructional' a theory which no patient is able to form correctly in his own case. Social progress would stand still for ever if nothing were to pass current but bare description; yet, in the history of a case, every thing else should be rigidly excluded; and it is better to trace out the disease as we do in childhood, by our unaided ob- servation, than to admit into our conception the statement of the patient that he is "bilious." No more expressive term exists for a certain condition of body than this; it is as true, strictly and legitimately true, as "fever," "rheumatism," &c: but it theorizes — it is a compendious expression of certaiu symptoms; and it is the duty of the physician, not of the patient, to determine whether this implied theory properly expresses the category of symptoms or not. In the present day, no ororan is more hardly deilt with than the stomach: whether we consider the starvation and improper food of the poor, the irregular hours of the man of busi- ness, the pampering and overfeeding of the rich, or the still more pernicious dis- regard of the proper evacuation of the effete contents of the alimentary canal, which false delicacy, sedentary habits, and sheer inattention produce. The habits of the patient therefore afford a further help to diagnosis, as one of the elements in the history of the case. The symptoms of dyspepsia may be referred to three distinct heads — pain, or nervous irritation, impaired muscular action, and faulty secretion. In their analysis, it is to be remembered that while pain is an evidence of irritability, and thus perhaps simply of faulty innervation, it may also depend on the condition of the mu- cous membrane, and the character of its secretion, or an -over-dis- tention and spasmodic contraction of the muscular fibre. Similarly, though distention be essentially the fault of the muscular structure, ■which has become relaxed, weak, and ineffective, yet this very weak- ness may be a symptom of nervous debility, or may be simply Caused by distention with gas, generated because the secretion is imperfect. In the same way, faulty secretion may be directly traceable to the condition of the mucous layer and follicles, but may also result from imperfect nervous or vascular action, or follow on the detention of food in the viscus from deficient muscular power. Nothing, indeed, can be more erroneous than the limitation of each of these effects to that particular structure which is directly concerned in their pro- duction. But we are not on this account to disregard the informa- tion thus conveyed; on the contrary, pretty nearly all the complex cases that come before us may be resolved into these three simpler elements — irritability, distention, and faulty secretion: caution is chiefly to be exercised in theorizing that this or that particular func- tion is the one primarily deranged. a. Irritability presents a great variety of phases, which receive from patients as many different appellations. It is often manifested in extreme intolerance of food; beginning by slow degrees, it at FUNCTIONAL DISORDERS. 315 length becomes such that every meal is rejected, and sometimes the quantity of food must be reduced to a mere spoonful, and its qua- lity be the very simplest and blandest possible, to prevent its rejec- tion. Such a form of irritability may be produced by ulceration, but is certainly not limited to it. Pain, referred so often by the hys- terical to the left side, or described as passing through the chest and being felt between the shoulders, or perceived in the centre of the sternum as well as over the epigastric region; a feeling of emptiness or craving, which, relieved for a short time by food, returns in its full extent before the stomach can by possibility be emptied; sen- sations of fulness, weight, dragging, &c. ; gnawing, cutting, tearing pains, &c, — must all be regarded as evidence of irritability. It is ma- nifestly impossible to assign to all of these their true pathological im- port, or even to guess why they are so differently described ; but it is of service to consider their relation to the ingestion of food, as tending to show in some measure their exciting cause. Thus, if the disagreeable or painful sensation be observed shortly after food is taken, — if some kinds of food produce it at once, and Others not at all, especially if bland fluids do not excite pain, as they generally do in ulceration, we should have strong reasons for believing that the symptom was chiefly nervous, that the irritability of the stomach was the primary affection. "Whereas, if a longer interval must elapse before the sensation be aroused, if it be accompanied by acidity or eructation, or if it exist when the stomach is empty, being rather relieved by the presence of food, we shall probably be right in re- garding it as symptomatic of faulty secretion. If a sense of weight or dragging be the form assumed, and it be experienced at a still later period, we may assume that there is some delay in the process of emptying the stomach, either as a consequence of torpidity of muscle, or more commonly as the effect of over-distention : still more, if the pain be of a spasmodic character, and very late in its occur- rence, it may be referred to the ineffective contractions of the mus- cular fibre distended beyond its proper limits, and vainly attempting to expel crude and half-digested aliments to which the pylorus re- fuses egress. h. Distention. — Dilatation, in its minor and less important signifi- cation — more probably distention or relaxation of muscle, indicated by the pain just referred to, and by the existence of unusual reso- nance — is more likely to be primary in persons of lax, flabby, mus- cular structure, than in those who have firm resilient flesh. Such a condition is more probable if there be coexisting constipation and want of intestinal peristaltic action, if the appetite be unaffected and the first stage of digestion easy; but it can scarcely persist without reacting on the mucous membrane, through the delay of the food in the stomach: and hence it becomes complicated by evi- dence of faulty secretion. On the other hand, one of the most constant effects of imperfect digestion is the generation of flatu- 316 DISEASES OF THE (ESOPHAGUS AND STOMACH. lence, which must necessarily distend the stomach till it find an outlet; crude and ill-digested food must also necessarily be delayed in passing the pylorus, whether the muscular action be at fault or not; and it is therefore by no means easy to say how much is due to the imperfection of the muscle, and how much to the defect of the secretions. More easily recognised are those cases in which the distention, the discomfort, and the delay of the digestive process are all of them caused by overloading the stomach, which sooner or later rebels against the habitual overtaxing of its powers. It may still be capable of disposing readily of a moderate meal, but it re- fuses to propel a large mass of heterogeneous contents: in such cases, probably the actual overstretching of the fibre is a more efficient cause of the distention than the character or quantity of the secre- tion. c. Faulty Secretion. — Manifestly combined with both the pre- ceding conditions, this cause of dyspepsia is perhaps the most fre- quent and tlae most difficult to manage. It is related to various conditions of health, acting either through the vascular or nervous system, but seems to be also primary and independent of them. (1.) Hyperemia. — Passing by the form of acute gastritis, we come to the congestion characterizing a fit of indigestion brought on by excess. Here the history of the case, if correctly given, leads at once to the true diagnosis: the attack is recent; all the symptoms severe; the tongue is generally foul and flabby; the bowels confined, or a good deal relaxed, but without febrile symp- toms. A timely emetic, imitating the relief which nature some- times provides, might have prevented the subsequent congestion ; but when once excited, the irritation may not subside after the in- gesta have passed into the bowels; vomiting may come too late, and persist even for days; the bowels, if unloaded by an aperient, be- come again confined, or are affected with diarrhoea. Congestion of the liver generally plays a prominent part in such conditions; but congestion of the stomach is equally evident as the direct effect of a debauch; and there is not only perverted secretion, but irritability dependent on the sort of erythematous condition of the mucous membrane which the very idea of congestion implies. Similar results are, no doubt, also traceable when the congestion of the stomach is of that passive form which, in its very marked examples, is accompanied by hrernatemesis, and is produced by obstructed hepatic circulation. General plethora evidently cannot be a cause of dyspepsia, because any interference with the action of the sto- mach would immediately reduce the quantity of material converted into blood, and of necessity diminish the plethora; but probably a fit of indigestion would be more severe in the plethoric individual than in another. (2.) AnEemia, on the other hand, is unknown as a local affection, but, as a general condition of system, evidently exercises great in- FUNCTIONAL DISORDERS. 317 fluence over the secretion of the stomach. When, therefore, we find dyspeptic symptoms associated with the aspect of thin and poor blood, the only question can be whether they are wholly dependent upon the anaemia, or have any separate cause ; and this is best known by ascertaining which class of symptoms, the dyspeptic or the anaemic, had the priority in commencement. And if the complex disorder began by the imperfect action of the stomach withholding the due supply of pabulum to the blood, we must still admit that the consequent anaemia will aggravate the dyspeptic symptoms ; just as we know that imperfect digestion, though caused by anaemia, necessarily tends to increase that state. It is probably in this way that bad food and chronic wasting diseases excite, as they occasion- ally do, persisting forms of dyspepsia, as they necessarily deterio- rate the quality of the blood: bad food does not primarily excite permanent disorder. (3.) In some forms of disease a specific blood-crasis seems to exist, which has a close relation to the secretion of the stomach. To this class we might legitimately refer the inaptitude for digestion p'roduced by inflammatory and febrile diseases ; but it must rather be restricted to indigestion arising in the gouty diathesis, the dys- pepsia of drunkards, &c. In other cases the dyspepsia is more distinctly associated with disturbance of brain and mental excite- ment; when it becomes difficult to say whether the effect be produced through the medium of the blood or of the nerves. (4.) There yet remain very numerous instances of dyspepsia, in which faulty secretion seems to be the principal cause of the defect in the digestive power, where we cannot trace it back to any ante- cedent circumstances, and cannot explain the agency by which it has been established. Among them we include cases characterized by heartburn, pyrosis, flatulence, nausea, loathing of food, vomiting, disagreeable tastes in the mouth, &c, which occasionally occur in persons in comparative health, and are found to yield to the simplest treatment, but which, in their habitual persistence, become so rebel- lious and intractable. . Under any of these circumstances the secretion of the stomach may be very variously modified. Thus, it may be deficient in the special principle (pepsine,) which acts as a solvent of the albuminous substances ; all animal food whatever will be found by the patient difficult of digestion; and as a consequence of its imperfect solu- tion, fetid gases will be evolved, and unaltered fibres will be seen in the evacuations; or, again, the secretion may be of such a cha- racter as to set up a process of fermentation rather than digestion, with the development of acid and flatus, which is very constantly associated with diarrhoea: or there maybe excessive secretion, of feeble power, rising up and filling the mouth with tasteless fluid when the stomach is empty. The first of these is the condition most frequently resulting from strain of mind; the second is the common precursor of gout; the third is the usual result of bad 318 DISEASES OF THE (ESOPIIAGUS AND STOMACH. and insufficient nutriment: but each of them may be met with casu- ally, or even persisting for a considerable period, without any such definite causes. This short sketch would be incomplete if no allusion were made to the spasmodic pain which attacks persons subject to gouty dys- pepsia, and commonly known as gout in the stomach. Its plaee would seem to be in that class of cases in which irritability is a prominent symptom, as it is especially marked by violent pain in the epigastric region ; it is generally, however, preceded by symp- toms of faulty secretion, and passes off with a discharge of flatu3 from the stomach. It has been already stated that dyspepsia is frequently associated with other chronic diseases: we especially look for anaemia and emaciation in its slighter forms; and in females for hysteria and functional derangements of the uterine or- gans. Among its causes we must not forget the possible effect of deleterious agents; not only those which are distinctly recognised as poisons, but those also which bear the name of luxuries, such as tobacco and fermented liquors. Tuber- cular diseases may give rise to symptoms of dyspepsia, and they are occasionally also first betrayed by them. The condition of the liver and the functions of the brain must be each inquired into, both as causes and complications of disordered stomach. Changes in the character of the urine will be found sometimes depend- ent solely on the mal-assimilation of nutriment; and sometimes, while affording evidence of disorders especially referrible to the kidney, are still very much in- fluenced by the condition of the digestion. Skin diseases, in like manner, have a very close relation to dyspepsia. 319 CHAPTER XXVII. DISEASES OF THE INTESTINAL CANAL. •imary. Division — General Relations of Inflammation. V. I. — Diseases attended with Constipation. — § 1, Constipation — Prima, Div. _ § 2, Enteritis— •§ 3, Ileus— § 4, Obstruction. p IV , n. — Diseases attended with Relaxation. — § 1, Diarrhoea — § 2, Dysentery — § 3, Ulceration. Div. III. — Diseases attended with altered Secretion. — § 1, Dis- ordered Bowels — § 2, Tympanites. All diseases of the intestinal canal have one feature in common, that they are accompanied either by constipation or relaxation, or by an alteration of these two states. This is detailed as part of the necessary history of the case; and it again comes before us in the inquiry which we have supposed it necessary to make into the evidences of the general state of the patient before commencing the investigation of individual organs: it will therefore, perhaps, best serve our present purpose to adopt this common feature as the basis of classification, and so follow out the symptoms which are available in discriminating the various conditions which these cir- cumstances serve primarily to indicate. It is necessary, before proceeding further, to make a few remarks on the subject of inflammation, to point out more clearly its relations to the action of the bowels. Idiopathic gastritis is almost unknown: peritonitis, as we shall see, is more com- mon: inflammation of the stomach is sometimes conjoined with that of the peri- toneum; but inflammation of the bowels is so more frequently, in consequence of their greater extent of surface. Enteritis, as a primary affection, holds a position in regard to frequency be- tween gastritis and peritonitis; but even when the inflammation seems to have begun in the bowel, it is almost always found to have affected the peritoneum ; so that in general it is not easy to say which disease has been first in the order of succession. The cases of enteritis "without peritoneal inflammation are among the curiosities of medical literature; and possibly the highly susceptible membrane of the peritoneum is the first to take on inflammatory action, whether the irritation have been conveyed to it from within or from without. The disease known as enteritis consists of inflammation involving all the structures and especially the muscular coat of the canal; and by common consent, inflammation of the mucous membrane alone is not meant, when the name enteritis is employed. A know- ledge of these relations is of great importance in symptomatology; because, first, the inflammation involving the peritoneum produces great tenderness on pressure; secondly, the inflammation of muscle produces paralysis, with interruption of pe- ristaltic action and constipation; and thirdly, the inflammation of other mucous membranes teaches us that the primary effect may be suppressed secretion ; but that this is soon replaced by increased and altered secretion, perhaps by effusion of blood — active hemorrhage. 320 DISEASES OF THE INTESTINAL CANAL. Div. I. — Diseases attended with Constipation. § 1. Constipation. — Let us assume that the other indications of the general state of health do not point to any febrile disorder. The tongue indeed may be coated, and the appetite bad; but thirst is not urgent, the skin has no unnatural heat, and the pulse is quiet: any specialty of the urine must be considered separately. In this simple form the patient merely seeks a remedy for constipation of the bowels. We inquire into the condition of the stomach, and most commonly find some indication of dyspepsia; and it may be a question which of the two is primary: we seek also for evidence of biliary derangement, knowing this secretion to be of paramount importance in aiding the expulsion of the feces. In such a case we derive much information from its history: the progress of the disorder has been gradual; the patient has had costive bowels for years probably, before he has consulted any one on the subject; he has taken aperients, and then again has tried to do without. His habits next serve to point out the nature of the evil: he has perhaps led a sedentary or irregular life; and in addi- tion to this, his food may have been either luxurious and over-stimu- lant, inducing plethora; or it may have been the reverse, and he has become anaemic. Patients, too, as they consider themselves competent to manage their own bowels, have something else to com- plain of when they seek advice — head-ache, occasional colic, or congestion of the lower abdominal viscera, resulting in hemor- rhoids, or in uterine hemorrhage or leucorrhoea. The two principal causes of constipation seem to be deficient se- cretion and want of peristaltic action: plethora rather points to the former, general anemia, or atony to the latter. But in the end, accumulation of feculent matter proceeds, the muscular fibres are necessarily stretched, and become incapable of contracting effi- ciently: the fluid portion is absorbed, and masses of hard impacted faeces remain in the bowels. Just as in other involuntary- muscles, the constant result of over-tension and imperfect power, is spas- modic and irregular action — colic, of which a very important variety has been mentioned as the effect of lead poisoning: the symptom is the same, Avhether there be lead in the system or not; but the blue line indicating its presence ought in such circumstances always to be sought for (see Chap. VI., Div. I., § 3.) A very important result of this imperfect action is, that the feces get impacted and indurated in the colon and rectum : this is followed by thin watery secretions, which find their way past the hardened mass, and lead the patient to imagine that he is suffering from diarrhoea, and to use astringents, which increase the disorder. The abdomen becomes tumid; dull percussion sound on the left side and over the brim of the pelvis indicates the existence of accumulation; and when pur- gatives fail to act, it may be suspected that there is some physical impediment to its egress, and the case puts on the characters of obstruction. ENTERITIS. 321 § 2. Unteritis. — This disease is only distinguished from other forms of obstruction by the presence of fever: it is accompanied by inaction of the bowels after the administration of purgative medicine, pain of every variety of intensity, and vomiting, which is apt to become fceculent or stercoraceous. A broad line of distinction is first found between those cases commencing suddenly without previous constipation, and those in which the attack is a mere aggravation of a pre-existing state. Colic has been mentioned as one of the results of habitual costive- ness ; but it is still more common when constipation i3 caused by some error in diet, or by some hardened mass unexpectedly inter- rupting the progress of the excrementitious matters, when the bowels had been acting regularly ; it occurs as a spasmodic and grinding or twisting pain, which is not at first accompanied by tenderness, but, on the contrary, is relieved by pressure. This circumstance serves at once to distinguish it from that of peritoneal inflammation: it is more liable to be confounded with the pain caused by the pas- sage of a gall-stone (see Chap. XXIX., Div. I., § 5.) By judicious treatment the peristaltic action perhaps once more returns to regu- larity, the bowels are evacuated, and the patient is restored to health. But if the remedies fail, the pain is soon accompanied by tender- ness, the spasmodic action ceases, and is followed by paralysis, in con- sequence of inflammation ; febrile symptoms are developed, medicines are rejected by vomiting, and no action of the bowel takes place; the pain is more permanent, its exacerbations and intermissions are less marked ; in short, enteritis has supervened in consequence of the obstruction, and there is more or less of its accompanying peri- tonitis: in the further progress of the disease, the abdomen becomes tense and tympanitic, the pulse small and thready, vomiting, which is partly stercoraceous, is followed by hiccup, and collapse, and death. These symptoms, however, may be developed without the pre- vious existence of any thing resembling colic; tenderness may exist from the first, and the inflammation may have arisen without the intervention of any obstructing cause; and then it has probably travelled from without, beginning in partial, local peritonitis, and obstruction only occurring as a consequence of the inflammation of the bowel. In both classes the existence of the inflammation is shown by the permanence of pain, the presence of tenderness, and the existence of febrile action ; and the question as to what was the exciting cause is one of minor importance. Indeed, any history which seems to point to obstruction, and the prominent symptom of inaction of the bowels, are both very apt to lead us away from the important fact of enteritis being really present. § 3. Ileus and Intussusception. — Physicians of the largest expe- rience and most comprehensive judgment have failed to deduce from the symptoms, indications which can be regarded wholly trust- 21 022 DISEASES OF TIIE INTESTINAL CANAL. worthy as to the nature of this disease. Its commencement is very analogous to the first form of enteritis just spoken of: the colic is more severe; there is usually complete remission of pain for a while, which again returns with increased violence. In contrast to simple colic, the spasm is more regular in its recurrence, there is less sensation of twisting and grinding, and more of a continued paroxysm, caused by the violent and energetic action of the muscu- lar fibre to overcome the obstruction: the large coils of intestine may sometimes be felt rolling and turning over in the abdomen during its continuance. In the progress of the disease when the bowel is inverted, paralysis of fibre induced by inflammation, acts as a further impediment, but primarily the obstacle is mechanical. As in enteritis, the cause of its occurrence may be the presence of some solid mass in the intestine : the symptoms of the two affec- tions are therefore often intermingled together, and the success of treatment may depend on a discrimination of their coexistence. In the first-mentioned form of enteritis, for example, a very limited amount of inflammation in the immediate proximity of the solid sub- stance may give rise to manifest and characteristic evidence of some form of obstruction; and yet, on the fact of the practitioner recog- nising and obviating the slighter and less-marked condition of local inflammation, may entirely rest the safety of his patient. Closely resembling intus-susception are those cases in which the bowel is enclosed in a band of adhesion when at first there is no in- flammation : the history maybe simply that the bowels have not acted, that medicine has been taken without effect, that sickness has come on, and, finally, that paroxysms of pain have recurred at intervals: or the order may be inverted, violent pain having first occurred, accompanied by vomiting from the commencement; and it is only discovered at a later period that the bowels will not act: or, again, the vomiting may be absent in either case for a considerable period. In all of them there is ultimately more or less of inflammation set up ; and if the patient be not seen till then, hope may for a short time linger over the possibility of relief following on the use of antiphlogistic measures, which is only dissipated by the utter fu- tility of the most judicious treatment. § 4. Obstruction. — The rules of diagnosis are so obscure, that a large number of cases must be classed under this head of which the only fact known is that the bowels obstinately refuse to act: but as in enteritis we found that very generally the attack commenced either with colic or tenderness on pressure, that in ileus the stoppage oc- curred suddenly without previous derangement of bowels, so we find in this class that long-continued constipation has usually preceded the obstruction. Here we have clearly two possible states — a gra- dually diminishing calibre of the bowel, or a condition of extreme distention from long standing accumulation and impaction, which are both quite different from those already referred to ; but the mere OBSTRUCTION. 323 fact of habitual constipation, although of great importance, does not necessarily indicate either condition ; the habit may exist with- out the evil effect. In cases of obstruction we have the additional fact of the bowels being loaded with feculent matter: when no or- ganic disease exists, this always occupies the lower end of the colon ; when pressure from without is the cause of obstruction, the accu- mulation will also generally be found where the bowel is fixed near its outlet: stricture usually affects the rectum or the lower part of the colon. In some rare cases it happens that the narrowed portion is found high up, and then large accumulation cannot take place; in such instances there is a great resemblance to ileus. In cases of obstruction we derive much help from physical dia- gnosis. Having first learned the fact of constipation, we endeavour by palpation, to discover the position of the distended bowel ; the pelvis must be explored in search of a tumour which might press on the canal from without; and, lastly, the rectum itself must be ex- amined to determine the presence of impacted faeces, or discover the position of stricture by digital examination and the introduction of instruments. This exploration ought never to be omitted when the bowels are obstructed; and much light is always to be obtained from the simple, and it may be said necessary employment of injections. When carefully performed, the amount of liquid that can be slowly injected into the canal may be said to be a direct measure of the extent of permeable intestine situated below the obstruction. In all cases in which it is towards the lower part of the bowels, vomiting, if prolonged or repeated, is apt to present a stercoraceous character. One or two points afford occasional aid in determining the position and charac- ter of the obstruction. If the point at which pain is felt be also that at which we can trace the transition from a distended to a collapsed and empty state of the canal, we may feel pretty sure that this is the point of obstruction : the condition of the colon, which through its whole extent is comparatively fixed and immove- able, especially demands examination with this view. Both symptoms, however, are apt to be indefinite — the pain extending over the whole abdomen — the rela- tion of the distended portion to the rest of the intestine not to be recognised: and this is especially true when the small intestine is affected. A less trustworthy sign is derived from the urinary secretion, which is generally scanty when the obstruction is high up, and more abundant when it is situated lower down. This is very liable to be interfered with by other circumstances, such as the existence of fever. Still less reliance is to be placed on the allegation that vomiting comes on earlier, aud is more distressing when the obstruction is high up. Of the cases of sudden stoppage, it may be said in general terms, that about one-third are due to intus-susception, one-third to some form of internal strangu- lation, and scarcely one-third to all other causes together. We incline to believe the cause of the obstruction to be invagination, if a little bloody mucus be passed by stool, if a sudden pain were felt before vomiting had been experienced, and when constipation had not been known to exist; we more readily assume that the gut is strangulated by a band of adhesion, if we can make out from the patient's history that he has had an attack of abdominal inflammation at any previous pe- riod: in their subsequent progress the former is more frequently associated with inflammatory fever than the latter. By far the greater number of cases of gradual obstruction depend on stricture, too frequently cancerous: it is scarcely necessary to allude to an appearance oc- casionally observed, that the fteces have been for some time previously of small 32-4 DISEASES OF TEE INTESTINAL CANAL. diameter, because in such a case the constriction of the bowel must be quite within the reach of physical examination. But, it may be observed, that a previous his- tory <>(' long-continued diarrhoea, with unhealthy discbarges of pus, blood, &c, the probability of contraction as a sequence of the ulcerative process at a burlier portion of the canal. Enteritis has to be distinguished from peritonitis, with which in some cases it Stands in very close relation: it is very apt to be simulated by calculous or gouty iralgia. The other forms of obstructive disease are more nearly allied to her- nia; it is, indeed, sometimes an internal hernia, which is only irremediable in so as it is removed from manual interference: great blame is justly due to the practitioner who omits examining every part where a hernia may possibly come within reach of relief in a case of insuperable constipation. Division II. — Diseases attended with Relaxation. $ 1. Diarrhoea. — We now come to those conditions of the in- %j e testinal canal which are marked by excessive action of the bowels: they are chiefly dependent on the state of the mucous membrane, including in that term the whole secreting apparatus. The dis- orders of this class may be formed into several distinct groups, from a consideration of their history and attendant phenomena. a. With no heat of skin or quickness of pulse, we have (1) a history of previous constipation, when slight watery discharges are taking place, in consequence of the irritation of the mucous mem- brane by the accumulation: (2) the ingestion of some unhealthy ali- ment, or of a larger quantity of food than the stomach can digest, which, passing into the intestines, causes irritation there. In both of these cases there is usually pain and a foul tongue ; the action is a preservative one, by which nature seeks to expel the offending material, and, if opposed, dangerous inflammation and obstruction may result. (3) This reaction may have served to remove the source of irritation, and yet the diarrhoea may persist merely as an ex- cessive secretion set up by the irritation and congestion of the mem- brane. (4) The irritation may be the effect of exposure to changes of temperature analogous to the more common effects of cold on the bronchial membrane. Of this kind seems to be that form of diar- rhoea which is often prevalent in summer when the tongue is coated, the stools dark, and there are griping pains in the abdomen. (5) The genuine summer cholera, on the other hand, is marked by copious, pale, watery evacuations, with a clean tongue, a cold skin, and no abdominal pain ; it is exactly like the choleraic diarrhoea, which at- tends the spread of epidemic cholera. (6) There is also a very well- marked form dependent on disorder of the liver and excessive secre- tion of bile, to which the name of bilious diarrhoea is not inappropriate ; it is most commonly, however, associated with excesses in eating and drinking, and is consequently allied with the class of cases caused by indigestion. b. When general symptoms are present they belong, in a large number of cases, to some other disease, of which diarrhoea is also only symptomatic. To determine this point we must refer to the modes of investiga- DYSENTERY. . 325 tion and sources of information enumerated in treating of these dis- eases themselves; as the most common we may mention continued fever with bowel-symptoms, tubercukr diseases, and albuminuria. In the first two it is always accompanied by ulceration, in the lat- ter the secretion seems to be often vicarious of that of the kidney. c. Diarrhoea, with febrile symptoms which are not referrible to any other disease, is more frequently seen in this country in child- hood than in adult life. Inflammation of the mucous membrane, with a tendency to ulceration, is the pathological condition which, in its fullest development, is only met with in dysentery. The tongue is coated, the pulse quick, the skin hot, with much thirst ; the bowels continue for some days to act very many times, and the stools soon become slimy and mixed with blood: among children there is very often prolapsus ani; then follow the appearances of putrid flesh and fetid puriform matter, corresponding to the analo- gous appearances in true dysentery. But the symptoms may stop short of this extreme condition, and then it is often hard to distin- guish them from those of dental irritation; there is nothing indeed to show that the latter may not pass into inflammation, and in in- fantile life it is a very frequent source of febrile diarrhoea. Again, we more frequently see the condition of membrane which is characterized by aphthse of the mouth and fauces in childhood, than we do in adult life, and we may be even more certain that in the former it is not a local malady from a similar condition exist- ing at the anus. d. Chronic diarrhoea is very often dependent on ulceration ; but we have abundant proof that it also sometimes persists for long pe- riods without any indication of such a condition from the character of the stools. Many persons are subject to it from the most trivial causes : and the complaint is often very obstinate in childhood, and yet the ultimate complete recovery proves that no structural change has occurred. In other instances it depends on disease of the me- senteric glands, and is only one form of its association with tuber- cles in early life. § 2. Dysentery. — This disease, which was at one time much more common in our own country than it now is, still continues to be one of the most serious affections of tropical climates. It presents to us the most severe form of .inflammation of the mucous membrane, tending to very extensive ulceration. In its pathological relations it is probably allied to acute diarrhoea with great irritation : the instances are perhaps more numerous than we are aware of in which the local action predominates, and the fever is only symptomatic, though they be at present regarded as fever with bowel complication, except when symptoms arise which are more distinctly dysenteric. Such appearances can only be seen when the large intestine is the principal site of the diseased action, because, if it were confined to the upper part of the bowel while the colon remained healthy, the se- cretions would be so changed in their passage that the peculiar characters could not be observed : and indeed this is in part true of dysentery itself as affecting dif- 32G DISEASES OF THE INTESTINAL CANAL. ferent portions of the colon. On the other hand, there are pood reasons for re- garding true dysentery as something quite distinct from affections of the small in- testine in which febrile symptoms are present; and perhaps as we have ceased to regard t he ulceration of the ileum as an}- tiling more than a symptom of common bowel fever, we ought to regard the ulceration of the colon only as a symptom ot another " lever;"' at all events, we find that, as in the one the ulceration seldom affects the colon, and then only in its upper end, so in the other, the ulceration seldom extends any distance from the colon into the small intestine. The chief symptom relied on in dysentery is the passing of bloody mucus with hardened* scybalous masses of faecujent matter; but this is really the evidence of a mild attack, in which the lower part of the colon is alone involved. In the severer cases diarrhoea first comes on, emptying the whole of the large intestine ; and only sub- sequently do bloody and mucous discharges, with tenesmus, occur. Its commencement is generally sudden, with pain in the abdomen, in the hypogastrium, and perhaps especially on the left side: if the lower end of the colon only suffer, the faeces from above are passed as scybala; glairy bloody mucus is discharged, which in a short time becomes purulent and offensive, and as ulceration proceeds a greater amount of hemorrhage generally continues: tenesmus is al- ways a distressing symptom, and is sometimes conjoined with irri- tation of the bladder and the urethra. When the pyrexia is not very evident, it is of importance to ascertain that the blood does not come from the rectum, where local disease may exist, either in the form of hemorrhoids, or as cancerous or fungoid growth. Chronic dysentery might also be classed under ulceration, for under no other circumstances does ulceration proceed so far; but we have reason to regard it as a specific disease, as it generally fol- lows on an acute attack: the patient has probably been in a tropi- cal climate, the bowels have since been always irregular, the motions unhealthy, commonly mingled with pus or muco-purulent secretion, and often with blood. The disease, however, remains quiescent until something arouses it to fresh activity; some disorder of stomach, or exposure to cold or wet brings on a partially acute attack: or else, from the extensive disorganization which has occurred, enormous accumulations arise in the colon, which it is unable to propel: these cannot be effectually got rid of by the aid of remedies ; low, wasting, suppurative fever supervenes, with gradual exhaustion, or the dis- eased structure is attacked by low inflammation, terminating in a condition allied to sphacelus. § 3. Ulceration. — Little can be said to elucidate this form of bowel-ailment. We know it to exist in phthisis, and in continued fever: and in either case when there is irritability of the canal, with watery, unhealthy, and frequently fetid stools, and the tongue is glazed or aphthous, we have good grounds for concluding that ulce- ration is going on. We may, perhaps, also be justified in predi- cating it, when in other instances similar conditions persist, in spite of treatment, and we are unable to discover any other disorder of ALTERED SECRETIONS. 327 the abdominal viscera to account for their presence. It is^not com- mon as an idiopathic disease, and it may exist for long periods with- out giving rise to any distinct symptoms at all. Hemorrhage is perhapsione of the most certain indications when it occurs spon- taneously and in considerable quantity; the appearance of the blood, in some measure, aids in determining from what portion of the canal it comes, because its colouring matter is very readily acted on by the secretion of the bowels, and can only present a florid aspect when the point of its discharge is situated near the anus: the colour is otherwise black, and hence the name of "melasnt," has been given to this form of hemorrhage. Evacuations of similar character occur when the blood comes from the stomach, and the blackest and most pitchy evacuations are seen when this is their source. Hrematemesis would of course determine that blood had been effused into the stomach itself, but, though a common consequence of its presence, it is by no means essential, and must not be made the basis of an absolute rule in diagnosis. The presence of pus in the stools can only indicate ulceration low down in the canal: its quantity cannot be large, unless the ulcerated surface be such as is seen in dysentery, and its admixture with feculent matter must necessarily alter its cha- racters and prevent its recognition if it pass through any great length of the intes- tine. A red and glazed tongue, with a tendency to the formation of aphthous crusts, has been before alluded to as indicating a ? general state of the mucous membrane which is disposed to ulceration; it is seldom noticed, however, except in cases of phthisis or bowel-fever. Drv. III. — Diseases attended with altered Secretion. It might very fairly be argued that many cases of which consti- pation is a prominent symptom, and all of those attended with diarrhoea, should be classed under this division. Our object, how- ever, is not pathological accuracy, but simplicity of arrangement, and we have now to do with cases in which either diarrhoea is con- tinually alternating with constipation, or the evacuations exhibit special characters which show that some form of secretion is want- ing or perverted. § 1. Disordered Bowels. — This first subdivision must include by far the larger number of cases ; we are yet far too ignorant of the special actions going on to attempt to classify them more accurately, and the only reason for their enumeration is, that the question of classification leads to investigating symptoms more closely, and thinking more clearly of the morbid actions presented, and there- fore tends to a more judicious selection of remedies. a. In childhood we often find a condition of mal-nutrition and anaemia, with a ravenous appetite and unhealthy secretions, when the rectum is very generally loaded with ascarides: in such cases it used to be imagined that the worms were the cause of all the symptoms ; it seems more probable that the true explanation is to be found in the faulty secretion of the canal affording a nisus for the development of the parasite. Whether the condition of the bowels be primary or secondary, it is of no importance to inquire, because it is invariably accompanied by symptoms of more general disorder, and these demand our attention and care quite as much 328 DISEASES OF TIIE INTESTINAL CANAL. as the local ailment. It is also quite a matter of accident whether there be diarrhoea or constipation at the time of examination, be- cause as a general rule we shall find that neither condition is per- sistent, but that the child has been subject to one or other for some time. The chief difficulty presented is the close analogy of such cases to those of mesenteric disease: so little is known of the scro- fulous element that we can scarcely form any correct diagnosis until the dry shrivelled skin and prominent belly leave us in no doubt; and our prognosis must be always guarded when any symptoms of scrofula have been marked in the child's history. b. In other cases the evacuations present appearances more or less definitely indicating the secretion that is at fault. _ Thus we have the "chopped spinach" appearance of the stools in infancy, their excessively dark colour, or the opposite, in adult life, each pointing out that the biliary secretion is that to which attention should be paid: in other instances, undigested aliment, mixed with fteculent matter, shows that the gastric juice is defective in quality, or insufficient in quantity: the lodgement of dark, offensive faeces, again, which are got rid of by nature or art, from time to time, rather leads to the belief that the secretion in the bowels themselves is defective. We must not forget in this enumeration the frothy, yeast-like motions which are occasionally passed, and seem to show that fer- mentation has taken the place of intestinal digestion, just as we found the same circumstance when occurring in the stomach indi- cated by vomiting of a similar character. Nor must we omit that rare condition which has been, with some reason, attributed to dis- ease of the pancreas — viz., the passage of fatty matter in a liquid state along with the feces, which floats on the surface of water, and consolidates with cold. Much may undoubtedly be learned from an inspection of the stools; and no careful practitioner will omit it when treating a case in which there is a possibility of disease of the abdominal viscera. In almost any of the cases just mentioned, the first complaint is very likely to be of a transient diarrhoea, in consequence of the irritation which these matters excite; or, passing by the repeated alternations of constipation, the patient may only speak of being subject to diarrhoea, and, until the excreta be seen, we may be ignorant of his real state. It seems pretty cer- tain that, when we find irregular action lasting for a considerable period, we may regard it as due to a fault in some of those secretions which serve to prepare the alimentary substances for the uses of the economy, and our chief object must be to detect and correct that fault: in the majority of instances this can only be done by seeing the character of the stools. § 2. Tympanites. — The presence of flatus in the abdomen, as it always results from any disorder of the bowels, would not deserve mention except that cases are occasionally Seen in which this is the principal ailment. We search in vain for other direct evidence of faulty secretion ; and, except that the bowels are usually sluggish, and the patient suffers much inconvenience from the distention, the circumstance might be disregarded altogether. The cases do not TYMPANITES. 