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.^^i- &0 






I%ysic3l Diagnosis and Diseases of the Lungs, Heart, and Aorta, 

Laryngology and Diseases of the Pharynx, Larynx, 

Nose, Thyroid Gland, and (Esophagus; 


hofeuor of Laryngology and DiKcates of the Chest , Rush Medical College ; ProfeMor of Diseauei of 

the Throat and Chest, Northwestern University Woman's Medical School ; Professor ot 

Laryngology and Rhinology, Chicago Polyclinic; Laryngologisi to the St. Joseph's 

Hospital and to the Presbyterian Hospital, etc.; Fellow of the American 

Laiyngological Association and American CI imalo logical Assodation ; 

Member of the American MiKlical Associatiui] , Illinois State 

Medical Society, Chicago Medical Society, Chicago 

Pathological Society, etc., etc. 

1ReY>i0e& Ii:bir& £Mtton 
With Appendix Containing Many Important AoDtrioNs 

Two Hundred and Forty Illustrations 




COPVKicHTKD, 1894, i8g8 

PBess o^ 
IME PUSlISHERS' printihq comamv 









ZbiB J9oott t0 BTTectlonatels S)edfcate& 



The rapid changes in medical science Iiave necessitated numerous 
additions to this work, which have been supplied in the Appendix, 
the alphabetical table of contents of which will enable the reader 
easily to locate the changes. 

The most importjmt additions will be found in the articles on 
Pneumonia, Pulmonary Tuberculosis, Actinomycosis of tlie Lungs 
and Mouth, Chronic Endocarditis, Diphtheria, Ludwig's Angina, and 
Goitre. E. F. I. 

September, 1B08. 


ri iHIS ia not meant for an encyclopedic work, but is intended, to pre- 
sent in convenient form the known facts relating to diseases of the 
respiratory tract and circulatory organs, and 1 have brought their con- 
sideration under one cover because the parts are so closely related that 
when one is diseased it is generally necessary to interrogate the others 
before a correct diagnosis or proper plan of treatment can be reached. 

I have not discussed questionable theories, and have not referred to 
methods of treatment which do not strongly comraend themselves to my 

The favor with which the preceding edition of this work has been 
received leads me to believe that I have succeeded in my efforts, not only 
to aid laryngologists in their daily work but also to place these subjects 
clearly before students and a large class of general practitioners who of 
necessity must bo prepared to meet any emergency. 

As it is but little over a year since the second edition was published 
no great alteration in tlie text has been necessary, but several minor 
changes have been made, and a few pages have been added to keep abreast 
of our advancing knowledge on these subjects. E. F, I, 

34-80 Washisotos St., Chicago. 


TN tlie first edition of this work, the consideration of the diseases of 
the respiratory and circulatory systems was restricted to such a 
presentation of the diagnosis and treatment as I had formerly made in 
my lectures to classes of students. With the purpose of completing the 
work and increasing the ralue of this edition to both students and prac- 
titioners, there have been added the subjects of Etiology, Pathology, 
Symptomatology, and Prognosis of the diseases to which these organs 
are liable. 

The chapters devoted to physical diagnosis have been but little 
changed. Those treating of diseases of the lungs and heart have been 
amplified and modified to correspond with the present advanced line of 
onr knowledge on these subjects, and those relating to diseases of the 
throat and nasal cavities have been entirely rewritten. I have endeav- 
ored to include all diseases of the chest, throat, and nnsal passjtges, as 
well as the more important affections of the ccsophagus and thyroid 
gland, and to give to each the consideration which its frequency and 
importance demand, I have carefully consulted the extensive litera- 
ture of these topics but hiive made no attempt to collate the viirious 
theories and methods suggested by different authors. I have limited 
the argument to that which personal knowledge of the diseases and of 
writers, commends to my own judgment; and I have generally confined 
my recommendations for treatment to those methods which have proved 
most efficacious in my own practice. The substance of the writings of 
BD individual soon becomes merged in general literature which makes it 
impossible for me to give personal credit as I would like, to all whose 
labors have enriched this field, but to all such I gladly acknowledge my 


indebtedneBS. I am indebted to Drs. Ephraim Ingals, Walter S. Haines, 
J, Edwin Rhodes, and Norman Bridge for aid in proof-reading, and to 
Dr. Arthur M. Corwin and James H. Blodgett for assistance in proof- 
reading and revision of copy, as well as to Dr. M. A. Olsen for the 


E. R L 
84r^ Washisoton St.. Chicaoo, 
Stptember, 1892. 


These lectures are designed to present a complete exposition of the 
subject of Physical Diagnosis so far as it relates to diseases of the Chest, 
Throat, and Nasal Passages; to give the essential symptoms of each 
disease; to point out the symptoms and signs which are of most value 
in a differential diagnosis; and to outline briefly the proper treatment 
for the various affections. The anatomical characteristics and the 
causes of these diseases have been pointed out wherever they are of 
special value in enabling the reader to understand the physical signs, 
or to properly apply remedial moasures. When these lectures were de- 
livered, notliing was said about treatment^ but in order to enhance the 
value of this work to both physician and student, I have appended to 
the consideration of the diiignosis of each disease an outline of the 
treatment which I have found most satisfactory. In so doing, I have 
not even mentioned many methods of treatment of more or less value 
which have been recommended by other physicians. 

In the preparation of these lectures I have availed myself of every 
source of information at my command, and I hope that little has been 
overlooked which would be of value to the student or practitioner. 
The study of this subject for several years, in connection with my lec- 
tures, and a large personal experience with these affections have enabled 
me to discriminate as to the relative importance of different signs and 
to detect numerous exceptions to the general rules. These exceptions, 
some of which are extremely rare, are of little importance to the general 
practitioner, and the study of them is a positive injury to the student 
unless their true significance is understood. Matter relating to them 
has, therefore, been set in small type, so that it may be omitted until 
the student has become thoroughly familiar with the facts that are 

The nature of these lectures, which contain information gathered 
from many different sources by study and by personal observation, and 


the fact that much of which they treat has long since become pablio 
property, renders it impossible for me in every instance to give the 
credit to individual authors which I desire, but I freely acknowledge 
my indebtedness to all who have preceded me in this field. I am in- 
debted to the courtesy of Doctors J. Solis Co}ien, of Philadelphia, and 
Lennox Browne and Morell Mackenzie, of London, for permission to 
use some of the cuts which illustrate their works. I take special 
pleasure in expressing my obligation to my clinical assistants. Doctors 
Philip Leach, W. H. Taylor, and J. T. Eggers, for valuable aid in the 
revision of my notes. 

Messrs. Sharp & Smith, of this city, have kindly famished electro- 
types for the illustrations of instruments. 

E. F. I. 



Preface vii 

List of illuBtrations, xziii 



Physical diagnosis 8 

DivisioDB of the chest 8 

Methods of ezaminatioii 9 


Palpation 14 

Mensuration, 16 

Succussion . . 20 


Physical diagnosis, continued, 21 

Percussion, 21 

In health, • 21 

In disease 38 

The Plessigrap)! 81 

Auscultatory percussion 32 


Physical diagnosis, continued, 84 

Auscultation, 84 

In health 80 

In disease, 41 


Physical diagnosis, continued, 48 

Adventitious sounds 48 

Vocal sounds, 54 


mmonary disease! 60 

Pleurisy 60 

Acute pleurisy 61 

Sabocnte pleurisy, 72 




Pulmonary diseases, continued 76 

Chronic pleurisy or empyema 70 

Peculiar local forms of pleurisy 83 

Hydrothorax 84 

Pneumothorax 84 

Pneumo-hydrotfaorax, 85 


Pulmonary diseases, continued 89 

Bronchitis, 89 

Acute and subacute bronchitis, 89 

Chronic bronchitis 90 

Capillary bronchitis 95 

Plastic bronchitis 99 

Dilatation of the bronchial tubes 100 

Asthma 102 

Pulmonary emphysema 107 


Pulmonary diseases, continued, 113 

Pneumonia, . 118 

Lobar pneumonia 118 

Lobular pneumonia 123 

Peculiar forms of pneumonia, 138 

Abscess of the lungs, 129 


Pulmonary diseases, continued 133 

Pulmonary hypertemia, 133 

Britwn induration 184 

Pulmonary hemorrhage 134 

Puliuonary apoplexy, 137 

PulinoDary thrombosis and embolism 138 

Pulmonary collapse. , . . 189 

Pulmonary cedema, 143 

Pulmonary gangrene, 144 

Pulmonary cancer 146 

Pulmonary tumoni 148 

Hydatid cyots of the lungs 148 

Distouia pulmonale 150 

Syphilitic diseases of the lungs, 151 

Enlarged bronchial glands 153 

Pertussis or whooping-cough 153 


Pulmonary diseases, continued, 156 

Pulmonary phthisis, 156 

Pulmonary tuberculosis, 156 

Acute miliary tuberculosis, 165 

Fibroid phthisis, 167 




The heart, 177 

Anatomy and physiology sf the heart, 177 

Fhysiolngical action of the heart 180 

Physical examination of the heart, . . 18S 

Cause of the heart sounds, 190 

Modification of the heart sounds by disease, 101 


Hie heart, continued 196 

Abnormal heart sounds, cardiac murmurs, 19S 

Anomalous heart sounds 305 

Subclavian murmurs, 206 

Venous signs. 306 

The spfaygmograph 306 


Cardiac diseases, 313 

Pericarditis 213 

Pneurao-hydropericardium, 318 

Hydropericardiimi, 318 

Endocarditis 219 

, Acute endocarditis, 219 

Ulcerative endocarditis 233 

Chronic endocarditis, valvular disease of tiie heart, . . . 33S 
Myocarditis 231 


Cardiac diseases, continued 384 

Simple cardiac hypertrophy 284 

Hypertrophy and dilatation of the heart 336 

Dilatation of the heart, 339 

Atrophy of the lieart, 342 

Fatty heart, 343 

Aneurism of the heart 245 

Rupture of the heart, 245 

Syphilitic disease of the heart, 345 

Tumors of the heart 346 

Morbus ceeruleus, 246 

Neurotic or functional disease of the heart, 347 

Tachycardia 249 

Bradycardia, 3.50 

Angina pectoris, 350 


Diseases of the thoracic arteries, 354 

Aortitis, 254 

Atheroma of the aorta 254 



Aortic or thoracic aneiirisni 396 

Anenrism of the ainuMa of VahalTa, S6T 

Aneazism oi the mrcfa of the aorta, SS7 

Anearism <rf the deacending aorta, 257 

Coarctation of the aorta, 368 

Solid nKdiastinal tumors, , . 367 



The throat, 871 

EzaminatioD of the fauces, 371 

l*ryngo«!cop>-. . . 273 

Obstacle) to larrogcecopf 389 

Infra'Klottic laryogoecopT'. 393 


The throat, continued S93 

The latTDxand rhinnt^ropr 393 

Examiuation of tlie trachea, 300 

RhinoHcopy, 30t 

Anf^rior rhinoncopr 301 

Pofltfcrior rhinfjscopr, ^ . 303 

OliHtaclefl to prjeterior rhini'AcopT 304 

Vault of the pharynx and jK«ter:or nasal caTitiee, 307 


Diseases of the faiiren. 

Acute Hort: thrctat, 

En'stfH-latoii^ h'lr^ thrrjAt, . 

Rheutiiatir- horf tlir<>at. 

Aciitf; rlifijiuatir sore throat, 
Chronif; rh'-urnatic wire throat, 

Sore lliroiit (.f siiiaM-|»ox, . 

Srjre llm^t of iiifa.'^lf-s, 

fkfre throat of hfsirU-t f*;ver. 

Simple iiieinhrMnoiJs Hor«; throat. 



Diwaws tif tlie faiireH, continufd, 

iJiplitli'-ria, .,..,. 



DiseaRes of the fauces. continin-<l, . 
Acute follHTiihir i>}iaryrii;ili-j, 
Chroitif follicular pluirvniritiH, . 
Acute follicuUr gloiwitiM 




Chronic follicular gloeaitis, 847 

ScrofuIouH sore tliroat, 846 

Acute tubercuar sore tliroat SSO 

Syphilitic sore throat 8S3 

Syphilitic sore throat in infants. 356 


Diseases of the fauc-es, continued SIS8 

Diseases of the uvula, 3S8 

Acute inflammation and oedema of the urula 35B 

Chronic inflammation and elongation of the uvula .... 858 

Malformation and new growths of the uvula 859 

IjBUcoplakia buccalis, 860 

Acute tonsillitis S62 

Phlegmonous tonsillitis, . 868 

Hypertrophy of the tonsils, v 370 

Concretions in the tonsils, 875 

Mycosis of the throat, 876 

Tubercular ulceration of the tonsils, 378 

Cancer of the tonsil, 380 


Diseases of the pharynx 883 

Foreign bodies in the pharynx, 383 

Retro-phurj-ngeal abscess, 383 

Tumors of the pharynx 386 

Cancer of the phar>'nx 386 

Neuroses of the pharj-ni. 388 

Anft>sthe8ia of the pharynx 388 

HypenuHthcsia of the pharynx 388 

Para>NtheHia of the pharynx, ' . . . 380 

Spa-sm of the pharynx, 390 

Paralysis of the pharj'nx, 391 

Scalds and burns of the phar>'nx 892 

Swallowing the tongue, 393 

Diseases of the valeculss and pyriform sinuses, 393 


Diseases of the larynx, 394 

Acute laryngitis 394 

Subacute laryngitis 397 

Traumatic laryngitis, 398 

Chronic laryngitis, 398 

Trachoma of the vocal cords, - 408 

Phlebectaais laryngea, 409 


Diseases of tiie larynx, continued, 411 

Uembranoua croup 411 




Diseases of the larynx, continued 427 

Phlegmonous laryngitis, 427 

Erysipelatous laryngitis, 428 

Abscess of the larynx, 429 

(Edema of the larynx, 480 

Chondritis and perichondritis of the laryngeal cartilages, . . . 488 

Tubercular laryngitis 484 

Syphilitic laryngitis 443 

Syphilitic laryngitis in infants, 449 


Diseases of the larynx, continued 461 

Lupus of the larynx, 461 

Lepra of the larynx 464 

Hypertrophy of the larynx, . . . ' 456 

Lfuyngitis of small-pox 456 

Laryngitis of measles 465 

Laryngitis of scarlet fever 465 

Chronic stenosis of the larynx, 456 

Stenosis of the trachea 460 

Tracheitis. 460 


Diseases of the larynx, continued 463 

Morbid growths in the larynx, 463 

Benign tumors of the larynx 465 

Malignant tumors of the larynx 476 

Eversion of tlie ventricle of Morgagni 483 

Tracheal tumors 483 

Post- tracheotomy vegetations, 485 

Involution of the trachea, 485 

Tracheocele 486 

Syphilis of the trachea, 487 


Diseases of the larynx, continued, ' . . . . 489 

Fracture of the larynx 489 

Dislocation of the larynx 490 

Foreign bodies in the larynx, 490 

Foreign bodies in the trachea 493 

Spasm of the glottis, 496 

Spasms of the larynx in adults, 497 

Irritative cough, 49S 

Nervous cough 498 

Anaesthesia of the larynx 499 

Hypersesthesia, pariesthesia, and neuralgia of the larynx, . . . 500 
Chorea laryngis, 501 



Spasm of the vocal ooids, 502 

Falsetto voice 503 

lArytigeal vertigo. 604 


DiBeasee of the larynx, continued, 505 

ParalyBisof the thyro-epiglottic and ary-epiglottic muscles, . . 505 

Paralysis of the crico-thyroid muscles, 506 

Paralysis of the thyro-arytenoid muscles, 507 

Bilateral paralysis of the lateral crico-arytenoid muscles, . . . 508 

Unilateral paralysis of the lateral crico- arytenoid muscles, . . . 010 

Paralysis of the arytenoid muscle 511 

Bilateral paralysis of the posterior crico-arytenoid muscles, . . 511 

Unilateral paralysis of the posterior crico-arytenoid muscles, . . . 514 

Anchylosis of the arytenoid cartilages, 514 

Atrophy of the vocal cords, .... 515 



Diseases of the nasal cavities 619 

Influenza, 619 

Rhinitis 622 

Simple acute rhinitis, 523 

Traumatic rhinitis 536 

Chronic rhinitis, 627 

Simple chronic rhinitis 538 


Diseases of the nasal cavities, continued 581 

Rhinitis, continued, 6S1 

Chronic rhinitis, continued 6S1 

Intumescent rhinitis, 631 

Hypertrophic rhinitis, 640 

Submucous infiltration at the sides of the vomer, . , . 647 
Atrophic rhinitis, . . 647 


Diseases of the nasal cavities, continued, 553 

Hay fever 553 

Fnrunculosis of the nose 558 

Epistaxis. 559 


DiaeassB of tiie naaal cavities, continued, 564 

Nasal mucous poly pi 564 

Nasal fibrous polypi . . 569 



Nasal papillary tumors, ... 069 

Nasal vascular tumors 570 

Nasal osseous cysts, 670 

Nasal cartilaginous tumors, 571 

Nasal bony tumors 571 

Nasal malignant tumors, 072 


Diseases of the nasal cavities, continued, 674 

Syphilis of the nose, . 574 

Congenitalsyphilisof the nose, ... . . , . . , 577 

Tuberculosis of tlie nares, 578 

Empyema of the antrum, 578 

Empyema of the sphenoidal sinuses, 588 

Intlammation of the frontal sinua 584 

Clironic suppurative ethmoiditia. 685 

Lupus of the nares 587 

Rliinoscleroma, 588 

Glanders 689 

Nasal afTectiona in acute diseases, . 591 

Perverted sense of smell 591 

Parosmia, 691 

Anosmia, 691 


Diseases of the nasal cavities, continued, 598 

Congenital deformity of the nose, . 593 

Fractures of the nose, 593 

Dislocation of the nasal bones, 594 

Deflection of tlie nasal septum, 694 

Ecchondrotna and exostosis of the nasal septum, 597 

Perforation of the nasal septum, 601 

Ila-niatoma of tlie nasal septum, 602 

Abscesses of the nasal septum, 603 

Foreign bodies in the nose, 603 

RhiDoliths 604 

Myasis narium or maggots in the nose, 605 


Diseases of the nasopharynx, . 

Rliino-pliarynfritis, .... 
Throat deafness. .... 

HyiHTtriiphy of the pharyngeal tonsil, 
Retronasal libi'ons tumors. 
Retronasal filiroiiiucous tumors. 

Retronasal cartilaginous tumors, 
Malignant tumors of the naso-pharynx, 
Cystic tumors of the naso-pharynx, . 







Goitre 629 

Exophthaltnio goitre 683 

CEsophagitis, 632 

Acute oesophagitis 633 

Chronic nsophagitis, . 688 

Stricture of tlie oesophagus, 684 

Compression of the oeflophagus, 687 

Spasm of the cesophaguB 687 

Paralysis of the oesophagus 688 

Foreign bodies in tlie oesophagus 640 

F&TEesthesia of the oesophagus, 643 


VBge of Page of 
Book. Appeudix. 

Actinomycosis of the Lungs. 

Etiology and Pathology, Symptomatology 156 (648) 

Diagnosis, Prognosis, Treatment 156 (648) 

Actinomycosis of the Mouth. 

Anatomy and Pathology, 363 (e-lfl) 

Etlofogy, Symptomatology 368 (656, 057) 

Diagnosis, Prognosis, Treatment, 868 (657) 

Angina Pectoris. 

Diagnosis, Prognosis, Treatment. 353 (652) 

Acute Sore Throat. 

Treatment, 313 (653) 

Abscew of the Tongue 363 (65& 

Anosmia rm (660) 

Antrum of Ilighmore, Operation on, 583 

Antiseptic Surgeon's Lint, 600 (661) 


Symptomatology, . aO (646) 

Bronchitis, Chronic. 

Symptomatology 91 (646) 

Bronchitis, Capillary. 

Dellnition 95 (046) 

Prognosis, 98 (046) 

Bradycardia 350 (053) 

Dilatation of the Heart. 

Etiology, 340 (651) 


Etiology, 329 (053) 

Diagnoflis, Bacteriological Examination 333 (653J 

Loffler's Blood-Serum Mixture, Prognosis 333 (653) 


VMge ot Pigeor 
Book. AppBodbc, 

Traatment, Topical 886 (654) 

Antitoxin, 837 (654) 

Fumigation, 887 (606) 

Deflection of the Nasal Septum 596 (661) 

Endocarditis, Clironic. 

Treatment 239 (650) 

Exercise, Oertel's and Schott's Methods 230 (650) 

Eversion of the Ventricle of Morgagni, 488 (658) 

Empyema, or Chronic Pleurisy, 77, 78 (645) 

Empyema of the Antrum. 

Treatment ' . .583 (669) 

Senn's Operation 583 (609) 

Ecchondroma and Exostosis of the Nasal Septum. 

Treatment, 598-600 (661) 

Fatty Heart. 

Symptomatology, 243 (651) 

Fracture of the Larynx. 

Prognosis 489 (65B) 

Foreign Bodies in the Larynx. 

Treatment, 492 (659) 

Foreign Bodies in the (EmpliagUB. 