329 present any great difficulty in diagnosis, but they are very trouble- some to manage: the only point which we have to ascertain with care is, that the enlargement of the abdomen is not produced by some other cause, while the resonance is no more than that usually heard on percussing over the intestines when thus pushed forward. Such a combination of distention and resonance, for example, may be observed when a small quantity of fluid exists low down in the peritoneum ; and mistakes of this kind have been made when the distention was produced by enlargement of some of the pelvic viscera ; e. ut the existence of one form of disease does not exclude the possibility of another being conjoined with it; on the contrary, we know that there is a constant alliance between disease of the heart and disease of the kidney. a. In all cases an abundance of pale, limpid urine, of low specific gravity, -which yields a distinct precipitate of albumen, affords cer- tain evidence of serious disease of the kidney. b. A very abundant precipitate of albumen, whatever be the condition of the urine, can only be caused by disease of the kidney, whether in the form of congestion or simple inflammation, or of scarlatinal nephritis, or of degeneration at a particular stage, or of a special form. c. If the amount of albumen be small, the evidence of its presence doubtful, and the secretion scanty, the inference is less certain when disease of the heart exists, because passive congestion of various organs is one of its usual concomitants. AVhen, therefore, there is evidence of valvular lesion traceable to rheumatic attacks, urine, which is scanty and loaded, may continue for a time to contain a trace of albumen, while no disease of the kidney exists: -when, on the other hand, the heart-disease is of the form of hypertrophy, or dilatation, the continuance of a trace of albumen is a more suspi- cious sign, because it is not improbable that the changes in its muscular structure, as they are not caused by valvular lesion, may be the effects of renal disease. In either case the diagnosis can only be considered certain when, with an increase of the secretion, the albumen persists, and the specific gravity falls. Somewhat similar relations have been observed when, in cases of dropsy dependent on other causes, any special circumstance gives rise to congestion of the kidney: such, for example, as anasarca accom- panying ascites or ovarian dropsy, when pressure opposes the return of the blood through the renal veins ; an exactly analogous relation is said to exist very frequently in the dropsy of pregnancy. d. "When dropsy is not present there are no doubt many circum- stances which may give rise to the casual occurrence of a trace of albumen ; and when this change is not constant, and the specific gravity is normal, great hope may be entertained that the condition of disease is only transient, and not altogether beyond the reach of art. In investigating these cases the microscope may be of much service in showing either the presence of a few blood-globules, or of pus, or what are called exudation-corpuscles, or mucus-globules in such numbers as to resemble pus rather than mucus, all of which arc found in simple congestion of the kidney; or it may discover fibrinous casts of the tubuli, which can only be present in very ALBUMINURIA. 3G9 active congestion, or in permanent disorganization. These casts present either a homogeneous appearance, smooth and transparent, or they are filled up with granular matter, and sometimes they contain blood-globules or particles of oil. The smooth or waxy casts, as they are called, serve to indicate the most advanced con- dition of disease, and those containing blood-globules generally result from congestion ; but their appearance must not be made too absolutely a guide to diagnosis. e. When the urine is tinged with blood, the indications are some- what similar to those derived from the presence of albumen, and what is true of the one is in great part true of the other, with this difference, that blood may come from any part whatever of the urinary organs and passages. The first question when blood is present is, whether more albumen can be precipitated than is accounted for by the admixture of blood if it had been added after the urine was voided. This is a point which experience only can determine, and for which no rules can be laid down. When we conceive the amount of albumen to be greater than would be con- tained in urine coloured by blood to the same extent, it must be regarded just as if the blood were not present, for we know that the excess of albumen must be secreted by the kidney: when the amount of albumen is small, the next question is as to the source of the hemorrhage; and probably the only reliable evidence of its coming from the kidney is when the microscope discovers tubular casts. The existence of small clots, visible to the naked eye-, proves that the hemorrhage has occurred in some part of the canal from its commencement in the pelvis of the kidney to its termination at the end of the urethra; and then there are generally local symptoms to guide us in determining at what point it took place. Sometimes it is distinctly passed before the urine begins to flow, and it probably issues from the urethra; sometimes it only escapes with the last drops of urine, when its source is generally the bladder. In females, blood flowing from the uterus may be mixed with the urine as it is voided: hoematuria is also one of the forms of hemorrhage which occurs without any special lesion, depending simply on a deficiency of plastic material in the blood itself. It is only when the blood retains somewhat of its natural colour, and the urine is red or pinkish, that doubts regarding the source of the hemorrhage can be entertained: when dark-coloured or smoky, the blood almost cer- tainly comes from the kidney. We do not class the albuminous urine which accompanies the presence of pus- globules under the head of albuminuria, because we presume that, in the exami- nation of the deposit, this fact has been observed, and it serves to characterize dis- tinct conditions of the kidneys or urinary passages. It must, however, be remem- bered that one of the features by which we are enabled to distinguish pus coming from the substance of the kidney, is that the urine contains an excess of albumen beyond that which is accounted for by the admixture of liquor puris. In this re- spect it is very analogous to hasmaturia, and the question of whether the kidney be directlv involved is to be determined simply by ascertaining whether it do or 24 :]T0 DISEASES OF THE URINARY ORGANS. do not secrete albumen: the great difference between the two is that the blood is .„„,,. | of chronic disease us an accidental admixture, while pus jn- ,1',,..,. ,'ml condition, and the albumen is only present because the kidney is altered in function and structure by the Buppuration. In both cases it is possible that the abnormal ingredients may have separate sour , albumen coining from the kidney, and the blood or the pus from the [er or urinary passages. Against such coincidences it is almost impossible iard, and it would lie vain to attempt to lay down rules for diagnosis: but they areiu practice not of very frequent occurrence; the accidental hemorrhage would not very greatly modify the treatment of the prominent disease of the kidney, and •nee of pus would lead to the adoption of similar measures, whether its source were the kidney or not, when it was found in a patient with albuminuria. The absolute diagnosis is therefore not very essential ; and probably some other symptom would suggest the bladder as the seat of suppuration or hemorrhage when they did not proceed from the kidney. In its results to the economy at large, permanent disorganization of these glands is a disease of the greatest importance: the constant drain of albumen, which at times passes off in enormous quantity, establishes a state of anaemia which is more or less the cause of many of the secondary ailments which spring from it: and, at the same time, the retention of effete matters, which are usually evacuated by this channel, seems to produce a sort of blood-poisoning which increases the anajmia, and is the more immediate exciting cause of the diarrhoea, and the plastic exuda- tions which so often appear during its progress. § 5. Diuresis. — As a temporary effect of direct stimulation of the kidney, an excessive secretion of urine is sufficiently common ; its persistence is very unusual, except as a sign of diabetes. In diagnosis, as in pathology, the indications are wholly negative : it has to be ascertained that there is no sugar and no albumen: the urine is of low specific gravity, and there cannot be any very unusual metamorphosis of tissue; but yet, when the quantity of urine is great, no doubt more solid matter passes out of the body than in health, and hence there is commonly some emaciation. At present it does not appear that any logical view of its cause has been suggested. The secretion of pale, limpid urine, as an effect of the hysteric pa#oxysm, has been already mentioned; but sometimes a spurious diuresis is kept up for a long time in hysterical persons by what might be termed a dypsomania, in which enormous quantities of fluid are drunk during the day, and of course find an outlet by the kidney. § 6. Cystitis. — Inflammation of the bladder is a frequent source of pus in the urine: the urgency to frequent evacuation which marks suppuration in the kidney is not so great in cystitis, or it is of another kind. The history very often dates from some retention of urine in the first instance, as, for example, an unavoidable delay in emptying the bladder, followed by over distention and subsequent spasm, with fruitless efforts at micturition; perhaps the presence of stricture in males, or in females the pressure of an enlarged uterus renders it impossible thoroughly to empty it. It is immaterial whether the first distention be the cause of the inflammatory action which ensues, or whether the retention of a small portion of urine DIABETES. 371 on each occasion lead to its decomposition, and this fetid urine acting as a ferment on what is subsequently secreted, the whole contents of the bladder become ammoniacal, and so irritate the mucous membrane, and give rise to purulent secretion. The latter is evidently the mode in which cystitis is developed in paraplegia, accompanied by paralysis of the bladder, because, by carefully washing it out daily with warm water the inflammation may be averted. In other cases cystitis occurs as the consequence of stone in the bladder, the symptoms of which form no part of medical diagnosis: it is only worthy of remark that the irritability of the bladder con- nected with calculus, while causing its frequent evacuation, is specially accompanied by pain over the arch of the pubis, at the glans penis, or in the perimeum ; and that for a long time the urine continues to be clear and transparent after the irritation ha3 been excited, not thick and opaque as when mixed with pus, because the purulent secretion is only a later event in the progress of the case. In inquiring into the .origin of symptoms, a distinction must be made between the difficulty in passing the urine, when it is voided in a small stream in stricture, and the sudden stoppage of a full stream which occurs in cases of stone. Sometimes cystitis comes on as a catarrh of the bladder propa- gated from the urethra, in cases of gonorrhoea: simple idiopathic catarrh is necessarily very rare. The principal source of information is the condition of the urine itself: when pus is derived from the kidney, as a general rule the urine is acid and the pus falls as a sediment to the bottom; when derived from the bladder, the urine is alkaline, and the pus more or less altered in character, becoming ropy and resembling mucus. Casual circumstances and the effect of treatment may alter these facts for a time, but, when observed in the first instance, or remarked as the usual condition, the evidence they afford, combined with the history of the case, are quite characteristic of the true nature of the disease in each of its forms. § 7. Diabetes. The chemical test for the presence of sugar is a »very certain one if applied with sufficient care: but the whole cir- cumstances connected with confirmed diabetes are so distinct that the diagnosis scarcely requires this corroboration. Unfortunately there are few symptoms which can lead to its early detection: the amount of urine passed in the twenty-four hours is so little regarded by most persons that they seldom think of adverting to it till it be in very great excess: it is generally the existence of weakness and emaciation which excites the patient's attention; sometimes the cir- cumstance is observed that where the urine fails it leaves a white crust when it dries ; sometimes the unusual appetite and craving for drinks leads him to suspect that something is wrong. To the eye of the practitioner the emaciation of diabetes is very 372 DISEASES OF TIIE URINARY ORGANS. different from that of other diseases; it is not marked by any un- heal; hv appearances such as characterize the various cachectic states: its combination with hunger may lead to the suspicion of the exist- ence of intestinal worms, but in following the scheme for the ex-- animation of the patient laid down in the early part of this work, the very next inquiries lead us at once to the true explanation. Along with the emaciation and craving appetite thirst is excessive, the urine is secreted in large quantity, the bowels are costive, and the fieces dry and solid: under no other condition of disease is the same train of symptoms ever remarked. § 8. Disordered Function. — Under the name of functional dis- turbance must be included variations in the proportion of water and other normal constituents which, as they are elaborated elsewhere, may pass out of the body through the kidneys without implying specific disease of any portion of the urinary apparatus. They cannot be easily classed according to the disease with which they are commonly associated ; but assuming that the history of the case and the examination of other organs has already led to an opinion bein^ formed on its nature, we have to inquire what additional light may be derived from an examination of the urine. Excess of water, while it constitutes the whole disease in what is called diabetes insipidus, and is present very frequently in albumi- nuria, and constantly in diabetes, may be casually observed after certain ingesta which stimulate the kidneys, and after an hysteric paroxysm: in such cases it is really of no importance. Deficiency of water is most remarkable in fevers, and in cases in which the perspiration is excessive: it is also observed when diar- rhoea exists, and sometimes as an effect of dyspepsia, the urine be- coming acid, scanty, and loaded, irritating the bladder and urinary passages. The secretion is also scanty when the renal circulation is interfered with by abdominal distention or disease of the hearty though very frequently in cases of the latter class there is more than mere functional disturbance, — congestion, if not actual disease be^un. In dropsy depending upon disease of the kidney, the secre- tion is always diminished while anasarca is on the increase, partly as its cause, but partly too as its effect. # "When the proportion of water falls much, below the healthy standard, those salts which are more soluble in warm than cold water, if present in their usual amount, ought to be precipitated, forming a sediment: but here another law comes into play, because their chemical constitution varies with the amount of what, for con- venience, we may term free acid or free alkali. If free acid be present, the lithates exhibit that form in which they are less solu- ble in cold than warm urine, and they are precipitated; if free al- kali be present, their condition is changed, and they are held in solution by a much smaller quantity of water. The deposition of jmosphatic or earthy salts is not so dependent on the proportion of FUNCTIONAL DISORDERS. 373 water, for they are very easily dissolved by free acid, and are very insoluble when free alkali is present. This explains to us why in acute rheumatism, when acid abounds, and there are copious sour-smelling perspirations, the urine is always loaded with lithates; whereas in typhus, when the powers of life are low, and free alkali is liable to be secreted by the kidney, the urine may be very scanty and very deep-coloured, and yet there is no deposit till some acid be added, when the whole becomes turbid. Such urine oftentimes appears slightly acid to test-paper, and it would appear that the lithate is secreted in a soluble form with ex- cess of alkali, and that the affinity of the acid is too weak subse- quently to convert it into the insoluble form. The fact is certain, the explanation perhaps unsatisfactory ; but it is the only one which our chemical knowledge of these salts at present gives. When acid is formed in excess in the stomach in dyspepsia, and afterwards passes off by the kidney, it tends to check the flow of urine, causing' a deficiency of water, and at the same time it deter- mines the formation of the less soluble lithates, which the small quantity of water present cannot hold in solution when cold. To speak therefore of an excess of lithates is a fallacy, because their deposition may depend merely on the proportion of water, or may be wholly prevented by deficiency of acid. When lithic acid is really in excess, it is more likely to occur in a crystalline form, un- combined with any base; and to this the name of the "lithic acid diathesis" more properly belongs than to that in which the deposit is amorphous. To speak of an excess of earthy phosphates is a more complete fallacy than that just alluded to. They are so very soluble when free acid is present, so insoluble when free alkali is present, that such a deposit indicates nothing more than the fact of the urine being alkaline. It is true that, as happens with the lithates in ty- phus, the urine may have a slightly acid reaction to test-paper, and yet earthy phosphates may be deposited ; and the only explanation that can be given is that they have been secreted in an alkaline condition, but the acid present is too weak to alter their chemical relations; for a single drop of stronger acid at once dissolves the deposit. Valuable information might no doubt be obtained from a knowledge whether the phosphoric acid be really in excess; but this can only be ascertained by a quantitative analysis, which re- quires much chemical skill and much expenditure of time. A deposit of earthy phosphates then only shows that alkali of some sort is in excess. Of this there are three principal causes: the decomposition of urea yielding free ammonia; the ingestion of alkalies or decomposable alkaline salts; and the secretion of excess of ammonia by the kidney. The first of these, when the urine is fetid, is very generally associated with cystitis, and is also developed in a very short space of time in urine which was alkaline on emis- sion ; the. second is only a casual occurrence, which has no patholo- o74 DISEASES OF THE URINARY ORGANS. gical value, and is only to be borne in mind as one of the possible causes; the third is that to which the name of the phosphatic dia- thesis has been given. It is evidently connected with states of de- bility, especially with exhaustion of nervous energy: we do not ex- pect to find it always present, because of the constant daily varia- tions in the acidity of the urine, but its recurrence at certain periods may aid us in ascertaining its specific causes. It should be remem- bered, too, that the amount of acid in the stomach at any given period is generally in an inverse proportion to that in the urine, and I have seen this most strikingly exemplified in cases of sarcina ventriculi when the fermentation going on in the stomach produced the greatest possible degree of alkalescence. Closely related to this change is one in which, without fetor or absolute decomposition, the urea is converted into the carbonate of ammonia, a change which is hastened by boiling, and gives rise to effervescence on the addi- tion of acid. In general terms, speaking of acidity and alkalescence of urine, we find them associated with very opposite conditions of health, modified by the actual state of the stomach at the period when the fluid is secreted. A man of full habit, who indulges in the pleasures of the table, and is not disposed to overtax his mental powers or his nervous system, is very likely to exhibit in his urine copious depo- sits of the lithate of ammonia, especially at those times when he has been suffer- ing from acidity of stomach, and that acid has begun to pass off by the kidney. "Whereas a man of spare habit and nervous temperament, during the period of ex- haustion following any excitement either of brain or nerve, is very liable to phos- phatic deposits, especially while the acid is still in the stomach, and before it has begun to pass off by the kidney. On the other hand, the urine of one whose di- gestive organs are in an enfeebled state will contain the one deposit or the other, according to the period after food at which it is examined. I think we may notice, with regard to the lithates deposited in such circum- stances, that those simply dependent on gastric derangement are of a paler colour than those which are produced by any excess. To some it has appeared that the pink colour was caused by chemical alteration of the same colouriug matter which is secreted by the liver, and the staining of the utensil has been taken as evidence of biliary derangement: the investigation of this point is not complete, but it may be usefully remembered in practice. Excess of urea is also one of the functional disturbances of the secretion. It is to be regarded as a proof of excessive metamor- phosis of the nitrogenized elements, whether in consequence of a too abundant supply, or of unusual waste of tissue, as it follows on the use of nitrogenized food in excess, or is increased by disease. There is apparently no specific cause to which it can be attributed; we must be content at present to employ such general expressions as disorder of stomach and depressing influences, while observing the fact of general emaciation, sense of lassitude, and depression of mind which accompany its existence. It is often associated with a deposit of oxalic acid, in the form of oxalate of lime. Probably too great stress has been laid on the presence of this salt, which has been often regarded as the first step in changes of which it is perhaps really the result; and this con- clusion is the more probable from the very many and very varied FUNCTIONAL DISORDERS. 375 circumstances in -which it is found. It coexists with alkaline urine and deposits of phosphates, with acid urine and amorphous lithates, with crystals of uric acid, as well as with excess of urea: but we may always trace indications of weakness and depression, whatever other special characters the case exhibits. We need not .stop to inquire whether it be formed by a reconversion of some of the normal ingredients, or by imperfect oxidation of carbon in the lungs, or whether it be formed at once in the process of assimilation, and carried into the urine as it is when food containing oxalic acid is taken into the stomach. Many other functional disorders might be enumerated, but they are chiefly mat- ters of curiosity; such, for example, as the presence of fibrine in chylous urine, of oily matter, of kiestine in the urine of pregnancy, of a milky albuminous matter in malacosteon, &c. These cases are so rare that the student must be referred to works on diseases of the kidney for further information regarding them. It may be added that haematuria is to be regarded* as a functional disorder when it de- pends only on some change in the condition of the blood, such as is manifested in other parts of the body by spots of purpura, or by uncontrollable hemorrhage. The entire dependence of functional disorder on causes altogether beyond the kidney itself, is not less remarkable than the extensive associations of its diseases with those occurring in other organs. Among fevers we find scarlatina giving rise to a form of nephritis with albuminuria: certain forms of chronic rheumatism and gout seem to be more or less depe'ndent on degeneration of the kidney; and the connexion existing between gout and uric acid brings that disease into close relation with the crystalline deposit in the urine. Dropsy is connected in two ways with disease of the kidney; as it is induced by deficient secretion of water, which thus necessarily accumulates in the system, or by changes slowly developed in the blood rendering its watery portion more liable to transude through the vessels into surrounding tissues. The same condition gives rise at times to hemorrhages, especially epistaxis, and is always marked by the waxy or pallid hue of anaemia. Tubercular phthisis often forms the conclusion of a case of diabetes; chorea and delirium tremens are each said to cause impor- tant changes in the relative amounts of certain of the constituents of the urine. Head affections are in a most especial manner associated with disease of the kidney; convulsions and coma are often the precursors of its fatal termination, whether caused by urasmic poisoning, or by serous effusion in the ventricles. In a large proportion of cases of apoplexy, granular degeneration is found, but the connexion of the two is probably to be traced to disease of the heart, which is so common in albuminuria. Occasionally this exists as simple hypertrophy; at other times there is atheromatous disease of the valves, and perhaps of the arteries: the former apparently produced by disturbed circulation, the latter probably only ano- ther expression of that faulty nutrition which also affects the kidney. Plastic exudations on serous surfaces are to be met with in the pericardium, in the pleura, and in the peritoneum more commonly than in other circumstances; and both bronchitis and laryngitis are more severe in consequence of the tendency to oedema to which it gives rise. The liver not uncommonly presents evidence of coincident disease, which it is not difficult to explain when we recognise habits of intemperance as the constant source of mischief to both organs. 376 CHAPTER XXXII. DISEASES OP THE OVARIES. General Considerations — Obscure Origin — Associations. — § 1 , Ovarian Drops)/ — Resemblance to Ascites — Distinguishing Cha- racters — § 2, Tumours — known by their Pelvic Attachments — distinguished from Pregnancy. In adverting to classes of disease peculiar to the female sex, it must be remem- bered that they are often mixed up with hysteria, and while that undefined malady may give rise to symptoms in any organ of the body, and may simulate any form of disease, the practitioner must be on his guard against assuming symptoms to be merely hysterical when they depend on some obscure cause which he has been unable to trace. The early changes in the ovaries, as they cannot be recognised, must therefore be borne in mind, as affording a possible explanation of symptoms otherwise unintelligible: but this is very different from the views which we cannot but regret to see advocated by any claiming for themselves a respectable position in the profession, who would refer to some undefined local changes all the anoma- lous characters which hysteria so constantly presents. If medicine is to be ranked as a science, we cannot ignore the clear and accurate teachings of pathological anatomy; we may not assign to any disease a cause which post mortem examina- tion proves to have no existence; we may not assume ovaritis, as it has been called, to be a common condition in the living, when we know that it is seldom met with in the dead body. Pathological anatomy does not teach us what hys- teria is, but it teaches us in unmistakeable language what it is not, and if we learn the lesson it conveys, no truth will come home with more force of demonstration than this, that neither ovarian changes nor ulcers of the os uteri have any thing to do with its occurrence, except as they figure in the opinion of the practitioner, or engross the thoughts of the patient: more than this, — it also teaches that disease of the ovaries, though not uncommon, is not of such a kind as can be traced to "inflammation" in any of the multifarious forms assigned to it. All that can be said of ovaritis is, that were it present its symptoms would be undistinguishable from local peritonitis confined to the region of the ovary. • The early history of ovarian growths is quite unknown to us. The first symptom is generally the patient's consciousness of enlargement of the abdomen: as an indication of disease this is classed among " alterations of size;" and it is worthy of observation that, in exter- nal form, the abdomen is liable to be unequally prominent on one side. The tumour may possibly be recognised by the practitioner be- fore its existence is known to the patient herself — as, for example, in pressing the abdomen during fever, with bowel ailment. More rarely the growth is found out in searching for the causes of con- stipation; but such a condition is so common among females in this country that it can scarcely lead to the discovery of the disease. Among early symptoms, pains in the groins, and a sensation of weight and bearing down in the pelvic viscera are mentioned, and may be of service in leading to more careful examination, but they are not in any way characteristic. When enlargement has actually DISEASES OF THE OVARIES. 377 taken place, it is not unimportant to notice in how many instances there is no disturbance of the general health. § 1. Ovarian Dropsy. — In the greater number of cases cysts are developed containing fluid — ovarian dropsy, as it has been termed. By percussion over the prominent part of the abdomen, want of resonance is discovered, and fluctuation will be made out more or less readily in the same situation, according to the stage which the disease has reached; but at its very commencement this must be im- perceptible. In speaking of ascites (Chap. VII. Div. I. § 2,) the sio-ns derived from these sources by which that disease is character- ized were pointed out; we have now to notice the indications which the same means of investigation afford in cases of encysted dropsy. A cyst developed from the ovary commences to one side of the mesian line, and consequently for a long period during the conti- nuance of the case, the dulness on percussion occupies one side of the abdomen much more than the other; fluctuation extends upwards on that side, and can be readily traced so long as one hand does not pass far beyond the umbilicus, but becomes at once obscure when it is placed towards the flank on the resonant side. _ When these two observations correspond, the evidence is more satisfactory than that derived from any other source : sometimes it is even more striking when the fluid is contained in several cysts, and the tumour is inultTlocular. In such cases fluctuation may be most clearly per- ceptible while the hands are placed only a few inches apart, but be- comes obscure as soon as the boundary between two cysts is passed; indeed the position of the septa, as they reach the surface of the ab- domen, is sometimes distinctly defined. Occasionally the enlarged ovary very early assumes a central position with reference to the viscera, pushing them aside into both lumbar regions pretty equally, and approaching the anterior wall of the abdomen in the hypogas- trium ; and then the diagnosis requires more care. As the disease advances it gradually encroaches more and more on the whole cavity of the abdomen, and then we have recourse to other measures to ascertain that the fluid is cysted, and not free in the peritoneum. The principles have been already laid down (p. 90) which ought to be present to the mind in every case that comes before us, and thev are equally applicable to the most self-evident as to the most obscure. Rising out of the pelvis, as the diseased ovary does, it is very often possible to trace in the lumbar and iliac regions resonant bowel pushed aside, not floated upwards upon the surface of the fluid. Even when the greater part of the intestines have been forced into the thorax by the enlargement of the cyst the ribs do not spread out as when subjected to the pressure of fluid lodged in the perito- neum, and the abdomen has a globular form ; at the same time, the height to which the dulness extends is not equal, but at some point resonance descends far below the level to which the fluid rises 378 DISEASES OF TIIE OVARIES. at another; for the very same reasons the relative position of dul- nesa and resonance arc but little altered by change of posture. At the risk of repetition it must be remarked that the whole of the facts upon which oar inductions are formed may be resolved into the simple effects of the laws of gravitation, as modified by the circumstance of the fluid being free in the p iritoneum, or confined in a cyst, and the intestine, which is specifically lighter, being at liberty to float on its surface or not. Hence, in applying the fact of re- sonance being observed below the fluid level, or even in the groin, we must be Careful that it is not caused by a portion of the intestine which is naturally limited in its movement, or one tied down by old adhesions. Mistakes are less likely to be made in observing the effects of change of posture, unless the whole of the vis- cera are pushed up under the ribs, when the observation may be difficult. In mere physical diagnosis those cases most resemble ovarian dropsy in which adhesions have been formed in consequence of an attack of peritonitis, by which the fluid effused is as much limited in position as if it had been contained in a true cyst. In such, however, the general symptoms, which are those of chronic peritonitis, are much more severe than are ever observed in the smaller sized ova- rian cysts, which alone they resemble; and tho history, if correct, is wholly differ- ent. The one commences with a severe attack, of which pain in the abdomen is a prominent feature, and continued uneasiness, tenderness on pressure, quick pulse and emaciation mark its progress; in the other, the commencement of the disease is not marked, pain is at juo time severe, and the general health is not much dis- turbed until it has lasted for a long time, and tapping has been more than once had recourse to. When the cyst is not very large, and its position central, there are two condi- tions which may produce analogous phenomena — a bladder or a uterus distended with fluid. In the former our necessary inquiry into the amount of the urine will be answered by a report either of retention or incontinence: no water passed at all, or a constant overflow from the paralyzed viscus, and either circumstance is sufficient to suggest the employment of the catheter. Hydrometra is so rare a form of disease that it may almost be passed over, and would be best recognised by vaginal examination, which may always be had recourse to when any doubt ex-* ists as to the nature of a local collection of fluid in the abdomen. The remarks on this mode of investigation must be reserved till the diagnosis of solid ovarian tumours has been discussed. •§ 2. Tumours. — The term is only relative, as in most instances the diseased structure contains cysts in larger or smaller collec- tions of fluid; and in the earlier stages, those in -which the fluid ul- timately accumulates to the greatest extent are scarcely distinguish- able from those in which none at all is found: were the distinction more easily made, there is no point of practical importance to be gained in attempting it, except we have regard to the more rapid growth and speedily fatal termination of some of the forms of solid growth. It is chiefly in these that symptoms are to be met with such as have been already mentioned as the only facts in the his- tory of ovarian disease which can call attention to its existence: pains in the groins, a sense of weight and bearing down among the pelvic viscera, constipation, haemorrhoids, and painful defecation; occasionally, too, the functions of the bladder are interfered with, but this chiefly occurs at a later period, when the tumour rises out of the pelvis. During its growth, occasional attacks of more severe pain may take the place of the constant dragging sensation, and as this may imply that the sensation is excited by local peritonitis, and is TUMOURS. 379 not the mere pain of abnormal growth, the observation would be of importance if the question of excision were ever entertained. When felt above the pubis, the surface of a solid tumour is seldom perfectly uniform, especially when it is one of rapid growth ; the feeling of elasticity is sometimes closely allied to the sense of fluc- tuation, when the latter is obscured by the depth at which the fluid is placed beneath the parietes and the thickness of the walls or the multitude of the cysts. Before it can be reached in this situation it must already have acquired some size, and therefore it cannot very well be confounded with fibrous tumour of the uterus: its mo- bility will distinguish it from chronic matting together of the tissues by local peritonitis; and its deep connexions leave no room for the supposition that it is attached to the bone3 of the pelvis: at the same time, it is distinguished from omental growths, or malignant enlarge- ment of abdominal glands, by our being able to trace it under fa- vourable circumstances down into the pelvis. No certain conclu- sion can be arrived at if the abdominal walls be tense and resisting; but when the patient is placed in a proper position, and the resis- tance can be overcome by gradual pressure, the practitioner can al- ways place his hand between the brim of the pelvis and the growth, when not ovarian, and cannot do so when the seat of the disease is the ovary itself. The position of the tumour generally determines that it is not due to pregnancy in its ordinary form: the exceptions are when the tumour is central, or the preg- nancy is tubal. The distinction in these cases must depend almost entirely on the absence or presence of other signs of pregnancy, and it is to be remembered that the two conditions'may coexist, and nothing is lost by waiting for the termination of gestation before pronouncing a definite opinion. In place of giving an elabo- rate account of the signs of pregnancy, which does not come into our classifica- tion, I would refer my readers to the treatises especially devoted to this subject, only remarking that this question, perhaps more than any other, calls for the ex- ercise of common sense. The history is full of instruction, if rightly read^ the time of the cessation or alleged irregularity of menstruation, and its assigned causes, compared with the appearance of the patient, with regard to size, aspect, manner, carriage, &c, give the practitioner hints that need not be quite disregarded, even when he is told of the casual recurrence of the menstrual flux; or if in an exceptional case, menstruation were irregular at the time of conception, or have persisted regularly since, the sum of the signs from the breast, from the abdomen, and from the tactus eruditus per vaginam, are sufficient for his guidance if taken together. Perhaps it is scarcely stated in general with sufficient distinctness that the colour of the areola is of much less moment than the development within it of the glandular follicles. It has been asserted that the fluid which so frequently oozes from the mamma presents under the microscope all the appearance of milk in cases of pregnancy. The result of my experience convinces me that the unde- fined fulness of the abdomen, and the feeling of solidity perceived in pregnancy, is never exactly simulated by enlargement from any other cause. The sound of the fcetal heart is unquestionably the most conclusive evidence, but it is often diffi- cult, and sometimes impossible, to discover it. Digital examination detects in the early stages of ovarian disease, a tumour to one side and at the back of the vaginal wall, — moveable, but independent of the movement of the os uteri, which at this pe- riod retains its normal position. As the ovary enlarges, the uterus 380 DISEASES OF THE OVARIES. maybe somewhat pushed down ; at a later period it is drawn up, and the neck is sometimes most remarkably elongated. The mobility of the mass and its regular form, as perceived in this examination, are the points which especially distinguish it from the matting to- gether of tissues which is produced by local peritonitis of a chronic form ; and the elongation of the neck of the uterus, when any change occurs there, proves that the enlargement is not a consequence of pregnancy. 381 CHAPTER XXXIII. DISEASES OF THE UTERUS. § 1, Amenorrhea — § 2, Menorrhagia — § 3, Leucorrhcea — Vaginitis — § 4, Tumours — fibrous — polypous — § 5, Prolapsus — Malposi- tion — § 6, Congestion — Ulceration — § 7, Cancer. There is but little to be said on the diagnosis of this class of diseases, ■which are perhaps legitimately regarded as a special de- partment of practical medicine: but in the very fact of a speciality there is a tendency to abuse, and unfortunately persons are always to be found who will use any pretext to enrich themselves at the expense of their patients, without regard to morality or propriety. A professional sect has grown up in England in consequence of the minute — the needlessly minute investigations of the accoucheurs of France, which, impelled by such motives, assumes to itself, under the guise of this spe"eialite, the management of all the diseases of the female sex; rightly or wrongly, with reason or without reason, referring them all to changes in the uterus. Diseases are spoken of as of frequent or constant occurrence which we search for in vain, except in a very few instances, in the dead body. In reality, small as is our list of local maladies connected with the uterus and vagina, even these are mainly due to constitutional causes, and are best met by constitutional remedies. § 1. Amenorrhoea. — Absence of the catamenia must be distin- guished from chlorosis, inasmuch as tardy, scanty, painful and sup- pressed, menstruation are very often found altogether independent of general signs of anaemia; the face may be florid, the pulse good, the body well nourished, and the general health fair, notwith- standing the coexistence of amenorrhoea. Perhaps all this indi- cates a condition of local as well as general congestion which inter- feres with the due performance of the function, but quite as often the aspect of the patient is fallacious, and the real condition is atonic, the colour of the face being the effect of venous congestion rather than of general plethora. This is proved not only by the coldness and clamminess of the hands and feet, but by the fact that the menstrual functions become regular under the judicious em- ployment of tonics, and that if they be not regulated, chlorosis will speedily supervene. When dependent on local causes, total absence of the secretion may persist through life; or the fluid, unable to find an outlet, may accumulate in the uterus and vagina: in each of these there is some defect of organization. In other instances, exposure to cold ex- 882 DISEASES OF THE UTERUS. cites probably to the first place congestion of the uterus, and so brings on Budden suppression; but, if the function be not speedily restored a constitutional state is developed, and the disorder loses its local character. Though so intimately connected with age, the function is really dependent on the development of organs which age implies, and therefore in cases of retarded menstruation we have to look to the girlish or womanly appearance of the patient before interfering with the uterus; while, in the absence of the catamenia after mid- life, we have to remember that the involution of the uterus and ovaries takes place much earlier in some females than others. Sup- pression for a time almost always follows after an attack of any severe disease, and, if the individual have attained a certain age, may be persistent. In amenorrhcea which is not accompanied by anocmia we must always remember the possible coexistence of pregnancy: this sus- picion is more likely to be just if previously the catamenia were always regular, and is proportionally less probable if they have been irregular in their appearance. Irregular menstruation is only to be regarded as a symptom of constitutional dis- turbance, and not as a local disorder. The catarnenial periods are then often at- tended with pain; dysmenorrhea is sometimes also complained of when the flux is regular, but scanty or pale: in all of these the disorder is unquestionably de- pendent on constitutional causes. The pain in such cases is probably neuralgic, as it is associated with other sensations of an analogous kind, head-ache, back ache, &c: it generally precedes the menstruation, and is most intense at the commence- ment of the discharge. In other instances painful menstruation is accompanied by no diminution, but perhaps by excess of the catamenia, and may be connected with hemorrhoids, loaded bowels, &c, or with other diseases of the uterus, irritability, tenderness, fibrous tumours, &c. Sometimes the function is wholly deranged, and coagula are discharged in place of the ordinary fluid, or it is mixed with membranous shreds. We have no knowledge of the pathological causes of these states, and must be content with the explanation which disordered function conveys. I think we must be cautious in admitting the possibility of a contracted state of the orifice as a cause of dysmenorrhcea. Dilatation at all events constantly fails in relieving it. § 2. Menorrhagia* — This term does not include occasional he- morrhage, but must be restricted to the undue persistence and the too frequent recurrence of regular menstruation. It is most com- monly dependent on some general state of system ; rarely produced by plethora, it is much more frequently due to impoverished blood: hence it is seen in disease of the kidney or in general debility, in- creasing the anaemia which accompanies these conditions. Sometimes it is the consequence, of undue excitement of the sex- ual organs : and it is not an uncommon consequence of the imper- fect return of the uterus to its normal state after tedious labour or miscarriage. Occasionally hemorrhage very closely resembles menorrhagia when it comes on at regular intervals, and these are determined by LEUCORRHCEA. 