Treatment 643 (663) 

Frontal Sinus, Inflammation of 584 (660) 


Treatment. 631 (663) 

Hypertrophy and Dilatation of the Heart 389 (651) 

Hypertrophy of Pharyngeal Tonsil. 

Anatomical and Pathol<«ieal Characteristics, ... 618 (661) 

Hypertrophy of the Tonsils. 

Pn^^oeiB and Treatment, 871 (658) 


Fatty, Symptomatology 348 (651) 

Syphilitic, Disease of 345 (651) 

Dilatation 340 (651) 

Hypertrophy and Dilatation 339 (651) 

Ldffler's Blood-Serum Mixture, 3S2 (653) 

Ludwig'B Angina 868 (657) 


Fracture of, 489 (659) 

Foreign Bodies in the 493 (659) 

Nasal Mucous Polypi. 

Anatomical and Pathological Characteristics, . . '>&'> (659) 

Perverted Sense of Smell— Parosmia 501 (660) 

Pharyngeal Tonsil, Hypertrophy of Q\3 (661) 


Exciting causes, 62 (645) 

Treatment 72 (645) 

Diagnosis and Prognosis 78 (646) 

Pleurisy, Chronic, or Empyema. 

Prognosis 77 (645) 

CONTENTS. xxili 

Pbko of PaK« of 
Book. Appendix. 

Treatment, Pleiirotomy 78 (040) 


Lobar 116 (640) 

Symptomatology, 116 (646) 

PrognoBiB, 121 (646) 

Treatment 123, 138 (646) 

Lobular. ^ 128 (657) 

Anatomical and Pathological CharacteriBticB, . .138 (647) 

Etiology 124 (647) 

PertusBis, or Whooping- Cough. 

Treatment, 155 (647) 

Pulmonary Phthisis. 

Etiology 159 (648) 

Diagnoeis 164 (648) 

Prognosis 169 (648) 

Treatment. 170-174 (649) 

Parosmia 091 (660) 

Retro-Nasal Fibrous Tumors, ...:.... 624 (661) 

Anatofnical and Pathological Characertistics, . .522 (659) 

Senn, N. , Operation on Antrum, 582 (6&9) 

Syphilitic Disease of the Heart, 345 (651) 

Ttehycardia, .349 (651) 


Prescriptions, 668 

Gargles . 665 

Sedatives 665 

Astringents, 665 

Stimulants, 665 

Antiseptics .*,... 605 

Trochisci or lozenges, 065 

Sedatires 665 

Demulcents, 660 

AstriagentB, 666 

Stimulants, 666 

Antiseptics 667 

Vapor inhalations 667 

Sedatives 668 

Antispasmodics 66tl 

Mild stimulants ecu 

Strong stimulants 669 

Spray inhalations OOi) 

Sedatives. 6^ 

Astringents and stimulants, 670 

Haamostatics, 871 

Antiseptics, i^Tl 



Dry inlialatioDfl BTS 

Sedatives, 872 

StimulantB 878 

Fuming inhalations 672 

Sedatives, 678 

Stimulants 673 

Pigments 673 

Local antestheticB, ... .... 673 

AstringentB, 674 

Stimulants and caustics, 674 

Antiseptics, 874 

Insufflationa 674 

Sedatives, 674 

Antiseptics and stimulants, 675 

A8trin«ent8 and stimulantB, . 675 

Nasal douches 076 


no. nan 

1. Regions of tbe chnt, 4 

2. Regions of the chest 

3. Outline of the chest, 10 

4. Quain's Btethometer, 17 

a. Cairoll's Btethometer .17 

6. Flint's cyrtonieter 18 

7. Spirometer 18 

8. Allison's stethogoniometer, .18 

9. Hamniond'i) heemadynamometer, 19 

10. Flint's hammer and pleximeter, 21 

11. Camman's stethoscope 32 

12. Ingals' emballometer 83 

13. Solid wooden stethoscope, 86 

14. Knight's stethoscope, .36 

15. Allison's differential stethoscope, , 37 

16. Fhlhisis, . 47 

17. Bronchial r&les 49 

18. Acute pleurisy, RS 

19. Curred line of flatness in pleurisy, posterior view, .... 04 

20. Curved line of flatuess in pleurisy, anterior view, 65 

21. Subacute pleurisy, 73 

22. Cabot's drainnge tubes 79 

33. Strong's drainage tubes, 79 

24. Ingals' flat trocar 79 

25. Ingals* drainage tubes 81 

26. Pneumo- hydrothorax, 86 

27. Pneumonia, 117 

28. Tubercle 157 

29. Tubercle bacilli, colored plate 168 

30. Globe nebulizer, 174 

31. Physiological action of the heart, 181 

32. Rhythm of the heart 183 

33. Areas of endo-cardial murmurs 198 

34. Auricular systole, 201 

35. Ventricular systole 202 

36. Marej's sphygmograph, 208 

37. Normal radial pulue, tracings, . 208 

38. Normal radial pulse, tracingH, 208 

89. Aortic obstruction '•^dlt 

40. Aortic obstruction, 20!) 

41. Uitral regurgitatiou, 30V 


no. PASS 

42. AneuriBm, 200 

43. Aortic regurgitatioD 209 

44. Aortic regurgitation and obstruction, 309 

45. Cardiac hypertrophy in Bright's disease, 210 

46. Tracing of the senile pulse, 310 

47. Mitral constriction, tracing 210 

48. Mitral constriction and aortic regut^itation, tracing, .... 211 

40. Mitral hypertrophy and dilatation ' . . . . 211 

.50. Torek's tongue depressor, 271 

51. Pocket tongue depressor, 271 

62. Bosworth's tongue depressor, 271 

58. Throat mirrors for laryngoscopy 278 

54. Scbrotter's head band with nasal rest, 278 

55. Krishaber's illuminator, 278 

56. Modified Mackenzie's rack-moTenient bull's-eye condenser, . . . 278 

57. Modification of Mackenzie's illuminator, 279 

58. LaryngOBCopic reflector 288 

59. Position of the bead giving the best view of the larynx, . . 284 
<t0. Position of the head giving a poor view of the larynx 285 

61. I^ryngoscopic mirror in position, . . . * 28S 

62. Brun's pincette 291 

63. Infra-glottic laryngoscopy 201 

64. Relative relations of the larynx and its image, 203 

65. Normmal larynx in respiratitxi, * . . 298 

66. Pitcher-shaped inter-arytenoid fold, 295 

67. Lapping of arytenoid cartilages in phonation, 295 

68. Cushion of epiglottis, 295 

69. Pointed epiglottis 205 

70. Jewe'-harp epiglottis 296 

71. Larynx of a woman in respiration SOS 

72. View of left side of larynx 207 

78. Normal larynx of woman in formation of head tones, .... 298 

74. View of posterior wall of tracliea, ........ 800 

75. View of anterior wall of trachea, 800 

76. IngaU' nasal speculum 801 

77. Jarvis' nasal speculum, 801 

78. SajouB' nasal speculum, 801 

79. Cross section of head ehowing ethmoid cells and nasal cavities, . . 802 

80. Fraenkel'srhinoscope 308 

81. Position for rhinoscopy, 804 

82. Rubber palate retractor 306 

83. Porcher's self-retaining uvula and palate retractor 306 

84. Palate retractor 806 

85. Rhinoecoi>e with uvula holder, 306 

86. Rhinoscopic image, . 307 

87. Adfuoid tissue at vault of the pharynx, 800 

88. Pharyngeal bursa 800 

80. ChroDic follicular pharyngitis, 348 

90. Modification of Sluirly's battery 845 

91. luj^al.-*' cimtcry ^-li-ctrDileK, ......... 346 

92. Perfuratiou of the piiiati'. syphilitic, 354 


no. FAOB 

98. SciBBora for amputating the uvula, 3S8 

04. Hathieu'B touBillitome 873 

95. Mathieu's tonsitlitome, oblique fenestra 873 

96. Ingals' tonsil forceps, 878 

07. Fibroma of pharynx 866 

98. SuperBcial uIcerB of the vocal cords, . 895 

99. Superficial ulceration of the epiglottia, . . . , • . . . 395 

100. Mackenzie's laryngeal lancet, . 897 

101. Catarrhal ulcer of the vocal cord 899 

103. Chronic catarrhal laryngitis, with defonui^, 899 

108. Chronic catarrhal laryngitis, 401 

104. Catarrhal laryngitis, with deformity, 401 

105. Subglottic oedema, 401 

106. Davidson's atomizers, set No. 66 405 

107. Ingals' laryngeal applicator, 405 

108. Davidson's atomizer. No. 69 old style 406 

109. Trachoma of vocal cords, . . 408 

110. Ingals' chromic acid applicator and handle, 409 

111. IngaU' galvano- cautery handle 409 

113. O'Dwyer's intubation instrumentu, 418 

113. Henrotin's gag, 419 

114. Waiham'sgag 419 

115. Allingham'sgag, 419 

116. O'Dwyer'B extractor, .420 

117. Abscess of the larynx, 429 

118. Infra-glottic abscess of the larynx, 430 

119. Infra-glottic abscess of the larynx, twelve hours after opening, . . 430 

120. (Edema of the larynx 482 

121. Tubercular laryngitis, .......... 435 

122. Tuberoular laryngitis, pyriform swelling of the arytenoids, . . 435 

123. Tubercular laryngitis, pyriform swelling of the arytenoids, . . 435 

124. Tubercular laryngitis, 485 

125. Incipient tubercular laryngitis, 436 

126. Tubercular laryngitis 436 

127. Tubercular ulceration of the vocal cords, 487 

128. Tubercular ulceration of the vocal cords 437 

139. Tubercular ulceration of the ventricular bands, ..... 438 
130. Tubercular ulceration of the ventricular bands and vocal cords, . . 438 
181. Tubercular laryngitis, sluggish action of the vocal cords, . . 438 

132. Tubercular ulceration of the larynx, 440 

133. Tubercular laryngitis, with syphiliB, 440 

134. Condyloma of the epiglottis, . . 444 

135. Gumma of the larynx, 444 

186. Multiple gumma of the larynx 444 

137. Syphilitic laryngitis 444 

138. Syphilitic laryngitis, 446 

189. Syphilitic ulceration of the epiglottis 446 

140. Syphilitic ulceration 446 

141. Lupus of the larynx (Ziemssen) 451 

142. Lupus of the larynx (TQrck), 452 

148. Lepra of the larynx, 454 


no, FAOB 

144. Syphilitic laryngitis 456 

145. Syphilitic stenosis of laryDX, ... 4S6 

146. Mackenzie's laryngeal dilator, , . 468 

147. Whistler's cutting dilator 458 

148. Tube for laryngO;tracheal stenosis '459 

149. Mount Bleyer's tongue depressor, 464 

mo. Papilloma of right vocal cord, 465 

151. Papilloma of the larynx, . . 465 

152. Papilloma of vocal cords, 466 

153. Papilloma of vocal cords, 466 

154. Papilloma of the lar>-nx, 466 

155. Fibroma of left vocal cord, 466 

166. Fibro-cellular tumor of the larynx, 467 

157. Cystic tumor of the larynx, 467 

158. Cystic tumor of the larynx 467 

159. Cyst of the epiglottis, 467 

160. Adenoid tumor of the larynx, 467 

161. Adenoid tumor of the larynx 467 

163. Cartilaginous tumor of the larj'nx, 468 

163. Vascular tumor of the larynx 468 

164. Vascular tumor of the larynx 468 

165. Laryngeal forceps, 471 

166. Mackenzie's tube forceps, 473 

167. Stoerk's larj-ngeal iustrumeuts . . 478 

168. Tobold's laryngeal knives, 474 

169. Cancer of the larynx, 477 

170. Cancer of the larj-nx 477 

171. Cancer of the larynx 477 

172. Cancer of the larynx, 477 

173. Cancer of the larynx 478 

174. Cancer of the larynx 478 

175. Mixed sarcoma of larynx, 478 

176. Cancer of the larynx 478 

177. Tumor in the trachea, 484 

17H. Ingals' punch forceps 485 

1T9. Syphilitic laryngitis, 487 

IMd. St'iler'a tube for eps, 495 

isi. Jiilateral paralysis of the cricothyroid muscles 507 

lHi>. Acute laryngitis, 507 

18:t. Paralysis of tlie thyro-arytenoid muscles 508 

184. Ptiralysis of the lateral criro-arytenoid muscles, 508 

185. Miickeiizie's laryngeal eli-ctroiles, 509 

IHfi. Unilateral paralysis of tlic liiteral crico-arytenoid muscles, respiration, 510 

187. Unilateral paralysis of tin' latoial crico-arytenoid muscles, phonation, . 510 

188. Unilateral paralynis of the cvico- arytenoid muscles, .... 510 

189. ZieniswTi'H laryngeal eleclroile.H, . 511 

190. Hilateral paralysiw of the piwterior crico-arytenoid muscles, inspira- 

tion 513 

191. Bilateral paralysiis of the |K»st('riorcrico-arytenoid muscles, expiration, 513 

192. Unilateral paralysis of the |io:jlerior crico-arytenoid muscles, inspira- 

tion, 614 


m. PAGE 

19S. tTailateral paralysis of the posterior crico-arytenoid muscles, pfaona- 

tion 514 

194. Anchylosis of the arytenoid cartilages 914 

195. Powder blower, 586 

190. Davidson's oil atomizer. No. 60, 586 

197. Flat nasal probe and applicator, 587 

198. Hypertrophy of the inferior turbinated body, Ml 

199. Hypertrophy of the posterior ends of the inferior turbinated bodies, . 642 

200. logals' nasal scissors, 54S 

201. Nasal burrs 546 

203. Nasal trephines 546 

203. Submucous infiltration at sides of the vomer, ..... 547 

204. Ingals' nasal syringe 550 

205. Nasal douclie, 551 

200. Nasal douche, traveller's, 551 

207. Galvauo-cautery handle with ecraseur 567 

208. Ingala' snare ."iO? 

209. Cotton applicator 568 

210. Hypodermic syringe, long silvernozzle, ,. S6H 

211. Ingals' nasal dressing forceps, ........ .576 

212. Cross section of head looking from behind forward, .... 579 

213. Ingals' electric lamp 581 

214. Brainanl's bone drill 582 

215. lugals' drainage tubes for antrum 583 

216. Cross section of head, 584 

217. Curtis' ethmoid-cell wash-bottle, 586 

218. Ingals' septum forceps, 596 

210. Ingals' septum knife, 596 

230. Ingals' right-angle cutting forceps, 597 

221. Exostosis from the septum 598 

222. Sajous' knife .509 

233. Nasal spud 509 

234. Ingals' nasal saw, 509 

225. Ingalri' flat nasal saw 509 

226 and 237. Sujous' saws 599 

228. Ingals' heavy hone scissors . 6(H> 

229. Ingals' nasal bone forceps, . (HM 

23'J. Ingalu' utiaal spatula 600 

2.'^1. Gross' instruments for removing foreign bodies. 604 

233. Post-nasal syringe, 009 

233. Curtis' Eustachian tube vaporizer 613 

2'*4. Rhinoscopic view of post-nasal vegetations, 614 

335. Mackenzie's, John N., post-nasal forceps, 617 

236. Ingrls' post-nasal snare applicator 633 

337. Retro-nasal fibro-mucous Dolypus, 624 

238. Sand's oesophagotom«, G3(> 

239. Flexible oesophageal forceps, . C41 

340. Bristle extractor, . . 642 

Diseases of the Chest 


Jy this vork I ehtill first describe the methods for dctocting disease 
which nre based upon the inithoIogicixJ changes in the organs iiffcutcd; 
next point out the ehuructeristics and significance of the various signs; 
aucl tiually consider the iudividuul diseases. 

The term physical diaguut^i:^ is used Lo designate the methods re- 
ferred to, whether used iu tlie examination of the chei<t or in the exnm- 
inatiou of any otiier purt of the body; but as it is in the exploration of 
the chest that such methods have yielded the most brilliant resnlls, it i» 
now customary tu apply the term physical diagnosis simply to the ex- 
AiuiuatioD of the thorax. 

It is iu this limited sense that we shall genemlly use it, though it 
will also be applied to the examination of the upper air passages. 


To simplify the study, and to enable us to fix accurately in mind the 
position of the intni-thoracic organs, the chest has been divided into a 
number of regions which are purely arbitrary, and their boundaries vary 
vith different authors. 

J. M. Du Costa divides the chest into the anterior, the posterior, and 
two lateral regions, and subdivides these into upper and lovrer regions. 
He locat<?8 signs present in these regions by certain fixed nuirkfi which 
may be found on the surface of the ohest. For instance, anteriorly, a 
sign may be located in a certain intercostal space, or beneath a rib or 
Ihe clavicle, at a given distance from the sternum. Posteriorly, a sign 
may be tucaled iu a similar manner with reference to the spinous proc- 
cews, or to the angles and the bordora of the scapulte. Such a division 
is well enough for the record of cases, but it dues not aid us in remem- 
bering the location of the intra-thomeic organs. 

The division here adopttnl is similar to one quite commonly taught, 
with only such changes as make it plainer and more easily remcmberetl. 

M'hile learning these boundaries, one should fix in mind the exact 
pOMition of the intra-thoracic organs. 

We divide the chest primarily into anterior, poaterior, and lateral 
regiong, and subdivide as follows. 

■i i'nraiCAL DiAQNoam. 

Upon the anterior surface on either side^ from ubove downward, we 
have tliti Hiipra-cluviculitr, elaviculur. infru-claviciilur, nmiiiniary. and 
infru-namniary regions; between tlieae two In t era] gruujw we And the 
supra-sternal above tlie line of the c.Iavirles, ant! the sternal region enb- 
divided into the enperinr-jftornnl and inferior-stenm!. 

The posterior portion of the chfst. on ejieh side, is subdivided into 
thesupni-ficapularancl tbesc:ipuTar regionit, between tliesc the inter-sciip- 
ular region, and below the erupnlte the infru-scBjuilar regionB (Fig. 2). 

XiSterally we have the axillary and the infra-axillary regions. 


Fio. 1.— A, Supra^Uvlcular redoa : B. clAricular rpgloa : C, Infra-vlftvlculAr tvclnii ; D, nuun- 
■DAry reiffton; E. Infra niiimniiir>' reKtoo : F. Hii|>T>rior4i«mal r«ittoa : n, lnr<!rinr-«t«rnal mrlon. 
Ttut wAvy Unn rv^rvnnttt tfie borderi ot [|i<* iuDgB and Ibe putijtuiuuy Ibwiin-n Tltp AvAitA linon 
cormpotut to the outlloen of Ihe vartouo organs. vU.. Iractifa. iu>rtn. brondiU) tubes, iMArt. Ilv«r, 
sjlivn, (uid titomscb. Tb» v<>i'>- dnrk iiluwllu|{i>vfr ili« hulnl rlKit-rn mIiob* Ibn oormMl «rp«« of 
itatocn. Bad the kJuuHng Dext4i«lit«r over tbe ut>pt-r piirt of ibe li«vr bIjowi Dii* hvpaik- duloeiiL 
Tbo bUck rwLuiKulu- qtol* ii«kr Um tliinl rib curi-miHNiil t« Uw podltJoii of lliv ralf es ot the bMUT. 

The bcpba-clavicular reoiox corresponds to that portion of the 
pleural cavity whieh extends above the clavicles. It is triiingular iu 
form, with il£ base internal, its apex external. It is bounded above by u 
line drawn from the up{)er ring of the trachea outward to the junction 
of the middle with the external third of the clavicle. The inferior 
boundary of this region corresponds to the npper margin of the inner 
two'tbirds of the clavicle. The internal boundary corresponds to the 
sterno-cleido-mii6toid mnsrlo. This region cuntaius, on either side, the 
_gf the luug and portions of the subclavian artery and vein. 

lOLATictiLAR RKOION corre8{>onds to the inner two-thirds of 


ihn claviole and In, bounded iibuve mid below by ibe borders uf tlio bono. 
It contains long ttosue. Upon tbe rigbt side. exUtniaU)' wo liud tho 
•abolnrian arterr, and at the inner cxlrcniity tlio ortvrin innominuu 
Mii ibe recurrent bryngenl nerve rts it passes up lo eti)ip)y (be niii«otefl 
of ibe larnix. Atiourisins in. tliis loailiiv, by jiressing iijmui iIuh nerve, 
give rise to seriouM symptoms due to jmndyeiU or spusm of ibp glottis. 
TTpon the left side, nt tbe inner end of tbirt region wo find tbe ctroltd 
and tbe eubcliiviiin iirterios, deeply ttuiiLetl jind rnnnini; iilmost nt ri^iht 
angles with the clnvicle. 