383 the congestion or whatever else it is that gives rise to the monthly return of the menses ; but hemorrhage means something more than mere excess of the natural flux. It is associated either with de- struction of surface, or with polypous or fibrous growth, or with irregular position of the placenta in pregnancy; sometimes it ap- pears during the early periods of pregnancy, simulating irregular rather than excessive menstruation: in all cases, sooner or later, hemorrhage ceases to wear the aspect of regularity, and its regular appearance is the best indication that it is not menorrhagia. § 3. Leueorrhcea. — This disorder is nothing more than an exces- sive secretion of the natural mucus which lubricates the passage. Attempts have been made by discriminating the especial characters of the secretion, to determine whether it comes from the uterus or the vagina. These facts may be interesting as curious pathological researches, but they are of no value in practice: whatever restores the tone of the system at large, and along with that gives a healthy character to the mucous lining of the generative organs, relieves leueorrhcea; local remedies may aid in its removal, but alone, though they check it for a time, they leave the cause of the dis- order untouched. It is not a true catarrh, and this it is which best distinguishes it from gonorrhoea: the latter begins with irritation, possibly painful micturition, which is soon followed by a copious se- cretion of thick puriform matter, and this at length assumes the character of a thin discharge which cannot be distinguished from leueorrhcea ; it is the history alone that enables us to determine in cases of long standing which disorder is present. In children true catarrh of the vagina, vaginitis as it is called, is not uncommon. It attacks the very same individuals who are from cachexia liable to ulcerations of the mouth, to excessive im- petiginous eruptions with copious purulent discharges; and like them is manifestly constitutional. It has often given rise to un- founded suspicions and charges of crime, but there ought not to be any doubt in a medico-llgal point of view, because of the absence of bruises or local injury; there are no signs of inflammation pre- sent except a degree of soreness or irritation of the surrounding skin from the purulent secretion lodging upon it. It may be de- pendent on the presence of ascarides. "Whenever vaginal discharge is spoken of, we ought to ascertain whether it be at all offensive, because it may be induced by cancerous disease :_ if blood-tinged at other than the monthly periods, it is not improbable that it is dependent on commencing scirrhus. Leueorrhcea is so uniformly connected with causes independent of the uterus itself, that its associations demand general investigation much more than its amount or its other peculiarities. It is found with an anaemic state, with a flabby and re- laxed habit, or with a condition of the rectum which excites irritation of the uterus or vao-ina. Upon a correct knowledge of these relations depends the successful treatment of the disease, and, on the other hand, the knowledge of its existence serves to make us acquainted with the habit of a patient who may be seeking re- 384 DISEASES OF THE UTERUS. lief for other disorders, or to the detection of derangement of health which might Otherwise be overlooked. § 4. Tumours. — It is unnecessary in such a short summary to separate the fibrous and the polypous tumours, because their re- co'Tiiition is almost wholly a question for the professed accoucheur. They are both frequently marked by the recurrence of occasional hemorrhage, by bearing down, sense of pain and weight, &c, which call attention to the condition of the uterus itself. A fibrous tu- mour may often be felt through the abdominal walls, just at the brim of the pelvis, when it is situated in the body of the organ : its central position and its elevation serve to distinguish it from commencing ovarian tumour: polypous growths can only be de- tected by examination per vaginam. Both diseases may continue for a long period without the possibility of their being actually traced. We infer the probability of polypus when occasional he- morrhage is accompanied by constant leucorrhcca, and a sense of bearing down; when, at. the same time, the os uteri is partly open, and there is no hardness or irregularitj of its lips. A fibrous tumour, again, may be suspected when there is menorrhagia unconnected with general disorder, or traceable alteration of parts, and which has not been attended with pain; and when, in course of time, this is followed by discomfort in micturition, or by bearing down pains and efforts at ex- pulsion. § 5. Prolapsus. — The sense of weight and bearing down is con- stantly produced by actual displacement of the womb. The history very generally dates from previous pregnancy, when the patient got up too soon, or continued in an enfeebled state at the time when she was allowed to get up: the ligaments fail to retain the organ in its proper place, and it falls by its own weight. Some- times in women who have never borne children an unusual tension of the abdominal walls, by strain or violent effort, may cause de- scent of the uterus, just as it may cause hernia. Occasionally it is produced by the constant carrying of heavy weights : the fact is only to be ascertained by examination. Of late years we have heard a great deal of form#f prolapsus, which very often exist only in the mind, perhaps we may venture to say, in the mouth of the prac- titioner, — ante-version, retro-version— ante-flexion, retro-flexion; the former imply- ing a displacement of the whole organ, the latter, that its body becomes flexed or bent on itself. No doubt retro-version does occasionally occur, as a very painful and annoying form of displacement, pressing upon and greatly interfering with the action of the rectum: ante-version must be a very rare condition considering the daily and hourly distention of the bladder, which lies in front of the uterus. Ante- flexion, as has been pointed out by some French physiologists, is the natural form of the womb in early life, and though it may continue abnormally after pregnancy, or may be even exaggerated, it seems absurd to assign any importance to it except when aggravated by the existence of a tumour, or abnormally fixed by peritoneal adhesion. Retro-flexion is the most unimportant among the changes of position. Prolapsus may be limited to the walls of the vagina, or they may be involved in the descent of the womb. This often gives rise to more annoyance to the patient in walking or making any exertion than prolapsus uteri when free from such a complication. One of CONGESTION AND ULCERATION. 385 its most prejudicial consequences is when a portion of the bladder descends into the interior of the fold of mucous membrane, render- ing it impossible to evacuate its contents completely: the same se- quence of events occurs as when the bladder is paralyzed; the urine decomposes, irritation of the bladder is set up, unhealthy mucus is secreted, and chronic cvstitis is established. Valuable information in regard to diagnosis is also gained from an opposite condition, when the os uteri is found unusually high up. It is constant in pregnancy after the fourth month: it is often found when there has been local inflammation of the surrounding tissues : and it affords one of the most complete contrasts between large ovarian dropsy and ascites, because in the latter the uterus is always depressed. § 6. Congestion and Ulceration. — A very prominent place has been given by certain practitioners to inflammation and ulceration of the os and cervix uteri: yet they are comparatively rare, and, as substantive diseases, unimportant. They do indeed accompany other conditions which may be of serious moment to the health of the patient, but in their uncomplicated form their ephemeral notoriety will ere long have passed away ; true pathology and useful practice have been neither advanced nor benefited by those who have made them their study: and posterity will regard very differently the in- ventor of the stethoscope and the speculum. Simple congestion may be the consequence of over-excitement, or of sudden suppression of the catamenia; it may be excited by irri- tation of the rectum, or it may be only an exaggeration of that normal condition which produces the menstrual discharge : it is often associated with tumours of the uterus, or with prolapsus of the or- gan. After repeated pregnancy, enlargement, fissure, or irregu- larity of the os uteri may be often detected, to which the name of congestion is evidently inapplicable; but sometimes enlargement of the whole organ continues after delivery, and a state of venous congestion is maintained, which may result in hypertrophy or indu- ration. Inflammation, as applied to a muscular structure, is generally a misappropriation of language; the event we know to be a rare one. When acute or subacute symptoms are present, their true source is in the mucous membrane which lines its interior, or the serous layer which encloses the womb and its appendages. Such circumstances occur as a consequence of the puerperal state, and there is no more frequent cause of partial peritonitis: (see Chap. XXVIII., § 1, a:) they are also developed occasionally in females with irregular men- struation ; and the lining membrane of the uterus has been some- times inflamed by the presence of the gonorrhoeal poison. What has been called ulceration is generally only an aphthous or granular condition of the mucous membrane, and depends simply on constitutional causes: very often a patch of adhering mucus has 25 386 DISEASES OF THE UTERUS. been mistaken for an ulcer; sometimes it is only a creation of the fancy; perhaps occasionally the result of excessive leucorrhcea;- it is then but a symptom, and a very minor one. True ulceration is almost certain to be either a development of scrofula, the result of cancerous disease, or of syphilitic poison. If none of these causes be present, we may safely regard the ulceration as of no conse- quence in so far as it is a local malady. The states of winch we have just spoken are described as giving rise to a very great variety of symptoms; but with the exception of the feeling of weight and sense of tenderness which are the real exponents of congestion, the relations have been found to be wholly casual. By carefully recorded observations it lias been ascertained that the excess and diminution of the menstrual flux, the leucorrhocal discharges, the varied sensations and imaginings of hysteria were quite as fre- quently traceable in cases which presented none of those characters which are said to mark "inflammation and ulceration of the os uteri" as in cases in which the advocates of this new nosology would have discovered the more direct signs of its presence. That these signs do indicate any important condition is probably a false inference, but that the other symptoms of which we have spoken are in any way excited by it, is absolutely disproved. Tenderness to the touch, while very probably indicating congestion, must at times be regarded as rheumatic, or neuralgic, because of the absence of any thing else indicating inflammatory action, and one of our first principles of diagnosis is, that pain and tenderness are not to be regarded, when standing alone, as evidence of inflammatory action. Induration, perceptible hardness of the neck of the womb, is generally to be viewed as a consequence of past inflammatory action of some kind or other; but when accompanied by irregularity of surface, it is one of the early indications of cancer. § 7. Cancer. — Nearly all the symptoms of uterine disorder -which have occupied our attention may be excited by the commencement or progress of malignant disease; monorrhagia, or true hemorrhage, painful menstruation, leucorrhoeal discharge, sensations of discom- fort, uneasiness, and bearing-down, as well as true pain, are each to be found in various instances. In its advanced stages no one who supposes himself at all conversant with the evidences of uterine disease ought to have any difficulty in recognising it. The wan and unhealthy aspect of the patient and the odour of the disease may reveal it without the need of asking a question; if it have made less progress, the existence of pain, of occasional hemorrhage, of constant discharge, which has very often a peculiar colour, or may have to the patient's own consciousness a disagreeable odour, partial emaciation and sallowness are its usual characters. But any or all of these symptoms may be partially or wholly absent, especially at the commencement of the disease: it may cause no pain, no hemor- rhage, no discharge differing from leucorrhcea, no emaciation or malignant aspect. Digital examination will detect the roughness, irregularity, or hardness of commencing cancer with more certainty, and tit earlier periods, than ocular examination with the speculum. But is examination often or always to be resorted to? To this question I would reply that we must be on our guard against the fancied excellence of accurate diagnosis, remembering that it is our CANCER. 387 business to treat disease, not to be supremely wise : one examination, when desired by the patient or her friends for their information, can do no harm ; repeated examinations can do no good. We may con- clude, with every probability of truth, that in such indistinct cases the persons who think most and talk most of the state of their uterine organs have nothing really the matter: if by examination we have discovered what we deem the indication of commencing scirrhus, the information can be of little practical use ; the know- ledge is unquestionably of value, but we can neither make use of it to arrest a disease which we believe incurable, nor to warn the pa- tient of impending danger, when our convictions are not quite eer- tain. By a little delay the symptoms become more pronounced, the examination more called for, and the result more certain ; in the early stages of disease, it is therefore unwise to press for it, if we mean to act as honourable members of the profession. A digital examination ought always to precede the use of the speculum, which may be productive of much mischief if introduced in cases of cancer. 388 CHAPTER XXXIV. DISEASES OF THE BONES, JOINTS, AND MUSCLE?. Div. I. — Diseases of Bones and Joints — their Constitutional Cha- racter — Periost it is — TtacTi it is — Mollit ies — Frag ilitas. Div. II. — Diseases of 31uscles. Division I. — Diseases of Bones and Joints. The more important points with reference to diseases of the joints have been already mentioned (Chap. V., § 4,) and it is only in their relation to rheumatism that they can become the subjects of medi- cal diagnosis. Their local management is referred to the depart- ment of surgery, and probably for this reason they are not regarded as legitimately belonging to the practice of medicine: but in fact they are almost invariably associated with depraved constitutional states, and must be met by remedies addressed to the system at large ; in this view much of the knowledge regarding their treatment must spring from an acquaintance with the characters by which these conditions are recognised. In very many cases the disease which has become located in the joint, from whatever cause it may have been originally derived, is beyond the aid of remedies: structures have been removed, or ma- terially altered in their minute organization, and new formations have been added, which can no longer be modified by treatment suited to the primary disease: even surgery is unable to offer any material relief. These changes sometimes serve as landmarks by which we are enabled to define more exactly the nature of a subse- quent attack. We recognise gout by its tophaceous deposits, as they are called; and rheumatic gout by chronic thickening of the liga- ments and distortion of the joints; and we feel greater certainty tlfat the case is one of simple rheumatism when all traces of previ- ous suffering have disappeared: in cases of repeated seizures, the symptoms tend to become' less and less distinctive of the special malady, and to present a certain similarity of character. Inflammation of bone, whether ending in suppuration or in ne- crosis or caries, belongs entirely to the surgeon, because local treat- ment and operative interference are constantly demanded. Perios- titis, according to its origin, is regarded either as medical or surgi- cal. It often has a distinctly rheumatic character ; but it is still more frequently syphilitic. It consists of a local enlargement on the surface of the bone, tense and tender, very generally smooth, but sometimes also irregular, interfering more or less with voluntary motion, because of its relations to the origin or insertion of muscles, DISEASES OF BONES AND JOINTS. 389 but not hindering passive movement, unless its position be in close proximity to the joint; these characteristics point very plainly to periosteal inflammation. When the acute stage is past, or when the affection has come on more gradually, the thickening and indura- tion may be accompanied by very little pain. Its relation to se- condary syphilis is so constant that the discovery of nodes is very often sufficient to guide our determination in an obscure case: their most common situation is on the front of the tibia, and next in fre- quency over the cranium. In all affections of the bones and joints in which motion is interfered with, we have to bear in mind the remarks already made upon posture and gait, and upon active and passive motion: these modes of examination serve to point out the various conditions of stiffness or immobility, of pain produced by the muscular effort, and of pain produced by the motion of diseased surfaces on each other, or by the stretching of inflamed ligaments; distinguishing them from muscular para- lysis. Loss of power is the usual complaint of the patient, when the condition consists really of inability to use the power which exists. Rachitis is essentially a disease of childhood, and is only known by the deformities, whether permanent or transient, to which it gives rise. In middle life, somewhat analogous effects result from molli- ties ossium, though pathologically the diseases are different; in the one the bones bend, but do not break, in the other there is generally a great tendency to spontaneous fracture. The fragility, fragilitas ossium, as it used to be called, is, on the other hand, more closely allied to atrophy, and is very generally a disease of old age, when the absorption of tissue exceeds its reproduction. In rickets and in mollifies ossium the earthy constituents of bone are dimi- nished, but their different characters are caused by the circumstance that in one the bone-earth is not deposited in sufficient quantity to meet the requirements of growth, in the other it is removed after its deposition, and is replaced by morbid structure: the one is rather a consequence of faulty nutrition, the other is the effect of actual disease. In atrophy the fibrous material is removed as well as the lime; and hence, while in mollities the remaining portion of earthy structure is crushed and splin- tered by the bending of the bone, in fragilitas the bone itself breaks across. Division II. — Diseases of Muscles. The diseases of muscular structure are not numerous, or of much importance: those chiefly concern us, in medical practice, which lead to paralysis, more or less complete. One of the most common is that which has been already traced in connexion with lead poi- soning (Chap. VI., Div. I., § 3.) It is in great measure limited to the extensors of the fore-arm, and is especially recognised by the blue line round the gums, which can always be traced when the sys- tem is impregnated with the mineral. Another condition, which is perhaps of greater importance, is that in which the true muscular fibre becomes replaced by fat, fatty degeneration is very frequently discovered in the walls of the heart, rendering its action feeble, and materially shortening existence by its effects on the circulation. In the voluntary muscles the same change is occasionally observed; • 390 DISEASES OF BONES AND JOINTS. and in the absence of direct evidence of its existence it may be ex- fcremely difficult to determine whether the resulting paralysis be caused by want of muscular power or of nervous energy; the only rule that can be applied to distinguish them is, that when the dis- ease is in the nervous system, the paralyzed muscles all derive their energy from the same source ; or if their sources be different, the muscles which are supplied by distal nerves on the same side of the body are always involved in paralysis affecting those which receive their nerves from a point nearer to the brain. When the paralysis is caused by disease of muscle, the same law does not hold good. On the other hand, it must be remembered that atrophy of muscle is a consequence of loss of nervous energy, and the causes of fatty degeneration are yet quite unknown. The muscles are constantly involved in cellular inflammation, and, when suppuration follows, the fibres are bathed in pus, which burrows among their structures. Occasionally the fleshy belly of the muscle becomes the site of small abscesses, but inflammation of the fibre apart from that of the investing sheath of areolar tissue is unknown. 391 CHAPTER XXXV. DISEASES OF THE SKIN AND CELLULAR TISSUE. General Principles of Diagnosis. — § 1, Erythema — Urticaria — Roseola — § 2, Papular Eruptions — Lichen — Prurigo — § 3, Squamous Eruptions — Ichthyosis — Lepra — Psoriasis — Pityri- as is — § 4, Vesicular Eruptions — Eczema — Herpes — Scabies — § 5, Pustular Eruptions — Impetigo — Ecthyma — Acne — Sycosis — § 6, Pemphigus — Rupia — § 7, Vegetable Parasites — Favus — Porrigo Decalvans — Pityriasis versicolor — § 8, Tubercle of the Skin — § 9, Syphilitic Eruptions — § 10, Lupus — Scrofulous Ul- cer — Cancer of Skin — § 11, — Endemial Diseases of Skin — § 12, Cellular Inflammation. It is pretty generally admitted that the information possessed by most practitioners of medicine in this department is exceedingly vague: the lines of demarcation between the various forms are in- definite, and the results of treatment for the most part unsatisfactory. It is true that in general the diseases of the skin are not of very great importance, but it is an erroneous conclusion that they will not there- fore repay the trouble of study. Our failures in treatment are not unfrequently the result of ignorance, and a little pains bestowed on ascertaining the true principles of diagnosis, and acquiring an ap- titude in discriminating the varieties which these diseases present, will very soon enable the student to learn for himself what mode of treatment is useful in one form, useless or even hurtful in another. It will thus limit the choice of his remedies to a few that may do real good, in place of his ringing the changes on a variety of impotent drugs, to be at last relieved of a tedious and unmanageable case only by some accidental change in the constitution of the patient which at once dissipates the local disorder. On a superficial view nothing should be simpler than the dia- gnosis of skin diseases. If a man but use his eyes aright, it maybe said, he ought to be able at once to distinguish them : here is surely an instance in which the symptom is pathognomonic of the disease. In this, I believe, consists the great difficulty, and this short-sighted reasoning is one of the chief causes of the ignorance that prevails. If the scope and intention of the preceding pages have been made at all intelligible, no argument is needed to prove that skin diseases do not in this respect differ from others; they are by no means iso- lated facts in the economy; and while we must acknowledge the faulty action in one tissue, we must not ignore it elsewhere. The evidence of the constitutional fault is, however, not always manifest, and when present, its language is not always the same. The symp- 392 DISEASES OF THE SKIN. toms which were enumerated in the early part of our inquiry, as in- dicating the general condition of the patient, have to be reviewed; but though we find some preponderating more than others in par- ticular classes of skin diseases, there are none which may be fairly classed as diagnostic of any individual disorder. AVe are thus forced to take up the two subjects separately, and frame our diagnosis of the cutaneous affection, independently of the more general derange- ment of which it, is chiefly a symptom; and this limitation prevents our being able to correct the opinions based upon one set of observa- tions by that derived from the other. One rule may be given at the outset as applicable to all cases, and especially to those about which there is doubt, that the distinguish- ing characters are most readily traced in the commencement of the disease, and the student should make it his business always to see the most recent spots of the eruption. This is in fact the history of the case, which is often written more correctly in the different patches on the skin of the patient than it is ever detailed in the most accurate case book. Next in value to seeing the eruption at its earliest stage is a good account of it from the patient himself; and in this we have only to guard against asking leading questions, where interrogation is so necessary to elicit the facts at all. In certain forms, concomitant fever may or may not exist, and in such it is essential to mark its presence or absence; but this rather with reference to treatment than to diagnosis, for we do not regard those as cutaneous diseases of which fever is an essential element: we deal with it simply as one of the constitutional states which must be considered in its casual relation to the eruption, of whatever nature, which is present. § 1. Erythema — Urticaria — Roseola. — In subdividing the subject of this chapter, it will be most convenient to consider those forms, first, in which the epidermis is not altered; the skin is red, perhaps elevated and tender, but its surface is unbroken. The eruption of erythema consists of a uniform redness, with puffiness of the skin, distributed in distinct patches of some size: it is accompanied by little constitutional disturbance. When fever is present, we suspect either that the disorder is not erythema, or that the febrile symptoms have some other cause. The skin, though some- what elevated, has not the hardness of erysipelas: after the first day or two the colour becomes bluish or livid, and this to an in- experienced eye might simulate the dusky redness of diffuse cellular inflammation ; but the heat and the tension are absent, as well as the constitutional irritation. One variety only deserves mention on account of its distinguish- ing characters — erythema nodosum: most commonly seen on the anterior aspect of the leg, it appears in distinct rounded patches, which are considerably elevated, and very tender. LICHEN AND PRURIGO. 393 This variety is believed by some to be a form of rheumatism : as the attack sub- sides the patches become soft, and present something very like a sense of fluctua- tion, but they do not suppurate. In the broadest sense, any red patch on the sur- face of the body which is not caused by erysipelas might be called erythema. Writers on skin diseases often enumerate all such cases, and describe the various causes which might give rise to the appearance: it seems better to restrict the name to those instances in which the redness is produced by something more than mere irritation of the skin, and in which it is not sympathetic only, as when a red patch is seen over a joint affected with acute rheumatism. But an erythematous blush so often points out the situation of grave and serious mischief that whenever fever is present it becomes our duty to study the case very carefully, in order to discover the deeper-seated lesion, of which none are more important than cellular inflammation and secondary suppuration. Urticaria, "nettle rash," by its very name, gives an idea of its general form; but while the sting of the nettle raises a white wheal on a sensitive skin, the colour of the patches of urticaria is generally redder than that of the surrounding surface. This is often perhaps the consequence of its duration, just as the mark of a lash is first paler, and then redder than the rest of the skin ; sometimes the patches are deep-coloured from the first, and when they continue for any length of time, they tend to become purple or bluish. The eruption is attended with tingling or itching: its progress is some- times very rapid, lasting not more than one or two days if it be the result of something taken as food or medicine; in other instances it continues for a week or two, and occasionally in its chronic form it mav exist in more or less distinctness for weeks or months. It is distinguished from all other cutaneous affections, which are similarly distributed, by its patches being perfectly smooth; there is neither oozing nor desquamation of the surface; it can hardly be confounded with erythema nodosum, which forms in much larger patches with less defined border. I am inclined to regard roseola as a sort of spurious exanthem; it is to be seen when measles are about, as well as when scarlatina prevails, but without the coryza of the one or the sore-throat of the other. It resembles those diseases in attacking young persons and presenting febrile symptoms, though of a very slight and evanescent character. It maybe best described negatively: the patches are not small and semilunar as in measles, nor are they punctuate and close-set as in scarlatina, and the whole surface is never involved, as is sometimes the case in the eruptive fevers; though roundish in form, the borders are not defined, nor the surface elevated as in ery- thema or urticaria, and there is no attendant irritation or itching. § 2. Lichen and Prurigo. — In this subdivision there is also no necessary breach of surface; the cuticle is elevated in small distinct points, without any secretion, and the desquamation is accidental: the eruption is of the form designated as papular. It seldom hap- pens, however, that it is seen exactly in this condition, because there is always itching, and the top of the papule becomes abraded, leaving a red spot or a small crust of coagulated blood. The dia- S04 DISEASES OF TIIE SKIN. gnosis is not difficult if these circumstances be considered; and even when, as in the severer form of lichen ajrius, suppuration exists, ca rcfal inquiry will disclose that such a condition has only arisen in consequence of the long continuance of the disorder in a cachectic individual, and was not the form in which it first appeared: other portions of the eruption may also be discovered in which the papular character is manifest. The distinction between ordinary lichen and prurigo is really more a question of names than of things. It may be observed that lichen is more generally grouped in patches, prurigo is more diffuse; the itching of the former is comparatively alight, that of the latter intense and intolerable; as a necessary consequence the skin is abraded by the nails, and a case of prurigo is always marked by scratches and bloody points. The cases in which the disease runs an acute course, and those in which it presents any tendency to ulceration and suppuration, are both commonly referred to lichen, the more ordinary chronic papular eruption is usually called prurigo. One or two varieties must be mentioned, not so much on account of their indi- vidual importance, as that their diagnosis is obscure. The lichen cireumscriptus assumes a very complete circular form, which in common parlance brings it under the general classification of "ringworm," a name which includes diseases by no means related to each other: to the student this appearance is apt to suggest the idea of lepra or even herpes. With the latter it ought not to be confounded, because e is no secretion, no vesication, no crust: from the former it is distinguished by the circumstance that desquamation is the principal feature of the one, is only an accidental occurrence in the other. In lepra lar^e white scales surround a portion of skin which scarcely differs from that of health, in lichen cireumscriptus the whole surface is rough, even though the edge be more elevated than the centre; the desquamation of the cuticle occurs as small fine scales, and is quite a subor- dinate phenomenon: the patches of lepra are large or numerous, of lichen smaller and solitary. The same affection occurring in the scalp gives rise to what is very often called porrigo decalvans, a name as undefined as the vulgar epithet of ring-worm. It is marked by the hair falling off in a circular patch, the surface being roughened and covered with minute scales; there is no vesication, suppuration, or ulceration. In this respect it differs from most other diseases which produce loss of hair, when there has been some previous severe affection of the scalp, and the patch of bald- ness only comes to be remarked when the skin has again recovered its natural con- dition ; in that form of porrigo to which the name decalvans should be limited, the hair falls off in consequence of disease of the bulb apparently caused by a pa- rasitic fungus, the skin being left perfectly smooth and free from scurf. In the lichen strophulus of childhood the papular character of the eruption is least defined. It consists of distinct spots scattered all over the body, but espe- cially the arms and legs, which are white and elevated, and have a semi-trans- parent appearance, almost exactly analogous to a vesicle : it is less to be dis- tinguished by its aspect than by the fact, that, with the exception of varicelloid eruptions, there is no disease in which solitary vesicles are uniformly distributed: they are either grouped together, or they affect certain localities more than others. The prurigo pudendi again deserves notice from the occasional absence of all eruptive character together. It is no doubt often caused by want of cleanliness, by the presence of irritating secretions, of slight eczema, or some form of parasite about the roots of the hair; but undoubtedly pruritus does exist without any of these causes, and it must then be regarded as sympathetic of internal irritation of the uterus, the bladder or the rectum. The same remarks apply even more con- stantly to prurigo podieis, which is constantly associated with internal haemor- rhoids and ascarides. If these be regarded as instances of a sympathetic or neu- ralgic character, it may be doubted whether, in a great number of cases, the same explanation might not be given, the appearance of eruption being really the effect of scratching: this is especially true of that form which is associated with a gouty habit. SQUAMOUS DISEASES. 395 Lichen and prurigo are generally distributed on the outward as- pect of the limbs, and avoid the flexures of the joints. In this respect they especially differ from scabies, with which, notwith- standing the great dissimilarity of the original lesion, they are sometimes confounded, because of their intolerable itching, and the change which is produced in their appearance by constant scratch- ing. § 3. Squamous Diseases. — The next class is one in which the cuticle is materially altered in its form and character. It does not desquamate accidentally in consequence of a casual interruption to the secretion, as in scarlatina or erysipelas; nor does the presence of a papule, as in the last class, cause the premature death, so to speak, of the small portion of cuticle which covers it; but the epi- dermis is secreted in some abnormal manner which leads to its agglomeration into scales of some size. In one form, ichthyosis, they remain attached, and acquire a horny hardness; in the others, lepra and psoriasis, they gradually become disconnected with the cutis, and fall off. There is no disease which can be confounded with ichthyosis. Certain trades produce an unusual thickness, hardness, and dry- ness of the cuticle, which may, in some degree, simulate it; but when occurring in parts of the skin not so exposed there cannot well be any mistake. Sometimes, indeed, on recovery from chronic eczema, the skin may for a time be hard and dry, but the history of the case sufficiently distinguishes the two disorders: ichthyosis is a congenital malady. There is no practical advantage in separating lepra from jisori- asis. Some cases are certainly more obstinate than others; and in the text-books of skin diseases several varieties are recorded which depend in great measure on the duration and intensity of the dis- ease: its essence is the same, and in diagnosis it matters little which name is assigned. As a general rule, those cases in which healthy skin is surrounded by squamous portions, especially in an annular form, are called lepra, while those in which numerous small spots, or single larger patches, are wholly covered by scales are called psoriasis ; the crusts, too, in the former are more adherent, and consequently larger and whiter than in the latter. The greatest difficulty in recognising the character of the eruption is experienced when the scales have been removed by a warm bath ; the fresh cuticle underneath them presents a red shining aspect, which may for a moment be mistaken for chronic eczema. When it begins by a solitary patch it may be difficult to dis- tinguish it from lichen circumscriptus, especially on the hand or face, where con- stant washing removes the scales as soon as formed. The distinction rests on the principle already enunciated, that in the squamous diseases the cuticle is secreted in an unnatural condition, and consequently where the scale has been removed the skin looks red, and smooth, and shining, whereas in lichen the detachment of the cuticle is only caused by its nutrition being interfered with from the existence of papules, which give a certain degree of irregularity to the surface. Like the previous class these diseases especially affect the outer sides of the 396 DISEASES OF THE SKIN. limbs, and avoid tl,.- flexures of the joints. They are not necessarily attended with itching, bnt if once irritated the itching sometimes becomes very intense. '1'i,,.. entially chronic in character, and the history only shows that there has b n a rough patch observed somewhi re or other which has not received any attention till it has attained some size, or till the same eruption has appeared else- where. Pityriasis used to be classed as a squamous disease; perhaps one of its varieties, pityriasis capitis, marked by a constant excessive desquamation of the cuticle over the scalp, which falls as white powder when the hair is brushed, ought still to be considered: it is nothing more than an excess of natural secretion, and can scarcely be classed among diseases of the skin. Pityriasis versicolor is now referred to the parasitic growths ; its most prominent feature is the change of colour over the parts affected. § 4. Vesicular Eruptions.— In this class we meet with cases of very varying intensity, which, according to the stage at which they are seen, may resemble squamous or pustular eruptions. The rea- son for grouping them together is, that the primary element in all is a vesicle, and the practical utility of such a classification consists in this, that when such an origin can be traced, there is no diffi- culty in deciding to which of the vesicular diseases any case ought to be referred. ° The first inquiry, therefore, will be how long the disease has lasted, and how it commenced; and then search must be made for a vesicle in the early stage. If the first appearance of the disorder cannot be traced, we have to remember that the serum must either continue to ooze away, keeping the part con- stantly moist, or harden into a gum-like crust, or that it may dry up altogether, leaving small, round, dry scales, as the only remains of the vesicle; but, on the other hand, by exposure, the cutis may be irritated, and produce a purulent secretion, which forms crusts like those of the pustular eruptions. The last two alone can give rise to any difficulty in diagnosis, and they belong to one form of eruption — viz., eczema. In this variety a number of vesicles are always found together, coalescing and forming a patch of varying size. It is distinguished from the'other vesicular eruptions by their neither being disposed in regular groups, nor occurring singly. In its simple form the vesicles either constantly form on an uninflaraed surface, and gradu- ally disappear, or the skin continues red and moist after they have burst; in the former, the appearance of flesh vesicles prevents our referring the shrivelled and dry ones to any scaly eruption ; in the latter, the moistened surface prevents its being mistaken for ery- thema, or erysipelas, which is the name commonly applied to it by patients. Occasionally the reddened skin is dry, and covered with small scales: that this is not psoriasis is proved by the circumstances, that the skin is evenly inflamed all over, and that the scales are rfbt aggregated in patches which run into each other. As a conse- VESICULAR ERUPTIONS. 397 quence of the inflammation, the skin is generally cracked and some- times bleeds, and this never happens with psoriasis unless the scales be very thick and adherent, when the diagnosis cannot be difficult. This form of eczema is best seen in what is called "grocer's itch," or on the hands of washerwomen. "When the oozing from the surface, in place of continuing as a thin serosity, becomes purulent and hardens into crusts, the name eczema impetiyinodes has been employed. It is quite unnecessary to distinguish this from real impetigo, foil the diseases are closely analogous, except when the borders of the eruption are red and in- flamed, and the eczema is spreading; if there be only a chronic purulent discharge, the name given is quite immaterial. The great characteristic of herpes is, that the vesicles are dis- tributed in groups or clusters: they are also larger than those of eczema, and do not so readily fuse together. On their disruption the secretion almost always forms a gum-like scab; their duration is commonly short. Among its more constant forms we find the following: Herpes labialis, — occur- ring in one or two patches on the lips, sometimes on the nose, and more rarely about the eyelids; in common parlance described as the effect of "a cold," and evidently associated with irritation of the mucous membrane. Herpes cireiinatus, — one of the "ring-worms"' in which the clusters assume an annular form; the vesication and the scab alike distinguish it from lichen circumscriptus and from lepra; there can be no excuse for a mistake, except when the eruption is disap- pearing. Herpes zoster is only remarkable for its situation, and the extent to which it may extend, encircling as it does the one-half of the trunk, and though generally bounded in a remarkable manner by the mesian line before or behind, jet some- times passing beyond. Herpes preputialis is worthy of notice because it has been sometimes mistaken for chancre; it has no peculiar characters to distinguish it from any other form of herpes; it is perfectly different from any syphilitic affection. Patches of herpes wherever occurring, usually known as "shin- gles," except in the few instances enumerated, are so exactly like the eruption on the lip, which is familiarly known to every one, that description is unnecessary. It is often preceded by considerable local irritation, and a sort of cutaneous neuralgia very frequently remains after it has died away. Scabies should not, perhaps, in a scientific work be classed as a vesicular disease, because the vesicle is really an accident, and may be replaced by a pustule. But for purposes of diagnosis it is well to retain it in its present place, because whereas lichen, prurigo and the scaly diseases all have their chief site on the outer sides of the limbs and back of the trunk, the vesicular eruptions gene- rally, and scabies in particular, select the inner aspects of the limbs and the flexures of the joints. The acarus, which is the essence of the disease, does not inhabit the vesicle, but grooves out a curved channel for itself, which may be generally seen as a black line like the letter S: but its presence always determines the eruption of solitary vesicles, which may in course of time become pustules; and these are sure to be found at the flexure of the wrist or between DISEASES OF THE SKIN. tin' fingers, and along the inner sale of the arm, wherever else they may be. One vesicle with a distinct groove from it in such a situa- tion, is enough for diagnosis; any amount of itching without these is of no value: prurigo causes quite as much itching, and pus- tular, or even quasi-vesicular eruptions, occur very frequently among children of the lower classes which closely resemble scabies, and can only be pronounced not to be so by observing this remarkable pre- dilection for locality and the constant presence of the groove Avhen the parasite is really present. § 5. Pustular Eruptions. — A fully-developed pustule is quite un- like any thing else, but just as at certain stages of the vesicular eruptions the secretion is not serum, so in the pustular the secretion is at first not true pus, and, after the pustule has burst and dis- charged, the crust may not be quite characteristic. In impetigo this difficulty is most likely to be met with, because its characters vary as the disease is spread over a large surface in solitary pus- tules, called impetigo sparsa, or is limited to distinct patches, when the name figurata is applied to it. In the former the single pus- tules have at first much the appearance of vesicles, but they very soon lose their transparency: among vesicular diseases we have found no such example except scabies; and therefore, when a case of this kind is met with, the question cannot be, is it eczema which exists only in patches, or herpes which forms small and well-defined groups, but whether it be scabies or impetigo: the answer is only to be obtained from the diagnosis of scabies. "When, again, the eruption occurs in patches it is more liable to be mistaken for her- pes: but the course of the two diseases is quite different; the one commences suddenly, and is preceded by irritation, the other is gradual, and its beginning is unobserved; the one terminates in a few days, the other lingers on for weeks or months. The common history of impetigo is that, after some degree of redness and tumefaction of the skin, one or more distinct pustules slowly make their appearance, the irritation which accompanies them being so slight as to escape observation in most instances, and the eruption itself receiving little attention. The matter con- tained in them very soon becomes decidedly purulent and forms a firm scab; but before those first observed have had time to dry up, others appear in succession, which are either scattered and distinct, or in close proximity to the former. . It is scarcely possible to say in the first instance which of the two varieties is likely to be developed. When the disease has already lasted some time, and a thick crust has formed, it matters little whether it be called eczema impetiginodes or impetigo, — -herpes it cannot be; for the only question worth considering is, whether there be any ap- pearance of redness or tendency to spread about its margin. The crusts of dry pus, when solitary and rather large, are very like those of the next subdivision, ecthyma; when in clusters, or covering a large surface of the scalp, they can only be mistaken for favus. The scalp and neck, and face, are the chief sites of im- ignrata, which is more rarely seen on the limbs: impetigo sparsa occurs chiefly on the back and arms, and less frequently on the legs. PEMPHIGUS AND RUPIA. 