The ixPRA-CLAVici'i.AK HKOlos jg bounded nliove hy the clnvielo, 
internally by the margin of tbe sternnin. iind externally by n stniigbt 



Tn. 1— Tba wsrx llofis eomKpoD-I to tli>- '>■ rt>'r- nn'X n«uro« of llw lunc«i. Tlw doU«d ltt»« 
11^ Lhescaimlar i<r<[)(>n iiiUtcali* thr> ]Ki<klii<«. nf iIk- '\Mif nr Uu*M'a|)iila TbiMlDtlMl lUMvaDil 
saa to tliv Ittf ra-fleapuUr mgtotH liMticutv Lba pOKliloti trf Ui« Uv«r anil Hfiln-a. 

line let full from the onter extremity of tbo rlnvicubir ref^iun, und puMfl- 
ingubuutan inch extermdly from the nipplv. It in buunditd below Uy 
the lower margin of the third rib. Thi* region contain* lung tiiwutt un 
either side. On ibe right, olo«y to the border of tbe sternum, wo Hnd 
portions of the aBcending oorto und of the deeeending venii oiva. Just 
beneath the second costal curtilage, wc Gnd tbe right bronchus as it 
passes into the rigbt lung. Upon the left, in tbe iiecond iiitercostiU 
s{«oe, close to tbe ninrgin of ihe Hternum, tbe ptilinoiuiry artery is 
lucated. In tbe same space is found thp left bronchas, which indinM 
more downward, und it bK^ited lower than tbe main bronchus on the 
oppoeite side. A portion of the base of the heart occupies tbe interiial 
inferior angle of this region. 

Tiir. MAMNAUV HKoioN. which lies immediately below tbe precrd* 
ing, ii bounded internally by the margin uf the •Lemnm, eztf!mally by 

a continuation of the Hue which bounds the infni-clavioular region, an 
iiiferiorly hy the lower iimrgin of the sixth rib. We may eaailv remem- 
ber the boundaries of lue infra-clavicular and the miuuiiiury regions, hy 
recollecting that we have three riba in each. The inferior border of the 
tliird rib forms the lower boundary of the upper region and the lower 
margin of the sixth rib bounds the lower region inferiorly. This region 
contains lung tissue on both sides. On the right, the thin margin of tlie 
lung, which overlaps tlie liver, reaches to the siJith interspace, and ejc- 
tends even lower in full inapiraiion. Deeper seated we lind the upper 
convex surface of the liver, carrying the diaphragm above it, as high as 
the fourth intercostal space. The nipple is usually located in the fuurili 
intercostal space; therefore, we expect to find the upper border of the 
liver beneath it. A small portion of both the right auricle and the right 
ventricle extends into this region. In the upper jmrt of the left mam- 
mary region, the lung tissue is ir. front as low as tlio fourlii rib. Hci-o 
the border of the tuug passes outward and downward to the fifth rib, 
leaving between it and the median line a triangular space iu vrhich the 
heart and its investing membrane are superficial. 

TiiK iNFHA-siAMMAKY KEoiON is bounded externally by ft Continua- 
tion of the outer boundary of the mammary region; above by the lower 
margin of the sixth rib, and internally and inferiorly by the ninrgin of 
the sternum and the lower borders of the false ribs. This region con- 
tains, on the right side, the liver, und occasionally the inferior margin of 
the lung during full inspiration. On the left side, near the sternum, 
•we find a portion of the left lobe of the liver; a little farther oulwanl, 
near the middle of the region, we liave the stomach; in the outer third 
is a portion of the spleen. The stomach and the spleen usually extend 
as high as the sixth rib. 

7'/i(r tiiaimnilliiry ar ntpph Uue is a vertical lino drawn through the 
nipple, and, according to some authors, it forms the external boundary 
of the infra-clavicular, mammary, and iufra-ninmmary regions. 

The regions between the lateral portions of the anterior enrfaco of 
the chest are three in number. 

The stPRA-STERNAL REGION, the first connting from aboTc, is 
bounded inferiorly by the upper end of the sternum, or inler-elavicular 
uotch; laterally by the stcmo-cleido-maetoid muscles; and above by the 
first ring of the trachea. The most important organs in this region are 
the trachea and the thyroid gland, the lobes of which lie nn each side of 
tlie trachea and are connected by the isthmus in the upper part of this 
region. Here are also found certain small veins and frteries which are 
of interest to the surgeon. In the lower right ang'e of this region the 
innominate artery is found, and in the inter-cloviculai notch we can 
frequently feel the arch of the aorta. 

The si'pehior-sterxai. itK<iios, next in order, is bounded below 
by a line connecting the lower margins of tlm third ribs, and lat* 



erally by the borders of the boue. This region contains Inng tissnc. 
Su peril ciaUy, the inner or anterior margin of each lung roaches the 
mclinn line. Deeper, we find tho descending vena cavn, the ascending, 
the tranavcrae, and a part of the descending portion uf the arch of the 
aorta, and at the left a portion of the pulmonary artery. At a point 
opposite the second costo-stemal jimetiou is tho bifurcation of the 

The iSFRniOK-STKBNAL REGION, known also as the sternal rrgion, 
haa for its houndsiries the borders of all that portion of the sternum 
lying below the third rib. In it the anterior margin of the right luug 
corresponds to the median line, and is superficially situated. But tho 
corresponding margin of tho left lung recedes from the median line at 
the levul of the fourth rib, paiitiing uutwiird and downward, leaving a 
triangular space between it and the niurgin of the right lung. In thii 
space the right ventricle of the heart is superficial. In the npper part 
of this region we find a hirge portion of the right auricle and the origin 
of bolh tho aorta and the pulmonary artery. The portions of the left 
side of Ihe heart which present anteriorly He to the left of this region. 

In tliis region mo find portions uf the four sets of valves which guard 
the orifices of the heart (Fig. 1). At the left edgeof the sternum, under 
the third rib, are the pulmonary valves ; a trifle lower, beneath the 
Ctitttre of the sternum, are located the aortic vidvrs; lower yet, at its left 
border in the tliird intercostal spnce, we find the mitral valves. We 
locate the tricuspid valves beneath the middle of the sternum on a line 
with the fourth costo-stcroal articuktion. These valves lie so closely 
that a circle scarcely more than an inch in diameter will include all of 
them, and a circle of half that diameter will embrace a portion of each. 

At the lower part of this region wc have a portion of tho liver and 
of the attachment of the pericardium to the diaphragm. 

The megoalertial Hue is an imaginary line passing down the centre of 
the sternum. 

The stfrrnal linen of the right and left sides correspond to the borders 
of the iitemum. 

Posteriorly are the supra-scapular and tho scapnlar regions on each 
side. FXtonding from the second to the seventh rib and corresponding 
very nearly to the outlines of the scapula when the patient's arms are 
banging loosely by his sides (Fig. 2). 

The suPRA-scAi'i'i.AR REoioN' Corresponds to the supni*6pinou8 
foen. It is occupied hy lung tissae. 

The scAprLAR REniOK corresponds to tho infra-spinous fossa. It is 
uccopied by lung ti^ue. 

Thb iNTEB-snAPCLAE BEOios lics between thebordors of the 8capul» 
divided hy the spinous processes of the vertebra?, and extends from the 
level of ihe second dorsal vertebra to the level of the seventh. It c^n- 
inini lung substance, the main bronchi* and the bronchial glands. The 


descending aorta runs along the left of the spinal column, beside the 
oesophagus. The trachea bifurcates opposite the third dorsal vertebra. 
In the three preceding regions the chest walls are very thick. 
The infea-scapulak beoiok on either side is bounded internally 
by the spinous processes of the vertebra; externally by a vertical lino 
let fall from the inferior angle of the scapula j above by the lower mar- 
gin of the scapular and inter-scapular regions, which corresponds to the 
seventh rib; and below by the inferior margin of the false ribs. This 
region contains lung tissue on either side, extending to the tenth or to 
the eleventh rib. BeloW the margin of the lung, on the right side, we 
have the liver; on the left side, the intestines are superficial near the 
middle portion of the region, and externally we find the spleen (Fig. 2). 
Ihe kidneys are located near the spinal column on either side. The 
left kidney extends an inch higher than the right, and its upper extrem- 
ity is frequently found in this region. 

Laterally we have two regions, the axillary and the infra-axillary. 
The axillary region is bounded below by a line drawn from the 
lower margin of the mammary region backward to the inferior angle of 
the scapula; above by the axilla; in front by the outer boundaries of 
the infra-clavicular and the mammary regions; and posteriorly by the 
axillary border of the scapula. This region contains lung tissue on 
each side and, deeply seated, the main bronchi. 

The infra-axili.ary region" is bounded above by the axillary; 
posteriorly by the outer margin of the infra-scapular region; anteriorly 
by the external margin of the infra-mammary region ; below by the margin 
of the false ribs. On either side we find the lower border of the lung- 
running from near the upper anterior angle of this region downward 
and backward. Below this, on the right the liver, and on the left the 
spleen, and a portion of the stomach, are superficial. 

Pulmonary Fissures. — On each side at a point about three inches 
below the apex of the lung, corresponding very nearly to the inner end 
of the spine of the scapula, we find the beginning of the pulmonary fis- 
sure which separates the upper from the lower lobe. These fissures run 
obliquely downward and forward to the sixth rib near the mammillary 
line. On the right side at a point on this fissure, four or five inches 
from the sternum, wo find the commencement of another fissure, which 
passes inward to the margin of the lung near the fourth costal cartilage. 
Uy this fissure a small triangular portion is cut off from the lower part 
of the upper lobe to form the middle lobe of the right lung. The posi- 
tions of these fissures necessarily change considerably with inspiration 
and expiration. 

It is a common error with students to suppose that the interlobar 
fissures run in the opposite direction; that is, downward and backward 
from the upper part of the anterior margins of the luugs. 



The principal methods of physical examination, six in number, are: 
Inspection, Palpation, Mensuration, Succussion, Percussion, and Auscul- 
tation. Unfortunately the majority of physicians rely for their diagno- 
bis almost exclusively upon auscultation. There are many cases in 
which it will be necessary to use every method and to scrutinize every 
symptom before one can arrive at an accurate diiignosis. 

The evidences of disease which these methods furnish are kuown as 
signs or physical signs. 

There is a marked difference between symptoms and signs. Sub- 
jective symptoms, which are chiefly derived from the statements of the 
patient, may be cyxWi^A presvniplive evidence of disease, while objective 
signs are considered positive evidence. 

The value of these signs will depend upon a knowledge of the altera- 
tions which produce them. 

The early students of physical diagnosis noted the various character- 
istics of a sign accurately, and located it upou the surface of the chest; 
tlien at the autopsy they sought to ascertain its causes. At present we 
only need to study the sign clinically, for its causes may be learned from 
text-books; however, it will be of great advantage, when possible, to 
study at the autopsy, lesions the evidences of whiob we have discovered 
by physical diagnosis. 


By inspection we learn the general appearantt of the patient, the 
color of the integument, the presence or abseno^jof subcutaneous em- 
physema, oedema, or tumors, and the size, form, and movements of the 

Whatever method oi. physical diagnosis is employed, it is necessary, 
first, to be familiar with the healthy conditions which it would reveal. 

The healthy chest has a generally rounded or convex' appearance; 
the shoulders are level, the clavicles are horizontal, and the two sides are 
almost perfectly symmetrical; however, in many cases more or less 
depression will be observed in the supra-clavicular and infra-clavicular 
regions, and not infrequently the pectoral muscles are better developed 
on one side than on the other. 

In men a deep furrow just below the fifth rib marks the lower bor- 
der of the pectoralis major muscle. ' At the borders of the sternum, 
about an inch below the clavicles, wo often notice rounded prominences 
about an inch in diameter, which mark the position of the second costal 
cartilages. These are frequently mistaken by students for abnormal 
swellings. In some patients the ribs and the intercostal spaces are 


Tory diBtinct, while in ntliora th«)* are liiddun by n(li[HJSti iig^ue. The 
ohliquitj of the inferior rilw viiries greatly in different iiuUvidiialH. 

In the fifth intercostal spare, about two inches to the left of the 
Bternum, we obi^crve ihe iiHpiiUe of ihe chest walls cyiused hy the a]ivx 
beat of the hejirt. 

Occaiiionally we find local bulging or depression, independent of dis- 
ease of the inlernul organ». 'I'he ]ironiinenL sternum known at> pigeon- 
breast, usually due to Tiolent cough or obHtriicled reapiration, as from 
citarrh or enlarged toneile in childhood; the pear-shaped rhcst, due to 
rachitis, and the long, narrow, and flat cheat, whioh often results from 
rapid growth, are all futuid iudcpendeut of intra-thoracic disease. 

There is often bulging of the prwconiial region, especially in chil- 
dren. Deep dBpressioua of the lower st^-rnal region, and of the ribs ia 

Tf. Sl— TlAicBTciisK OcTUKW or Cektaih Fomw or TKK Chest (TnoinwMO. 

rare instances, occur in healthy iudividuala. I have a cast taken from 
life, which shows u depression of the lower sternal region from an inch 
and a htilf to two inc-hes in depth; yet the individual from whom it was 
taken enjoyed perfect health. 

Most deviations from symmetry in the two sides are due to slight 
ourvatures of the spinal column. In the examination of a large number 
of patieuta, not more than ono in seven will be found with a perfectly 
symmetrical chest. 

In health, the respiratory movpments are repeated sixteen to twenty 
times a minute in adults, and from twenty to twenty-five or even thirty 
times in children. 

Considerable difTerenco in the form and in the movements of the 
cheat exkts in peraons of different ages and sexes. In women the upper 



portion is more prominent tliun in men. The resjiiratory moremeiit-s 
vary afconlingly, being more inarkert at the upper part in women, Mt 
the lower pan in men. This liisijarity is most conspicnmis in rapiii res- 
eviration. In children of either sex, the cliest wulls often hardly move at 
nil; and respirntion seems to be performed hy the uiiHominjil mtiBcles. 
Tiie respiratory movements in these tbrco localities Sltc numed 8U|)tiriur- 
»tal, iuferior-costal, and abdominal breathing. 

The movetnuntsof the chest may bo altered considerably, irrespective 
of pulmonary or cardiac disease. In health, the respiratory nioremeuts 
are rejidily accelerated by active esercise, and in hyKteriwd patients tliey 
lire noiirly always rapid and snpcrficiul, being confined mostly to the upper 
part of the chest. In persons siilTering from some diseiises of the brnin 
the respiratory movement* hecomo slower and slower until they may not 
excet-d ihree ur four per minute. In hemiplegia the respiratory niove- 
tnonts an? incomplete or wanting, on the affected side of the chest. 

Pregiiuney, ascites, or large abdominal tumors cause pressure ou the 
diaphragm, and consequent intHrference with respimtiun. The pain of 
peritonitis compels the pationt to roalrain the movements of the abdom- 
iual muscles, and thus continei; the respiratory movements to the 
chest and renders thent deficient and consequently more frequent. 

Often among the first signs noticeable on inspecting a patient with 
diaeuse of the iutra-thoracic organs are pallor, cyuuosis, icterus, pityria- 
siSj dropsy, and subcutaneous emphysema. 

Pallor of the liurface and emaciatiun are seen in chronic pulmonary 
disease. Pallur uUo results from fatty degeneration of the heart, and, in 
aomo cases, from mitral disease. 

Cy(inwf»V, more or less marked, indicates incomplete oxidation of the 
blood, due to obstruction of the air passages or tu diminution of breath- 
ing surface; also to affections of the heart, such as congenital malfor- 
mnliousor valvular disease. Occiisionally this sign results from inter- 
ference with the descent of the diaphragm by disease of the abdominal 

IrteruH h found in bilious pneumonia and in the later st^es of those 
cardiac diseases which cause congestion of the portal circulation, 

Piljfriw*iit is often found with phthisis pulmonalis. but it also occurs 
with other diseases, ^nd sometimes even in apparently healthy indi- 

lirop-stf due to recent renal disease usually shows itself first in the 
lower eyelids, and subsequently disappears from this Ioi?ality. to appear 
in the lower limbs and in the barks of the hands. Dropsy due to t'<ir- 
diac disease usually ajipears first over the instep, and gradually extends 
upward, involving the limbs, trnnk, and serons cavities. 

SuhcutanettHs fimphtfsema may be caused by internal or external in- 
joriea of the larynx, the trachea., or the lungs. Air escaping from the 


larynx or the trachea causes emphysema in the region of the throat. 
Kupture of the air cells from over- distention, as in croup, diphtheritis 
of the larynx, whooping-cough, bronchitis in children, and emphysema 
in the aged, causes subcutaneous emphysema, which appears first in the 
areolar tissue of the neck, and subsequently extends to the chest. The 
air in these cases finds its way into the mediastinum, and thence to the 
neck. Subcutaneous emphysema from external injury appeitrs first on 
the chest. 

Alterations in the form and in the movements of the chest may be 
most advantageously studied when grouped together as they occur in 
differen t thoracic diseases. First, let us consider the modifications found 
in pleurisy. 

Pleurisy is divided into threo stages: first, a dry stage; second, a 
stage of liquid effusion into the pleural sac; third, the stage of resolu- 
tion or absorption. In the first stage we find decubitus upon the sound 
side; respiratory movements rapid, short, and catching. 

In the second stage we usually find movements of the affected side 
diminished, and intercostal depressions less marked than in health; im- 
pulse of the heart displaced to the right or to the left, according as the 
left or the right pleura is distended. 

In the third stage, the signs of the second stage gradually subside. 
Sub-acute pleurisy manifests the same signs as acute pleurisy, with 
excessive exudation. 

Chronic pleurisy at first manifests signs which do not differ from 
those of the second stage of acute pleurisy. After absorption or evacu- 
ation of the liquid takes place, the affected side becomes retracted and 
fiattened; the shoulder is depressed; the inner border of the scipula pro- 
jects like a wing and respiratory movements are limited. 

In pulmonary emphysema^ on first sight of the patient wo notice a 
dusky hue of tlie countenance, often a sunken condition of the cheeks, 
marked general emaciation, and more or less turgescence of the super- 
ficial veins of the neck and upper extremities. The nostrils dilate on 
inspiration, and there is a peculiar drawing downward of the corners of 
the mouth. There is elevation and drawing forward of the shoulders, 
with anterior curvature of the spine, giving a young patient the stooj> 
ing appearance of old age. 

Inspection generiilly reveals the peculiar form known as the barrel- 
shaped chest. In this condition the antero-posterior diameter of the 
chest is incrciiscd {Fig, 3), its surface is rounded, and the upper ante- 
rior portion stands out considerably beyond its normal plane. Lat- 
erally, the diameter is diminished, and its inferior portion, in the region 
of the false ribs, is more or less retracted. The elevation and drawing 
forward of the shniildors cause the neck to appear unusually short. The 
scaleni and stcrno-cleido-mastoid muscles are hypertrophied and promi- 
nent so that they stand out like tense cords, resulting from excessive use 



of these roueolee whicli elevato and fix the anteriur .ind tipper part uf tbo 

Inspiration is short and qnirk, followed by prolonged and sometimes 
labored expiration. With inspinition, the iiuterior iiud HUperior portiouK 
of the ohoet are lifted as though composod of a single bone, uiid there 
IS iip]iiireully no auteiior ov Iiitcntl expunsiuii of the chest wiilIs, huoaUBe 
tho ribci »re itlreiidy rolnted it8 far att tlieir urticiilation with the spinal 
column will permit. The ribs Iihto less obliqnity, forming with the 
, costal cartilages more obtuse angles than in the normal chest. 

The iutL>rcoBtal spaces above are much wider than nsiial. but at the 
lower, lateral portion of the chest the ribs are closer together than iu 
the norraiil romlition, sometimes even to the oblitenitiun of inWi^pacea. 
In well-marked c'i8eH there i» generally with ini<inratiun retraction of 
the inferior ribs instead of lateral expansion. This falling in of the 
thoracic walla is not noticed if the disease is slight. 

Sometimes wo meet with local emphysema, where a single Inng or 
only one lobe is alTectcd, In suoh ins ances wc notice local bulging of 
the chest, with loss of motion. 

In extreme emphysema the anterior margin of the left lung overlapa 
the heart, so that llie apex cannot strike tlio chest wnll, hence no ira- 
pnlse can bo seen. In milder cases the impulse may bo seen closer to 
the Hternnm than in health. 

Jr pneumo/ild, upon first jrlance we generally notice a dusky flnsh 
©f the Jieek and accelerated respiration. Inspection of the ehcst shows 
diminished motion over the diseased organ. This loss of motion may he 
tna ked, hut is si-ldom or never comiilete. 

/i p hnonary jthlhisin, the signs obtained by inspection are of non- 
•idortiblo value. If the case is advnnccd the chest wall over the diseased 
lung will be depressed and its movements restricted, in phthisis more 
apt to o:'cor at the apes, uud contntry to tlic general belief, quite us 
commonly ujioii the rigbt us upon the left side. These phenomena 
duo to local shrinkago and loss of pulmonary elasticity. 

Jn pncwr.othoritx wo obsarvo distention of the chest, proportionate 
to the tension of the air or gas in the pleural sac, and a corresponding 
loss of motion. 

With groat distention there will bo no motion of the lower ribs, but 
]>roroincnce of the spaces between thom. 

JCxcepii(ni<il.—la some rare cases of tins disense the upper portion of fh« 

lITected s'kIq itoi.'mit \f* move mere tlmn thecorrenpondlng' pnrt of the suurid siile. 

Thi.1 19 Jne lo lh« cxtn>iiio cITorl* on itispirulion by wliiiOi tlic Miprrior ril« 

are tiflcil direclty tipwut-il n» in vmp)iy»eiua, Ihoti^h thofe is little ur no iinterior 

Tlifilrothfirax presents a condition, on hotii sidcfi, similar U> that 
found in pleurisy with effusion upon one side: hence lofis of motion and 
more or leas bulging of the infra-axillary regions. 