399 In Ecthyma the pustules are large and solitary, although very often a number are found together on one limb, and none else- where, showing thus a tendency to aggregation. The great dis- tinction between it and impetigo, independently of the difference of size in the pustules, seems to be that the cutaneous texture is more deeply affected: in the one there is an abraded surface which se- cretes pus, in the other there is a nearer approach to an ulcer under the dry crust with which it is covered. This brings it into close rela- tion to rupia, which is only distinguished by the ulceration being more unequivocal, the scab larger and more adhering: in rupia, too, there is no tendency to aggregation, the scabs are few and solitary. Ecthyma is seldom found in the chronic form : it is easily distinguished from boils or carbuncle by the circumstance that it is quite superficial, and there is con- sequently no surrounding elevation of hard and tumid skin, as when the suppura- tion proceeds from the deeper textures. Nothing has been said of the syphilitic eruptions, because they must be taken by themselves, but it is worth noticing here that when there is much approach to ulceration this disease comes nearer in ap- pearance to one of the common forms of secondary eruption than any we have yet had to refer to. Acne and Sycosis are names applied to suppuration of the follicles. The latter confined to that which appears at the roots of the hair in the beard, the former including all other cases. In this sense, every common pimple maybe called acne; but. the name is reserved for cases in which there are so many as to show a general tendency to this kind of suppuration. Although the course of each individual pimple be not very prolonged, yet the progress of the disease is slow: not unfrequently this tardiness is shown in persistent redness after the actual suppuration is at an end, and its continued recur- rence in the same follicles. When such a blotchy redness alone remains, and no pustule is to be seen, a learner may be at a loss to what class he ought to refer the case; its rugged surface renders it unlike eczema, and the absence of crust shows that it is not im- petigo; its redness and its position, only on the face or back of the neck, prevent its being confounded with lichen or psoriasis: it is most apt to be taken for tubercle-of the skin. Sycosis much more nearly resembles impetigo: crusts generally form, and are very obstinate and adherent: but it is to be observed that the skin is elevated round the crust, which is just what we should expect from the circumstance that the suppuration proceeds from a follicle deeply-seated in the cutis, and not from its surface. Favus, which has been classed among pustules, we shall refer to its true place as a parasitic growth. § 6. Pemphigus orPompholyx and Rupia. — These two disorders, although very different in their history and causes, may conveniently be classed together, because they are characterized by the existence of bullae (literally bubbles.) In pemphigus the contents of the 400 DISEASES OF THE SKIN. bulla arc always serous, in rupia puriform ; and tlicy thus correspond in Borne measure to the division of the smaller eruptions into vesicular and pustular. In connexion with this there is a similarity in history, the one appearing more frequently in an acute form, the other being always chronic; there is also a chronic pemphigus, to which name pompholyz is given, to complete the analogy with chronic eczema. Whether this disease be of shorter or longer duration there i3 always redness of the skin, the cuticle rising in separate blisters, generally rounded and prominent, and filled with serum; the dura- tion of each blister is not long, but great difference is observed in the rapidity with which the subsequent healing process goes on. There can be no question as to whether it be a vesicular eruption, because of the immense difference in size; indeed, the only disease in which similar blisters are ever seen is erysipelas; and for this it cannot be taken. In the sequel the appearance of the skin depends much on the rapidity of the healing process; and when fresh bullae have ceased to appear, or the morbid ac- tion is for a time suspended, there may be considerable doubt as to the true nature of the disorder. The skin may be merely morbidly red in patches, or it may be covered with roundish spots over which the cuticle has been r< moved, and new epidermis is funning; or again, these spots may be covered with a sero-purulent discharge, which in some is converted into a thin crust: in such instances the his- tory of the case will best explain the meaning of what is seen. Rupia, although it be said to commence as pemphigus does, in a bulla of some size, presents but few r analogies to it. It is far more nearly related to ecthyma; it is not a blister full of clear liquid, but a very large pustule, which does not come from beneath the skin like a boil, but yet goes deeper into its texture than the mere pus- tular eruptions, leaving an ulcerated surface, of considerable depth, covered by a thick crust. This, its ulterior stage, is the character- istic one of rupia. It has been compared to a limpet-shell, and the resemblance is in some instances not far-fetched. In its earlier stage the spots are few and large, and there is not much redness around; they contain unmixed pus, not bloody or sanious matter: but it is only when there remain .solitary spots of ulceration, of a circular form, covered with a thick crust, around which the skin is moderately elevated, that the disease deserves the name of rupia ; and in whatever way it have commenced, whether like ecthyma or even impetigo, it is now rupia; and the name is of importance, be- cause it at once points to a condition of system. We shall have to refer to this form of disease when speaking of syphilitic affec- tions, and it is of vast importance to be able to say whether rupia be or be not specific. But there is one mistake which I have seen made by persons who form diagnosis from pathognomonic signs. A limpet-shell crust is to them the Bign of rupia, and when the desquamating crust of psoriasis assumes this form, the one is mistaken for the other. It is surely needless to say that the shape is only accidental, the history and the condition of skin are perfectly distinct, and not less so the condition of system. TUBERCLE OF THE SKIN. 401 § 7. Vegetable Parasites. — The distinction which this name im- plies is only of recent date; perhaps microscopical researches may yet extend the class, and at all events we may hope for more de- finite knowledge of the relation of the variouaforms of parasitic life to the eruptions with which they are associated; such as in acne and sycosis. The most important of this class is one that has its seat in the hair follicles — favus, or porrigo favosa. It used to be classed among the pustular eruptions, because it first appears as a small yellow spot, the sheath of the hah- filled with fungous growth ; but it has no tendency to suppurate. It grows with great rapidity, and when neglected forms large, hard, dry crusts, which have a peculiar mouse-like odour. It is most liable to be confounded with impetigo, but it requires only moderate care to determine whether the crust be hardened pus or an independent growth. The distinction is based on the presence or absence of secretion : be the crust of impetigo never so dry, some trace of purulent secretion is sure to be met with ; and if removed by a poultice, the moist, exuding surfaces cannot be mistaken. Knowing this fact, we have no need to par- ticularize the rounded form, the cracked, broken-looking surface, and all the other characters which older writers were obliged to enumerate. It is met with commonly in the head, but sometimes also down the back of the neck or in front of the ear. One form of porrigo decalvans belongs to this class. The hair falls out in a patch of a circular form, leaving the skin of the head perfectly smooth: the absence of cutaneous eruption of any kind proves that it is connected simply with disease of the hair and not of the skin: this, too, is found to be a microscopic fungus. Pityriasis versicolor was long a puzzle, because it has certainly something of a squamous character, but in a very subordinate degree. Its chief mark is a yellowish-brown discoloration, in small circular patches, which sometimes spread all over the body. There is no vesication, no crust; the small scales of the epidermis fall in larger quantity than in health, producing some degree of roughness ; and the eruption is sometimes attended with much itching. It is now shown to be connected with the growth of a fungus. The varieties called rubra and nigra probably belong to the same category : they are described as being very rare, and none have come under my own observation. § 8. Tubercle of the Shin. — Although not a very common malady, it is necessary to point out how it may be distinguished from other cutaneous affections to which it bears some resemblance. It is most frequently seen on the face, and is sometimes limited to the nose or the ear, producing a most disagreeable alteration of the features. The disease consists of smooth, rounded eminences, which are accompanied by a general puffiness of the adjacent skin, and marked by livid or bronze discoloration. The name is an unfortunate one, 26 402 DISEASES OF THE SKIN. because it is usually applied to one particular development of the strum oua diathesis, with which tubercles of the skin have nothing in common. Usually aggregated over a limited surface, the erup- tion does not present ajiy regular groups, except in those rare forms which have received the names of frambossia and molluscum, from fancied resemblances which they present. In very severe cases it may implicate large tracts of skin, and then the name "Elephan- tiasis of the Greeks" is applied to it: "Elephantiasis of the Arabians" is a wholly different disease: French authors employ this name even in mild cases. It is always accompanied by dis- order of the assimilating functions, and common belief assigns as its frequent cause the improper use of stimulants. In speaking of acne it was mentioned that at one stage of its progress, when no suppuration was going on, and the skin presented a red and rugged appearance, it was liable to be confounded with tubercle. Such a mistake is very liable to be made by one who knows skin diseases only as described in books, because both are equally found in persons of dissipated habits. Very little experience serves to distinguish the smaller size and brighter colour of the hardened points in acne from the rounded knobs and livid colour of tubercles: the disagreeable expression produced by the tumid features of the latter are very different from the bloated aspect of the drunkard whose nose and cheeks are inflamed by an eruption of acne. In addition to this, the history if rightly inquired into, details the existence of previous suppuration in the one and its absence in the other. Tubercle of the skin is one of those cutaneous affections which have a counter- part among the syphilitic eruptions: its diagnosis, however, is, as we shall find, not diilicult. § 9. Syphilitic Eruptions. — This class of eruptions has no legi- timate place among cutaneous disorders; they are the mere expo- nents of a specific disease; but it is necessary in a work on dia- gnosis to point out their resemblance to some of those which have been already enumerated, and to show how they may be distinguished from them. Their most marked feature is the copper-coloured tint of the surrounding skin ; but this is only another instance in which persons who trust to one sign, however uniform, are sure to be occasionally mistaken. Not only do eruptions, which are certainly not syphi- litic, sometimes present a discoloration in healing which can be called by no otlw name, but true syphilitic eruptions are occasion- ally free from it. It is only by studying the whole history of the affection that a correct opinion can be formed. The first question is whether the characters of the eruption correspond exactly to those belonging to any of the classes of the diseases already enume- rated, because an individual may have had primary syphilis, and the system may still not have become infected. If it present any peculiarities, and especially if marked by the coppery tint, the next point is to inquire into the possibility of syphilitic contagion; and this can only be done, especially with females, by indirect interro- gation: it is still more important to ascertain whether there have been any symptoms of syphilitic poison, such as sore throat or SYPHILITIC ERUPTIONS. 403 periosteal inflammation: the circumstance of the hair falling off, or the existence of iritis, tends to the same conclusion. In regard to the eruption itself, we notice that the copper-colour is not limited to parts which are already healed, except perhaps in urticaria; and the disorder does not exactly correspond to any of the. definitions already given: it approaches nearer to one than another, and may simulate any of them except the vesicular, which, if it ever exist, is extremely rare. The urticaria or roseola is no longer a simple redness of the skin, assuming a livid hue as it dies away; but it has a tendency to desquamation — it becomes brown instead of purple. The lichen is larger and discoloured, and has a more decided scab on its top ; it approaches more nearly to the characters of psoriasis. The squa- mous affection again is much less scaly and more tubercular; the desquamating cuticle does not cover the entire surface; it is thin and subordinate. The form resembling tubercle does not present a smooth elevation, which gradually subsides into the tumid skin around; but it is prominent, covered with scales or crusts, and is scattered over the body in place of being aggregated together. In the pustular eruptions the analogies are closer, but still the characters are defined. If resembling impetigo, it forms a well- marked ring, the suppuration penetrates deeper, and the skin around is consequently elevated. If it seem more like ecthyma, we shall have a difficulty in saying that it is not rupia; the skin is deeply ulcerated, and a thick crust forms on its surface; its circumference is round, and its edges high; while in its commencement there is neither the bright redness nor the occasional mixture of blood with the pus, which is common in ecthyma. When the disease assumes these suppurative forms, ulceration of the angle of the lips is not uncommon, and greatly confirms the diagnosis. Its discrimination from rupia is less important, because the same treatment which is called for in the one is equally suitable to the other; but it is less frequently like true rupia than intermediate between that and ecthyma. Coincident with any of the foregoing eruptions, especially when their character is pustular, we sometimes find deep burrowing ulcers on the face, and at the alas of the nose, resembling lupus, or there may be ozaena from commencing disease of the bones of the nose, with soreness of its lining membrane. Congenital syphilis is chiefly marked by ulcers at the angles of the mouth, cracked lips, running of the nose, "snuffles," condy- lomata, and ulceration of the anus and pudendum, with emaciation. In reference to the copper colour of syphilitic eruptions, a few words may be added on the subject of cutaneous discoloration generally. As an objective phe- nomenon it forms the direct exponent of purpura and of jaundice, and is the chief feature of anaemia and chlorosis: it helps us to distinguish measles from scarlatina, and it materially aids our diagnosis of cancer, and of disease of the heart and kidneys. In other cases the change of colour is more distinctly confined to the skin itself, IQ4 DISEASES OF THE SKIN. . ben, for example, a dusky gray or blue colour is produced by tbe internal use of citrate of silver. In some persons the existence of any simple cutaneous dis- ., herpe3, lepra; is always followed on its decline by a brown stain, which fter the skin has acquired its natural condition in all other respects, and this is particularly the case with persona of a dark complexion: it is the very same change as is seen after syphilitic ail' cept that the colour in the latter may be much darker, and commonly lasts for a longer period. In others, in, patches of a brown or yellowish colour form, which have been called ephe- lidi J, from their supposed connexion with sun burning: they are very like syphi- litic stains, except that they are scarcely so dark, and they have not been preceded by any other eruption. In their commencement they resemble pityriasis versicolor, in the absence of branny scales and roughness. They begin with small spots like freckles, which gradually enlarge and coalesce, forming large maculas which have not the circular form which pityriasis usually presents. In what is called bronzed skin, the whole body becomes gradually of a brown colour, sometimes variegated here and there by portions of natural colour. Tim condition has been thought of late years to be perhaps connected with disease of the suprarenal capsules. We need not allude to the congenital peculiarities of naevi, or the freckles of early life: neither does the deficiency of colour in the albino belong to conditions of disease. Occasionally white spots are developed in advanced years, especially on the scrotum of old men known as vitiligo, the true nature of which is as yet not understood. It does not seem connected with disease properly so called. § 10. Lupus and Scrofulous Ulceration. — Though generally re- garded as belonging to the domain of surgery, these diseases are evidently of constitutional origin, and their characteristics ought at least to be known to the physician. There seems reason to believe that they belong to the same diathesis, and are chiefly modified by the age of the patient. They are marked by the same general feature of indolence and unwillingness to heal, by the inefficiency of local treatment, and by their being both modified by the same internal remedies. Lupus is more distinctly cutaneous ; it is super- ficial, and shows a great tendency to spread. Scrofulous ulcer is always preceded by abscess, and can only be regarded in a second- ary sense as a disease of the skin. Lupus may arise in several ways, and it is only the constitutional cachexia which, modifying its subsequent course, gives it a specific character. Its seat is most frequently about the aire of the nose, the lips, and the cheeks. Its commencement may be referred to three principal varieties of cutaneous eruption, the vesicular, the pustular, and the tubercular: occasionally resembling herpes, it more usually begins like a spot of impetigo; and when it attacks the cheek, it sometimes presents the form of tubercles. In the early stage it differs from the two former by its insidious commence- ment and slower progress, by the firm adhesion of the crust and the surrounding tumefaction of the skin, and its dusky colour. When such characters mark any form of eruption about the nose or the cheek, it is not improbably lupus, especially if scrofula can be traced in the family: if it be lupus, the crust covers an ulcera- ted surface, which very soon begins to spread. From tubercle of the skin it is chiefly distinguished by the absence of the bronze tint, and by its forming a defined group or patch on one cheek. In the ENDEMIAL DISEASES OF THE SKIN. 405 majority of cases of lupus scales or crusts soon form on the surface, which gradually thicken into scabs, and leave ulcers behind when removed ; but in one variety the disease proceeds without any ulcera- tion at all, the destruction of the skin in its progress being marked by seams and scars, which are not seen in tubercle: such cases are naturally less distinct than those in which ulceration has occurred. Scrofulous ulceration is very commonly seen in the side of the neck, and the formation of an abscess there must always be re- garded with great suspicion. Indolent abscesses in other parts of the body, without assignable cause, are also very probably due to scrofula. They are not uncommon on the back of the hand, and in the neighbourhood of the elbow. The characters by which scrofula is recognised have already been discussed (Chap. IX. Div. I. § 1 ;) and we may here call to mind the fact that, in scrofulous children the cutaneous eruptions are usually of the suppurative kind, and are remarkably indolent and untractable: impetigo larvalis is one of this class; they often excite inflammation and enlargement of the cervical glands, which may be the first beginning of scrofulous ulcer. Although the one disease be most common in childhood, while the other occurs at adolescence, or after maturity, yet occasionally scrofulous ulcers are seen in adults, and lupus at a very early age. The ravages of syphilis on the face are sometimes closely allied to lupus, and there is every probability that in such cases the scrofulous diathesis is present as well as the syphilitic taint: it is recognised by its coppery tint, aud the coexistence of other symptoms, such as sore throat, eruption on other parts of the body, &c. Syphilitic lupus is quite distinct from caries of the bones of the nose, which is to be regarded as a specific action of the venereal poison: it usually results in ex- tensive ulceration aud great disfigurement. We have to distinguish lupus from epithelial cancer of the lip, which usually commences by a single nodule, and gradually increases in size without ulcerating, until it has acquired considerable dimensions. The distinction is less easily made between it and another form of cancer of the skin in the early stage, when there is no appearance of morbid growth, and only a spot of ulceration, which subse- quently spreads in every direction, and commits frightful ravages. Subsequently the distinction is less difficult, because lupus in its progress leaves scars behind when the disease has subsided, while in cancer there is no trace of the healing process at all. Cancrum oris in childhood again has not the indolent, sluggish characters whi< h mark all the preceding conditions: it begins with ulceration in the interior of the cheek, which spreads with great rapidity, producing sloughing and destruction of all the tissues adjoining. The fetid smell and rapid progress of the disease pre- vents its being confounded with any other of analogous character. § 11. — Endemial Diseases of the Skin. Systematic authors refer to a variety of diseases as inherent in various localities, to which particular names have been assigned in the districts where they occur. Examination of the statements given seems to prove pretty clearly that many of them are referrible to syphilis and scrofula; others again are probably varieties of tubercle of the skin, which is much more liable to be developed in warm climates than our own; the worst cases seen in this country generally occur in persons who have returned from India. The Arabian Elephantiasis consists rather in hyper- trophy and induration of the cellular tissue than in auy true disease of the skin. Such disordei'S need not occupy a place in these pages, because they are so rarely met with, and are not likely to throw any difficulties in the way of the student. 40G DISEASES OF THE SKIN. § 12. Cellular Inflammation. — Practically, it is very inconvenient that we arc obliged to separate this disease from erysipelas, when. Btadying its diagnosis: and to make the distinctions clear we ought to hear in mind, at the same time, the characters of phlebitis, se- condary suppurations, and even erythema. All are, more or less, allied to each other, but yet their true history and their pathology present them to our notice as distinct diseases. The history of cellular inflammation classes it at once as an acute febrile disease; from the first rigor till its distinct localization there is nothing to indicate what or where the inflammation is to be. Deep-seated pain first calls attention to the part affected, and is very likely to be referred to some internal organ, because it has not the" burning or stinging character which in erysipelas draws the at- tention of the patient or the attendant to the skin : cases of this kind have been treated as some curious or anomalous example of internal disease, until accident has revealed the mistake. This lesson should not be forgotten. The skin presents a lurid redness, and is tense, but not hard to the touch; pain is aggravated by pressure, but there is not much superficial tenderness ; the border of the redness is not defined, but gradually dies away in the sur- rounding skin. These characters are quite sufficient to mark the disease: to erysipelas it is allied by the fever and the redness, but the colour and the sense of touch at once distinguish it: the condi- tion of the skin is more like erythema, but there is no fever or ten- sion in that disease. From the swelling accompanying phlebitis it is completely removed by the redness of the one affection, and the white oedematous condition of the other. It may be one of the forms in which secondary suppuration occurs; and it may give rise to secondary suppuration elsewhere. In both cases the characters of pysemia may be traced in addition to the cellular inflammation ; the local abscesses, the inflamed ab- sorbents, and the profuse perspirations, suggest to the observant practitioner what is going on. In its progress suppuration always supervenes: rigors, which have been absent since the commencement of the attack, recur, and are followed by sweating; the inflamed surface becomes less angry, and assumes a more livid colour; the tension subsides, and is followed by what is called a "boggy" feeling, which is partly produced by superficial oedema, partly by purulent infiltration and deep-seated fluctuation. In tracing the main features by which diseases of the skin are to be discrimi- nated, and applying to them the rules of diagnosis, we are in great measure re- stricted to the distinct objective phenomenon which each case presents in addi- tion to its other and more general symptoms. In many cases the inspection of the eruption is all that is wanted to determine its classification; and this is espe- cially true of what may be called typical examples, but quite as frequently our judgment is influenced by other circumstances which the history of the case re- is. Practical habitude can alone give the power of determining which among these have any direct bearing on the cutaneous affection; and the educated eye can often determine the class to which any case belongs from its general aspect and history, without entering on a minute examination of its specific character. CELLULAR INFLAMMATION. 407 When seeking for the solution of a difficulty, subordinate matters must not be neglected, such as the station in life, the probability of hereditary taint, of unsuit- able food, or of exposure to infection, which the appearance and manner of the patient suggest. With this object the physician may be induced to ask many questions which seem to have little to do with the skin: unquestionably in a great many instances it is true that the more correct the history of the patient's past life, the more certain is the diagnosis of any particular ailment. I will add a few illus- trations of the manner in which these additional facts afford hints for our guidance in diagnosis. A febrile state more or less accompanies erythema and roseola, but seldom co- exists with urticaria, and its comparative mildness separates these from erysipelas, phlegmon, measles, and scarlatina. It distinguishes the acute from the chronic form of eczema, and marks the boundary very often between eczema impetiginodes and true impetigo. It draws an equally clear line of demarkation between pem- phigus and rupia. It is always present with herpes, but when the fever is severe, the eruption is certainly only subordinate to some internal disease. Insufficient nutriment or exhaustion of body cause many of the varieties of skin disease to as- sume a suppurative character; the bearing this in mind will often lead to the dis- covery of the true original lesidh where lichen, eczema, or scabies have undergone such a change. The same causes, as they explain the presence of ecthyma and rupia, guard against the needless assumption of a syphilitic taint. Poverty and dirt alike go hand in hand with scabies and prurigo, but with the latter there is poverty of blood as well as of purse. The character of the food recently taken has often a definite relation to urticaria. The habits of the individual and the condi- tion of the digestive organs have a close relation both to acne and tubercle of the skin. A life of dissipation affords grounds for the suspicion of syphilis; and it is espe- cially to be remarked that the diseases more nearly resembling it are chiefly of a cachectic character; and in so far as such a condition is opposed to a life of gayety, does the suspicion become stronger, that the eruption is specific, if the idea of ca- chexia be not suggested by the aspect of the individual, when no distinct avowal of primary symptoms can be obtained. Close confinement and impure air cer- tainly prepare the way for the scrofulous forms of disease to which the more ob- stinate of the pustular eruptions have been with justice referred. A life in a warm climate is much more likely to give rise to tubercle of the skin than to lupus or acne. The probability of contagion is another circumstance which sometimes influences the judgment. It must be remarked that, excluding syphilis, those eruptions only can be viewed as really contagious in which parasitic life is concerned; at the same time there are sufficient facts to make us hesitate in asserting that others are not propagated in the same way. We can easily conceive that pustular matter reaching an abraded skin may give rise to suppuration there, and the disease once excited may continue, if the system be in a condition likely to ensure its perma- nence: but the persons who seem to afford instances of this sort of contagion are usually exposed to the same influences, whatever they may be, that develop the disease: and thus the spread of impetigo through a family or a school is no proof that it was communicated from one child to another. The mistake more frequently made is that of assuming that impetigo must be either favus or scabies, as it happens to be on the scalp or on the limbs, because there seems to be good evidence of its having spread by contact. Much attention must not be paid to the statement that the eruption itches or causes great irritation, as a guide to diagnosis. The susceptibility of the skin varies so remarkably in different individuals, and not less the moral courage to resist the inclination to alleviate the distress by scratching, which seems almost like an instinct provided for the purpose; and yet we all know how very greatly the itching is increased by the fresh irritation so produced. In one sense the in- formation is of use, because where itching is complaiffed of we may be sure that the inclination has been indulged, and that the appearance of the eruption is mo- dified by it. Xo circumstance tends more tn create varieties among the forms of skin diseases, and a great many .of the anomalous examples may be referred to this cause. INDEX. Abdomex, Abscess in, 113, 117; Cancer in, 119; Diseases of, characters, 304; associations, 305 ; Distended or retracted, 306 ; Physical examination of, 306 ; inspection, 306; palpation, 306; percussion, 307; Tubercles in, 109; Tumours in, 116, 306. Abortion, 99. Abscess, Abdominal, 113, 117; Hepatic, 340; Of lungs, 241 ; Lumbar, 113; Mus- cular, 390; Psoas, 113; Pytemic, 106; Renal, 365; Thoracic, 113, 116. Acarus of scabies, 397. Acephalo-cysts, 82, 119. Acinesis, 171. Acne, 399. Adipose tissue, hypertrophy of, 113 ; Adipose diarrhoea. 347. iEgophony as a symptom, 206; term objectionable, 209; in pleurisy, 243. Ague, 64 ; Ague-cake, 347. Albuminuria, 366; Anasarca of. 86; Chemistry of, 358; Causes, 368; Complica- tions, 373 ; -with dropsy, 367 ; with hematuria, 97, 369 ; with morbus cordis, 285, 292, 368; with pregnancy, 368; with purulent urine, 370; Coma in, 133; Epistaxis in, 92 ; Microscope in, 355 ; Without dropsy, 368. Amaurosis, 100. Amcnorrhoea, 381; Anremia of, 103. Antemia, 101 ; Anasarca in, 103 ; Blood-murmurs in, 103 ; Chlorosis, 103 ; Dyspepsia from, 316 ; Mania with, 141. Anaesthesia, 171 ; Numbness of other kinds, 180. Analysis of urine, 349 ; quantitative and qualitative, 348 ; Table of, 3G2. Anasarca, 86 ; in anremia, 103 ; General increase of size from, 39 ; the type of general dropsy, 86. Aneurism, 293; Abdominal, 295; as a tumour, 118; Of arch of aorta resembling laryngitis, 235; Hrcniatemesis from, 95; Hemoptysis from, 94; Superficial, 293 ; Thoracic, 294 ; as a tumour, 259. Angina pectoris, 185; from dilated heart, 286. Antimony, poisoning by, 78. Aortic valves, Disease of, 291 ; murmurs in, 275,276-; the pulse in, 43, 288. Aphonia in inflammation of larynx, 234 ; Hysterical, 234. Aphthas, 300; associated with diarrhcea, 385. Apoplexy, 159; Coma of, 132; Paralysis from, 174; Poisoning, simulated by, 77; Pulmonary, 94; Serous, 160: Spinal, 176; Transient, 134. Appearance, general, of patient, 39. Appetite, state of, 39, 44. Arachnoid, inflammation of, 156. Arrangement of symptoms, 26. Arsenic, poisoning by, 78. Arteries, diseases of, 293; of brain, degeneration of, 158, 175. Ascarides, 84; with disordered bowels, 327. Ascites. 88; Causes various, 86; Distinguished from ovarian dropsy, 91, 378; from cirrhosis, 342; from mesenteric disease, 118; from peritonitis, 334; Produces local enlargement, 112 : Simulated by dilated stomach, 313. Aspect and expression, 40, 45 ; Malignant, 102. Asthma, 251 ; with empbysema, 252; restriction of term, 252; Hay asthma, 252. 410 INDEX. Auscultation, 195; Kb intricacies, 196; practice, 195; study, 102; theory, 102; uses, 202, 205; and abuses, 19; Of Aneurism, abdominal, 205; thoracic, 294; superficial, 298; Bl L-murmurs, 103,278; Of Heart, 270; Modifications of normal Bounds, 27<»; Murmurs, diastolic, 275; endocardial, 273; friction, 272; Bystolic at apex, 270; at base, 277: Summary, '^78; With relation to endocar- ditis, 282; dilatation, 286; hypertrophy, 285; pericarditis, 281; valvular lesion, 286 ; Of lungs with percussion, 198 ; Modified breath and voice-sounds, : in clavicular region, 198; in posterior and lateral regions, 206; Summary*, 211; Superadded sounds, 195, 215; continuous, 21G ; creaking, 217; crepita- tion, 215; crumpling, 217; friction, 216; gurgling, 216; interrupted, 215; metallic tinkling, 216; moist sounds, 21 (J; sonorous and sibilant, 216; succus- sion, 216; in Clavicular region, 217; in posterior and lateral regions, 222; Summary, 230; With reference to Bronchitis, acute, 248; chronic, 240; Con- densation, 278; Croup, 236; Diseases of lungs in childhood, 263; Effusion, 243; Emphysema, 250; Empyema, 243; Expansion of tissue, 270; Hydro- pneumo-thorax, 247 ; Hydro-thorax, 243; Laryngitis, 234} Phthisis pulmonalis, 252; Pleurisy, 242; Pleuro-pneumonia, 243; Pneumonia, 237; Pneumothorax, 246; Tuberculosis, acute, 207; Tumours in chest, 259. Btle, faulty secretion of, 328; in excess or defective, 345. Bilious headache, 160. Biliousness, 338; analogy to dyspepsia, 338; causes, 345; erroneous employment of term, 314. Bladder, calculus in, 07, 371; Catarrh of, distinguished from renal abscess, 365; Distended, as a form of abdominal tumour, 92, 117; Mistaken for ovarian dropsy, 378 ; Producing cystitis, 370; Hemorrhage from, 96; Inflammation of, 370; Paralysis of, 179 ; Rupture of, with peritonitis, 331. Bladder, Gall, distention of, 117; With gall-stones, 346. Blindness in amaurosis, 143 ; in disease of brain, 143; in hydrocephalus, 153. Blood, Circulation of, in disease of heart, 287; mechanism of, 275; Chronic blood- ailments, 100; Depraved states, 105; their effect on the brain, 133; Pus in, 106; Spitting of, 93; in aneurism, 95; in disease of heart, 94; in phthisis, 111; Urea in, 134; Vomiting of, 95; White-cell, 102. Blood-ailments, chronic, 100. Blood-murmurs, anaemic, 103. See Bruits. Bones, Caries of, 113; in head, 154; Diseases of, 388; Fragilitas, 389; Growths from, 120; in chest, 261 ; Inflammation of, 113, 388 ; Mollities. 380; Rachitis, 389. Bothrio-cephalus latus, 83. Bowels, Constipation of, 320; Diarrhoea, 324; Diseases of, 319; Disordered, 327; Dysentery, 325 ; Enteritis, 320; Hemorrhages from, 98, 327 ; Ileus and Intus- susception, 321 ; Inflammation generally, 319; Obstruction, 323 ; in enteritis, 322; causes and diagnosis, 323; Perforation, 330; Quantity of bile as affecting, 345; Symptoms from, general, 39; special, 44; Ulceration, 326; in fever, 55. Brain, diseases of, 149; Acute, 149; Apoplexy, 159; Chronic, 157: with active symptoms supervening, 150; Functional disturbance, 164; General indications, 128; inflammation, simple, 154; delirium of, 130; scrofulous, 150; delirium of, 137; Paralysis from, 148; distinguished from disease of nerves, 174; Modes of investigation, 165; Pathology of, 131; concussion, 132, 133; extravasation of blood, 132; serous effusion, 133; Semeiology of, 130; coma, 132; delirium, 134; insomnia, 134; mental phenomena, 131; muscular movements, 146; para- lysis, 147; spasm, 147; sensibility, 142; stupor, 133; Rheumatism in con- nexion with, US, 70; metastasis, 137; Sympathetic irritation of stomach, 312; Tubercles in, 112, 152; Tumours of, 174. Breath-sound, 105; Abolished, 204; Modified, 196; in clavicular region, 198; in posterior and lateral regions, 206 ; Obstructed in condensation, 212; in expan- sion, 213. See Auscultation. Brighfs disease, 366. See Albuminuria. Bronchitis, Acute, 247 ; auscultatory phenomena, 248 ; compared with influenza, 2 IS; with pneumonia and phthisis, 2 18; complicating pleurisy, 243; Chronic, 2 IS : auscultatory phenomena. 240; complications, 249; with emphysema, 251 ; simulating phthisis. 2 10, 258; of Childhood, 264; of Fever, 55; of Heart- disease, 201 ; Modified breath-sound in, 204; Superadded sound in, 225, 226. INDEX. 411 Bronchocele, 116. Brouchorrhoea, 2-50. Bronchus, dilated, 202, 204. Bruits all produced in the blood, 104; Cardiac, 270; "De diable," 105; its value, 279; Valvular contrasted with ansemic, 278. Bursas, enlarged, 202, 204. Causes of morbid phenomena, complex, 23. Cachreniia, 105. Cachexia, 105; antenna from, 101; of cancer, 119; in skin disease, 391. Calculus, Biliary, 345; passage of a gall-stone, 346; simulating peritonitis, 346 Renal, 3 \4 :' exciting hemorrhage, 97 ; simulating peritonitis, 332: Vesical, 371 Cancer, Abdominal, 92; of liver, 341, 343 ; of pancreas, 347; of peritoneum, 336 of stomach, 96, 311; its situation, 117; of uterus, 386; Complexion in, 102, 117; Osseous, 119; Thoracic, 119; Varieties, colloid, 119; encephaloid, 119 epithelial, 115; fungoid, 119; scirrhus, 119; their diagnosis, 120. Cancrum oris, 300, 405. Caries, 388 ; Of spine, Causing inflammation of cord, 168 ; lumbar abscess, 113 ; paralysis, 175: Simulating rheumatism, 72. Carnification of lung tissue, 212. Catheter, manipulation of, 366. Cellular tis-ue, inflammation of, 406. Chest, general symptoms of disease in, 129, 188; Examination of, 188 ; Alterations in form, 193 ; in movement, 193 ; Auscultation, 195 ; Percussion, 194 : Physical signs, 192; Tumours of, 259. See Auscultation, Percussion, Lung*, §c. Children, Convulsions of, 147, 162; Diarrhoea of, 325; Diseases of brain in, 151, 164; symptoms of, 137 ; Diseases of lungs in, 263 ; of skin in, 394: scrofulous, 404; syphilitic. 402: Fevers of, 152: remittent, 56; eruptive, 61 ; Hoarseness, its importance. 256 ; Hooping-cough, 262; Thrush, 300; Tracheitis and crowing inspiration, 256; Ulcer of mouth in, 300. Chlorosis, 96 ; Pain in side in, 183. Cholera, English, 58; Epidemic, 58; Mortality in, as relating to diagnosis, 59. Chorea, 124; Brain in, 146, 165; Heart-disease in, 288; From worms, 83. Circulation, with reference to murmurs, 287; Mechanism of, 275. Cirrhosis of Liver, 342 ; evidence of previous inflammation, 340 ; indicated by ascites, 343; not a cause of jaundice, 344. Classification of Diseases, 20 ; of Fevers, 52, 54 ; of spots in, 53 ; of Eruptive fevers, 61 ; Chronic blood-ailments, 100; Depraved constitutional states, 108; Paralysis, 173. See also Diseases. Of Symptoms, 26 ; General indications. 36 ; from re- gions and organs, 127; Special indications, 43; of Brain-disease, 130; of Delirium, 136; of Heart-disease, 266; diastolic murmurs, 275; systolic mur- murs at apex, 276 : at base, 277 ; of Lung-disease, 198 ; modified breath and voice-sounds, 199, 206; superadded sounds, 215: of Symptoms derived from the urine, 349 ; chemical relations, table of, 362 ; sediments, 353, 355 ; Of Tumours, 115. Clavicular region, modified sounds, 198; superadded sounds, 217. Clinical Clerk, outline of notes for, viii. Colic, from constipation, 320; Lead, 80; Simulating nephralgia, 364. Colica Pictonum, 80. Collapse in cholera, 58; in peritonitis, 330. Coma. 132; of apoplexy, 132, 160; of poisoning, 77; Partial, 133. Complexion as a symptom, 39, 45; in blood diseases, 102. Concussion of brain with coma, 132; with stupor, 134. Condensation of lung-tissue, 212. Condition of patient, general, 36. Constipation, 320; in disease of brain, 155; inducing obstruction, 323; in perito- nitis, 332. Convulsions, Apoplectic, 30; Attendant on false croup. 237: in Brain- disease, 156; functional, 165; in Childhood. 147, 162; Distinguished from epilepsy, 162; Ge- neral, 146; with paralysis, 174. Cord, spinal, 168; Chronic disease of, 169; Inflammation of, 168; Paralysis from apoplexy of, 177; from disease of, 174, 175; from injury of, 176. Coronary arteries, disease of, 186. 412 INDEX. Coryza, 61. Cougb. absent in acute laryngitis, 233; Characters of, 100; in chronic laryngitis, I; in croup, 286; with elongated uvula, 3U2; Hooping-cough, 262. Crump* in cholera, 59. Crepitation, 252; in pneumonia, 22^: not infallible, 19, 239. Group, 236; causing laryngitis, 234; distinguished from laryngitis, 237 ; false, 237; hoarseness in, 237; tracheotomy, 237. Crowing inspiration, 287. Cysticercus, 84. Cysts, Acephalo-, 119: Hydatid, 116, 118; contains a parasite, 86; Ovarian, 37G ; Serous, 120; causing local dropsy, 80; distinguished from ascites, 90. Cystitis, 370. Deafxess. in disease of brain, 144; in disease of fauces, 301; in fever, 13G; in hy- drocephalus, 152. Delusions, 140. Delirium, 134; in erysipelas, 137; in fever, 54, 136; in insanity, 139; in pneumo- nia, 137; in rheumatism, 68, 137; in simple inflammation, 139, 154; in tuber- cular inflammation, 138; Passive, 138: Points to cerebral disease, 138; Re- ferred to reflective faculties, 131; Sub-divisions, 135; Tremens, 126, 136; dis- tinguished from insanity, 140; With subsultus in fever, 146; With tremor in delirium tremens, 146. Diabetes, 371; insipidus, 370; tests for urine of, 360; thirst of, with hunger, 39. Diable, bruit de, 106. Diagnosis, abuse of, 18; advance of, 192; caution in, 304; difficulties of, 118, 130 errors of, 24, 230, 239; fancied excellence of accuracy, 386; general indica tions in, 35, 127; illustrations of, from geometry, 22; method of, 25. 