Pericarditis, if the ainouut of effu^iiou is fiutliuient, causes oonsiooiu* 
ble bulging of the prscordial regiou, eB|)€cially in children; but Id older 
pntientR, on account oE the firraneea of the cartllageft, this is not so likely 
to occur. Thery is uUo tiiminution of the rcspinitory movemouls on 
iho left side, due to jiressurc from tho distondod pericardiura. 

Cardiac hypertrophy wUq occasions local bulging, most marked in 
young patients. Tho impulse, if visible, will ha seen to the left, below 
its normal ]iosition. Its urea will also be iucreased. 

Tumors within the thoracic cavity cause bulging when of sufficient 
size to press upon the parietes. If the tumor be ancurismal or solid and 
rest upon a large artery, it will usually pnlKite synchronously with tho 
contraction of the heart. An enlarged liver or spleen may occasioa 
local bulging. 

In cases of pneumothorax and pleurisy with great effusion, we ob- 
tain valuable infurniation by exaniiriing tho impulse cjuigfd by the apex 
of tlio lieart, which will be seen crowded from Its normal position toward 
tho unaffected side. 

/« membramiHs croups oedema glottidis, foreign bodies or morbid 
growths in the larynx or in the tnicbea, the amount of air entering the 
'ung is considerubiy less than normal. This has the effect of prolong- 
ing inspiration and rendering it laborious, though expiration is not 
notably affected. Hero the respiration is not quickened as in most pul- 
monary diseases, and it may be even slower than usnal This diffora 
^rom cinjihysema in that here there is obstruction to inspiration; in 
emphytienia, tho princi|wl interference is with expiration. 

Wlien the obstruction in the larynx or trachea is considerable, wo 
observe sinking in of the soft parts of the chest above the claviclo and in 
the intercostal spaces, especially at the luwer part of the chest, during in- 
spiration. This is duo to atmospheric pressure from without, as tho 
chest walls expand more rapidly than air can enter through the ob- 
structed passage to fill the lungs. 

In chronic br»nt:kitis the signs obtained by inspection are of little 
value, though we may occasionally observe prolonged expiration, and 
in some instances irregular pxp:insIon of the chest, in different parts* 
due to plugging of the bronchial tubes by secretions. 


Palpation consists of physical exploration by the sense of touch* 
oither with the tips of tho fingers or the palms of the hands. 

In practising palpation upon the chest, the palmar surface of the 
hands should be used, and in many instances it is desirable to cross the 
I'uads so that, aa one site in front of the patient, the right hand rests 
"|>o»i his right side and the left up<)n his left side. If the signs aro 
*^"Jy slight, we thus appreciate them more clearly. 



By the sense of touch we appreciate slight alterations in Ihc move- 
oienta of the heurt mid thorncic wulls; we sometimes detect the presence 
of intrii-ihoracic tumors which cuut>e no bulging of the surfuce, aud 
deleruiine their nature, wbeLher hurd, soft, ur pulsating; tind we may 
diHerentiiile between the pain of intercostal nearolgia aud thftt of 
pleurodyniA or pleurisy. 

The iuformutiun rt-giirding size, form, nnd moTementg obtainable by 
this method is esaentiiilly (lie same as that furnished by inspection. 

NuftM.vL vutjAL FitKUiTCd is a peculiar vibration which will be 
felt if the hand be getitly placed upon the chest of a healthy person 
while ho is speaking. It is produced by the trangnii^sion to the chest 
wall of tfao vibrations of air in the brouchi, C4Uiscd by the act of speak- 
ing. Moditicatious of vocal fremitus are unioug the most important 
Bigna which are obtained by palpation. 

The normal vocal fremitus varies in different individuals. It is not 
usually marked in women and children. In males it will be found more 
or less defined in proportion to the pitch or force of the voice. Voices 
of low pilch cause a more distinct fn'niitus than those which arc higher. 
The distinctness of this sign also depends upon the thickness of the 
chest walls, the diameter of the bronchi, the proximity of the bronchi 
to the parietes, and the distance of the point examined from the larynx. 
It is therefore more marked npon the right than npon (he left side, 
aud in the infrn-clavicuhir region than in the lower part of the chest. 

In women, this sign may be obtained over the upper portion of 
the chest, but is seldom found over the lower part. In men it is usu- 
ally perceptible over the whole chest. 

Xonual vocal freniiLus rnay be increused,diminis}ied, or abolished by 
di»eaee. As a ride, it is tULreased by all diseasi-s uiusing consolidation 
of lung tissue, ns phthkis, jnieunionwy mUmo, and apophj:t/ of the lunge. 
It is gcnerully increased by tlthfation of the bfonchiul fifftem, in which 
CflKt there is more or less induration of tlio parenehyma of the lungs. 

f'xreptional. — In pnc'umonia, w \wn tbo l^ronchtul liilies are completely filled 
by Utc iiilliinmiatory depo^^it, vocal frpniitun ctiunot ho r<>U. 

Owing to the great variation of this sign in different individuals and 
to ilif mutations in disease without ck-arly deiined causes, it is not of 
yery much value when taken ulone. 

Vocal fremitus is diniiiiisbed or suppressed by any diseHse caamng 
separation i\t the lung from the chest wall by the intervention of air, 
pn»«, «r fluid. In /meunKiffionix, hijdfotlior'ix, and j>/euriiif wiih effusion, 
nlwcnce of vocal fremitus over the air or the (laid is a sign of great value. 

£!wej»f/«7rrt7,— Presence of vocal rn>mltiis is not always a oortain Men iliat 
liil di.f-» DmI I'KiRl, Oil Bttown by a fow rarpcunes. ITtlifn- is hut a»>mnllcu1. 
-rtion of an- or tlui>l in the pleural sao. vocul rremitiiH may beKJm|»ly diminnhedt 
and ia miilii1i>culiir pleurisy it remains over the bauds of adhesion. 


In emphysema, rocal fremitus is diminished. 
- Aneurismal or other xntra-thoracic tumors cause diminution or ab- 
sence of vocal fremitus directly over them, providing no lung tissue in- 
tervenes between the tumor and the chest wall. 

Vocal fremitus is principally of value in difiEerentiating between con- 
solidation of lung tissue and fluid in the lower part of the chest. When 
lung tissue is consolidated, fremitus is increased, but when there is a col- 
lection of fluid, it is absent. Exceptions to this rule are unimportant. 

Friction fremitus, vibration caused by rubbing together of the 
roughened surfaces of the pericardium or pleura, is indicative of inflam- 
mation, with exudation, which causes roughening of the serous surface. 

Bronchial or rhoncal fremitus is the term applied in acute or 
chronic bronchitis, especially in children, when secretion is abundant, 
and the chest walls are thrown into vibration by air bubbling through 
fluid within the bronchi. The vibrations communicate to the hand a 
distinct bubbling sensation, which cannot be mistaken. 

Fluctuation of fluid within the pleural cavity may often be felt in 
the intercostal spaces by the fingers while tapping at a little distance 
■With the fingers of the other hand. 


Mensuration is rarely used, since inspection and palpation give suffi- 
ciently accurate and more quickly obtainable knowledge of the signs 
furnished. Many instruments have been devised for determining the 
size, capacity, and degrees of curvature or flatness of the chest. The 
O'lly nieasurement of special clinical value is that of the circumference, 
in inspiration and in expiration, which may be readily taken by means 
^f 11 simple tape. 

A good device for tliis consists of two tapes joined at their extremi- 
ties and so padded near the line of junction as to form a sort of saddle, 
^'h:ch rests upon tlie spinous processes and prevents slipping. In using 
*^his ii.strument, adjust the pads to the spine and carry the tapes about 
the chest on both sides to the median lino in front. The exact amount 
^i motion of tlie two sides may thus be easily ascertained. 

In measuring with a single tape, place the thumb nail at a certain 
point on the tape, tlic first finger about one-fourth of an inch nearer its 
end. Then press the tape with the thumb nail against the middle of a 
spinous ])rocess and press the forefinger down beside it. This enables 
^"p to iiold tlie tape firmly in position, and, by preventing the skin from 
sliding in respiration, gives a fixed point from which to measure. It is 
'^'wiivs desirable to mark the median line in front before commencing 
thi^ measurement. 

The circumference of the chest may be taken above or below tlie 
^^Pples, but best on a level with the sixth costo-sternal articulation. In 
^*^cording cases, always note the level of the measurement. 

ME.y^iCIiA TtuN. 







The meusiircnieut should b« tuk»ii during butli full inspiration and 
forced u^tjjii-ution, ami tlie two results should hv oninpared to detenuiae 
the expHiisioii. The Iwu eidea must bo compared lo asconain whutbor 
either U diutended or deflciont in movonien^. Quniu and Onnoll in- 
vt-ntcd very sntisfactory Instrunifnts for taking these iiiuiitturi'iiif'iiU, 
kno»n fts ^tethometers. Qttttiu's instrunieut (Kig. 4j cunsittts of n cylin- 
drical box with a dial mid an imkx, moved byu ruck 
towhirh in iiltachei) a cord long enough to (joinpjLis 
tiie cheat. Eiich rotation of the indox about tho 
dial indicates one inch of raovemont. Tho box is 
plart^I upon tbu centre of the chest in front, and 
the ntring is carried liurizuutally around 
the chest; as the patient breathes, the r^ 

index revolvefi about the dial, registering 
necuniU'ly tlie expansion of the clieat 
walls. Carroll'^ Btethometer is ciinple and exact (Fig- o). Ordinnrily 
n simple tape is sufficient. 

Meii^urenicnts of the healthy chest, of course, Tary in difl'erent indi- 
Tiduala. The avragc in men U thirty-tn'o and one h;df inches, (ieiier- 
ally, the right side exceeds the left hy half an inch, but in Jeft-hiuided 
persons the rerereeis true. 

In flisfiiw, the atfected side may be distended or coiitnirted, and lU 
movements may be diminished or increased, conditions usually notlcca- 
blr on inspection and by palpation, but it Ig not uneomutou to Snd,upun 
men^irution. that a side which had the appeajfuuco of distention ia 

Fio, 4.— QfAix's STcntoMcm. 

I ' 1 ■ ■ 

FiH. n — 4".iii«i>u.ii SrKTHojiErEa. 

nnalleT than its fellow; frecjuently expansion, which hus seemed com- 
paratiTety free, w*ill bo found by the tape not to cxceetl one-eighth of lui 

The diseuses causing oxpansiun or contraction, and loss of move- 
menu of the chest walls, were mentioned under inspection. 

The tninsperso diameter of the chest may be uliti.ined by means of a 
pair of calipers, or by Flint's cyrlunieter (Fig, 0). 