28 neglect of, 18, 391; object of, 21, 23; peculiar cases, 122, 25'.'. 379; province of, 17; relation to theory of disease, 22; special indications, 42; theory of, 21 uncertainty of, 290, 308. Diarrhea. 324; adiposa, 306; bilious, 305; chronic, 325; choleraic, 59; febrile, 324 ordinary, 324; Associations, 324; with fever, 55; with phthisis, 110; in Child- hood, 321. Diathesis, Hemorrhagic, distinguished from purpura, 100; with epistaxis, 92; with ha?maturia. 97 : with uterine hemorrhage, 99; Scrofulous and Tubercular, 108; with delirium, 137; with inflammation of brain, 150. Digestive organs, derangements of, 309; Indications, 232. Digitalis, poisoning by, 78. Dilatation of stomach, 313. Diphtheritis, 303 ; leading to croup, 236. Disease, theory of, 17, 23. Diseases, Acute and chronic, 32; Classification, 29; of adventitious origin, 75; of arteries, 293; of brain, 149; of bones, 388; of cellular tissue, 400; of chest, 180; chronic blood-ailments, 100; depraved constitutional states, 108: febrile, 48; gout, 72; of heart, 280; of intestinal canal, 319; of joints, 388; of kidneys, 363; of liver, 338; of lungs in childhood, 203; of mouth and pharynx, 299; of muscles. 389; of nerves, 181; of oesophagus, 308; of ovaries, 376; of pancreas, 347; paralysis, 171; of peritoneum, 330; quasi-nervous, 122: of respiratory or- gans, 232; rheumatism, 66; of skin, 391; of spinal cord, 168; of spleen, 346; of stomach, 308; of urinary organs, 363; of uterus and vagina, 381; of varia- ble seat, 85; of veins, 296; Simulated in hysteria, 124; epilepsy, 163; para- lysis, 172, 178; Table, 29. Distention of stomach, 315. Distoma, 84. Distortion of chest, 193. Diuresis, 370. Dropsies, 103 ; Encysted, 90. » Dropsy, Acute, 87; as a symptom, 39; Chronic, 87: Ovarian, 112. 376; With ance- mia, 103; with disease of kidney, 308, 375; of heart, 280, 291; of liver, 344; of peritoneum. 334; with pregnancy, 368. Drop-wri>t, 82, 17'.'. Drunkards, disease of liver in, 372; of stomach, 311; Dyspepsia of, 317; Delirium of, 120; Biliousness in, 339. INDEX. 413 Duration of disease, 32 ; and sequence of phenomena, 33. Dysentery, acute, 325; chronic, 326; Hemorrhage in, 98. Dysmenorrhoea, 382. Dyspepsia, 313; Associations of, 313, 318; Complex cases, 314, 317; Connexion with brain-disease, 160 ; Diagnosis by exclusion, 309; General characters, 308; Palpitation of, 166; Simulating gall-stones, 34G; Sympathetic affections, 309; Varieties, 314; from abuse of stimulants, 318; of tobacco, 318; anajmic, 102, 316; of drunkards, 317; from distention, 315; faulty secretion, 310; gouty, 317; hyperasmic, 316; from irritability, 314. Dysphagia in aneurism, 236; in croup, 236; in diseases of mouth and pharynx, 299; in laryngitis, 235; in stricture of the oesophagus, 309. Dyspnoea as characteristic of emphysema, 249 ; of pleurisy, 222 ; of heart-disease, 280; indicating disease of the chest, 190; peculiar in laryngitis, 233; and croup, 236. EcnTNO-coccns, 82. Ecthyma, 399; connexion -with rupia, 400. Eczema, 396; impetiginodes, 397, 398. Effusion, Abdominal, 88; evidence of, by fluctuation, 89; Causes of, 91; General and local, 86; cause of enlargement, 45, 112; Pleuritic, 193; auscultation in, 206; symptoms of, 242; In Ventricles of brain, 138; hydrocephalus, 151; serous apoplexy, 160. Elephantiasis of the Greeks, 402; of the Arabians, 405. Emaciation, 59, 190. Emphysema, 39; of Lungs, 250; auscultation in, 203, 210; complication with asth- ma, 251; with bronchitis, 251; distinguished from pneumo-thorax, 247; gene- ral symptoms, 249. Empiricism, 21. Empyema, 112, 116; auscultation in, 208; symptoms of, 243. Enchondroma, 120. Endocarditis, 282; rheumatic, 68, 283; distinguished from old disease, 284. Enlargements, local, 112; general, 45. Enteritis, 321; from obstruction, 321; with peritonitis, 333; its relative frequency, 319. Entozoa, 82. Ephelides, 404. Epilepsy, 162; Distinguished from apoplexy, 160; from convulsions, 162; from hys- teria, 124; from poisoning, 77; Feigned, 163; General indications, 147; Hyi teric, 124, 163; with Worms, 83. Epistaxis, 92, 93. Eruptions on skin, colour of, 404; early stage of, 392; observation of, 129; In Fe- ver, 53; Scrofula, 108, 404; Syphilis, 79, 402; Varieties of, see Skin-diseases. Erysipelas, 61, 63; analogy to puerperal fever, 331; delirium of, 137; metastasis, 137; of throat, causing oedema glottidis, 234. Erythema, 392 ; nodosum, 106, 392. Evidence of disease of lungs, basis of, 196. Examination of patient, general plan, 26; of abdomen, 244; of chest, 188; of heart, 26&; of lungs, 196, 215; of regions and organs, 127; of urine, 348. Expectoration, characters of, 19(1. Expression and aspect of patient, 40. Eyes, changes in, 142; contraction and dilatation of pupils, 143; perversions of vi- sion, 143; ptosis, 148; strabismus, 147, 148. Facultiks, mental, as indications of disease, 131. Fasces, Accumulation of, in constipation, 320 ; in obstruction, 323 ; simulating tu- mour, 117; Characters of, in cholera, 59; in disordered bowels, 328; in dysen- tery, 326; in jaundice, 344; Special indications from, 43; fatty, 328; yeasty, 328. Fai-cv, acute, 147. Fat, deposit of, 39, 112. Fatty degeneration of heart, 286 ; of muscles, 389. Fauces, diseases of, 300; inflamed in croup, 237; in laryngitis, 232; ulceration of, 302. s- 414 INDEX. Favus, 101. Febrioala, 60. Febrile diseases, 48. ned epilepsy, 168; paralysis, 172, 180; paraplegia. 178. Fermentation in the intestine, 828; in the stomach, 818; mine of, 860. Fever. Continued, 60; classifications, 62, 68, 6 I ; complications, 54; deafness in, 130; delirium, 186, 188, 163; peritonitis, 888; pneumonia, 241; resembling acute phthisis, 110; sub:;, 56; typhus, 50, 100; urine of, 373; of Children, •"><;. 162; Eruptive, 60; Hectic, 11 1, 189; Intermittent, 03, 155; Puerperal, 331; Remittent, 50; Scarlet, 01; Yellow, 96. Fevers in general, 50; subdivisions, 29. Filiaria, 84. Floccitatio, 145. Fluctuation, 89. Formication, 170; differs from anaesthesia, 180. Fragilitas ossium, 389. Frambcesia, 402. Fremitus, vocal, 198. Friction-sounds in Heart, 272; characters of, 273; in pericarditis, 281; in rheumatic fever, 283; in Pleura, 210; its position, 217, 222; in pleurisy, 242. Fungoid growtbs, 119; a cause of haemoptysis, 95. Gall-bladder, distended with bile, 116; with concretions, 345. Gall-stones, 345; passage of, 346. Gangrene of lungs, 241. Gaseous poisoning, 78. Gastritis, chronic, 312; idiopathic, 312; its rarity, 319; resulting from poison, 312. Glands, enlargement of, 115; from Morbid growth, 117; in abdomen, 336; in chest, 259: from Scrofulous deposit, 108; in abdomen, 109; in chest, 204; in the neck, 303 ; from Skin-disease, 404 ; Sub-maxillary, inflamed, 303. Glanders, 80, 107. Globus hystericus, 124. Glottis, oedema of, 234. Goitre, 115. Gonorrhoea, 75; distinguished from leucorrhcea, 383; giving rise to cystitis, 370; obscuring diagnosis in examination of urine, 383. Gout, 72; alteration of joints from, 389; distinguished from rheumatism, 68; dys- pepsia of, 317; erratic, 73; in the stomach, 34$; masked, 186; nephralgia of, 304; retrocedent, 186; rheumatic, 73, 389. Growths, morbid, 112; from bone, 120; in chest, 259; cystic, 119; in liver, 341; ma- lignant, 116, 119; myeloid, 120; in peritoneum, 336. Habits of patient, 32. Haematemesis, 95; in disease of stomach, 311; distinguished from haemoptysis, 95. Hematocele, 112. Hematuria, 90; with albuminuria, 369; causes, 369; microscopic appearances, 355. Haemoptysis, 93, 110; in disease of heart, 291 ; hysterical, 93; iu malignant disease, 200: in phthisis, 253; in pneumonia, 237. Hemorrhage, 92; from bladder, 97; from kidney, 97, 355; from intestines, 98, 327; from lungs, 94, 110; from nose, 92; from prostate gland, 98; from stomach, 96, 312; from uterus, 98; An;emia from, 101; Hysterical, 93; Internal, 100; with Purpura, 100; Subcutaneous, 100; Vicarious, 95. Hemorrhagic diathesis differs from purpura, 100; With epistaxis, 92; hematuria, 97; uterine hemorrhage, 99. Hallucinations. 141, 144. Hay-asthma, 252. Headache as a symptom, 145; dyspeptic, 166; in constipation, 320; in inflammation of brain, 155; in chronic disease, 158. Head symptoms, 149', 165; increased or diminished by horizontal posture, 145. Hearing, alteration in sense of, 144. Heart, Diseases of, 280; acute and chronic, 280; adherent pericardium, 268, 281; congenital, 290; dilatation, 286; endocarditis, 282; fatty, 280, 389; hypertrophy, 285; pericarditis, 281; valvular lesion, 286; aortic, 291; mitral, 290; Ausculta- INDEX. 415 tory phenomena, 270; altered rhythm. 271 ; modification of normal sounds, 270; murmurs, 270; diastolic, 275; endocardial, 273; friction, 272 ; musical, 290; systolic at apex, 276; at base, 277; "to and fro," 272; valvular and ana?mic, 278; nomenclature faulty, 270; reduplication, 271; Associations, 292; with an- gina, 185; brain-disease, 161; chorea, 289; dropsy, 86; epistasis, 93; ha^mop- tysi-. 94; kidney-disease, 368; rheumatism, 68, 283; its metastasis, 137; Causes of disease, 292 ; Delirium in inflammation of, 137 ; Evidence of alteration of size, 267; enlargement, 267, 269; irregular action, 267, 269; intermission, 268; Ex- amination of, 266; Foetal, sound of, 379; General indications, 12'.), 188; Me- chanism of circulation, 275; explanatory of bruits, 287; Nervous palpitation, 268, 271; Normal sounds, 266; Pulse in disease of, 43, 288; Simulation of fluid in pericardium, 268, 284. Hectic, 110, 190. Hemicrania, 185. Hemiplegia, 148, 173. Hepatitis, 339; with pleuro-pneumonia, 340. Hernia, 115; internal strangulation, 323. Herpes, 397; circinatus, 397; labialis, 397; preputialis, 397; zoster, 397. History of case, its meaning, 25 ; its importance, 32. Homoeopathy, 24. Hooping-cough, 232; symptoms, 261; complications, 262. Hydatids, 119; connected with the echino- coccus, 82; distinguished from ascites, 91, in liver, 341, 342; position, 116. Hydrencephaloid disease, 153. Hydrocele, 112. Hydrocephalus, acute, 112, 151; chronic, 112. Hydrocyanic acid, poisoning by, 78. Hydrometra, 91, 378. Hydropathy, 24. Hydropericardium, 284; simulated by dilatation, 208, 285. Hydrophobia, 79. Hydro-pneumo-thorax, 246. Hydrothuras, 112; from albuminuria, 244; auscultatory signs, 209; from acute pleu- risy, 242; passive, 244. Hyperemia of stomach, 340. Hyperesthesia, 169. Hypertrophy, simple, 112. Hypochondriasis, 122. Hysteria. 122: in men, 122; its pathology, 376; sensations of pain in, 142. Hysterical chorea, 125; epilepsy, 163; haemoptysis, 93, 95; laryngitis, 235; neu- ralgia, 183, 187; paralysis, 123, 165; tetanus, 125 ; tympanites, 329. Hunger, 39, 44. Icterus, see Jaundice. Ichthyosis, 395. Idiosyncrasy, 19. Ileus, 321. Illusions, 141. Impetigo, 39S; figurata, 398; sparsa, 398. Incoherence, 134. Inconsistency of history, 26 ; of phenomena, 33. Inflammation, accompanied by pain and tenderness, 141; of brain, delirium of, 139; not synonymous with pain, 123; nor with neuralgia, 182; ovarian disease inde- pendent of, 376; suppuration, 113; of uterus, rarity of, 386. Influenza, 57; an ephemeral fever, 52; relation to bronchitis, 247; simulated by phthisis, 109. Innervation, 131. Insanity, as a symptom, 131; delirium of, 139; nature of, 140; perverted sensations in, 142; puerperal, 141. Insensibility, 132. Insomnia, 134; attendant on delirium, 134; in delirium tremens, 136. Intermittents, 63; hemicrania as a form of, 185. Intestinal canal, diseases of, 319; their classification, 319; Constipation, 320; Diar. 41G INDEX. rhna. •'•-I; Disordered bowels, 827; special forms of, 828; Dysentery, 325; En- teritis, 821 : Hemorrhage, 98; Ileus, 821; Obstruction, 822; its investigation and c .,,. Relations of inflammation, 819; its importance in semeiology, 319; Tympanites, 828; Ulceration, 326. Intolerance of li.nht. 148. Intoxication, its distinction from apoplexy, 132; from narcotic poisoning, 77. Intue Busception, 821. Irritation, nervous, 184; spinal, 168. Irritability of stomach, 314. Ischuria, 866. Itch, "grocer's," 397. Jaundice, 8 13; accidental, 312 ; its colour simulated, 343; produced by biliary cal- culus, 34(1; by emotion, 344; by hepatitis, 339; its theory not always under- stood, 343; varieties, 344. Kidneys, Diseases of, 363; abscess of, 365; albuminuria, 366; calculus, 97, 364; diabetes. 371; diuresis, 370; functional disorder, 372; ischuria/ 366 ; nephritis and nephralgia, 363; Associations of, 374; with brain disease, 161; -with dropsy, 86, 375; with dyspepsia, 374: with gout, 73; with hydrothorax, 244; with hy- pertrophy of heart, 285; with oedema of glottis, 234; with rheumatism, 72; Bleeding from, 369; its varieties, 97; Bright' s disease, 366; Examination of urine, 348; table of chemical relations, 362; Fungus of, 97; General state, re- lation of urine to, 38; General symptoms, 129; the Lithic-acid diathesis, 373; the Phosphatic diathesis, 373. See Urine. Kiestine in urine, 375. LAKYxr.iTis. acute, 233; bastard, 234; chronic, 235; from disease of bone, 235; idiopathic, 234; from injury, 234; from quinsy or croup, 234; syphilitic, 235; tubercular, 235 ; Aphonia of, 234 ; Distinguished from aneurism, 235 ; from croup, 237; Simulated in hysteria, 228; by tumour, 261. Laryngismus stridulus, see Crowing Inspiration. Lead, poisoning by, 81 ; paralysis of, 179, 386. Lepra, 395. Leucocytlueniia, 102. Leucorrhoea, 383 ; its causes and source, 383 ; in children, vaginitis, 383. Lichen, 393: agrius, 394; circumscriptus, 394; strophulus, 394. Liver, diseases of, 338 ; abscess, 340 ; cancer, 119; cirrhosis, 342 ; congestion, 340; enlargement, 341; fatty, 341; "hobnail," 342; hydatid cysts of, 119, 341; inflammation of, 339; jaundice, 343; lardaceous, 341; "nutmeg," 341; scirrhus of, 343; tumours, 116; yellow atrophy, 343; Ascites, caused by, 91, 343; Associations, 345 ; Faulty secretion, 345 ; Gall-stones, 345 ; Eiematemesis from, 96 ; Obscurity of symptoms, 338. Lumbago, 70. Lumbrici, 83. Lungs, Auscultation of, 198, 215; in clavicular region, modified breath and voice sounds, 199; superadded sounds, 217; in posterior and lateral regions, modified sounds, 20G; superadded sounds, 222; summary of modified sounds, 211; of superadded sounds, 230; Condensation of, 212; carnification, 212: compression, 2ii'.'; consolidation, evidence of, 196; compared with compression, 209; hepati- zation, 212; tuberculization, 212; Diseases of, 232; abscess, 241; apoplexy, 94; asthma, 251; bronchitis, 247; emphysema, 249; gangrene, 241; inflammation, 237; chronic, 241; phthisis, 253; pleurisy, 242; pleurodynia, 245; pleuro-pneu- monia, 243; pneumonia, 237; pneumo-thorax, 245; suppuration, 191; tumours, 193; Diseases in childhood, 263; Expansion of, 213; General indications. 129, 188; Percussion, 194, 198; with modified sounds in clavicular region, 198; in posterior and lateral regions, 206 ; with superadded sounds in clavicular region, 217; in posterior and lateral regions, 222; Physical examination, 193; precedes that of heart, 192; Special external signs, 194; Tubercles in, 105; at both apices, 257: at base, 257; detection in early stage, 201, 220; distinguished from inflammation, 240; relation of sounds to, 256. Malaise, 142. Malaria, 185. INDEX. 417 Mania, acute, 134, 141; puerperal, 141. Materia Medica, uses of, 17. Measles, 61, 62; sequels of, 110. Medecine expectante, 18. Melcena, 327. Meningitis, 156; delirium of, 139, 156; Spinal, 168. £ ^Menorrhagia, ZQfc distinguished from hemorrhage, 98. Menstruation, condition of, 129; Irregular, 382; Painful, 382; Profuse, 382; in Pregnancy, 371 ; Suppressed, 381 ; distinguished from chlorosis, 103; with hse- matemesis, 96; with haemoptysis, 95; Vicarious, 95, 96. Mercurial paralysis, 178. Mesenteric disease, 109; anaemia from, 101. Mesentery, growths in, 386. Metastasis of Erysipelas, 137; of Parotitis, 303; of Rheumatism, 107; in the acute form, 68 ; in the synovial, 69. Method of diagnosis, 25; of obtaining a history. 28; good and bad methods, 21. Metritis, 386. Mind, unsound, 131, 141: its definition, 140. Mitral valve, disease of, 290. Mobility, alterations of, 171. Mollities ossium, 389. Molluscum, 402. Mouth, disease of, 299. Mumps, 303. Murmurs, blood-, 104; dependent on antemia, 103; distinguished from valvular, 278; Arterial, 104; Cardiac, 270; Diastolic, 275; Musical, 290; Systolic, 275; Venous, 105; Vesicular in respiration, 195. Muscae volitantes, 144. Muscles, diseases of, 389; abscess, 390; atrophy, 390; fatty degeneration, 179, 389; local paralysis, 179; from lead, 81; from over-strain, 179. Muscular movements as a symptom of brain disease, 146. Nakcotic poisoning, 77. Nares, hemorrhage from, 92 ; simulating haemoptysis, 93. Neck, tumours of, 116. Nephralgia and Nephritis, 362. Nerves, Anatomical relations of, in neuralgia, 181; in paralysis, 173, 178; Cranial, paralysis of, 147, 179; Fifth pair, neuralgia of, 184; Laryngeal, affection of, 236; in false croup, 237; Paralysis as the effect of pressure on, 179: Spinal, pain of, 187 ; F Nervous system. 'general indications regarding, 129; irritation, 184. Nervousness, 122. Nettle-rash, 393. Neuralgia, 181; spinal, 187. Nodes, syphilitic, 389. Nomenclature, objectionable, in disease of lungs, 195, 215; in disease of heart, 270. Nose, bleeding from, 92 ; polypus of, 93. Nosology, 17; new uterine, 386. Notes of cases, importance of, 28, 128 ; outline of, v. Obesity, 39; when not occurring after mid-life, 305. Object of author, 20. Objective phenomena, 2G, 35. Obstruction of bowels, 322. (Edema, or local dropsy, 87; caused by anosmia, 103; by diseased glands, 118; of glottis, 237; of Upper half of body, 261. (Esophagus, diseases of, 308; spasm, 309; stricture, 309. Omentum, diseases of, 118; cancer, 119; tumours, 007. Opium, poisoning by, 77; producing coma, 102. Organs, examination of, 127; Diseases of, see Diseases. Orthopnoea, 40. Ovarian dropsy, 376: a cause of enlargement, 112; resembles ascites, 90; rules for its diagnosis, 378. 27 418 INDEX. i. 876; not inflammatory, 370; enlargement, .",77; tumours, 378; frith hysteria, : '>7i'>. Vain, distinguished from inflammation, 128; from neuralgia, 1S1; Duration of. 32; Indications from, 142; in brain-disease, 111; in cancer, 120; in chest-disease, I; in colica Pictonum, 81 ; in heart-disease, 266 ; in hysteria, 122; in kidney- tase, 868; in peritonitis, 188; in rheumatism, 66, 70; Influence on posture, ■II: Local, 188; Relation to stiffness, 389; Sympathetic, 188. Palpitation, dyspeptic, 180; nervous, 267; distinguished from hypertrophy, 20S, 271. l'al-y, 8e< Pa nth/sis. Pancreas, cancer of, 317; disease of, 347; stools in, 32$; tumour of, 117. dyBiB, Associated with coma, 182; with stupor, 133; Distinguished from pain and stillness, 172; Hysterical, 123; Lead palsy, 81, 179; Of the Insane, 172, 177: Simulated, 172: detected by gait, 178; a Symptom of brain-di-ease, 147; Varieties, 171; ngit.-ms, 17*; general, 177; local, 174, 178; of bladder, 179; of bowels in peritonitis, 332; of fore-arm, 179; hemiplegia, 173; muscular, 17'.'; paraplegia, 175. Paraplegia, 175; as a symptom of disease of brain, 147; of cord, 170. Parotitis, 303 ; metastasis of, 303. Pathology, uses of, 17. Patient, general appearance of, 38; general state, 36; habits, 32 ; position, 40; posture in chest disease, 190; in peritonitis, 41, 332; his theories, 314. Pemphigus, 899. Pepsine, deficiency of. 317. Perception, faculty of, in disease of brain, 181. Percussion, 194; and Auscultation, 198; With Modified breath and voice-sounds in Clavicular region, 198; dulness absent, 200; indistinct, 200; marked, 199; resonance, 199; in Posterior and Lateral regions, 200; dulness absent, 207 ; indistinct, 207; marked, 206; resonance, 207; Summary, 211; With Super- added sounds, 215; in Clavicular region, 217; dulness absent, 219; indistinct, 218; marked, 217; resonance, 218; in Posterior and Lateral regions, 222: dul- ness absent, 225; indistinct, 223; marked, 222; resonance, 223; Information limited, 194, 202; Phenomena simple, 19; Theory of, 192. Pericarditis, 281; friction, 273, 281; rheumatic, 68; with endocardial bruit, 289; with pleurisy, 282. Pericardium, Adherent, with dilatation, 286; signs of, 268, 281; Bruit in, friction, 272. Periostitis, 113, 388; syphilitic, 388. Peritoneum, Abscess of, 112, 113; Cancer of, 119; Diseases of, 330; Fluid in, 88; Inflammation of, 330; Morbid growths in, 330; Tubercles in, 111. Peritonitis, Acute, 330; with enteritis, 333; with fever, 55, 333; with gastritis, 312; Chronic, 334; with ascites, 335; dropsy after, 91 ; with morbid growths, 335; with suppuration, 334; with tubercles, 336; Idiopathic, 331; Partial or local, 332; as a tumour, 177; with ulceration of bowels, 333; Puerperal, 331; Traumatic, 330; Simulated, 332; Uterine, 333, 385. Perspiration in phthisis. 109; rheumatic, 07. Pertussis, 201; complications of, 202; place in classification, 233. Petechias, 53, 101. Pharynx, diseases of, 300. Phenomena, duration and sequence of, 32; objective and subjective, 20, 35; of per- cussion and auscultation, 199. Philosophical view of auscultation, 196. Phlebitis, 297; associated with oedema, 87, 297: Capillary, 298 ; with acute dropsy, 87 ; Occlusion resulting from, 298 ; Suppurative, 297 ; Theory of its action in causing pyaemia, 100. Phlegmasia dolens, 297 ; rarely ending in suppuration, 106. Phrenology. 130. Phthisis, 109; acute, 109; chronic. 110; laryngsea, 235; pulmonalis, 252; Associ- ated with hemoptysis, 93; with inflammation of brain, 153, 259; with pleurisy, 245,258; with pneumonia, 241, 259; Auscultation of, 254; cautions, 25 1 ; dif- ficulties, 255; the early stage, 202, 221 ; phenomena in detail, 250; In Child- hood, 264; Distinguished from bronchitis, 249, 258; from pneumonia, 240; INDEX. 419 General symptoms, 189; Its Place in classification, 2:12; Resemblance to fever, 110; Symptoms vary in intensity, 253. See Tubercles. Physiognomy of disease, 36. Physiology, uses of, 17. Pia mater, inflammation of, 156. Pictonum, colica, 80. Pityriasis, 396; capitis, 396; versicolor, 401. Plan of investigation of general state, 28; of various organs, 127. Plethora, hemorrhage in, 92, 95; with reference to stomach, 310. Pleura, Adherent. 243; Air in, 245; Effusion of lymph in, 243; of serum, auscul- tation, 206, 222; from Inflammation, 243; Passive, 222, 244; Pus in, 21:;. Pleurisy, Auscultation in, 242; dulness of, 209; friction in, 222: Complicated with bronchitis, 243; with pericarditis, 282; with peritonitis, 332; with phthisis, 244,258; with pneumonia, 243; General symptoms, 242; Injury a cause of. 244; Simulated by pleurodynia, 245. Pleurodynia, 245. Pleuro-pneumonia, 241, 243; auscultatory signs, 206, 222; with hepatitis, 340. Pneumonia, auscultation in, 237; fine crepitation, 217, 223; Chronic, 241; In Childhood, 263; Complicated with fever, 241; with pleurisy, 243; with tuber- cles, 241 ; Distinguished from bronchitis, 24S ; from phthisis in upper lobe, 218,240; General symptoms, 238; delirium, 136, 241; hcenioptysis, 238 ; sputa, 191; Pyceniic, 233; Terminating in abscess, 241. Pneumo-thorax, 245; Auscultation, 202, 210; metallic tinkling, 223: percussion, 214; succussion, 223; in their totality, 246; Causes, 245, 247; Distinguished from emphysema, 246; General symptoms, 245. Poisoning, 75; Blood-, 91; Irritant, 90; effects on the stomach, 312; Lead, 81; drop- wrist without, 179; Narcotic, 77; coma of, 132; Slow, 78; painter's colic a form of, 80. Polypus of nose, 93; of uterus, 384. Pompholyx, 399. Porrigo favosa, 401 ; decalvans, 391, 401. Position of patient, 36; in bed, 40, 45; in chest disease, 190; in heart-disease, 45; in paralysis, 46; of pain in peritonitis, 41, 332; prone, 40; in prostration, 41; in rheumatic fever, 41. Posture of patient, 36; bent, 46; erect, 41; horizontal with reference to pain in head, 146; semi-erect, especially in heart-disease, 190; expressing pain in ab- domen, 333. Pregnancy, amenorrhoea of, 381; character of abdominal fulness in, 379; menstru- ation in, 379; symptoms of, 379; tubal, 379; urine of, 375. Prolapsus uteri, 384 ; of vagina involving bladder, 384. Prostate gland, disease of, 97. Prurigo, 393; podicis, 394; pudendi, 394. Psoas abscess, 113. Psoriasis, 395. Ptosis, 148. Puerperal fever, 331; peritonitis, 331. Pulsation, abdominal, 225; of tumours, 118: direction of, 293. Pulse, characters of, 36; Irregular, 268; Intermitted, 268 ; Special indications, 43; in chest-disease, 189; in heart-disease, 288; Uneven, 268. Pupil, action of, in disease, 143. Purpura, 100; with haemoptysis, 95; with htematemesis, 90; with hsematuria, 97. Pus in abdomen, 113, 334 ; in blood, 106, 290 ; in thorax, 113, 243 : in urine, 3 its Chemical relations, 354 ; Microscopic appearances, 355. Pyaemia, 290; Associated with pneumonia, 239; with purpura, 100; with suppura- tive phlebitis, 106, 290 ; Distinguished from gout, 73 ; from rheumatism, 68 ; Resemblance to glanders, 80. Pyelitis, 365. Pylorus, stricture of, 310; cancerous, 311. Qitackert, language of, in exaggeration, 381 : in imagination, 384; in unfavoura- ble opinion, 221 ; in ulceration of uterus, 385 ; Success of, based on faulty diag- nosis, 24; on false prognosis, 71. Quinsy, 301 ; with laryngitis, 234. 420 INDEX. Rai nma, 889. Rational medicine, 21. turn, scirrhus of, 110. Ki'ilection, faculty of, as an indication of disease, 131. Regions, examination of, 119. ii of the chest, Modified sounds in, 108; the clavicular, 108; the posterior " and Literal. 206 ; Superadded sounds in, 215; the clavicular, 217 ; the posterior and lateral, 222. Remedies, selection of, 28. Remittent fever, 56. Resonance of Bowel in ascites, 80: in examination of abdomen, 306; in ovarian dropsy, 377; in chronic peritonitis, 335; in tympanitis, 328 ; of Chest, 103; ex- cessive, in emphysema, 261; in pueunio-thorax, 240; modifications of, 108; of Voice, 195; segophony, 200; in early consolidation, 208; modifications of, 108. See Auscultation and Percussion. Respiration, characters of, indicating disease, 100 ; healthy, 195 ; modifications of, 198. See Auscultation. Respiratory organs, diseases of, 232 ; general examination, 129 ; general symptoms, 188; history, 188. See Lungs. Rheumatism, 66 ; acute, 66; in children, 67; chorea in, 125; chronic, 70; delirium in, 137 ; fibrous, CO ; gonorrhocal, 69; muscular, GO; sub-acute, 08 ; synovial, 69. Rheumatic gout, 73. Rib, fracture of, causing pleurisy, 244. Rickets, 389. Rigor, 48. Ringworm so-called, a lichen, .304;. herpes, 397; True, favus, 401. Roseola, 393. Rupia, 400. Sarcina Venteicula, 313 ; urine with, 350. Scabies, 398. Scalp, tumours of, 115. Scarlatina, 62 ; albuminuria of, 3G7 ; dropsy of, 87 ; with hematuria, 97 ; its pecu- liar tension, 39. Sciatica, 185 ; a form of rheumatism, 71. Scirrhus of Liver, 343; of Lungs, 260; of Pancreas, 347; observed as a tumour, 119; of Rectum, 119; of Stomach, 311; hjematemesis in, 96; its position, 117; the usual form of cancer in, 119; of Uterus, 386. Scrofula, 108. Scrofulous Abscesses, 303, 405; Enlargements, 111; Inflammation of brain, 151; de- lirium of, 138; Ulcer, 404 ; in throat, 302. Scurvy, 100; hocmatemesis in, 06. Semeiology, 17; of the brain, 130; special indications, 43. Sensation, altered, in disease of brain, 142; loss of, anesthesia. 171. Sensations of patient, 36, 41; in disease of chest, 190; of pain, exaggerated, 122; mistaken for loss of power, 387; in disease of stomach, errors from, 314; un- usual, 47. • Senses, special affection of, 142. Sensibility, alterations of, 142; loss of, 171. Sequence of phenomena, 33. Serum, effusion of, 112; in dropsy, 103; in the pericardium, 268, 281; in perito- neum, 88; in pleura, 200, 244; in ventricles of brain, 132, 151. Sexual organs in nervous disorders, 167. Shingles, 397. Simulation of epilepsy, 163; of paralysis, 172; of partial loss of power, 180; espe- cially recogni«ed by the gait, 178. Sight, alterations in, 142 ; perversions of, 143. Skin, condition of, in reference to general state, 36; Cellular inflammation, 406; Difficulties of diagnosis of disease, 388; Discolorations of, 403; bronzed, 404; ephelides, 404; vitiligo, 404 ; Diseases of, 391; acne, 300: ecthyma, 300; eczema, ■ ; erythema, 302; favus, 401; herpes, 307 ; icthyosis, 305; impetigo, 398 ; lepra, 305; lichen, 303; lupus, 404; pemphigus, 309; pityriasis, 396; versi- color, 401 ; pompholyx, 309; porrigo decalvans, 301, 401 ; favosa, 401 ; prurigo, INDEX. 421 393; psoriasis, 395; roseola, 392; rupia, 400; scabies, 398; scrofulous ulcer, 404; strophulus, 394; sycosis, 398; syphilitic eruptions, 402; tubercle of skin, 401; uticaria, 393; Cancrum oris, 300, 405; Coutagion of disease, 407; Ele- phantiasis of the Arabians, 405; of the Greeks, 401; Endemial diseases, 405; Symptoms associated with disease of, 407. Skull/fracture of, 132. Smallpox, 62. Solids and fluids, relation of, in the chest, 194. Sore-throat, 301; its importance in laryngitis, 232. Sounds, Breath and Voice, modifications of, 19G; and of percussion-resonance, 18G; deductions, 194; Superadded, 195; continuous, 210; interrupted, 215; their teaching, 230; of the Heart, 270; modifications of normal, 270; morbid, 270; of Percussion, 194; of Respiration, 195. See Auscultation and Percussion. Spantemia, 102. Spasm, 146 ; of asthma, 251 ; in disease of cord, 168 ; with paralysis, 171, 177 ; of oesophagus, 309 ; varieties, 124. Spectra, ocular, 144. Speculum, uses of, 385 ; abuse of, 24 ; injury from, 385. Spermatorrhoea, 167. Spermatozoa in urine, 356. Spinal cord, Diseases of, 168; apoplexy, 177; atrophy, 175; chronic disease, 169; inflammation, 168,176; meningitis, 168 ; tumoui*, 176 ; Producing hemiplegia, 174; paraplegia, 175. Spinal curvature interfering with auscultation, 193 ; ia relation to paralysis, 176. Spinal irritation, 168, 187. Spinal neuralgia, 157. Spine, caries of, Associated with disease of cord, 168; with lumbar abscess, 113; with paraplegia, 175; Distinguished from hysteria, 187 ; from rheumatism, 72. Spleen, disease of, 346 ; enlargement, as a tumour, 121 ; hreniateniesis from, 96 ; as a sequel of ague, 347. Spots in fever, 52, 100. Sputa, characters of, 190. Starvation a cause of antcmia, 101. Stethoscope, how applicable, 196. Stomach, Dilatation of, 313; simulating ascites, 313; from stricture of pylorus, 310; Diseases of, 308; Distention, 315; Dyspepsia, 313; Effect of irritant poisons on, 312 ; Faulty secretion, 315 ; Fermentation and sarcina, 313 ; Func- tional disorders, 313 ; Gout in, 318 ; Hemorrhage from, 96 ; its characters, 312 ; in scirrhus, 96; Hyperoemia of, 316; Inflammation of, 312 ; Irritation of, 314; sympathetic, 312'; Organic diseases of, 310; Scirrhus, 117, 311; the common form of cancer of, 119; Stricture of pylorus, 310; Theories of patient, 314; Ulceration, 311. Strabismus, caused by paralysis, 148; in childhood, 180; mode of determining its duration, 171 ; a symptom of disease of brain, 147. Stricture of oesophagus, 309; of pylorus, 310; of urethra as a cause of cystitis, 370. Strongylus gigas, 84. Strophulus, 394. Struma, 108, 115. Strumous diathesis in inflammation of brain, 151. Sec Scrofulous. Strychnia, poisoning by, 86; convulsions in, 125. Student, advice to, in auscultation of the chest, 192, 195: of the heart, 266; in examination of urine, 349, 355 ; definite course of inquiry recommended, 27, 127; how to form a correct opinion, 20, 48, 205; outline of clinical notes for, v. ; warning against pathognomonic signs, 19, 198. Stupor, or partial coma, 133. St. Vitus's dance, 124. Subjective phenomena, 26, 35. Subsultus, 145. Succussion, sound of, 216: in hydro-pneumo-thorax, 247. Sugar in urine, tests of, 360. Suppuration, 115; causing inflammation of brain, 150; in hydatid cyst, 341; in kidney, 365; in liver, 341; in peritoneum, 334; in pleurisy, 243; in pneu- monia, 241 ; rigor of, 100 ; resembling ague, 64; scrofulous, 113, 404; secon- dary, 106 ; in veins, causing pyaemia, 106. 422 INDEX. Byoo Sympathetic affections in dyspepsia, 308; pains, 183; in disease of abdomen, 303. ptomatology, ■■ Si meiology. S'vm \rrangement nf. 26; < 'omplex character of, 22 ; Duration, 32 : General, 86; of disease of abdomen, 804 ; of brain, 130; of chest, 188; of regions and organs, 127; Sequence of, 32 ; Special, 48; derived from nrine, 847 ; indicating disease in other organs, 871 ; hysterical, falsely referred to uterus, 380; sj pathetic, excited by dyspepsia, 300. For oth' Jffflg!? 8 *™ now a standard work in Medical literature, and dur- London Med. Tones and Gazette, June 2, , B57. This work, now the standard book of reference on the diseases of which it treats, has been carefully revised, and many new illustrations of the views of the learned author added in the present edition. — Dublin Quarterly Journal, Aug. lfroT. ing the intervals which have elapsed between the successive editions, the author has incorporated into the text the most striking novelties which have cha- racterized the recent progress of hepatic physiology and pathology ; so that although the size of the book BY THE SAME AUTHOR. ON THE ORGANIC DISEASES AND FUNCTIONAL DISORDERS OF THE STOMACH. In one neat octavo volume, extra cloth. $1 50. From the high position occupied by Dr. Budd as style, the subjects are well arranged, and the practi- a teacher, a writer, and a practitioner, it is almost , cal precepts, both of diagnosis and treatment, denote needless to state that the present book may be con- ' the character of a thoughtful and experienced phy- ■ulted with great advantage. It is written man easy I sician.— London Med. Times and Gazette. I BLANCHARD & LEA'S MEDICAL BROWN (ISAAC BAKER), BuTgeon-Acoonohem to St. Mary's Hospital) Ice. ON SOME DI8EASBS OF WOMEN ADMITTING OF SURGICAL TREAT- MENT. With handsome illustrations. One vol. 8vo., extra cloth, pp 27fl. »i 80. Mr. Brown has earned for himself a high repnta- and merit the careful attention of every surgeon- tlon in the operative treatment of sundry diseases accoucheur. — Association Journal. and injuries to which females are P ,-rul,Mriy sul,j,,-t hesitation in recommending this book Wecan truly say of h»work that it is an important tothecarefu , ttttention ,„• a „ Bur geons who make ition tn obstetrical literature. Thejoperative SUggl >"<>"■>" ■•" '""•""' , ", ' ,., V female complaints a part of their study and practice, md contrivances which Mr. Brown de- ,.,,,■. ,,' , ,„,;„ ;„„,...„/ *Ugge8MOns imu cuumvau«« wim .. i. i . uiurrii ... - /,,./,/;,. (ntarl^rlM Inurnal scribes, exhibit much practical sagacity and skill, . —VuUlin quarterly Journal BENNETT (J. HUGHES), M.D., F. R. S.E., Professor of Clinical Medicine in the University of Edinburgh, &c. THE PATHOLOGY AND TREATMENT OP PULMONARY TUBERCU- LOSIS, and on the Local Medication of Pharyngeal and Laryngeal Diseases frequently mistaken for or associated with, Phthisis. One vol. 8vo.,extra cloth, with wood-cuts. pp. 130. $1 ~'-j. BENNETT (HENRY), M. D. A PRACTICAL TREATISE ON INFLAMMATION OP THE UTERUS, ITS CERVIX AND APPENDAGES, and on its connection with Uterine Disease. Fourth American, from the third and revised London edition. To which isadded (Jul '//, 1856), a Review of the Present State OF Uterine Pathology. In one neat octavo volume, extra cloth, of 500 pages, with wood-cuts. $2 00 Also, the "Review," for sale separate. Price 50 cents. The addition of the "Review" presents the recent aspects of the questions discussed in this well-known work. When, a few years back, the first edition of the present work was published, the subject was one al- most entirely unknown t<> the obstetrical celebrities of the day ; and even now we have reason to know that the bulk of the profession are not fully alive no the importance and frequency of the disease of which it takes cognizance. The present edition is so much enlarged, altered, and improved, that it can scarcely be considered the same work. — Dr. Ranking' s Ab- stract. This edition has been carefully revised and altered, and various additions have been made, which render it more complete, and, if possible, more worthy of the high appreciation in which it is held by the medical profession throughout the world. A copy should be in the possession of every physician.— Charleston Med. Journal and Revitw. 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In one neat octavo volume, extra cloth, of 424 pages. (JSow Ready.) 92 ou: Of works exclusively devoted to this important has not exceeded his powers. We have thus gi. branch, our profession has at command, coinpara- a specimen of Barclay's generalizing spirit in tively, but few, and, therefore, in the publication of direction; but the game pervades his whole work, the present work. Messrs. Blanchard & I. and will, we are sure, induce teachers to recommend conferred a great favor upon us. Dr. Barclay, from it strong!) to their pupils. It is impossible for us having occupied, for a long period, the position of here to follow the book into its particulars; and, in- Medical Registrar at St. George's Hospital, pos- deed, we think it enough to indicate, as we ha sessed advantages for correct observation and reli- the importance of the teaching which it offers to the able conclusions, as to the significance of symptoms, rising generation of medicine, 10 insure for it a I earl which have fallen to the lot of but few, either in reception at the hands of the profession. It is the ivs own or any other country. He has carefully work of a physician and a gentleman. — British Med. systematized the results of his observation of ovi r Journal, Dec. 5, \i twelve thousand patients, and by his diligence and ^Ve hope the volume will have an extensive fir- judicious classification, the profession has been eu i a tion, not among students of medicine only, but presented with the most convenient and reliable prac ti turners also. Thev will never regret a faith - work on the subject of Diagnosis that it has been fu j Btm |y of its pages.— Cincinnati Eancet Mar. our good fortune ever to examine; we can, there- „, . „ , , ._ ,. , ... . .. fore? say of Dr. Barclay's work, that, from his svs- This Manual i bnky Smith, M. D., Professor of the Institutes of Medicine in the Pennsyl- vania Medical College, Bee In one very large and beautiful octavo volume, of about nine hundred lartre pages, handsomely printed and strongly hound in leather, with raised bands. (Just Issued, 1856.) | In the preparation of this new edition, the author has spared no labor to render it, as heretofore. a complete and lucid exposition of the most advanced condition of its important subject. The amount ol the additions required to effect this object thoroughly, joined to the former large size ol the vol e, presenting objections arising from the unwieldy hulk of the work, he has omitted all those portions not bearing directly upon Human Physiology, designing to incorporate them in his forthcoming Treatise on General Physiology. As a lull and accurate text-book on the Phy- siology ol -Man, the work in its present condition therefore presents even greater claims upon the student and physician than those which have heretofore won for it the very wide and distin- guished favor which it has so long enjoyed. The additions of Prof. Smith will he found to supply whatever may have been wanting to the American student, while the introduction of many new illustrations, and the most careful mechanical execution, render the volume one of the most at- tractive as yet issued. For upwards of thirteen years Dr. Carpenter's 1 To eulogize this great work would be superfluous work has been considered by the profession gene- We should observe, however, that in this edition rally, both in tliis country and England, as the most the author has remodelled a large portion of the valuable compendium on the subject of physiology former, and the editor has added much matter of in- 111 our language. This distinction it owes to the high terest, especially in the form of illustrations. We attainments and unwearied industry of its accom- may confidently recommend it, as the most complete f dished author. The present edition (which, like the work on Human Physiology in our language. — ast American one, was prepared by the author him- Southern Med. and Surg. Journal, December, 1&55. self), is the result of such extensive revision that it The mogt complete work <)n the BC i e nce in our may almost be consideredanew work. We need language.— .Ajm. Med. Journal. hardly say, in concluding this brief notice, that while the work is indispensable to every student of medi- cine in this country, it will amply repay the practi- tioner for its perusal by the interest and value of its contents. — Boston Med. and Surg. Journal. This is a standard work — the text-book used by all medical students who read the English language. It has passed through several editions in order to The most complete work now extant in our lan- guage. — N. O. Med. Register. The best text-book in the language on this ex- tensive subject. — London Med. Times. A complete cyclopaedia of this branch of science. —N. Y. Med. Times. The profession of this country, and perhaps also keep pace with the fapidly growing science of Phy- of Europe, have anxiously and for some time awaited siology. Nothing need be said in its praise, for its , the announcement of this new edition of Carpenter's merits are universally known; we have nothing to: Human Physiology. H4s former editions have for say of its defects, for they only appear where the ; many years been almost the only text-book on Phy- siology in all our medical schools, and its circula- tion among the profession has been unsurpassed by any work "in any department of medical science. It is quite unnecessary for us to speak of this work as its merits would justify. The mere an- nouncement of itsappearance will afford the highest The greatest, the most reliable, and the best book ' pleasure to every student of Physiology, while its on the subject which we know of in the English perusal will be of infinite service in advancing language. — Stethoscope. j physiological science. — Ohio Med. and Surg. Journ. science of which it treats is incomplete. — Western Lancet. The most complete exposition of physiology which any language can at present give. — Brit, and For. Mtd.-Chiritrg. Review. by the same author. (Lately Issued.) PRINCIPLES OF COMPARATIVE PHYSIOLOGY. New American, from the Fourth and Revised London edition. In one large and handsome octavo volume, with over three hundred beautiful illustrations, pp. 7. r r2. Extra cloth, $4 80; leather, raised bands, $5 25. The delay which has existed in the appearance of this work has been caused by the very thorough revision and remodelling which it has undergone at the hands of the author, and the large number of new illustrations which have been prepared for it. It will, therefore, be found almost a new work, and fully up to the day in every department of the subject, rendering it a reliable text-book for all students engaged in this branch of science. Every effort has been made to render its typo- graphical finish and mechanical execution worthy of its exalted reputation, and creditable to the mechanical arts of this country. This book should not only be read but thoroughly studied by every member of the profession. None are too wise or old, to be benefited thereby. But especially to the younger class would we cordially commend it as best fitted of any work in the English language to qualify them for the reception and com- prehension of those truths which are daily being de- veloped in physiology. — Medical Counsellor. Without pretending to it, it is an encyclopedia of the Bubjeet, accurate and complete in all respects — a truthful reflection of the advanced state at which the science has now arrived. — Dublin Quarterly Journal of Medical Science. A truly magnificent work — in itself a perfect phy- siological study. — Ranking's Abstract. This work stands without its fellow. It is one few men in Europe could have undertaken ; it is one no man, we believe, could have brought to so suc- cessful an issue as Dr. Carpenter. It required for its production a physiologist at once deeply read in the labors of others, capable of taking a general, critical, and unprejudiced view of those labors, and of combining the varied, heterogeneous materials at his disposal, so as to form an harmonious whole. We feel that this abstract can give the reader a very imperfect idea of the fulness of this work, and no idea of its unity, of the admirable manner in which material has been brought, from the most various sources, to conduce to its completeness, of the lucid- ity of the reasoning it contains, or of the clearness of language in which the whole is clothed. Not the profession only, but the scientific world at large, must feel deeply indebted to Dr. Carpenter for this great work. It must, indeed, add largely even to his high reputation. — Medical Times. AND SCIENTIFIC PUBLICATIONS. CARPENTER (WILLIAM BJ, M. D., F. R. S., Examiner in Physiology and Comparative Anatomy in the University of London. {Just Issued, 1856.) THE MICROSCOPE AND ITS REVELATIONS. With an Appendix con- taming the Applications of the Microscope to Clinical Medicine, ece. By F. G. Smith M D Illustrated by lour hundred and thirty-four beautiful engravings on wood. In one large and v'err handsome octavo volume, of 724 pages, extra cloth, S4 00 ; leather, $4 50. Dr. Carpenter's position as a microscopic and physiologist, and his great experience as a teacher eminently qualify htm to produce what has long been wanted-a good text-book on !he practical use of the microscope In the present volume his object has been, as staled in his Preface « to combine, within a moderate compass, that information with regard lo the use of his < t0 oN ' which is most essential to the working microscopist, with such an account of the objects be<* fitted for nis study, as might qualify him to comprehend what he observes, and might thus prepare him to benefit science, whilst expanding and refreshing his own mind " That he has succeeded in accom- plishing this, no one acquainted with his previous labors can doubt. The great importance of the microscope as a means of diagnosis, and the number of microseo- pists who are also physicians, have induced the American publishers, with the author's approval to add an Appendix, carefully prepared by Professor Smith, on the applications of the instrument to clinical medicine, together with an account of American Microscopes, their modifications and accessories. This portion of the work is illustrated with nearly one hundred wood-cuts and it is hoped, will adapt the volume more particularly to the use of the American student Every care has been taken in the mechanical execution of the work, which is confidently pre sented as in no respect inferior to the choicest productions of the London press. " The mode in which the author has executed his intentions may be gathered from the following condensed synopsis of the ' s CONTENTS. Introduction— History of the Microscope. Chap. I. Optical Principles of the Microscope Chap. II. Construction of the Microscope. Chap. III. Accessory Apparatus Cmp fV Management of the Microscope Chap. V. Preparation, Mounting, and Collection of Objects' Chap. VI. Microscopic Forms of Vegetable Life— Protophytes. Chap. VII. Higher CrvDto°-a' mia. Chap. VIII. Phanerogamic Plants. Chap. IX. Microscopic Forms of Animal Life—Pro tozoa— Animalcules. Chap. X. Foraminifera, Polycystina, and Sponges. Chap. XI Zoophvtes Chap. XII. Echinodermata. Chap. XIII. Polyzoa and Compound Tunicata Chap XIV* Molluscous Animals Generally. Chap. XV. Annulosa. Chap. XVI. Crustacea Chap'xViV Insects and Arachnida. Chap. XVIII. Vertebrated Animals. Chap. XIX. Applications of the Microscope to Geology. Chap. XX. Inorgauic or Mineral Kingdom— Polarization. Appendix Microscope as a means of Diagnosis— Injections— Microscopes of American Manufacture. Those who are acquainted with Dr. Carpenter's medical work, the additions bv Prof Smith srive it previous writings on Animal and Vegetable Physio- ; a positive claim upon the profession, for which we logy, will tully understand how vast a store of know- doubt not he will receive their sincere thanks In ledge he is able to bring to bear upon so comprehen- deed, we know not where the student of medicine sive a subject as the revelations of the microscope ; will find such a complete and satisfactory collection and even those who have no previous acquaintance of microscopic facts bearing upon phyaioloev and with the construction or uses of this instrument, ; practical medicine as is contained in Prof Smith's Will find abundance of information conveyed in clear [ appendix; and this of itself, it seems to us is fullv and simple language.— Med. Times and Gazette. | worth the cost of the volume.— Louisville 'Medical Although originally not intended as a strictly | Review, Nov. 1S56. BY THE SAME AUTHOR. ELEMENTS (OR MANUAL) OF PHYSIOLOGY, INCLUDING PHYSIO- LOGICAL ANATOMY. Second American, from a new and revised London edition. With one hundred and ninety illustrations. In one very handsome octavo volume, leather, pp. 566. In publishing the first edition of this work, its title was altered from that of the London volume by the substitution of the word " Elements" for that of " Manual," and with the author's sanction the title of "Elements" is still retained as being more expressive of the scope of the treatise. To say that it is the best manual of Physiology i Those who have occasion for an elementary trea now before the public, would not do sufficient justice to the author. — Buffalo Medical Journal. In his former works it would seem that he had exhausted the subject of Physiology. In the present, he gives the essence, as it were, of the whole. — N. Y. Journal of Medicine. tise on Physiology, cannot do better than to possess themselves of the manual of Dr. Carpenter. Medical Examiner. The best and most complete expose 1 of modern Physiology, in one volume, extant in the English language. — St. Louis Medical Journal. BY THE SAME AUTHOR. (Preparing.) PRINCIPLES OF GENERAL PHYSIOLOGY, INCLUDING ORGANIC CHEMISTRY AND HISTOLOGY. With a General Sketch of the Vegetable and Animal Kingdom. In one large and very handsome octavo volume, with several hundred illustrations. The subject of general physiology having been omitted in the last editions oi the author's " Com- parative Physiology" and "Human Physiology," he has undertaken to prepare a volume which shall present it more thoroughly and fully than has yet been attempted, and which may be regarded as an introduction to his other works. BY THE SAME AUTHOR. A PRIZE ESSAY ON THE USE OF ALCOHOLIC LIQUORS IN HEALTH AND DISEASE. New edition, with a Preface by D. F. Conpie, M. D., and explanations of scientific words. In one neat 12mo. volume, extra cloth, pp. 178. 50 cents. c BLANCHARD & LEA'S MEDICAL CONDIE (D. F.), M. D., &.C. A PRACTICAL TREATISE ON THE DISEASES OF CHILDREN. Fourth edition, revised and augmented. In one large volume, 8vo., leather, of nearly 750 pages. $3 00. From the Author's Preface. The demand for another edition has afforded the author an opportunity of again subjecting the entire treatise to a careful revision, and of incorporating in it every important observation recorded s ince i be appearance ol the last edition, in relerence to the pathology and therapeutics of the several c -o- ol W inch it treats. iii the preparation of the present edition, as in those which have preceded, while the author has appropriated to his use every important fact that he has found recorded in the works of others, having a direct bearing upon either oi the subjects of which he treats, and the numerous valuable observations — pathological as well as practical — dispersed throughout the pages of the medical journi Is "i Europe and America, he has, nevertheless, relied chiefly upon his own observations and experience, acquired during a long and somewhat extensive practice, and under circumstances pe- culiarly well adapted for the clinical study of the diseases of early life. Every species of hypothetical reasoning has. as much as possible, been avoided. The author lias endeavored throughout the work to confine himself to a simple statement of well-ascertained patho- logical lads, and plain therapeutical directions — his chief desire being to render it what its title its it to be, A PRACTICAL TREATISE OX THE DISEASES OF CHILDREN. Dr. Condie's scholarship, acumen, industry, and practical sense are manifested in this, as in all his numerous contributions to science. — Dr. Holmes's H'j'ort to the American Medical Association. Taken as a whole, in our judgment, Dr. Condie's Treatise is the one from the perusal of which the practitioner in this Country will rise with the great- est satisfaction. — Western Journal of Medicine and Surgery. One of the best works upon the Diseases of Chil- dren in the English language. — Western Lancet. Perhaps the most, full and complete work now be- fore i lie profession of the United States; indeed, we may say in the English language, ft. is vastly supe- rior to most of its predecessors. — Transylvania Med. Journal. We feel assured from actual experience that no physician's library can be complete without a copy of this work. — N. Y. Journal of Medicine. A veritable psedintric encyclopaedia, and an honor to American medical literature. — Ohio Medical and Surgical Journal. We feel persuaded that the American medical pro- fession will soon regard it not only as a very good, but as the vkry best "Practical Treatise on the Diseases of Children." — American Medical Journal . We pronounced the first edition to be the best work on the diseases of children in the English language, and, notwithstanding all that has oeen published, we still regard it in that light. — Medical Examiner. CHRISTISON (ROBERT), M. D., V. P. R. S. E. 3 &c. A DISPENSATORY; or, Commentary on the Pharmacopoeias of Great Britain and the United States comprising the Natural History, Description, Chemistry, Pharmacy, Ac- tions, Uses, and Doses of the Articles of the Materia Medica. Second edition, revised and im- proved, with a Supplement containing the most important New Remedies. With copious Addi- tions, and two hundred and thirteen large wood-engravings. By R. Eglesfeld Griffith, M. D. In one very large and handsome octavo volume, leather, raised bands, of over 1000 pages. $3 50. It is not needful that we should compare it with the other pharmacopoeias extant, which enjoy and merit the confidence of the profession : it is enough to say that it appears to us as perfect as a Dispensa- tory, in the present state of pharmaceutical science, could be made. If it omits any details pertaining to this branch of knowledge which the student, has a right to expect in such a work, we confess the omis- sion has escaped our scrutiny. We cordially recom- mend this work to such of our readers as are in need of a Dispensatory. They cannot make choice of a better. — Western Journ. of Medicine and Surgery. COOPER (BRANSBY B.), F. R. S. LECTURES ON THE PRINCIPLES AND PRACTICE OF SURGERY. In one very large octavo volume, extra cloth, of 750 pages. $3 00. COOPER ON DISLOCATIONS AND FRAC- TURES OF THE JOINTS —Edited by Bransby B. Cooper, F.R.S., &c. With additional Ob- servations by Prof. J. C. Warren. A new Ame- rican edition. In one handsome octavo volume, extra eloih, of about 500 pages, with numerous illustrations on wood. $3 25. COOPER ON THE ANATOMY AND DISEASES OF THE BREAST, with twenty-five Miscellane- ous and Surgical Papers. One large volume, im- perial Svo., extra cloth, with 252 figures, on 36 plates. S2 50. COOPER ON THE STRUCTURE AND DfS- EASES OF THE TESTIS, AND ON THE THYMUS GLAND. One vol. imperial Svo., ex- tra cloth, with 177 tigures on 29 plates. ©2 00. COPLAND ON THE CAUSES, NATURE, AND TREATMENT OF PALSY AND APOPLEXY. In one volume, royal 12mo., extra cloth, pp. 326. 80 cents. CLYMER ON FEVERS; THEIR DIAGNOSIS, PATHOLOGY, AND TREATMENT In one octavo volume, leather, of 600 pages. $1 50. COLOMBAT DE L'ISERE ON THE DISEASES OF FEMALES, and on the special Hygiene of their Sex. Translated, with many Notes and Ad- ditions, by C. D. Meigs, M. D. Second edition, revised and improved. In one large volume, oc- tavo, leather, with numerous wood-cuts. pp. 720. S3 50. CARSON (JOSEPH), M . D., Professor of Materia Medica and Pharmacy in the University of Pennsylvania. SYNOPSIS OF THE COURSE OF LECTURES ON MATERIA MEDICA AND PHARMACY, delivered in the University of Pennsylvania. Second and revised edi- tion. In one very neat octavo volume, extra c/oth, of 208 pages. $1 50. AND SCIENTIFIC PUBLICATIONS. CHURCHILL (FLEETWOOD), M. D., M. R. I. A. ON THE THEORY AND PRACTICE OF MIDWIFERY. Edited, with Notes and Additions, by D. Francis Condie, M. D., author of a "Practical Treatise on the Diseases of Children," &c. With 139 illustrations. In one very handsome octavo volume, leather, pp.510. $3 00. To bestow praise on a book that has received such marked approbation would be superfluous. We need only say, therefore, that if the first edition was thought worthy of a favorable reception by the medical public, we can confidently affirm that this will be found much more so. The lecturer, the practitioner, and the student, may all have recourse to its pages, and derive from their perusal much in- terest and instruction in everything relating to theo- retical and practical midwifery. — Dublin Quarterly Journal of Medical Science. A work of very great merit, and such as we can confidently recommend to the study of every obste- tric practitioner. — London Medical Gazette. This is certainly the most perfect system extant. It is the best adapted for the purposes of a text- book, and that which he whose necessities confine him to one book, should select in preference to all others. — Southern Medical and Surgical Journal. The most popular work on midwifery ever issued from the American press. — Charleston Med. Journal. Were we reduced to the necessity of having but one work on midwifery, and permitted to choose, we would unhesitatingly take Churchill. — Western Med. and Surg. Journal. It is impossible to conceive a more useful and elegant manual than Dr. Churchill's Practice of Midwifery. — Provincial Medical Journal. Certainly, in our opinion, the very best work on the subject which exists. — N. Y. Annalist. No work holds a higher position, or is more de- serving of being placed in the hands of th tyro, the advanced student, or the practitioner. — Medical Examiner. Previous editions, under the editorial supervision of Prof R. M. Huston, have been received with marked favor, and they deserved it; but this, re- printed from a very late Dublin edition, can-fully revised and brought up by the author to the present time, does present an unusually accurate and able exposition of every important particular embraced in the department of midwifery. * * The clearness, directness, and precision of its teachings, together with the great amount of statistical research which its text exhibits, have served to place it already in the foremost rank of works in i his department at re- medial science. — N. O. Med. and Surg. Journal. In our opinion, it forms one of the best if not the very best text-book and epitome of obstetric science which we at present possess in the English lan- guage. — Monthly Journal of Medical Science. The clearness and precision of style in which it is written, and the great amount of statistical research which it contains, have served to place it in the first rank of works in this departmentof medical science. — N. Y. Journal of Medicine. Few treatises will be found better adapted as a text-book for the student, or as a manual for the frequent consultation of the young practitioner. — American Medical Journal. BY the same author. (J list Issued.) ON THE DISEASES OF INFANTS AND CHILDREN. Second American Edition, revised and enlarged by the author. Edited, with Notes, by W. V. Keating, M. D. In one large and handsome volume, extra cloth, of over 700 pages. $3 00, or in leather, $3 25. In preparing this work a second time for the American profession, the author has spared no labor in giving it a very thorough revision, introducing several new chapters, and rewriting others, while every portion of the volume has been subjected to a severe scrutiny. The efforts of the American editor have been directed to supplying such information relative to matters peculiar to this country as might have escaped the attention of the author, and the whole may, there- fore, be safely pronounced one of the most complete works on the subject accessible to lire Ame- rican Profession. By an alteration in the size of the page, these very extensive additions have been accommodated without unduly increasing the size of the work. A few notices of the former edition are subjoined : — We regard this volume as possessing more claims [ The present volume will sustain the reputation to completeness than any other of the kind with I acquired by the author from his previous works. which we are acquainted. Most cordially and ear- J The reader will find in it full and judicious direc- nestly, therefore, do we commend it to our profession- : tions for the management of infants at birth, and a al brethren, and we feel assured that the stamp of '■ compendious, but clear account of the diseases to their approbation will indue time be impressed upon j which children are liable, and the most successful it. After an attentive perusal of its contents, we | mode of treating them. We must not close this no- hesitate not to say, that it is one of the most com- i tice without calling attention to the author's style, prehensive ever written upon the diseases of chil- I which is perspicuous and polished to a degree, we dren, and that, for copiousness of reference, extent of ; regret to say, not generally characteristic of medical research, and perspicuity of detail, it is scarcely to ; works. We recommend the work of Dr. Churchill be equalled, and not to be excelled, in any lan- guage. — Dublin Quarterly Journal. After this meagre, and we know, very imperfect notice of Dr. Churchill's work, we shall conclude by saying, that it is one that cannot fail from its co- piousness, extensive research, and general accuracy, to exalt still higher the reputation of the author in this country. The American reader will be particu- larly pleased to find that Dr. Churchill has done full justice throughout his work to the various American authors on this subject. The names of Dewees, Eberle, Condie, and Stewart, occur on nearly every page, and these authors are constantly referred to by the author in terms of the highest praise, and with the most liberal courtesy. — The Medical Examiner. most cordially, both to students and practitioners. as a valuable and reliable guide in the treatment of the diseases of children. — Am. Journ. of the Mod. Sciences. AVe know of no work on this department of Prac- tical Medicine which presents so candid and unpre- judiced a statement or posting up of our actual knowledgeas this. — N. Y. Journal of Medicine. Its claims to merit both as a scientific and practi- cal work, are of the highest order. Whilst we would not elevate it above every other treatise on the same subject, we certainly believe that very few are equal to it, and none superior. — Southern Med. and Surgical Journal. BY THE SAME AUTHOR. ESSAYS ON THE PUERPERAL FEVER, AND OTHER DISEASES PE- CULIAR TO WOMEN. Selected from the writingsof British Authors previous to the close of the Eighteenth Century. In one neat octavo volume, extra cloth, oi about 450 pages. $2 50. 10 BLANCHARD & LEA'S MEDICAL CHURCHILL (FLEETWOOD), M.D., M.R. I.A., «tc. ON THE DISEASES OF WOMEN; including those of Pregnancy and Child- bed. A iii-w American edition, revised by the Author. With Notes and Additions, by D Fran- OM Co nii IK. M. 1>., author ol "A Practical Treatise on the Diseases of Children." With nume- 1)8 illustrations. In one large and handsome octavo volume, leather, of 768 pages. (Now Ready, May. IS 00. This edition of Or. Churchill's very popular treatise may almost be termed a new work, so thoroughly has be revised it in every portion. It will be found greatly enlarged, and thoroughly brought up to the most recent condition of the subject, while the very handsome series of illustra- tions introduced, representing such pathological conditions as can be accurately portrayed, present ;i novel feature, and afford valuable assistance to the young practitioner. Such additions as ap- peared ■ I.- iral>le lor the American student have been made by the editor, Dr. Condie, while a narked improvement in the mechanical execution keeps puce with the advance in all other respects \ N |, ch i lie volume lias undergone, while the price has been kept at the former very moderate rate. .\ few Helices of the former edition are subjoined : — extent that Dr. Churchill does. His, indeed, is the only thorough treatise we know of on the sufiject ; and it may he commended to practitioners and stu- dents as a masterpiece in its particular department. The former editions of this Work have been com- mended strongly in this journal, and they have won heir v'mv to an extended, and a well-deserved popu- larity. This fifth edition, hefore us. is well calcu- lated to maintain Dr. Churchill's high reputation. It was revised and enlarged by the author, for his American publishers, and it seems to us that there is scarcely any species of desirable information on its subjects that may not be found in this work. — The Western Journal of Medicine and Surgery. It comprises, unquestionably, < ne of the most ex- acl and comprehensive expositions of the present state of medical knowledge in respect to the diseases of women that has yet I een published. — Am.Journ. M I . Sciences, July, 1857. We bail with much pleasure the volume before us, thoroughly revised, corrected, and brought up to the latest date, by Dr. Churchill himself, and rendered still more valuable by notes, from the ex- perienced and aide pen of Dr. D. F. Condie, of Phil- ad< Iphia.— Southern Mid. and Surg. Journal, Oct. 1&57. This work is the most reliable which we possess on tti is subject; and is deservedly popular with the profetsion. — Charleston Med. Journal, July, 1857. Dr. Churchill's treatise on the Diseases of Women is, perhaps, i he most popular of his works with the profession m this country. It has been very gene- rally received both as a text-book and manual of practice. Tin' present edition has undergone the most elaborate revision, and additions of an import- ant character have been made, to render it a com- plete exponent of the present state of our knowledge of these diseases. — N, Y. Journ. of Med., i^ept. Is.37. We now regretfully take leave of Dr. Churchill's book. Had our typographical limits permitted, we should gladly have borrowed more from its richly stored pages. In conclusion, we heartily recom- mend it to the profession, and would at the same time express our firm conviction that it will not only add to the reputation of its author, but will prove a work of great and extensive utility to obstetric practitioners. — Dublin Mediral Press. We know of no author who deserves that appro- bation, on " the diseases of females," to the same We are gratified to announce a new and revised edition of Dr. Churchill's valuable work on" the dis- eases of females We have ever regarded it as one of the very best works on the subjects embraced within its scope, in the English language; and the present edition, enlarged and revised by the author, renders it still more entitled to the confidence of the profession. The valuable notes of Prof. Huston have been retained, and contribute, in no small de- gree, to enhance the value of the work. It is a source of congratulation that the publishers have permitted the author to be, in this instance, his own editor, thus securing all the revision which an author alone is capable of making. — The Western Lanret. Asa comprehensive manual for students, or a work of reference for practitioners, we only speak with common justice when we say that it surpasses any other that has ever issued on the same sub- ject from the British press. — The Dublin Quarterly Journal. DICKSON (S. H.), M. D., Professor of Institutes and Practice of Medicine in the Medical College of South Carolina. ELEMENTS OP MEDICINE; a Compendious View of Pathology and Thera- peutics, or the History and Treatment of Diseases. In one large and handsome octavo volume, of 7")0 pages, leather (Lately Issued.) $3 75. As an American text-book on the Practice of Medicine for the student, and as a condensed work of reference for the practitioner, this volume will have strong claims on the attention of the profession. Few physicians have had wider opportunities than the author for observation and experience, and few perhaps have used them better. As the result of a life of study and practice, therefore, the present volume will doubtless be received with the welcome it deserves. This book is eminently what it professes to be ; a I merits, and we have no hesitation in predicting for distinguished merit in these days. Designed for " Teachers and students of Medicine," and admira- bly suited to their wants, we think it will he received, on its own merits, with a hearty welcome. — Boston Med. and Surg. Journal. Indited by one of the most accomplished writers of our country, as well as by one who has long held a high position among teachers and practitioners of medicine, tins work is entitled to patronage and caret. il study. The learned author has endeavored to condense in this volume most of the practical matter contained in Ins former productions, so as to adapt it to the use of those who have not time to devote to more extensive works. — Southern Med. and Surg. Journal. Prof. Dickson's work supplies, to a great extent, a desideratum long felt in American medicine. — N. O. Med. and Surg. Journal. Estimating this work according to the purpose for which it is designed, we must think highly of its it a favorable reception by both students and teachers. Not professing to be a complete and comprehensive treatise, it will not be found full in detail, nor filled with discussions of theories and opinions, but em- bracing all that is essential in theory and practice, it is admirably adapted to the wants of the American student. Avoiding all that is uncertain, it presents more clearly to the mind of the reader that which is established and verified by experience. The varied and extensive reading of the author is conspicuously apparent, and all the recent improvements anil dis- coveries in therapeutics and pathology are chroni- cled in its pages. — Charleston Med Journal. In the first part of the work the subject of gene- ral pathology is presented in outline, giving a beau- tiful picture of its distinguishing features, and throughout the succeeding chapters we find that he has kept scrupulously within the bounds of sound reasoning and legitimate deduction. .Upon the whole, we do not hesitate to pronounce it a superior work in its class, and that Dr. Dickson merits a place in the first rank of American writers.— Western Lancet. AND SCIENTIFIC PUBLICATIONS II DRUITT (ROBERT), M.R.C.S., &.c. THE PRINCIPLES AND PRACTICE OF MODERN SURGERY. Edited by F. \V. Sargent, M. D., author of « Minor Surgerv," &c. Illustrated with one hundred and ninety-three wood-engravings. In one very handsomely printed octavo volume, leather, of 576 large pages. $3 00. Dr. Druitt's researches into the literature of his subject have been not only extensive, but well di- rected ; the most discordant authors are fairly and impartially quoted, and, while due credit is given to each, their respective merits are weighed with an unprejudiced hand. The grain of wheat is pre- served, and the chaff is unmercifully stripped off. The arrangement is simple and philosophical, and the style, though clear and interesting, is 80 precise, that the book contains more information condensed into a few words than any other surgical work with which we are acquainted.— London Medical Times and Gazette. No work, in our opinion, equals it in presenting so much valuable surgical matter in so small a compass.— St. Louis Med. and Surgical Journal. Druitt's Surgery is too well known to the Ameri- can medical profession to require its announcement anywhere. Probably no work of the kind has ever been more cordially received and extensively circu- lated than this. The fact that it comprehends in a comparatively small compass, all the essential ele- ments of theoretical and practical Surgery — tiiat it is found to contain reliable and authentic informa- tion on the nature and treatment of nearly all surgi- cal affections — is a sufficient reason for the liberal patronage it has obtained. The editor, Dr. F. W. Sargent, has contributed much to enhance the value of the work, by such American improvements as are calculated more perfectly to adapt it to our own views and practice in this country. It abounds everywhere with spirited and life-like illustrations, which to the young surgeon, especially, are of no minor consideration. Every medical man frequently nt/eds just such a work as this, for immediate refer- ence in moments of sudden emergency, when he has not time to consult more elaborate treatises. — The Ohio Medical and Surgical Journal. The author has evidently ransacked every stand- ard treatise of ancient and modern times, and all that is really practically useful at the bedside will be found in a form at once clear, distinct, and interest- ing.— Edinburgh Monthly Medical Journal. Druitt's work, condensed, systematic, lucid, and practical as it is, beyond most works on Surgery accessible to the American student, has had much currency in this country, and under its present au- spices promises to rise to yet higher ta.voi.-Tkt Western Journal of Medicine and Surgery. The most accurate and ample resume of the pre- sent state of Surgery that we areacquainted with.— Dublin Medical Journal. A better book on the principles and practice of Surgery as now understood in England and America, has not. been given to the profession.— Boston Medi- cal and Surgical Journal. An unsurpassable compendium, not only of Sur- gical, but of Medical Practice.— London Medical Gazette. This work merits our warmest commendations, and we strongly recommend it to young surgeons as an admirable digest of the principles and practice of modern Surgery. — Medical Gazette. It may be said with truth that the work of Mr. Druitt affords a complete, though brief and con- densed view, of the entire field of modern surgery. We know of no work on the same subject having the appearance of a manual, which includes so many topics of interest to the surgeon ; and the terse man- ner in which each has been treated evinces a most enviable quality of ijiind on the part of the author, who seems to have an innate power of searching out and grasping the leading facts and features of the most elaborate productions of the pen. It is a useful handbook for the practitioner, and we should deem a teacher of surgery unpardonable who did not recommend it to his pupils. In our own opinion, it is admirably adapted to the wants of the student. Provincial Medical and Surgical Journal. DUNGLISON, FORBES, TWEEDIE, AND CONOLLY. THE CYCLOPAEDIA OP PRACTICAL MEDICINE: comprisin«z Treatises on the Nature and Treatment of Diseases, Materia Medica, and Therapeutics, Diseases of Women and Children, Medical Jurisprudence, &c. &c. in four large super-royal octavo volumes, of 3254 double-columned pages, strongly and handsomely bound, with raised bands. $12 00. *#* This work contains no less than four hundred and eighteen distinct treatises, contributed by sixty-eight distinguished physicians, rendering it a complete library of reference for the country practitioner. The most complete work on Practical Medicine extant; or, at least, in our language.— Buffalo Medical and Surgical Journal. For reference, it is above all price to every prac- titioner. — Western Lancet. One of the most valuable medical publications of the day — as a work of reference it is invaluable. — Western Journal of Medicine and Surgery. It has been to us, both as learner and teacher, a work for ready and frequent reference, one in which modern English medicine is exhibited in the most advantageous light. — Medical Examiner. We rejoice that this work is to be placed within the reach of the profession in this country, it being { unquestionably one of very great value to the prae- I titioner. This estimate of it has not been formed from a hasty examination, but after an intimate ac- quaintance derived from frequent consultation of it during the past nine or ten years. The editors are practitioners of established reputation, ami the list of contributors embraces many of the most eminent professors and teachers of London, Edinburgh, Dub- lin, and Glasgow. It is, indeed, thegreat merit of this work that the principal articles have been fur- nished by practitioners who have not only devoted especial attention to the diseases about which they have written, but have also enjoyed opportunities for an extensive practical acquaintance with them, and whose reputation carries the assurance of their competency justly to appreciate the opinions of others, while it stamps their own doctrines with high and just authority. — American Medical Journ. DEWEES'S COMPREHENSIVE SYSTEM OF l MIDWIFERY. Illustrated by occasional cases and many engravings. Twelfth edition, with the author's last improvements and corrections In one octavo volume, extra cloth, of GOO pages. $3 20. DEWEES'S TREATISE ON THE PHYSICAL AND MEDICAL TREATMENT OF CHILD- REN. Tenth edition. In one volume, octavo, extra cloth, 54S pages. $2 80. DEWEES'S TREATISE ON THE DISEASES OF FEMALES. Tenth edition. In one volume, octavo, extra efoth, 532 pages, with plates. $3 00. DANA ON ZOOPHYTES AND CORALS. In one volume, imperial quarto, extra cloth, with \\ . cuts. $15 00. Also, AN ATLAS, in one volume. imperial folio, with sixty-one magnificent colored plates. Bound in half morocco. $30 HO. DE LA BECHE'S GEOLOGICAL OBSERVER. In one very large and handsome octavo volume, ex- tra cloth, of 700 pages, with 300 wood-cats. S4 00. FRICK ON RENAL AFFECTIONS; theirDiag- nosis and Pathology. 'With illustrations. One volume, royal 12mo., extra cloth. 75 cents. 12 BLANCHARU «te LEA'S MEDICAL DUNGLISON (ROBLEY), M.D., Professor of Institute! of Medicine in the Jefferson Medical College, Philadelphia. NEW AND ENLARGED EDITION, Now Ready. MEPTCAL LEXICON; a Dictionary of Medical Science, containing a concise Uion of the various SubjectB and Terms of Anatomy, Physiology, Pathology, Ilvgiene, (utics Pharmacology, Pharmacy, Surgery, Obstetrics, Medical jurisprudence, 1 tehtistry, lot ices of Climate mid of .Mineral Waters; Formula 1 for Officinal, Empirical, and Dietetic Preparations, &c. With French and other Synonymes. Fifteenth edition, revised and very ,_.,,. rged. In one very large and handsome octavovolume ; of 992 double-columned pages, m small :\ pe ; strongly bound in leather, with raised bands. Price $4 00. No care, labor, "r expense has been spared in the preparation of this edition to render it in every r»t worthy a continuance of the very remarkable favor which u has hitherto enjoyed. The ale of I'll' 1 1 en large editions, and the constantly increasing demand, show thai it t~ regarded by tli ( ' profession as the standard authority. Stimulated by this lacf, the author has endeavored in presenl revision to introduce whatever might be necessary to make it a satisfactory and desira- I,], — ifrol indispensabb — lexicon, in which the student may search without disappointment for every term thai has been legitimated in the nomenclature of the science". To accomplish this, e additions have been found requisite, and the extent of the author's labors may be estimated from the fact thai aboul Six Thousand subjects and terms have been introduced throughout, ren- dering the whole number of definitions about Sixty Thousand, to accommodate which, the num- ber ol pages has been increased by nearly a hundred, notwithstanding an enlargement in the size of the page. The medical press, both in this country and in England, has pronounced the work in- dispensable to all medical students and practitioners, and the piesent improved edition will not lose that enviable reputation. The publishers have endeavored to render the mechanical execution worthy of a volume of such universal use in daily reference. The greatest care has been exercised to obtain the typographical uracy so necessary in a work of the kind. By the small but exceedingly clear type employed, an immeuse amount ol matter is condensed in its thousand ample pages, while the binding will be found strong and durable. With all these improvements and enlargements, the price has been kept at the former very moderate rate, placing it within the reach of all. tells as ill his preface that- he has added about six thousand terms and subjects to this edition, which, before, was considered universally as the best work of the kind in any language. — Silliman's Journal, March, 1&5S. He has razed his gigantic structure to the founda- tions, and remodelled and reconstructed the entire pile. No less than six thousand additional subjects ami terms are illustrated and analyzed in this new edition, swelling the grand aggregate to heyond sixty thousand .' Thus is placed before the profes- sion a complete and thorough exponent el" medical terminology, without rival 01 possibility of rivalry. — Nashville Journ. of Med. and Surg.. Jan. 1858. It is universally acknowledged, we belb ve, that this work is incomparably the best and most com- plete Medical Lexicon in the English language. The amount of labor which the distinguished author has bestowed upon it is truly wonderful, and the learning and research displayed in its preparation are equally remarkable. Comment and commenda- tion are unnecessary, as no one at the present day thinks of purchasing any other Medical Dictionary than this. — St. Louis Med. and Surg. Journ., Jan. 1858. It is the foundation stone of a good medical libra- ry, and should always he included in the first list of books purchased by the medical student. — Am. Med. Month/!/, Jan, lfs.56. A very perfect work of the kind, undoubtedly the most perfect in the English language. — Med. and Surg. Reporter, Jan. J858. It is now emphatically the Medical Dictionary of the English language, and for it there is no substi- tute.— A'. H. Med. Journ., Jan. 1858. It is scarcely necessary to remark that any medi- cal library wanting a copy of Dunglison's Lexicon must be imperfect. — Cin. Lancet. Jan. I We have ever considered it the lies' authority pub- lished, and the present edition we may safely say has no equal in the world — Peninsular Med. Journal, Jan. 1858. The most complete authority on the subject to he found in any language. — Va. Med. Journal , Feb. '5t>. This work, the appearance of the fifteenth edition i f which, it has In e ear duty and pleasure to ami' ia nee. is perhaps the most stupendous monument of labor and erudition in medical literature. One would hardly suppose after constant use of the pre- ceding editions, where we have never failed to find a sufficiently full explanation of even medical term, that in this edition " about six thousand subjects and ti rms have been added," with a careful revision and corn ction of the entire work. It is only neces- sary to announce the advent of this edition to make it occupy the place of the preceding one on the table of every medical man. as it is without doubt the best and most comprehensive work of the kind which has ever appeared. — Bvjt'alo Med. Journ., Jan. 1S5S. The work is a monument of patient research, skilful judgment, and vast, physical labor, that will perpetuate the name of the author more effectually than any possible device of stone or metal. Dr. Dunglison deserves the thanks not only of the Ame- rican profession, but. of the whole medical world. — North Am. Medico- Chir. Review, Jan. lbSS. A Medical Dictionary better adapted for the wants of the profession than tiny other with which we are acquainted, and of a character which places it far above comparison and competition. — Am. Journ. Mnl. Sri' nets, Jan. J858. We need only say, that the addition of 6,000 new terms, with their accompanying definitions. ma) be said to constitute a new work, by itself. We have examined the Dictionary attentively, and are most py to pronounce it unrivalled of its kind. The erudition displayed, and the extraordinary industry which must have been demanded, in its preparation and perfection, redound to the lasting credit of its author, and have furnished us with a volume indis- , nsable at the present day. to all who would find themselves aw niveau with the Inulies t standards of medical in format] in. — Boston Medical and Surgical Journal. Dec. 31, 1857. Good lea ind encyclopedic works generally, are the most labor-saving contrivances which lite- rary men enjoy; and the labor which is required to produce them in the perfect, manner of this example is something appalling to contemplate. The author ; BY THE SAME AUTHOR. THE PRACTICE OF MEDICINE. A Treatise on Special Pathology and The- rapeutics. Third Edition. In two large octavo volumes, leather, of 1,500 pages. $6 25. AND SCIENTIFIC PUBLICATIONS. 13 DUNGLISON (ROBLEY), M.D., Professor of Institutes of Medicine in the Jefferson Medical College, Philadelphia. HUMAN PHYSIOLOGY. Eighth edition. Thoroughly revised and exten- sively modified and enlarged, with five hundred and thirty-two illustrations. In two Iar"-e and handsomely primed octavo volumes, leather, of about 1600 pages. {Just Issued, 1856.) - 7 00. In revising this work lor its eighth appearance, the author has spared no labor to render it worthy a continuance of the very preat favor which has been extended to it by the profession. The whole contents have been rearranged, and to a great extent remodelled ; the" investigations which of late years have been so numerous and so important, have been carefully examined and incorporated and the work in every respect has teen brought up to a level with the present state of the subject The object of the author has been to render it a concise but comprehensive treatise, containing the whole body of physiological science, to which the student and man of science can at all times refer with the certainty of" finding whatever they are in search of, fully presented in all its aspects ; and on no former edition has the author bestowed more labor to seciire this result. We believe that it can truly be said.no more com- The best work of the kind in the English lan- plete repertory of facls upon the subject treated, guage — Siltimnn's Jnvrnal. can anvwhere befound. The author has. moreover, TU „,„„ „, .... ., .. . that enviable tact at description and that facility ? f r P * X ,ci Z i? ?,? ""' '' P 7 feCt and ease of expression wliich render him peculiarly T"'l U «„?£ I • "1 the present hour acceptable to 'the casual, or the studious reader. $*?, *,. ^"n^\ u '"?," W'i •'T'" 1 ' 6 'if This faculty, so requisite in setting forth many filj 1 i? ' HI?* 1 Z J, 7 V ' < n '>'* '"' 'tadentwill eraver and less attractive subjects, lends additional s^nt 1856 tBtiw—Nashville Journ. of VLtd. '•harms to one always fascinating. — Boston Med. ' ' ° ' and Surg. Journal, Sept. 1856. That he has succeeded, most admirably succeeded in his purpose, is apparent from the appearai lne most complete and satisfactory system of an eighth edition. It is now the irreat encyclopedia Physiology in the English language.— Amer. Med. on the subject, and worthy of a place in every phy- Joumal. sician's library. — Western Lancet, Sept. 1S.3U. EY the same author. (Now Ready.) GENERAL THERAPEUTICS AND MATERIA MEDIC A; adapted for a Medical Text-book. With Indexes of Remedies and of Diseases and their Remedies. Sixth Edition-, revised and improved. With one hundred and ninety-three illustrations. In two lar°-e and handsomely printed octavo vols., leather, of about 1100 pages. $6 00. From the Author's Preface. " Another edition of this work being called for, the author has subjected it to a thorough and careful revision. It ha-; been gratifying to him that it has been found so extensively useful by thi bom il was e-pecially intended, as to require that a sixth edition should be issued in so sh irt 1 time afier the publication of a filth. Grateful for the favorable reception of the work by the profession, he has bestowed on the preparation of the present edition all those cares which were demanded by the former editions, and has spared no pains to render it a faithful epitome of General Therapeutics and Materia Medica. The copious Indexes of Remedies and of Diseases and their Remedies can- not fail, the author conceives, to add materially to the value of the work." This work is too widely and too favorably known to require more than the assurance that the author has revised it with his customary industry, introducing whatever has been found necessary to bring it on a level with the most advanced condition of the subject. The number of illustrations has been somewhat enlarged, and the mechanical execution of the volumes will be found to have undergone a decided improvement. by the same author. (A new Edition.) NEW REMEDIES, WITH FORMULA FOR THEIR PREPARATION AND ADMINISTRATION. Seventh edition, with extensive Additions. In one very large octavo volume, leather, of 770 pages. (Just Issued.) $3 75. Another edition of the " New Remedies" having been called for, the author has endeavored to add everything of moment ihat has appeared since the publication of the last edition. The chief remedial means which have obtained a place, for the first time, in this volume, either owing to their having been recently introduced into pharmacology, or to their having received novel applications — and which, consequently, belong to the category of " New Remedies" — are the fol- lowing : — Apiol,Caffein, Carbazotic acid, Cauterization and catheterism of the larynx and trachea. Cedron, Cerium. Chloride of bromine, Chloride of iron, Chloride of sodium. Cinchonicine, Cod-liver olein, Congelation, Eau de Pagliari, Galvanic cautery, Hydriodic ether, Hyposulphite of soda and silver, Inunction, Iodide of sodium, Nickel, Permanganate of potassa, Phosphate of lime. Pumpkin. Quinidia, Rennet, Saccharine carbonate of iron and manganese. Santonin, Tellurium, and Traumaticine. The articles treated of in the former editions will befound to have undergone considerable ex- pansion in this, in order that the author might be enabled to introduce, as far as practicable, the results of the subsequent experience of others, as well as of his own observation and reflection; and to make the work still more deserving of the extended circulation with which the preceding editions have been favored by the profession. By an enlargement of the page, the numerous addi- tions have been incorporated without greatly increasing the bulk of the volume. — Pre/ One of the most useful of the author's works. — I The great learning ol the author, and his remark- Sovtkurn Medical and Surgical Journal, able industry in pushing his researches into every This elaborate and useful volume should be source whence information is derivable,have enabled found in every medical library, for as a book of re- '""> to throw together an extensive mass of tacts ference, for physicians, it is unsurpassed by any Bnd , statements, accompanied by lull reference to other Work in existence, and the double index for authorities; which last feature renders the work diseases and for remedies, will be found greatly to practically valuable to investigators who desire to enhance its value— Mu> York Med. Gazette. examine the original papers— The Am, r, can Journal of Pharmacy. M BLANCHARD & LEA'S MEDICAL ERICHSEN (JOHN), Professor of Surgery in University College, London, &.C. THE SCIENCE AND ART OF SURGERY; being a Treattse on Suraical Inukiks, DlSBASKB, and Operations. Edited by John H. BBITfTON, M. D. Illustrated with three hundred and eleven engravings on wood. In one large and handsome octavo volume, of over Dine hundred closely printed pages, leather, raised hands. $4 25. li is. in oar h u 111 1 > I •* judgment, decidedly the best book of the kind in ihe Rnglish language. Strange that jnai such books arc notoflener produced by puii lie tender- of surgery in this country and Great Britain indeed, it i- a matlerof great astonishment, hot no less true than astonishing, that of the many work- on surgery republished in this country within the la-i fifteen or twenty years n* text- booh; s for mediriil students, Ihis i- the 01 ly one that even ap- prnzimate8 10 the fulfilment of the peculiar want? of young men just entering upon the study of thi« branch of i he pn d'es- ion. — Western Jour. of Med. anl Surgery. It* value is greatly enhanced by a very copious well- arranged index. We regard this as one of the most valuable contributions to modem surgery. To one entering his novitiate of practice, we regard it ih'- mo*' serviceable guide which he can consult. He will find a fulness of detail leading him th rough every step of the operation, and not deserting him until the final issue of the ea-e is decided For the same rea- son we recommend it to those whose routine of prac- tice lies in such parts of the country that they must rarely encounter cases requiring surgical manage- in e n t . — Stethoscope. Embracing, as will he perceived, the whole surgi- cal domain, and each division of itself almost com- plete and perfect, each chapter full and explicit, each subject faithfully exhibited, we can only express our estimate of it in the aggregate. We consider it an excellent contribution to surgery, as probably the lie-' sintrle volume now extant on the subject, and with great pleasure we add it to our text-hooks — Nashville Journal of Medicine and Surgery. Prof. Enchsen's work, for its size, has not been surpassed; his nine hundred and eight pages, pro- fu-ely illustrated, are rich in physiological, patholo- gical, and operative suggestions, doctrines, details, and processes; and will prove a reliable resource for information, both to physician and sursreon, in the hour of peril. — A r . 0. Med. and Surg. Journal. We are acquainted with no other work wherein so much good sense, sound principle, and practical inferences, stamp every page. — American Lancet. ELLIS (BENJAMIN), M.D. THE MEDICAL FORMULARY : being a Collection of Prescriptions, derived from the writings and practice of many of the most eminent physicians of America and Europe. Together with the usual Dietetic Preparations and Antidotes for Poisons. To which is added an Appendix, on the Endermic use of Medicines, and on the use of Ether and Chloroform. The whole accompanied with a lew brief Pharmaceutic and Medical Observations. Tenth edition, revised and much extended by Robert P. Thomas, M. D., Professor of Materia Medica in the Philadelphia College of Pharmacy. In one neat octavo volume, extra cloth, of pages. $1 50. HUGHES' CLINICAL INTRODUCTION TO THE PRACTICE OF AUSCULTATION AND OTHER MODES OF PHYSICAL DIAGNOSIS, IN DISEASES OF THE LUNGS AND HEART. Second American, from the second London edition. 1 vol. royal l'iino., ex. cloth, pp. 304. $1 00. HUNTER'S COMPLETE WORKS, in 1 vols. 8vo., leather, with plates. S10. AND SCIENTIFIC PUBLICATIONS. 17 HOBLYN (RICHARD D.), M . D. A DICTIONARY OF THE TERMS USED IN MEDICINE AND • THE COLLATERAL SCIENCES. By Richard D. Hoblyn, A. M, &rc. A new American edi- tion. Revised, with numerous Additions, by Isaac Hays, M. D., editor of the "American Journal of the Medical Sciences." In one large royal 12mo. volume, leather, of over 000 double columned pages. {Just Issued, 1856.) $1 50. If the frequency with which we have referred to nor desire to procure a larger work.- American this volume since its reception from the publisher, two or three weeks ago, be uny criterion for the nor desire Lancet. Hoblyn lias always been a favorite dictionary, and future, the binding will soon have to be renewed, even i in its present enlarged and improved form will give with careful handling. We find that Dr. Hays lias done the profession great service by his careful and industrious labors. The Dictionary has thus become eminently suited to our medical brethren in this country. The additions by Dr. Hays are in brackets, and we believe there is not a single page but bears these insignia; in every instance which we have thus far noticed, the additions are really needed and ex- ceedingly valuable. We heartily commend the work to all who wish to be au courant in medical termi- nology. — Boston, Med. and Surg. Journal. To both practitioner and student, we recommend this dictionary as being convenient in size, accurate in definition, and sufficiently full and complete for ordinary consultation. — Charleston Med. Journ. and Review. Admirably calculated to meet the wants of the practitioner or student, who has neither the means greater satisfaction than ever. The American editor, Dr. Hays, has made many very valuable additions. — N.J. Med. Rejiorter. To supply the want of the medical reader arising from this cause, we know of no dictionary better arranged and adapted than the one bearing the above title. It is not encumbered with the obsolete terms of a bygone age, but it contains all that are now in use; embracing every department of medical science down to the very latest date. The volume is of a convenient size to be used by the medical student, and yet large enough to make a respectable appear- ance in the library of a physician. — Western Lancet. Hoblyn's Dictionary has long been a favorite with us. It is the best book of definitions we have, and ought always to be upon the student's table. — Southern Med. and Surg. Journal. HOLLAND (SIR HENRY), BART., M.D..F. R.S., Physician in Ordinary to the Queen of England, &c. MEDICAL NOTES AND REFLECTIONS. From the third London edition. In one handsome octavo volume, extra cloth. (Now Ready.) $3 00. As the work of a thoughtful and observant physician, embodying the results of forty years' ac- tive professional experience, on topics of the highest interest, this volume is commended to the American practitioner as well worthy his attention. Few will rise from its perusal without feel- ing their convictions strengthened, and armed with new weapons for the daily struggle with disease. HABERSHON (S. O.), M . D., Assistant Physician to and Lecturer on Materia Medica and Therapeutics at Guy's Hospital, &c. PATHOLOGICAL AND PRACTICAL OBSERVATIONS ON DISK \SES OF THE ALIMENTARY CANAL, OESOPHAGUS, STOMACH, CiECUM, AND INTES- TINES. With illustrations on wood. In one handsome octavo volume. (KepuOlu/Mig vn tM Medical News and Library for 1858.) HORNER (WILLIAM E.), M . D., Professor of Anatomy in the University of Pennsylvania. SPECIAL ANATOMY AND HISTOLOGY. Eighth edition. Extensively revised and modified. In two large octavo volumes, extra cloth, of more than one thousand pages, handsomely printed, with over three hundred illustrations. m oo. HAMILTON (FRANK H.), M. D., Professor of Surgery, in Buffalo Medical College, Hospital, fee. In one large, handsome royal 12mo. volume, extra cloth, of 500 pages. $1 o0. We are confident that the reader will find, on perusal, that the execution of the work amply fulfils the promise of the preface, and sustains, in every point, the already high reputation of the author as an ophthalmic surgeon as well as a physiologist and pathologist. The book is evidently the result of much labor and research, and has been writti D with the greatest care and attention; it possesses that best, quality which a general work, like a sys- tem or manual can show, viz : the quality of having all the materials whencesoever derived, so thorough- ly wrought up. and digested in the author's mind, as to come forth with the freshness ami impressive- ,1 production, w e entertain little doubf thai tins book will become what its author ) oped it might become, a manual for daily reference and consultation by the student and the general prac- titioner. The workis marked by that correctness, clearness, ai ■ " style which distinguish all the productions of the learned author.— British and For. Med. Review. !» HLANCHAKD & LEA'S MEDICAL JONES (C. HAND FIELD), F. R. S., &. EDWARD H. SI EV EKING, M.D., Assistant Physicians and Lecturers in St. Mary's Hospital, London. A MANUAL OF PATHOLOGICAL ANATOMY. First American Edition, Kevi-cd. With throe hundred ami ninety-seven handsome wood engravings. In one large and beautiful octavo volume of nearly 750 pages, leather. S3 75. present condition of pathological anatomy. In this As a concise text-book-. Containing, in a condensed form, a complete outline of what is known in the domain of Pathological Anatomy, it is perhaps the beat work in the English, language. Its great merit consists in iik completeness and brevity, and in this respect it supplies a great desideratum in our lite- rature. Heretofore the student of pathology was obliged toglean from a great number of monographs. and the field was so extensive that but few cultivated n with any degree of success. As a simple work of reference, therefore, it is of great value to the student of pathological anatomy, and should be in every physician's library.— Western Lancet. In offering the above titled work to the public, the authors have not attempted to intrude new views on their professional brethren, but simply to lay before them, what has long been wanted, an outline of the they have been completely successful. The work is one of the best compilations which we have ever perused. — Charleston Medical Journal and Review. We urge upon our readers and the profession gene- rally the importance of informing themselves in re- gard to modern views of pathology, and recommend to them to procure the work before us as the best means of obtaining this information. — Stethoscope. From the casual examination we have given we are inclined to regard it as a text-book, plain, ra- tional, and intelligible, such a book as the practical man needs for daily reference. For this reason it will be likely to be largely useful, as it suits itself to those busy men who have little time for minute investigation, and prefer a summary to an elaborate tieatise. — Buffalo Medical Journal. KIRKES (WILLIAM SENHOUSE), M. D., Demonstrator of Morbid Anatomy at St. Bartholomew's Hospital, &c. A MANUAL OF PHYSIOLOGY. A now American, from the third and improved London edition. With two hundred illustrations. In one large and handsome royal 12mo. volume, leather, pp. 580. $2 00. (Now Ready, 1857.) In again passing this work through his hands, the author has endeavored to render it a correct exposition of the present condition of the science, making such alterations and additions as have been dictated by further experience, or as the progress of investigation has rendered desirable. In every point of mechanical execution the publishers have sought to make it superior to former edi- tions, and at the very low price at which it is offered, it will be found one of the handsomest and cheapest volumes before the profession. In making these improvements, care has been exercised not unduly to increase its size, thus maintaining its distinctive characteristic of presenting within a moderate compass a clear and con- nected view of its subjects, sufficient for the wants of the student. This is a new and very much improved edition of j One of the very best handbooks of Physiology we Dr. Kirkes' well-known Handbook of Physiology. Originally constructed on the basis of the admirable treatise of Miller, it has in successive editions de- veloped itself into an almost original work, though no change has been made in the plan or arrangement. It combines conciseness with completeness, and is, therefore, admirably adapted for consultation by the busv practitioner. — Dublin Quarterly Journal .Feb. 1857. Its excellence is in its compactness, its clearness, and its carefully cited authorities. It is the most convenient of text-books. These gentlemen, Messrs Kirkes and Paget, have really an immense talent for silence, which is not so common or so cheap as prat- ing people fancy. They have the gift of telling us what we want to know, without thinking it neces- sary to tell us all they know.— Boston Med and Surg. Journal, May 14, 1857. possess— presenting just such an outline of the sci- ence, comprising an account of its leading facts and generally admitted principles, as the student requires during his attendance upon a course of lectures, or for reference whilst preparing for examination. — Am. Medical Journal. We need only say, that, without entering into dis- cussions of unsettled questions, it contains all the recent improvements in this department of medical science. For the student beginning this study, and the practitioner who has but leisure to refresh his memory, this book is invaluable, as it contains all that it is important to know, without special details, which are read with interest only by those who would make a specialty, or desire to possess a criti 1 cal knowledge of the subject. — Charleston Medical Journal. KNAPP'S TECHNOLOGY; or, Chemistry applied to the Arts and to Manufactures. Edited, with numerous Notes and Additions, by Dr. Edmund Ronalds and Dr. Thomas Richardson. First American edition, with Notes and Additions, by- Prof. Walter R. Johnson. In two handsome octavo volumes, extra cloth, with about 500 wood- engravings. $6 00. LALLEMAND ON SPERMATORRHOEA lated and edited by Henry J. McDocgal volume, octavo, extra cloth, 320 pages. American edition. SI 75. Trans- In one Second LUDLOW (J. L.S M. D. A MANUAL OF EXAMINATIONS upon Anatomy, Physiology, Surgery, Practice of Medicine, Obstetrics, Materia Medica, Chemistry, Pharmacy, and Therapeutics. To which is added a Medical Formulary. Designed for Students of Medicine throughout the United States. Third edition, thoroughly revised and greatly extended and enlarged. With three hundred and seventy illustrations. In one large and handsome royal 12mo. volume, leather, of over 800 closely printed pages (Now Ready.) S2 50. The t> , Magnetism, and Galvanism, one volume, large royal 12mo., of 450 pages, with 250 illustrations. 61 25. Third Course (now ready)., containing Meteorology and Astronomy, in one large volume, royal 12mo. of nearly 800 pages, with 37 plates and 200 wood-cuts. $2 00. LAYCOCK (THOMAS), M . D., F. R. S. E., Professor of Practical and Clinical Medicine in the University of Edinburgh, &c. LECTURES ON THE PRINCIPLES AND METHODS OF MEDICAL ORSFRVATION AND RESEARCH. For the Use of Advanced Students and Junior Jrac- SSiers 1 onTvery neat foyal 12mo. volume, extra cloth. Price SI 00. (Just Published, 1S57.) 20 BLANCH .\ i; I) & LEA'S MEDICAL LA ROCHE (R.), M. D., &c. 3TBLL0W FEVER, considered in its Historical, Pathological, Etiological, and Therapeutical Relations. Including a Sketch of the Disease as it has occurred in Philadelphia from 1699 to 1854, with an examination oi Hie connections between it and the lovers known under the same name in other parts of temperate as well as in tropical regions. In two large and handsome octavo volumes of nearly 1500 pages, extra cloth. $7 00. arduous research and careful study, and the result is such as will reflect the highest honor npon tlLft author and our country.— Southern Med. and Surg. From Professor S. II- Dirk son. Charleston, S. C, mbi r 18, 1855. A irtonpmenl of intelligent and well applied re- ■earch, almost without example. It is, indeed, in library, ami is destined to constitute the special resort as n book of reference, in the subject of which it treats, to all future tfme. We have not lime at present, engaged as we nre, by da* and by night, in the work of combating this very disease, now prevailing in our city, to do mure than five this cursory notice of what we consider us undoubtedly the must able and erudite medical publication our country has yet produced But in \ i. v.- ol the startling fact, that this, the most malig- nant and unmanageable disease of modern times, has for several rears been prevailing in our country toa greater extent than ever before; that it is no longer confined to either large or small cities, but penetrates country villages) plantations, and farm- houses; that it is treated witli scarcely better suc- cess now than thirty or forty years agoi that there is vast mischief done by ignorant pretenders to know- ledge in regard to the disease, and in view of the pro- bability that a majority of southern physicians will be called upon to treat the disease, we trust that this able and comprehensive treatise will be very gene- rally read in the south. — Memphis Med. Recorder. This is decidedly the great American medical work Of the day — a full, complete, and systematic treatise, unequalled by any other upon the all-important sub- jectof Yellow Fever. The laborious, indefatigable, and learned author has devoted to it many years of Journal. The genius and scholarship of thisgreat physician could not have been better employed than' in the erect i, mi of tins towering monument to his own fame, and to the glory of the medical literature of his own country. It is destined to remain the great autho- rity upon the subject of Yellow Fever. The stud, at and physician will find in these volumes a risumt of the sum total Of the knowledge of the world upon the a win I scourge which they so elaborately discuss. The style is so soft and so pure as to refresh and in- vigorate the mind while absorbing the thoughts of the gifted author, while the publishers have suc- ceeded in bringing the externals into a most felicitous harmony with the inspiration that dwells within. Take it all in all, it is a book we have often dreamed Of, but dreamed not that it would ever meet our waking eye as a tangible reality. — Nashville Journal of Medicine. We deem it fortunate that the splendid work of Dr. La Roche should have been issued from the press at this particular time. The want Of a reliable di- gest of all that is known in relation in this frightful malady has long been felt — a Want very satisfactorily met in the work before us. We deem it but faint praise to say that Dr. La R many years as a teacher of his favorite branch, has given him a familiarity with the wants of stu- dents and a facility of conveying instruction, which cannot fail to render the volume eminently adapted to its purposes. We congratulate the author that the task is done. We congratulate him that he has given to the medi- cal public a work which will secure for him a high and permanent position among the standard autho- rities on the principles and practice of obstetrics. Congratulations are not less due to the medical pro- fession of this country, on the acquisition of a trea- tise embodying the results of the studies, reflections, and experience of Prof. .Miller. Few men, if any. in this country, are more competent than he to write on this department of medicine. Engaged for thirty- five years in an extended practice of obstetrics, for many years a teacher of this branch of instruction in one of the largest of our institutions, a diligent student as well asa careful observer, an original and independent thinker, wedded to no hobbies, ever ready to Consider without prejudice new views, and to adopt innovations if they are really improvements, and withal a clear, agreeable writer, a practical treatise from his pen could not fail to possess great value. Returning to Prof. Miller's work we have only to add that we hope most sincerely it will be in the hands of every reading and thinking practitioner of this country.— Buffalo Med Journal, Mar. J853. In fact, this volume must take its place among the standard systematic treatises on obstetrics; a posi- tion to which its merits justly entitle it. The style is such that the descriptions are clear, and each sub- ject is discussed and elucidated with due regard to Us practical bearings, which cannot fail to make it acceptable and valuable to both students and prac- titioners. We cannot, however, close this brief notice without congratulating the author and the profession on the production of such an excellent treatise. The author is a western man of whom we feel proud, and we cannot but, think that his book will find many readers and -warm admirers wherever obstetrics is taught and studied as a science and an art. — The Cincinnati Lancetand Observer, Feb. 1858. A most respeclahle and valuable addition to our home medical literature, and one reflecting credit alike on the author and the institution to which he is attached. The student will find in this work a most useful guide to his studies; the country prac- titioner, rusty in his reading, can obtain from its pages a fair resume of the modern literature of the science; and we hope to see this American produc- tion generally consulted by the profession. — Va. Med. Journal, Feb. 1858. AND SCIENTIFIC PUBLICATIONS. 21 MEIGS (CHARLES D.), M. D., Professor of Obstetrics, &c. in the Jefferson Medical College, Philadelphia. OBSTETRICS : THE SCIENCE AND THE -ART. Third edition, revised and improved. With one hundred and twenty-nine illustrations. In one beautifully printed octavo volume, leather, of seven hundred and fifty-two large pages. $3 75. The rapid demand for another edition of this work- is a sufficienl expression of the favorable verdict of the profession. In thus preparing it a third time for the press, the author has endeavored to render it in every respect worthy of the favor which it has received. To accomplish this he has thoroughly revised it in every part. Some portions have been rewritten, others added, new illustrations have been in many instances substituted for such as w.-rc oot deemed satisfactory, while, by an alteration in the typographical arrangement, the size of the work has qoI been increased, and the price remains unaltered. In itspresent improved form, it is, therefore, hoped that the work will continue to meet the wants of the American profession as a sound, practical, and extended System of Midwifery. Though the work has received only five pages of enlargement, its chapters throughout wear the im- pressof careful revision. Expunging and rewriting, remodelling its sentences, with occasional new ma- terial, all evince a lively desire that it shall deserve to be regarded as improved in manner as well as matter. In the matter, every stroke of the pen has increased the value of the book, both in expungings and additions — Western Lancet, Jan. 1S57. The best American work on Midwiferv that is accessible to the student and practitioner— iV. W. Mtd. an,/ Surg. Journal, Jan. 1-57. This is a standard work by a great American Ob- stetrician. It is the third and las' edition, and, in the lai guage of the preface, the author lias "brought the subject up to the latest dates of real improve- ment in our art au.l Science." — Nashville Journ. of Med. and Surg., May, lb57. BY THE SAME AUTHOR. (Lately Issued.) HER DISEASES AND THEIR REMEDIES. A Series of Lec- Class. Third and Improved edition. In one large and beautifully printed octavo WOMAN : tures to hi volume, leather. pp. 672. $3 60 The gratifying appreciation of his labors, as evinced by the exhaustion of two large impressions of this work within a few years, has not been lost upon the author, who has endeavored in every way to render it worthy of the favor with which it has been received. The opportunity thus afforded for a second revision has been improved, and the work is now presented as in every way superior to its predecessors, additions and alterations having been made whenever the advance of science has rendered them desirable. The typographical execution of the work will also be found to have undergone a similar improvement, and the work is now confidently presented as in every way worthy the position it has acquired as the standard American text-book on the Diseases of Females. It contains a vast amount of practical knowledge, by one who has accurately observed and retained the experience of many years, and who tells the re- sult in a free, familiar, and pleasant manner. — Dub- lin Quarterly Journal. There is an off-hand fervor, a glow, and a warm- heartedness infecting the eff>rt of Dr. Meigs, which is entirely captivating, and which absolutely hur- ries the reader through from beginning to end. Be- sides, the book teems with solid instruction, and it shows the very highest evidence of ability, viz., the clearness with which the information is pre- sented. We know of no better test of one's under- standing a subject than the evidence of the power of lucidly explaining it. The most elementary, as well as the obscurest subjects, under the pencil of Prof. Meigs, are isolated and made to stand out in | by the same author. (Lately Published.') ON THE NATURE, SIGNS, AND TREATMENT OF CHILDBED FEVER. In a Series of Letters addressed to the Students of his Class. In one handsome octavo volume, extra cloth, of 365 pages. §2 50. such bold relief, as to produce distinct impressions upon the mind and memory of the reader. — The Charleston Med. Journal. Professor Meigs has enlarged and amended this great work, for such it unquestionably is, having passed the ordeal of criticism at home and abroad, but been improved thereby ; for in this new edition the author has introduced real improvements, and increased the value and utility of the book im- measurably. It presents so many novel, bright, and sparkling thoughts; such an exuberance of new ideas on almost every page, that we confess our- selves to have become enamored with the book and its author ; and cannot withhold on r congratu- lations from our Philadelphia confreres, that such a teacher is in their service. — N. Y. Med. Gazette. The instructive and interesting author of this work, whose previous labors in the department of medicine which he so sedulously cultivates, have placed his countrymen under deep and abiding obli- gations, again challenges their admiration in the fresh and vigorous, attractive and racy pages before ns. It is a delectable book. # * # This treatise upon child-bed fevers will have an extensive sale, being destined, as it deserves, to find a place in the library of every practitioner who scorns to lag in the rear .—Nashville Journal of Medi:ine and Surgery. I This book will add more to his fame than either of those which bear his name. Indeed we doubt whether any material improvement will be made on the teachings of this volume for a century to come, since it is so eminently practical, and based on pro- found knowledge of the sri'nce and consummate skill in the art of healing, and ratified by an ample and extensive experience, such ns few men have the industry or good fortune to acquire. — N. Y. Med. Gazette. BY THE SAME AUTHOR: WITH COLORED PLATES. A TREATISE ON ACUTE AND CHRONIC DISEASES OF THE NECK OF THE UTERUS. With numerous plates, drawn and colored from nature in the highest style of art. In one handsome octavo volume, extra cloth. $4 50. MAYXB'S DISPENSATORY AXD THERA- MALGAIGNE'S OPERATIVE SURGERY, based PEUTICAL REMEMBRANCER. Comprising the entire lists of Materia Medica, with every Practical Formula contained in the three British Pharmacopoeias. Edited, with the addition of the Formulae of the U. S. Pharmacopoeia, by R. E. Griffith, M.D. 1 l2mo. vol. ex. cl., 300 pp. 75 c. on .Normal and Pathological Anatomy. Trans- lated from the French iiy FREDERICK BrittaN, A. B.,M. D.. With numerous illustrations on wood. In one handsome octavo volume, extra cloth, of nearly six hundred pages. $2 25. 23 BLANCHARU & LEA'S MEDICAL MACLISE (JOSEPH), SURGEON. SURGICAL ANATOMY. Forming one volume, very large imperial quarto. Willi M\iy-i'iirlii large and splendid Plates, drawn in the best style and beautifully colored. Con- taining one hundred and ninety Figures, many of them the size of life. Together with copious and explanatory letter-press. Strongly and handsomely hound in extra cloth, being one of the cheapesl and best executed Surgical works as yet issued in this country. $11 00. *„* The size of this work prevents ils transmission through the post-office as a whole, hut those who desire to havi forwarded by mail, can receive them in five parts, done up in stout wrappers. Price $9 00. One of the greatest artistic triumphs of the age i of keeping up hiB anatomical knowledge. — Medical in Burgical Anatomy. — Briti^li Anurieem Medical Times. The mechanical execution cannot be excelled. — Too much cannot be said in its'praise; indeed, We have not language to do it justice. — Ohio Medi- cal and Surgical Journal. The most admirable surgical atlas we have seen. To the practitioner deprived or demonstrative dis- sections iipcin the human subject, it is an invaluable companion. — N. J. Mtdical Reporter. The most accurately engraved and beautifully colored plates we have ever seen in an American hook — one of the best and cheapest surgical works ever published. — Buffalo Medical Journal. It is very rare that so elegantly printed, go well illustrated, and so useful a work, is offered at so moderate a price. — Charleston Medical Journal. Its plates can boast, a superiority which places them almost beyond the reach of competition. — Medi- cal Examiner. Every practitioner, we think, should have a work of this kind within reach. — Southern. Medical and Surgical Journal. No such lithographic illustrations of surgical re- gions have hitherto, we think, been given. — Boston Medical and Surgical Journal. As a surgical anatomist, Mr. Maclise has proba- bly no superior. — British and Foreign Medico-Chi- rurgical Review. Of great value to the student engaged in dissect- Transylvania Mtdical Journal. A work which has no parallel in point of accu- racy and cheapness in the English language. — JV. Y. Journal of Medicine. To all engaged in the Btudy or practice of their profession, bucIi a work is almost indispensable. — Dublin Quarterly Medical Journal. No practitioner whose means will admit should fail to possess it. — Ranking's Abstract. Country practitioners will find these plates of im- mense value. — N. Y. Medical Gazette. We are extremely gratified to announce to the profession the completion of this truly magnificent work, which, as a whole, certainly stands unri- valled, both for accuracy of drawing, beauty of coloring, and all the requisite explanations of the subject in hand. — The New Orleans Medical and Surgical Journal. This is by far the ablest work on Surgical Ana- tomy that has come under our observation. We know of no other work that would justify a stu- dent, in any degree, for neglect of actual dissec- tion. Jn those sudden emergencies that so often arise, and which require the instantaneous command of minute anatomical knowledge, a work of this kind keeps the details of the dissecting-room perpetually fresh in the memory. — The Western Journal of Medi- ing, and to the surgeon at a distance from the means I cine and Surgery BSsT" The very low price at which this work is furnished, and the beauty of its execution, require an extended sale to compensate the publishers for the heavy expenses incurred. MULLER'S PRINCIPLES OF^PHYSICS AND METEOROLOGY. Edited, with Additions, by R. Eglesfeld Griffith, M. D. In one large and handsome octavo volume, extra cloth, with 550 wood-cuts, and two colored plates, pp. 636. $3 50. MOHR (FRANCIS), PH. D., AND REDWOOD (TH EOPH I LUS). PRACTICAL PHARMACY. Comprising the Arrangements, Apparatus, and Manipulations of the Pharmaceutical Shop and Laboratory. Edited, with extensive Additions, by Prof. William Procter, of the Philadelphia College of Pharmacy. In one handsomely printed octavo volume, extra cloth, of 570 pages, with over 500 engravings ou wood. $2 75. MACKENZIE (W.), M . D., Surgeon Oculist in Scotland in ordinary to Her Majesty, &c.&c. A PRACTICAL TREATISE ON DISEASES AND INJURIES OF THE EVE. To which is prefixed an Anatomical Introduction explanatory of a Horizontal Section of the Human Eyeball, by Thomas Wharton Jones, F. R. S. From the Fourth Revised and En- larged London Edition. With Notes and Additions by Addinell Hewson, M. D., Surgeon to Wills Hospital, &c. &c. In one very large and handsome octavo volume, leather, raised bands, with plates and numerous wood-cuts. $5 25. The treatise of Dr. Mackenzie indisputably holds the first place, and forms, in respect of learning and research, an Encyclopaedia unequalled in extent by any other work of the kind, either English or foreign. — Dixon on Diseases of the Eye. Few modern books on any department of medicine or surgery have'met with such extended circulation, or have procured for their authors a like amount of European celebrity. The immense research which i it displayed, the thorough acquaintance with the I subject, practically as well as theoretically, and the ! able manner in which the author's stores of learning and experience Were rendered availablefor general use, at onrc procured for the first edition, as well on the continent as in this country, that "high position as a standard work which each successive edition has more firmly established, in spite of the attrac- tions of several rivals of no mean ability. We con- sider it the duty of every one who has the love of his profession and the welfare of his patient at heart, to make himself familiar with this the most complete work in the English language, upon the diseases of the eye. — Med. Times and Gazette. The fourth edition of this standard work will no doubt be as fully appreciated as the three former edi- tions. It is unnecessary to say aword in its praise, for the verdict has already been passed upon it by the most competent judges, and " Mackenzie on the Eye" has justly obtained a reputation which it is no figure of speech to call world-wide. — British and Foreign Medico-C hirurgical Review. This new edition of Dr. Mackenzie's celebrated treatise on diseases of the eye, is truly a miracle of industry and learning. We need scarcely say that he has entirely exhausted the subject of his specialty. — Dublin Quarterly Journal. AND SCIENTIFIC PUBLICATIONS. 23 MILLER (JAMES), F. R. S. E., Professor of Surgery in the University of Edinburgh, &c. PRINCIPLES OF SURGERY. Fourth American, from the third and revised Edinburgh edition. In one large and very beautiful volume, leather, of 700 pages, with two hundred and forty exquisite illustrations on wood. (Jtt.it Issued, 1856.) $3 75. The extended reputation enjoyed by this work will be fully maintained by the present edition. Thoroughly revised by the author, it will be found a clear and compendious exposition of surgical science in its most advanced condition. In connection with the recently issued third edition of the author's " Practice of Surgery," it forms a very complete system of Surgery in all its branches. The work of Mr. Miller is too well and too favor- ably known among us, as one of our best text-books, to render any further notice of it necessary than the announcement of a new edition, the fourth in our country, a proof of its extensive circulation among us. As a concise and reliable exposition of the sci- ence of modern surgery, it stands deservedly high — we know not its superior. — Boston Med. and Surg. Journal. It presents the most satisfactory exposition of the modern doctrines of the principles of surgery to be found in any volume in any language. — N. Y. journal of Medicine. The work takes rank with Watson's Practice of Physic; it certainly does not fall behind that great work in soundness of principle or depth of reason- ing and research. No physician who values his re- | BY the same author. (Now Ready.) THE PRACTICE OF SURGERY. Fourth American from the last Edin- burgh edition. Pievised by the American editor. Illustrated by three hundred and sixty-four engravings on wood. In one large octavo volume, leather, of nearly 700 pages. $3 75. No encomium of ours could add to the popularity [ his works, both on the principles and practice of of Miller's Surgery. Its reputation in this country | surgery have been assigned the highest rank. If we is unsurpassed by that of any other work, and, when were limited to but one work on surgery, that one taken in connection with the author's Principles of 1 should be Miller's, as we regard itas superior to all putation, or seeksthe interests of his clii-nts. can acquit himself before his God and the world without making himself familiar with the sound and philo- sophical views developed in the foregoing book. — New Orleans Med. and Surg. Journal. Without doubt the ablest exposition of the prin- ciples of that branch of the healing art in any lan- guage. This opinion, deliberately formed after a careful study of the first edition, we have had no cause to change on examining the second. This edition has undergone thorough revision by the au- thor; many expressions have been modified, and a mass of new matter introduced. The book is got up in the finest style, and is an evidence of the progress of typography in our country. — Charleston Medical Journal and Review. Surgery, constitutes a whole, without reference to which no conscientious surgeon would be willing to practice his art. The additions, by Dr. Sargent, have materially enhanced the value of the work. — Southern Medical and Surgical Journal. It is seldom that two volumes have ever made so profound an impression in so short a time as the " Principles" and the " Practice" of Surgery by Mr. Miller — or so richly merited the reputation they have acquired. The author is an eminently sensi- ble, practical, and well-informed man, who knows exactly what he is talking about and exactly how to talk it. — Kentucky Medical Recorder. By the almost unanimous voice of the profession, others. — St. Louis Med. and Surg. Journal. The author, distinguished alike as a practitioner and writer, has in tins and his " Principles," pre- sented to the profession one of the most complete and reliable, systems of Surgery extant. His style of writing is original, impressive, and engaging, ener- getic, concise, and lucid. Few have the faculty of condensing so much in small space, and at the same time so persistently holding the attention; indeed, he appears to make the very process of condensation a means of eliminating attractions. Whether as a text-book for students or a book of reference for practitioners, it cannot be too strongly recommend- ed. — Southern Journal of Med. and Phys. Sciences. MONTGOMERY (W. F.), M, D., M R. I. A., &.c. Professor of Midwifery in the King and Queen's College of Physicians in Ireland, &c. AN EXPOSITION OF THE SIGNS AND SYMPTOMS OF PREGNANCY. With some other Papers on Subjects connected with Midwifery. From the second and enlarged English edition. With two exquisite colored plates, and numerous wood-cuts. In one very handsome octavo volume, extra cloth, of nearly 600 pages. (Just Issued, 1857.) $3 75. The present edition of this classical volume is fairly entitled to be regarded as anew work, every sentence having been carefully rewritten, and the whole increased to more than double the original size. The title of the work scarcely does justice to the extent and importance of the topics brought under consideration, embracing, with the exception of the operative procedures of mid- wifery, almost everything connected with obstetries, either directly or incidentally ; and there are few physicians who'will not find in its pages much that will prove of great interest and value in their dailv practice. The special Essays on the Period of Human Gestation, the Si^ns of Delivery, and the Spontaneous Amputation and other Lesions oftheFuetus in Utero present topics of the highest interest fully treated and beautifully illustrated. In every point of mechanical execution the work will be found one of the handsomest yet issued from the American press. A book unusually rich in practical suggestions. — Am. Journal Med. Sciences, Jan. 1S57. These several subjects so interesting in them- selves, and so important, every one of them, to the most delicate and precious of social relations, con- trolling often the honor and domestic peace of a family, the legitimacy of offspring, or the life of its parent, are all treated with an elegance of diction, fulness of illustrations, acutenessand justice of rea- soning, unparalleled in obstetrics, and unsurpassed in medicine. The reader's interest can never flag, so fresh, and vigorous, and classical is our author's style; and one forgets, in the renewed charm of every page, that it, and every line, and every word has been weighed and reweighed through years of preparation; that this is of all others the book of Obstetric Law, on each of its several topics ; on all points connected with pregnancy, to be everywhere received as a manual of special jurisprudence, at once announcing fact, affording' argument, establish- ing precedent, and governing alike the juryman, ad- vocate, and judge. It is not merely in its legal re- lations that we lind this work so interesting. Hardly a page but that has its hints or facts important to the general practitioner ; and not a chapter without especial matter for the anatomist, physiologist, Or pathologist.— A'. A. Med.-Chir. Review, .March, 1857. BLANCHARD & LEA'S MEDICAL NEILL (JOHN), M. D., Surgeon to the Pennsylvania Hospital, &c; and FRANCIS GURNEY SMITH, M. D., Professor of Institutes of Medicine in the Pennsylvania Medical College. AN ANALYTICAL COMPENDIUM OF THE VARIOUS BRANCHES OF MEDICAL SCIENCE; for the Use and Examination of Students. A new edition, revised and improved. In one very large and handsomely printed royal 12mo. volume, of about one thousand pages, with 374 wood-cuts. Strongly bound in leather, with raised bands. $3 00. The very flattering reception which has been accorded to this work, and the high estimale placed upon it by the profession, as evinced by the constant and increasing demand which has rapidly ex- hausted two large editions, have stimulated the authors to render the volume in its present revision more worthy of the success which has attended it. It has accordingly been thoroughly examined, and such errors as had on former occasions escaped observation have been corrected, and whatever additio i- were necessary to maintain it on a level with the advance of science have been introduced. The e Ltended series of illustrations has been still further increased and much improved, while, by a slighl enlargement of the page, these various additions have been incorporated without increasing the bulk of the volume. The work- is, therefore, again presented as eminently worthy of the favor with which it has hitherto been received. As a book for daily reference by the student requiring a guide to his more elaborate text-books, as a manual for preceptors desiring to stimulate their students by frequent and accurate examinai i< r as a source from which the practitioners of older date may easily and cheaply acquire a knowledge of the changes and improvement in professional science, its reputation is permanently established. The best work of the kind with which we are I the students is heavy, and review necessary for an acquainted.— Med. Examiner. ' examination, a compend is not only valuable, but who examine their pupils. It will save the teacher Pavements and discoveries are exnlcitly though much labor by enabling him readily to recall all of i concisely, laid before the student. There is a class the points upon wh.ci, his pupils' should be ex- towh ^?r^^ C TflS»S amined. A work of this sort should be in the hands as worth its weight in silver-that class is the gradu- of every one who takes pupils into his office with a *tes in medicine of more than ten years standing view Of examining them and this is unquestionably , who have not studied medicine since They will the best Of its dais-Transylvania Med. Journal. perhaps find out from it that the scenee ,snot exactly , now what it was when they left it oiT. — Ine btet/io- In the rapid course of lectures, where work for scope NEILL (JOHN), M. D., Professor of Surgery in the Pennsylvania Medical College, &c. OUTLINES OF THE VEINS AND LYMPHATICS. With handsome colored plates. 1 vol., cloth. SI 25. OUTLINES OF THE NERVES. With handsome plates. 1 vol., cloth. $1 25. NELIGAN (J. MOORE), M. D., M. R. I. A., &c. (A splendid ivork. Just Issued.) ATLAS OF CUTANEOUS DISEASES. In one beautiful quarto volume, extra cloth, with splendid colored plates, presenting nearly one hundred elaborate representations of disease. $4 50. This beautiful volume is intended as a complete and accurate representation of all the varieties of Diseases of the Skin. While it can be consulted iu conjunction with any work on Practice, it has especial reference to the author's " Treatise on Diseases of the Skin," so favorably received by the profession some years since. The publishers feel justified in saying that few more beautifully exe- cuted plates have ever been presented to the profession of this country. A compend which will very much aid the praeti- long existent desideratum much felt by the largest tioner in this difficult branch of diagnosis. Taken class of our profession. It presents, in quarto size, with the beautiful plates of the Atlas, which are 16 plates, each containing- from 3 to 6 figures, and remarkable for their accuracy and beauty of color- forming in all a total of 90 distinct representations ing. it constitutes a very valuable addition to the of the different species of skin affections, grouped library of a practical man.— Buffalo Med. Journal, together in genera or families. The illustrations Sept 1856 have been taken from nature, and have I een copied Nothing is often more difficult than the diagnosis withsuch fidelity that they present a striking picture of disease of the skin ; and hitherto, the only works « f " fe j » which the reduced scale up y s< yes to containing illustrations have been at rather incon- S've, at a coup dad, the remarkale peculiarities venient prices-prices, indeed, that prevented gene- " f <*? h individual variety. And while thus the dis- ral us.-.' The work before us will supply a want ™ se ls rendered more definable, there ,s jet no loss lomrfelt, and minister to a more perfect acquaintance £ proportion incurred by the necessar eoncentra- With the nature and treatment of a very frequent '"»;. Each figure ^highly colored and so truthful and troublesome form of disease.-0/.to Med and ha8 , the * nis \ been that the mos t fas l.d.u "observer <.-./r.r ; „-„„; r.,i,. iqsp. , could not justly take exception to the correctness of burg. Journal, Julj , 1856. the executinn ' o[ the pictures unuur bis scrutiny— Neligan's Atlas of Cutaneous Diseases supplies a Montreal Med. Chronicle. BY THE SAME AUTHOR. A PRACTICAL TREATISE ON DISEASES OF THE SKIN. Second American edition. In one neat royal 12mo. volume, extra cloth, of 334 pages. $1 00. ££^* The two volumes will be sent by mail on receipt of Five Dollars. OWEN ON THE DIFFERENT FORMS OF I One vol. royal 12mo., extra cloth, with numerous THE SKELETON, AND OF THE TEETH. | illustrations. (Just Issued.) SI 25. aJND scientific publications. (Now Comp/ete.) PEREIRA (JONATHAN), M. D., F. R. S., AND L. S. THE ELEMENTS OF MATERIA MEDICA AND THERAPEUTICS. Third American edition, enlarged and improved by the author; including Notices of most of the Medicinal Substances in use in the civilized world, and forming an Encyclopaedia of Materia Medica. Edited, with Additions, by Joseph Carson, M. D., Professor of Materia Medica and Pharmacy in the University of Pennsylvania. In two very large octavo volumes of 2100 pages, on small type, with about 500 illustrations on stone and wood, strongly bound in leather, with raised bands. $9 00. Gentlemen who have the first volume are recommended to complete their copies without delay. Price of Vol. II. $5 00. and to the directions of the United States Pharma- copoeia, in connect ion with all the articles contained in the volume which are referred toby it The il- lustrations have been increased, and this edition by Dr. Carson cannot well be regarded in any other light than that of a treasure which should be found in the library of every physician. — New York Journ- al of Medical and Collateral Science. The work, in its present shape, forms the most comprehensive and complete treatise on materia medica extant in the English language. The ac- counts of the physiological and therapeutic effects of remedies are given with great clearness and ac- curacy, and in a manner calculated to interest as well as instruct the reader. — Edinburgh Medical and Surgical Journal. The first volume will no longer be sold separate. The third edition of his " Elements of Materia Medica, although completed under the supervision of others, is by far the most elaborate treatise in the English language, and will, while medical literature is cherished, continue a monument alike honorable to his genius, as to his learning and industry. — American Journal of Pharmacy. Our own opinion of its merits is that of its editors, and also that of the whole profession, both of this and foreign countries— namely, " that in copious- ness of details, in extent, variety, and accuracy of information, and in lucid explanation of difficult and recondite subjects, it surpasses all other works on Materia Medica hitherto published." We can- not close this notice without alluding to the special additions of the A merican editor, which pertain to the prominent vegetable productions of this country, PEASLEE (E. R.), M . D., Professor of Physiology and General Pathology in the New York Medical College. HUMAN HISTOLOGY, in its relations to Anatomy, Physiology, and Pathology; for the use of Medical Students. With four hundred and thirty-four illustrations. In one hand- some octavo volume, of over 600 pages. (Now Ready.) $3 75. The rapid advances made of late years in our knowledge of the structure and functions of the elements which constitute the human body, have rendered the subject of Histology of fhe highest importance to all who regard medicine as a science. At the same time, the vast body of facta covered by Physiology has caused our text-books on that subject to be necessarily restricted in their treatment of the portions devoted to Histology. A want has, therefore, arisen of a w irk de- moted especially to the minute anatomy of the body, giving a complete and detailed account of the structure of the various tissues, as well as the solids and fluids, in all the different organs — their functions in health, and their changes in disease. In undertaking this task, the author has endea- vored to present his extensive subject in the manner most likely to interest and benefit Ibe physician, confident that in these details will be found the basis of true medical science. The very large number of illustrations introduced throughout, serves amply to elucidate the text, while the typo- graphy of the volume will in every respect be found of the handsomest description. It embraces a library upon the topics discussed | into a harmonious whole. We commend t le work- within itself, and is just what the teacher and learner need. Another advantage, by no means to be over- looked, everything of real value in the wide range which it embraces, is with great skill compressed into an octavo volume of but little more than six hundred pages. We have not only the whole sub- ject o( Histology, interesting in itself, ably and fully discussed, but what is of infinitely greater interest to the student, because of greater practical value, are its relations to Anatomy, Physiology, and Pa- thology, which are here fully and satisfactorily set forth. These great supporting branches of practical medicine are thus linked together, and while estab- lishing and illustrating each other, are interwoven to students and physicians generally. — Nashville Joum. of Med. and Surgery, Dec. 18 It far surpasses our expectation. We never con- ceived the possibility of compressing so much valu- able information into so compact a form. We will not consume space with commendations. We re- ceive this contribution to physiological science, " Not with vain thanks, but with acceptance boun- teous." We have already paid it the practical compliment of making abundant use of it in the preparation of our lectures, and also of recommend- ing its further perusal most cordially to our alumni; a recommendation which we now extend to our readers. — Memphis Med. Recorder, Jan. 1S53. PIRRIE (WILLIAM), F. R. S. E., Professor of Surgery in the University of Aberdeen. THE PRINCIPLES AND PRACTICE OP SURGERY. Edited by John Neill, M. D., Professor of Surgerv in the Penna. Medical College, Surgeon to the Pennsylvania Hospital, &c. In one very handsome octavo volume, leather, of 780 pages, with 316 illustrations. $3 75. We know of no other surgical work of a reason- able size, wherein there is so much theory and prac- tice, or where subjects are more soundly or clearly taught. — The Stethoscope. There is scarcely a disease of the bones or soft parts, fracture, or dislocation, that is not illustrated by accurate wood-engravings. Then, again, every instrument employed by the surgeon is thus repre- sented. These engravings are not only correct, but really beautiful, showing the astonishing degree of perfection to which the art of wood-engraving has arrived. Prof. Pirrie, in the work before us, haa elaborately discussed the principles of surgery, and a safe and effectual practice predicated upon them. Perhaps no work upon this subject heretofore issued is so full upon the science of the art of surgery. — Nashville Journal of Mtdicine and Surgery. One of the best treatises on surgery in the English language. — Canada Med. Journal. Our impression is, that, as a manual for students, Pirrie's is the best work extant. — Western Med. and Surg. Journal. PARKER (LANGSTON), Surgeon to the Queen's Hospital, Birmingham. THE MODERN TREATMENT OP SYPHILITIC DISEASES, BOTH PRI- MARY AND SECONDARY; comprising the Treatment of Constitutional and Confirmed Syphi- lis by a safe and successful method. With numerous Cases, Formulas, and Clinical Observa- tions: From the Third and entirely rewritten London edition, extra cloth, of 316 pages. $175. In one neat octavo volume, BLANCHAKI) & LEA'S MEDICAL PARRISH (EDWARD), Lactam in Practical Pharmacy and Materie Medics in the Pennsylvania Academy of Medicine, &c. AN INTRODUCTION TO PRACTICAL PHARMACY. Designed as a Text- Book lor tin' Student, and as a Guide for the Physician and Pharmaceutist. With many For- mulae and Prescriptions. In one handsome oclavo volume, extra cloth, of 550 pages, with 243 Illostrat . 7-">. A careful examination of this work enables us to Medica; it familiarizes liim with the compounding ..■I it in the highest terms, as being the best of drags, and supplies those minntiss whieh but few treatise on practical pharmacy with which we are practitioners cun impart. The junior practitioner acquainted, and an invaluable oaeU -mi rum, nol only will, also, find this volume replete with i nut ruction, to the apothecary snd >" 'hose practitioners Who arc — Charleston Med. Journal and H' cf.tr, Mar. 1^50. accustomed to prepare their own medicines, but to | There is no useful information in the details of the every medical man and medical student Through- oat the work are interspersed valuable tables, useful formula:, and practical hints, and the whole is ill US' : by a large number of excellent wood-engrav- ings.— !■ I. and Surg. Journal. apothecary's or country physician's office conducted according to science that is omitted. The young physician will find it an encyclopedia of indispensa- ble medical knowledge, from the purchase of a spa- tula to the compounding of the most learned pre- Thia is altogether one of the most useful books we script ions. The work is by the ablest pharmaceutist have seen. It is just what we have long felt to be in the United Slides, and' must meet with an im- needc.l by apothecaries, students, and practitioners , mense sale. — JS'ashville Journal of Medicine, April, of medicine, most of whom in this country have to 1S5G. put up their own prescriptions. Itbears, upon every page, the impress of practical knowledge, conveyed I tu a plain common sense manner, nnd adapted to the comprehension of all who may rend it. No detail has been omitted, however trivial it may seem, al- I though really important to thedispenser of medicine. — Southt rn Mtd. and Surg. Journal. To both the country practitioner and the city apo- j thecary this work of Mr. Parrish is a godsend. A careful study of its contents will give the young graduate a familiarity with the value and mode of We are glad to receive this excellent work. It will supply a want long felt by the profession, and especially by the student of Pharmacy. A large majority of physicians are obliged to compound their own medicines, and to them o work of this kind is indispensable. — N. O. Medical and Surgical Journal. AVe cannot say but that this volume is one of the most welcome and appropriate which has for a long time been issued from the press. It is a work which we doubt not will at once secure an extensive cir- administering his prescriptions, which will be of as : C nlation, as it is designed not only for the druggist much use to his patient as to himself. — Va. Med. Journal. Mr. Parrish has rendered a very acceptable service and pharmaceutist, but also for the great body of practitioners throughout the country, who not only have to prescribe medicines, but in the majority of to the practitioner and student, by furnishing this , instances have to rely upon their own resources — book, which contains the leading facts and principles of the science of Pharmacy, conveniently arranged for study, and with special reference to those features of the subject which possess nn especial practical in- terest to the physician. It furnishes the student, at the commencement of his studies, with that infor- mation which is of the greatest importance in ini- tiating him into the domain of Chemistry and Materia whatever these may be — not only to compound, but also to manufacture the remedies they are called upon to administer. The author has not mistaken the idea in writing this volume, as it is alike useful and invaluable to those engaged in the active pur- suits of the profession, and to those preparing to en- ter upon the field of professional labors. — American Lancet, March 24, 185G. RICORD ( A TREATISE ON THE VENEREAL Wilh copious Additions, by Ph. Ricord, M. D. M. D. Iu one handsome octavo volume, extra Every one will recognize the attractiveness and value which this work derives from ihus presenting the opinions of these two masters side by side. Bui, it must be admitted, what has made the fortune of the book, is the fact that it contains the "most com- plete embodiment of the veritable doctrines of the Hopital du Midi," which has ever been made public. The doctrinal ideas of M. Ricord, ideas which, if not universally adopted, are incontestably dominant, have heretofore only been interpreted by more or less skilful P.), M. D., DISE AS K. By John Hunter, F. R. S. Edited, with Notes, by Freeman J. Bumstead, cloth, of 520 pages, with plates. $3 25. I secretaries, sometimes accredited and* sometime? no'. In the notes to Hunter, the master substitutes him- selfforlns interpreters, and give 6 hisoriginal thought? to the world in a lucid and perfectly intelligible man- ner. In conclusion we can say that ibis is incon- testably the best treatise on syphilis with which we are acquainted, and. as we do nol often employ the phrase, we may be excused for expressin? the hope that it may find a place in the library of every phy- sician. — Virginia Med. and Surg. Journal. BY THE SAME AUTHOR. ILLUSTRATIONS OF SYPHILITIC DISEASE. Translated by Thomas F. Bettox, M. D. With fifty large quarto colored plates. In one large quarto volume, extra cloth. $15 00. LETTERS ON SYPHILIS, addressed to the Chiet Editor of the Union Medicale. Translated by W. P. Lattimore, M. D. In one neat, octavo vol- ume, of 270 pages, extra cloth. $2 00. RIGBY (EDWARD), M. D., Senior Physician to the General Lying-in Hospital, &c. A SYSTEM OF MIDWIFERY. With Notes and Additional Illustrations. Second American Edition. One volume octavo, extra cloth, 422 pages. $2 50. by the same author. (Now Ready, 1857.) ON TnE CONSTITUTIONAL TREATMENT OF FEMALE DISEASES. In one neat royal 12mo. volume, extra cloth, of about 250 pages. $1 00. The aim of the author has been throughout to present sound practical views of the important subjects under consideration ; and without entering into theoretical disputations and disquisitions to embody the results of his long and extended experience in such a condensed form as would be easily accessible to the practitioner. T» 11. 1 III',.. , ..~.. .... — J ~« ~.., «._. _•-■ - . . In one large octavo volume, extra cloth, of about 700 pages. $3 00 the States. (ration*. AND SCIENTIFIC PUBLICATIONS. 27 RAMSBOTHAM (FRANCIS H.), M.D. THE PRINCIPLES AND PRACTICE OF OBSTETRIC MEDICINE AND SURGERY, in reference to the Process of Parturition. A new and enlarged edition, thoroughly revised by the Author. W ith Additions by W. V. Keating, M. D. In one large and handsome imperial octavo volume, ol 050 pages, strongly bound in leather, with raised bands; with sixty- lour beautiful Plates, and numerous Wood-cuts in the text, containing in all nearly two hundred large and beautiful figures. (Lately Issued, 1856.) $5 00. In calling the attention of the profession to the new edition of this standard work, the publishers would remark that no efforts have been spared to secure for it a continuance and extension of the remarkable favor with which it has been received. The last London issue, which was considera- bly enlarged, has received a further revision from the author, especially for this country. It- pas- sage through the press here has been supervised by Dr. Keating, who has made numerous addi- tions with a view of presenting more fully whatever was necessary to adapt it thoroughly to American modes of practice. In its mechanical execution, n like superiority over former editions will be found. From Prof. Hodge, of the University of Pa. To the American public, it is most valuable, from its intrinsic undoubted excellence, and as beinu the best authorized exponent of British Midwifery. Its circulation will, I trust, be extensive throughout our country. ° cine and Surgery to our library, and confidently recommend it to our readers, with the assurance that it will not disappoint their most sanguine ex- pectations. — Western Lancet. our country The publishers have shown their appreciation of the merits of this work and secured its success by the truly elegant style in which they have brought it out, excelling themselves in its production, espe- cially in its plates. It is dedicated to Prof. Meigs, and has the emphatic endorsement of Prof. Hodge, as the best exponent of British Midwifery. We know of no text-hook which deserves in all respects to be more highly recommended to students, and we could wish to see it in the hands of every practitioner, for they will find it invaluable for reference. — Med. Gazette. But once in a long time some brilliant genius rears his head above the horizon of science, and illumi- nates and purifies every department that he investi- gates ; and his works become types, by which innu- merable imitators model their feeble productions. Such a genius we find in the younger Ramsbotham, and such a type we find in the work now before us. The binding, paper, type, the engravings and wood- i work are so well known and thoroughly established! cuts are all so excellent as to make this book one of that comment is unnecessary and praise superfluous. ■ The illustrations, which are numerous and accurate, are executed in the highest style of art. We cannot too highly recommend the work to our readers. St. Louis Med. and Surg. Journal. It is unnecessary to say anything in regard to the utility of this work. It is already appreciated in our country for the value of the matter, the clearness of its style, and the fulness of its illustrations. To the physician's library it is indispensable, while to the student as a text- book, from which to extract the material for laying the foundation of an education on obstetrical science, it has no superior. — Ohio Med. and Surg. Journal. We will only add that the student will learn from it all he need to know, and the practitioner will find it, as a book of reference, surpassed by none other. Stethoscope. The character and merits of Dr. Ramshotham'g the finest specimens of the art of printing that have given such a world-wide reputation to irs enter- prising and liberal publishers. We welcome Rams- botham's Principles and Practice of Obstetric Medi- ROKITANSKY (CARL), M.D., Curator of the Imperial Pathological Museum, and Professor at the University of Vienna, &c A MANUAL OF PATHOLOGICAL ANATOMY. Four volumes, octavo, bound in two, extra cloth, of about 1200 pages. Translated by W. E. Swaine, Edward Sieve- king, C. H. Moore, and G. E. Day. (Just Issued.) $5 50 To render this large and important work more easy of reference, and at the same time less cum- brous and costly, the four volumes have been arranged in two, retaining, however, the separale paging, &c. The publishers feel much pleasure in presenting to the profession of the United States the great work of Prof. Rokitansky, which is universally referred to as the standard of authority by the pa- thologists of all nations. Under the auspices of the Sydenham Society of London, the combined labor of four translators has at length overcome the almost insuperable difficulties which have - long prevented the appearance of the work in an English dress. To a work so widely known, eulogy is unnecessary, and the publishers would merely state that it is said to contain the results of not less than thirty thousand post-mortem examinations made by the author, diligently com- pared, generalized, and wrought into one complete and harmonious system. The profession is too well acquainted with the re- putation of Rokitansky's work to need our assur- ance that this is one of the most profound, thorough, and valuable books ever issued from the medical press. It is sui generis, and has no standard of com- parison. It is only necessary to announce that it is issued in a form as cheap as is compatible with its size and preservation, and its sale follows as a matter of course. No library can be called com- plete without it. — Buffalo Med. Journal. An attempt to give our readers any adequate idea of the vast amount of instruction accumulated in these volumes, would be feeble and hopeless. The effort of the distinguished author to concentrate in a small space his great fund of knowledge, has I Am. Med. Monthly. so charged his text with valuable truths, that any attempt of a reviewer to epitomize is at once para- lyzed, and must end in a failure. — Western Lancet. As this is the highest source of knowledge upon the important subject of which it treats, "no real student can afford to be without it. The American publishers have entitled themselves to the thanks of the profession of their country, for this timeoua and beautiful edition. — Nashville Journal oj' Mtdicint. As a book of reference, therefore, this work inns* prove of inestima hie value, and we cannot too highly recommend it to the profession. — Charleston Med. Journal and Review, Jan. 1856. This book is a necessity to every practitioner. — SCHOEDLER (FRIEDRICH), PH.D., Professor of the Natural Sciences at Worms, ; extra cloth, $2 00. And a capital little book it is. . ■ Minor Surgery, we repeat, is really Major Surgery, and anyl which teaches h is worth having. So we cordially recommend this little book of Dr. Smith's.— Aferf.- fair . /;. oil W. This beautiful little work has been railed with a view to the waata of the profession in the matter f ba be, and well and ably lias the author performed Bib labors. Well adapted to give the requisite information on the subjects of which it . — Medical Ezamiiu r. The directions arc plain, and illustrated through- nut with clear engravings. — London Lancet. One of the best works they can consult on the ■nbjeel <>l" which it treats. — Southern Journal of I works. Illus- ln one liund- A work such as the present is therefore highly useful to the stndent, and we commend tins one to their attention. — American Journal of M-dicul Seu nces. No operator, however eminent, need hesitate to consul! this unpretending yet exoellenl book. Those who are young in the business would Bad Dr. Smith's treatise s necessary companion, alter once under- standing its true character. — Boston Med. and Surg. Journal. \o young practitioner should be without this little. volume ; and we venture to assert, that it maybe a insulted by the senior members of the profession with more real benefit, than the more voluminous Western Lancd. int and Pharmacy. BY THE SAME AUTHOR, AND HORNER (WILLIAM E.), M.D. Late Professor of Anatomy in the University of Pennsylvania. AN ANATOMICAL ATLAS, illustrative of the Structure of the Human Body. In one volume, large imperial octavo, extra cloth, with about six hundred and fifty beautiful figures. $3 00. These figures are well selected, and present a late the student upon the completion of this Atlas, Complete and accurate representation of that won- as it is the most convenient work of the kind that derful fabric, the human body. The plan of this has yet appeared ; and we must add, the very beau- Atlas, which renders it so peculiarly convenient tiful manner in which it is " got up" is so creditable for the student, and its superb arlistieiil execution, to the country as to be flattering to our national have been already pointed out. We must congratu- | pride. — American Medical Journal. SARGENT (F. W.), M . D. ON BANDAGING AND OTHER OPERATIONS OF MINOR SURGERY. Second edition, enlarged. One handsome royal 12mo. vol., of nearly 400 pages, with 182 wood- cuts. Extra cloth, $1 40; leather, $1 50. This very useful little work has long been a favor- ite with practitioners and students. The recent call for a new edition has induced its author to make numerous important additions. A slight alteration in the size of the page has enabled liiiu to introduce the new matter, to the extent of some fifty pages of the former edition, at the same time that his volume is rendered still more compact than its less compre- hensive predecessor. A double gain in thus effected, which, in a vade-mecum of this kind, is a material improvement. — Am. Medical Journal. Sargent's Minor Surgery has always been popular, and deservedly so. It furnishes that knowledge of the most frequently requisite performances of surgical art which cannot he entirely understood by attend- ing clinical lectures. The art of bandaging, which is regularly taught in Europe, is very frequently overlooked by teachers in this country; the student and junior practitioner, therefore, may often require that knowledge which this little volume so tersely and happily supplies. It is neatly printed and copi- ously illustrated by the enterprising publishers, and should be possessed by till who desire Vo he thorough- ly conversant with the details of this branch of our art. — Charleston Med. Journ. and Hevieio, March, 1856. A work that has been so long and favorably known to the profession as Dr. Sargent's Minor Surgery, needs no commendation from us. We would remark, however, in this connection, that minor surgery sel- dom gets that attention in our schools that its im- portance deserves. Our larger works are also v< defective in their teaching on these small practical points. This little book will supply the void which all must feel who have not studied its pages. — West- em Lancet, March, 1856. We confess our indebtedness to this little volume on many occasions, and can warmly recommend it to our readers, as it is not above the consideration of the oldest and most experienced. — American Lan- SKEY'S OPERATIVE SURGERY. In one very handsome octavo volume, extra cloth, of over 050 pages, with about one hundred wood-cuts. $3 25. STANLEY'S TREATISE ON DISEASES OF THE HONES, 286 pages. $1 50. SOU. YON THE HUMAN BRAIN; its Structure, Physiology, and Diseases. From the Second and I none volume, octavo, extra cloth, much enlarged London edition. In one octavo volume, extra cloth, of 500 pages, with 120 wood- cuts. $2 00. SIMON'S GENERAL PATHOLOGY, as conduc- ive to the Establishment of Rational Principles for the prevention and Cure of Disease. In one neat octavo volume, extra cloth, of 212 pages. SI 25. STILLE (ALFRED), M. D. PRINCIPLES OF GENERAL AND SPECIAL THERAPEUTICS In handsome octavo. {Preparing.) SIBSON (FRANCIS), M.D., Physician to St. Mary's Hospital. MEDICAL ANATOMY. Illustrating the Form, Structure, and Position of the Internal Organs in Health and Disease. In large imperial quarto, with splendid colored plates. To match "Maclise's Surgical Anatomy." Part I. (Preparing.) AND SCIENTIFIC PUBLICATIONS. 29 SHARPEY (WILLIAM), M. D., JONES QUAIN, M. D., AND RICHARD QUAIN, F. R: S., &c. HUMAN ANATOMY. Revised, with Notes and Additions, by Joseph Leidy M. D., Professor of Anatomy in the University of Pennsylvania. Complete in two large octai o I~!^*'_. *_ —>° * .. In one large octavj volume, leather, of 6SS pages. S3 00 TANNER (T. H.) f M. D., Physician to the Hospital for Women, &c. A MANUAL OF CLINICAL MEDICINE AND PHYSICAL DIAGNOSIS. To which is added The Code of Ethics ol the American Medical Association. Second American Edition. In one neat volume, small 12mo. Price iu extra cloth, 87| cents ; flexible style, for the pocket, SO cents. The work is an honor to its writer, and must ob- tain a wide circulation by its intrinsic merit alone. Suited alike to the wants of students and practi- tioners, it has only to be seen, to win for itself a place upon the shelves of every medical library. Xor will it be " shelved" long at a time ; if we mis- take not, it will be found, in the best sense of the homely but expressive word, " handy." The style is admirably clear, while it is so sententious as not m harden the memory. Tlie arrangement is, to our mind, unexceptionable. The work, in short, de- serves the heartiest commendation.— Boston Med. and Surg. Journal. 30 BLANCH AKD & LEA'S MEDICAL Now Complete (April, 1857.) TODD (ROBERT BENTLEYi, M. D., F. R. S., Profeuoi ol Physiology in King's College, London; and WILLIAM BOWMAN, F. R. S., Demonstrator of Anatomy in King'i College, London. THK PHYSIOLOGICAL ANATOM? AND PHYSIOLOGY OF MAN. With about three hundred large and beautiful illustrations oa wood. Complete in one large octavo vol , of ''in pages, leather. Price 1 1 50. The very greal delay which has occurred in the completion of this work has arisen from the de- sire of the authors to verify by their own examination ihe various questions and statements pre- tented, thus rendering the work one of peculiar value and authority. By the wideness ol its Bcope and the accuracy of its facts it thus occupies a position of its own, and becomes necessary to all physiological students. fey Gentlemen who have received portions of this work, as published in the " Medical News ahd Library," can now complete their copies, it' immediate application be made. It will be fur- nished as follows, free by mail, in paper covers, with cloth backs. Paets [., n., III. (pp. 25 to 552), $2 50. PART IV. (pp. '>•'>'( to end. with Title, Preface, Contents, ire), S2 00. Or, PART IV.. SeCTIOH II. (pp. 725 to end, with Title, Preface, Contents, ecc), $1 25. A magnificent contribution to British medicine, i One of the very best books ever issued from any and the American physician who shall fail topeiuse medical press. We think it indispensable to every it, Will have failed to read one of the most instruc tive books of the nineteenth century. — If. O. Med and Surg. Journal, Sept. 1857. It is more concise than Carpenter's Principles, and more modern than the accessible edition of Mailer's Elements; Us details are brief, but sufficient; its descriptions vivid ; its illustrations exact and copi- ous ; and its language terse and perspicuous. — Charleston Med. Journal, July, 1857. We recommend this work not only for its many origiral investigations especially into the minute anatomy and physiology of man, but we ndmire the constant association of anatomy with physiology. The motive power is studied in its connections and adaptations to the machine it is destined to guide, and the student feels constantly impressed with the necessity for an accurate knowledge of the structure of the human body before he can make himself mas- ter of its functions. — Va. Med. Journal, June, 1857. We know of no work on the subject of physiology so well adapted to the wants of the medical student. Its completion has been thus long delayed, that the authors might secure accuracy by personal observa- tion. — St. Louis Med. and Surg. Journal, Sept. '57. reading medical man, and it may, with all propriety, and with the utmost advantage be macea text-book by any student who would thoroughly comprehend the groundwork of medicine. — N. O. Med. News, June, 1S57. Our notice, though it conveys but a very feeble and imperfect idea of the magnitude and importance of the work now under consideration, already tran- scends our limits ; and, with the indulgi nee of our readers, and the hope that they will peruse the book for themselves, as we feel we can with confidence recommend it, we leave it in their hands for them to judge Of its merits.— The Northwestern Med. and Surg. Journal, Oct. Is57. It has been a far more pleasant task to us to point out its features of remarkable excellence, and to show in how many particulars the results which it embodies of skilful and zealous research do the highest credit to its able and accomplished authors. It would be a serious omission were we not to take special notice of the admirable and copious illustra- tions, the execution of which (by Mr. Vasey) is in the very finest style of wood-engraving.— Brit, and For. Medico-Chir. Review, Jan. 1858. TODD (R. 8.), M. D., F. R. S., &c. CLINICAL LECTURES ON CERTAIN DISEASES OF THE URINARY ORGANS AND ON DROPSIES. In one octavo volume. (Now Ready, 1857.) $1 50 The valuable practical nature of Dr. Todd's writings have deservedly rendered them favorites with Ihe pro ession, and the present volume, embodying the medical aspects of a class of diseases not elsewhere to be found similarly treated, can hardly fail to supply a want long felt by the prac- titioner WATSON (THOMAS), M.D., &.C. LECTURES ON THE PRINCIPLES AND PRACTICE OF PHYSIC. Third American edition, revised, with Additions, by D. Francis Condie, M. D., author of a " Treatise on the Diseases of Children," &c. large pages, strongly bound with raised bands. To say that it is the very best work on the sub- ject now extant, is but to echo the sentiment of the medical press throughout the country. — N. O. Medical Journal. Of the text-books recently republished Watson is very justly the principal favorite. — Holmes's Hep. to Nat. Med. Assoc. By universal consent the work ranks among the very best text-books in our language. — Illinois and Indiana Med. Journal. Regarded on all hands as one of the very best, if not the very best, systematic treatise on practical medicine extant. — St. Louis Med. Journal. In one octavo volume, of nearly eleven hundred $3 25. Confessedly one of the very best works on the principles and practice of physic in the English or any other language. — Med. Examiner. Asa text-book it has no equal; as a compendium of pathology and practice no superior. — New York Annalist. We know of no work better calculated for being placed in the hands of the student, and for a text- book ; on every important point the author seems to have posted up his knowledge to the day. — Amer. Med. Journal. One of the most practically useful books that ever was presented to the student. — N. Y. Med. Journal. WHAT TO OBSERVE AT THE BEDSIDE AND AFTER DEATH, IN MEDICAL CASES. Published under the authority of the London Society for Medical Observation. A new American, from the second and revised London edition. In one very handsome volume, royal 12mo., extra cloth. SI 00. To the observer who prefers accuracy to blunders and precision to carelessness, this little book is in- raluable. — N. II. Journal of Medicine. One of the finest aids to a young practitioner we have ever seen. — Peninsular Journal of Medicine. AND SCIENTIFIC PUBLICATIONS 31 WILSON (ERASMUS), M.D., F. R. S., Lecturer on Anatomy, London. A SYSTEM OF HUMAN ANATOMY, General and Special. Fourth Ameri- can, from the last English edition. Edited by Paul B. Goddard, A. M., M. D. With two hun- dred and filly illustrations. Beautifully printed, in one large octavo volume, leather, of nearly six hundred pages. $3 00. In many, if not all the Colleges of the Union, it has become a standard text-book. This, of itself, is sufficiently expressive of its value. A work very It offers to the student all the assistance that can be expected from such a work. — Medical Examiner. The most complete and COnVl nienl manual for the desirable to the student; one, the possession of * i„ '" ' L '""l"" c "»" convenient imin,,;, i „,r the which will greatly facilitate his progress in the '^ We P osse8S — Amertcan Journal of Medical study of Practical Anatomy. — New York Journal of Medicine. In every respect, this work ns an anatomical guide for the studenl and practitioner, merits our Its author ranks with the highest on Anatomy.— warmest and most decided praise.— London Medical Southern Medical and Surgical Journal. I Gazette. BY THE SAME AUTHOR. (Just IsSUed.) THE DISSECTOR'S MANUAL; or, Practical and Surgical Anatomy. Third American, from the last revised and flilarged English edition. Modified and rearranged by William Hunt, M. U., Demonstrator of Anatomy in the University of Pennsylvania. In one large and handsome royal 12mo. volume, leather, of 582 pages, with 154 illustrations. $2 00. The modifications and additions which this work has received in passing recently through the author's hands, is sufficiently indicated by the fact that it is enlarged by more than one hundred pages, notwithstanding that it is printed m smaller type, and with a greatly enlarged page. It remains only to add, that after a careful exami- I ing very superior claims, well calculated to facilitate nation, we have no hesitation in recommending this | their studies, and render their labor less irksomi work to the notice of those for whom it has been I constantly keeping betore them definite objects of expressly written— the students— as a guide possess- | interest. — The Lancet. BY the same author. (Now Ready, May, 1S57.) ON DISEASES OF THE SKIN. Fourth and enlarged American, from the last and improved London edition. In one large octavo volume, of 650 pages, extra cloth, $2 75, This volume in passing for the fourth time through the hands of the author, has received a care- ful revision, and has been greatly enlarged and improved. About one hundred and fifty pages have been added, including new chapters on Classification, on General Pathology, on GeneraT Thera- peutics, on Furuncular Eruptions, and on Diseases of the Nails, besides extensive additions through- out the text, wherever they have seemed desirable, either from former omissions or from the pro- gress of science and the increased experience of the author. Appended to the volume will also now be found a collection of Selected Formula, consisting for the most part of prescriptions ol which the author has tested the value. a place in this volume, which, without a doubt, will, for a very long period, be acknowledged ns the chief standard work on dermatology. The principles of an enlightened and rational therapeia are introduced on every appropriate occasion. The general prac- titioner and surgeon who, peradventure, may have for years regarded cutanrous maladies as scarcely worthy their attention, because, forsooth, they are not fatal in their tendency; or who, if they have attempted their cure, have followed the blind guid- ance of empiricism, will almost assuredly be roused to a new and becoming interest in this department of practice, through the inspiring agency of this book. — Am. Jour. Med. Science, Oct. 1857. The writings of Wilson, upon diseases of the skin, are by far the most scientific and practical that have ever been presented to the medical world on this subject. The present edition isa great improve- ment on all its predecessors. To dwell upon all the great merits and high claims of the work before us. seriatim, would indeed be an agreeable service ; it would be a mental homage which we could freely offer, but we Ehould thus occupy an undue amount of space in this Journal. We will, howtver look at some of the more salient points with which it abounds, and which make it incompars bly superior in excellence to all other treatises on the subject of der- matology. No mere speculative views are allowed also, just ready, A SERIES OF PLATES ILLUSTRATING WILSON ON DISEASES OF THE SKIN ; consisting of nineteen beautifully executed plates, of which twelve are exquisitely colored, presenting the Normal Anatomy and Pathology of the Skin, and containing accurate it- presentations of about one hundred varieties of disease, most of them the size of nature. Price in cloth $4 25. In beauty of drawing and accuracy and finish of coloring these plates will be found superior u> anything of the kind as yet issued in this country. The plates by which this edition is accompanied The representations of the various forms of cutnne- leave nothing to be desired, so far as excellence of ous disease are singularly accurate, and the coloring delineation and perfect accuracy of illustration are exceeds almost anything we have met with in point concerned. — Medico-Chirurgical Review. of delicacy and finish. — British and Foreign Medical Of these plates it is impossible to speak too highly. ««**«**•. BY THE SAME AUTHOR. ON CONSTITUTIONAL AND HEREDITARY SYPHILIS, AND ON SYPHILITIC ERUPTIONS. In one small octavo volume, exlra cloth, beautifully printed, with four exquisite colored plates, presenting more than thirty varieties of syphilitic eruption-. $2 25. by the same author. (Just Issued.) HEALTHY SKIN; A Popular Treatise on the Skin and Hair, their Preserva- tion and Management. Second American, from the fourth London edition. One neat volume, royal 12rno. : extra cloth, of about 300 pages, with numerous illustrations. $1 00 ; paper cover, 75 cents. WILDE (W. R.), Surgeon to St. Mark's Ophthalmic and Aural Hospital, Dublin. AURAL SURGERY, AND THE NATURE AND TREATMENT OF DIS- EASES OF THE EAR. In one handsome octavo volume, extra cloth, of 476 pages, with illustrations. $2 80. 32 BLANCHARD i nearly five hundred pagea. 98 <>u. ligation by (his able, thorough, and finished work upon ii subject which almost daily taxes to the ut- mOBt the- skill of the general practitioner. He tins with siiiun 1-- r felicity threaded ins way through all the toTtoons labyrinths of the difficult subject he has undertaken to elucidate, and has in many of the darkest corners left a light, which will never be extinguished. — XnthvilU Medical Journal. We take leave of Dr. West with great respect for his attainments, a due appreciation .of ins acute powers of observation, and a deep sense of obliga- tion for this valuable contribution to our profes- sional literature. His book is undoubtedly i any respects th< besl we possess on diseases of children. Dublin Quartt rly Journal of Medical S< u net. Dr. West tins placed the profession under deep ob« BY THE SAME AUTHOR. (Just Issued.) LECTURES ON THE DISEASES OF WOMEN. In two parts. Part 1. Svo. cloth, of about 300 pages, comprising^!* Diseases of the Uterus. SI GO. Bart II. {Preparing)) will contain Diseases of the Ovaries, and of all the parts, connected ■with the Uteris; of the Bladder, Vagina, and External Organs. The objoct of the author in this work is to present a complete but succinct treatise on Female Diseases, embodying the results of his experience during the last ten years at St. Bartholomew's and the Midwilery Hospitals, a^ well as in private practice. The characteristics which have se- cured to his former works so favorable a reception, cannot fail to render the present volume a standard authority on its important subject. To show the general scope of the work, an outline of the Contents of Bart I. is subjoined. Lectures I , II. — Introductory — Symptoms — Examination of Symptoms — Modes of Examina- tions. Lectures III., IV., V — Disorders of Menstruation, Amenorrhea, Menorrhagia, Dys- menorrhea. Lectures VI., VII, VIII. — Inflammation of the Uterus, Hypertrophy, Acute Inflammation, Chronic Inflammation, Ulceration of the Os Uteri, Cervical Leucorrhcea. Lectures IX., X., XI, XIL, XIII. — Misplacement of the Uterus, Prolapsus, Anteversion, Retrover- sion, Inversion. Lectures XIV., XV., XVI., XVII. — Uterine Tumors and Outgrowths, Mucous, Fibro-cellular, and Glandular Polypi. Mucous Cysts, Fibrinous Polypi. Fibrous Tumors, Fibrous Polypi, Fatty Tumors, Tubercular Diseases. Lectures XV III., XIX., XX. — Cancer of the Uterus. Part II. will receive an equally extended treatment, rendering the whole an admirable text-book lor the student, and a reliable work for reference by the practitioner. by the same author. (Just Issued) AN ENQUIRY INTO THE PATHOLOGICAL IMPORTANCE OF ULCER- ATION OF THE OS UTERI. In one neat octavo volume, extra cloth. $1 00. WILLIAMS (C. J. B.), M. D., F. R. S., Professor of Clinical Medicine in University College, London, &c. PRINCIPLES OF MEDICINE. An Elementary View of the Causes, Nature, Treatment, Diagnosis, and Prognosis of Disease; with brief remarks on Hygienics, or the pre- servation of health. A new American, from the third and revised London edition. In one octavo volume, leather, of about 500 pages. $2 50. (Now Ready, May, 1857.) The very recent and thorough revision which this work has enjoyed at the hands of the author has brought it so completely up to the present state of the subject that in reproducing it no i dditions have been (bund necessary. The success which the work has heretofore met shows that its im- portance has been appreciated, and in its present form it will be found eminently worthy a continu- ance of the same favor, possessing as it does the strongest claims to the attention of the medical student and practitioner, from the admirable manner in which the various inquiries in the different branches of pathology are investigated, combined and generalized by an experienced practical phy- sician, and directly applied to the investigation and treatment of disease. recommend it for a text-book, guide, and constant We find that the deeply-interesting matter and style of this hook have so far fascinated us, that we have unconsciously hung upon its pages, not too long, indeed, for our own profit, hut longer than re- viewers can he permitted to indulge. We leave the further analysis to the student and practitioner. Our judgment of the work has already been sufficiently expressed. It is a judgment of almost unqualified praise. The work is not of a controversial, but of a didactic character; and as such we hail it, and companion to every practitioner and every student who wishes to extricate himself from the well-worn ruts of empiricism, and to base his practice of medi- cine upon principles. — London Lancet, Dec. 27, 1S56. A text-book to which no other in our language is comparable. — Charleston Medical Journal. No work has ever achieved or maintained a more deserved reputation. — Va. Med. and Surg. Journal. WHITEHEAD ON THE CAUSES AND TREAT- I Second American Edition. In one volume, octa- MENT OP ABORTION AND STERILITY. | vo, extra cloth, pp. 308. $1 75. YOUATT (WILLIAM), V. S. THE HORSE. A new edition, with numerous illustrations; together with a general history of the Horse; a Dissertation on the American Trotting Horse; how Trained and Jockeyed; an Account of his Remarkable Performances; and an Essay on the Ass and the Mule. By 3. H. Skinner, formerly Assistant Postmaster-General, and Editor of the Turf Register. One large octavo volume, extra cloth. $1 50. by the same author. THE DOG. Edited by E. J. Lewis, M. D. With numerous and beautiful illustrations In one very handsome volume, crown Svo., crimson cloth, gilt. $1 25. I ii '; i k ^ Tnulili