Gee*a cyrtouieter, cunsiatiug of two pieces of conipositlou g:i8-pipe 
joineil tugether by uicaus of a piece i)f rubber tubing, is the cheapest 
and prrbupB the best instrument fur aacertaiuing the transverse outliua 
of the cheat. In using it, the joint is places! upon the apine^ und the 
piece* of pipe are accurately moulded round the chest. The instrument 



b then removed and laid on jwipor, vhon an exnct tracing can be maie. 
In a well-formed chest, the an tero* posterior diameter will be to the 
tmnsveree diameter in men as tbree to four, in women as four to Sw 
(Fig. 3). Scott Allison invented an instrument, known as a stetho- 
goniometer, for measuring the curve* or the fiatness of the surfcicfl '>t 


Ito, «.— FuKT** CifirroiimB. 

no. r.— ftPiRoxcTsa. 

the chest (Fig. 8). It has been claimed that the infra-clavicular space 
should always bo convex iu hcnltli. With this instrument the cnrvn- 
tures could beaccunilely u^certairicd, but unfortumitvly the information 
iaof very little vulue, because, iu healthy individuals, this region is often 
Hat or evfu concave. 

Spiromelers are used for measuring the chest capnciiy. Hutchinson 
wu, I think, tho inventor of the epirometer, but muuy modificationa 

WjQ. 8.— A.UiBOf*« BrrrRoooxicMnTEit. 

have been devised. Recently portulde instruments about the bIzq of a 
watch Imve been made. In on© of thciiOt as the patient inspires, or 
blows into tbo tube, tho iiirlcx revolves on the dial, rtgisteriug the num- 
ber of cubic inches of iiir inhaled or expired. 

Hutchinson found Ihnt people five fwt in height usually possess a 
vital capacity of one htindrod and sovputy-four cubic inches, and for 
t tt height above five feet, eight cubic inches should be added 


pumwAL DiAoyosia, 

uals Ave feet eight inches in height possess the muximam respirator; 
power. Ilia iustrnmcnt (l''ig. y) consists of a bene glass tube fastened 
to a graduated aculc, aud JoUied iit each end by a rubber tube, throogh 
which the patient is to brcutbe. The instrument Is portiully filled with 
mcrcnrj, whic]i rises on one side or the other us the patient inspires or 
expires through the mouth-piei-e jiiid falls after he censes. 

Hammond found the expiratory power much greater than the 
iuBpiratory, the uverago man being able to raise the column of mercury 
three inches by expiration, and only two by inspinition. This is a fad 
which at once explains some of the phenomena of disease. For insUince, 
Lnennec's hypothesis as to the cause of pulmouary emphysema was baeeJ 
upon the supposition that the itiHpiratory jiowcr was greater than thh 
expiratory, a supposition clearly untenable after Hammond's demon- 


SuccuBsion, the fourth method of physical explomtion, was known to 
Hippocrates. It consists of suddenly shaking the patient's body wliilo 
the ear is placed against Iiis chest. 

When air and fluid occupy the plenml sac, this proceeding will causo 
a splashing sound. The sign is of value in pnenmo-bydrothonix (Fig. 
2C). The succiission sound wiH v;iry more or less in quality with the 
density of the fluid. Thick pus will not yield the 8.ime sonnd as thin 
semm, bnt the quality of these sounds is not usually snfficiently distino 
tive to aid us matcriully iu our diugnosis. 

Meiailic tinkling, due to dropping of fluid from tho tipper part oi 
the cavity into the effusion below, cua usually be heard wlien the sdcco* 
fiioD signs are present (Fig. Z^), 






Percussion is the art of eliciting eoiind by striking with the flngcn, 
cr with iiietniments coiitftructed (or the purpose. 

As a meaus of diuf^nosis, it is gencTAlly 6up]>oscd to hare originated 
daring the lH*t ufinlury witli Avcnbriigger, a physician of Vienna, hot 
the WL>rk8 of Uippocratea iuUic-utc timl he wua fiimlliur with ii, to a 
limited extent. 

Ilippocnites and Avenbrnffger recommended ivimpttiafi percusnion, 
in vhiuU ihu blow is strnck directly upon the chest walL 


This form of perciiseiou h:i8 been nearly supplanted hy one which 
ttriginatod about sixty years ago, with M. Piorry, termed tnediate pereu9' 
tuotif in which the blow is received on some intervening substance. 

Before mediate percUHfiion was employed, ft was quite esseDtiat to ioteosify 
Uic sounds; tbia was accontpHsheU by pliicing' the patient with his biick against 
ft hollow wall. In some women the sij^na elicited by inimcdiale percussion are 
quite distinct over the upper part ol the chest, but usually Ibis method is very 

In mediate pnrcuesion, a small hammer or plexor and an instrument 
known as a jdeximeter or plcs^imeter are employed. The hammer in 
common use consists of a cylindrical rnbber head attached to a light 
handle abont eight inches in length. Metallic hammers fciced with 
robber, 08 sometimes used, are objectiouablo on nccount or their weight, 
which renders the bkw so forcible that it is apt to cause pain. 



Pleximetere are made of tarioiis mnterials, as rubber, bono, wood, 
ivor)', or leather. Some of Ihem are graduated in onler that ihay may 
be used in menanration. Among tbe b«st ia one wliicli cutiBit<ta of 
B narrow oval diac of hard rubber, with largo ears at each extremity. 

It a1iciii1<l be narrow enonsrh to lie placed between Uie ribs* find sliould have 
alarpra pri>j<H:tiua at each etui, tliat It inuy be firmly gni^spixl. I have fretjuetitly 
Us«<1 a smalt cvlinJur of sort lulilter about two inclu*!! I'titi^' and Imtf nti inch in 
diuniotrr. It has tlic ndvaolago of being easily adapted tutlioiiiLorcosUiiBpaocft« 
and of emitting no sounds of its own wlien Ktruok. 

For ordinary percussion it is best to use the middle or index finger 
of one hand in place uf the pleximcter> iiud two or three fini^'cre oX the 
other, with their tips brought into Vmv, us a hiiininer. The £ugi>rs used 
as u plexor should be brought as nearly as possible to a right angle at 
the second joint, that the terminal phalanges may strike perpendicularly 
upon the finger of the opposite hand. 

When the fingers are used, there is noticeable a certaiu sense of 
resistance which ia not obtained with Ingtrumunta. Often tliis would 
raable ns to detect internal organic changes even witli our ears com- 
pletely stopped. So raluablo ia it in intricate cases that, when there is 
difficulty in making an accurate diagnosis, I always employ the fiugcra 
instead of instruments for percnssion. 

The sounds obtained by percuseiou arc generally described as clear, 
dull, and tympanitic, but these terms are not sufficiently precise to aid 
tis much in studying the method. I prefer a clasttiflcution based upon 
acoustic properties. The elemt-iits of sound which concern us in per- 
cussion are intensity, pitch, quality, and duration. 

The intensity of a sound determines the distance at which tho 
Bound maybe heArd. Other things being eqnni, the intensity of a Bound 
in pulmonary percussion varies with the furcu of the blow, the volume 
of air in the lung, and the thickness and elasticity of the chest wall«. 
It is diminished by thick layers of fat or muscle, by rigidity of the costal 
cartilages, and by coutmctiou or consolidation of the lung, and it ia iu- 
creuscd by the opposite conditions. 

The pitch of a percussion sound may be high or low. Those famil* 
iar with mnsio will understand this, hut a common mistake is to con- 
found pitch with intensity. Many students suppose that the higher the 
pitch, the greater the intensity. The reverse of this is usuallv true in 
pulmonary percussion, intense sounds being low pitched, and high- 
pitched sounds possessing feeble intensity. 

This difference Between pitch and intenBJty can be easily recognized by 

•trikin^' two note« at opposite etuis of Itie keylioaol or a piano. By striking a 

bfgh note forcibly, one will obtain n notind tuuO enough to bo heard Boinc dt»> 

tance ; then by gently tappmg a key at tlie other end, one will obtain a sound 

[^beard at exactly the same difiiance, but of a much lower pitch. 

■» pitch of the percussion note over a healthy lung is always low. 







but it will vary iu different pwrtiona of tlie chest, owing to difffrence ia 
tlif; volume of air and Iho position of other intra- thoracic orgiuitj. 

Quality of sound is tliut element by vrhieh we distinguish botveea 
thv tones of musical instruments, or of voices of different individual^ 
liuviuj;, it ntiiy be, tlio same iutensity and pitch. 

In pulmonary percnssion, we obtain a peculiar quality tenned vesic- 
aliir, impossible to describe, but always to be obtained by percussion of 
the healthy chest. It is soft and low iu pitch, and -usually seems as 
though coming from a point, a couple of inches beneath the surface. It 
£au be learned only by studying the healthy chest. 

DcRATioK of the healthy iitTCUssiun note depends upon the same 
ctinst^ as its pitch. If its pitch is high, the duration is short; if tho 
pilch is low, the dunition is prolongbd. Indeeil,a definite relation exists 
between all these different elementis; that is, intense sounds are opt to 
be lowpitolied; those which are feeble are generally short and high 
pitched, and, instead of the vesicular, they possess a solid character. 

I'erciiesion seems very simple as practised by an adept, but accuracy 
U not ucouired without much practice. 

Certuiu rules essential to accurate percussion should be early fixed in 

The surface of the chest should be bare; but if for any reason this 
cnnnot be secured, have the covering soft, thin, and smooth. It is abso* 
lately useless to percuss the chest of a patient who has on one or two 
shirts and perhaps a chest protector or corset. 

The patient should bo In a comfortable position, whether sitting, 
standing, or lying upon the back, and the two sides must be relatively 
symmetrical. The fii-st two }}ositions are preferable, but very sick pa- 
tients should not rise for the examination; it will be belter to make a 
less critical examination than to endanger the patient. 

Persons suffering from diseodes which catiitR feebleness of the heart sliould 
not be askod to sit or stand. Illiuliutitig the importance of tliin ctution, I have 
Men cases of sudden death from ovcrtaxinj^ of a weak heart, by nlight exertion, 
•urh as the getting out of bed of a patient convalescing from pneumonia or 

Do not allow the patient to twist the body or move the arms during 
percussion, as such motions change the relations of the mnsclos, and 
thus alter the percussion note. 

The physician's ear should be squarely in front of the part percussed. 
If he stand partially to one side, the signs obtained on that side, even 
though the stune as those ou the other, will reach the oar with & different 
tone. His position should be easy and unrestrained, or he will not 
recognize slight differences in sound. 

Iu percussing any particular region of the chest, aim to hare the 
chest walls as thin and tense as possible. To secure this on the anterior 
portions of the chest, the arms should hang at the sides and the shoulders 



ahould bo throvu backw»ril. In examiniug t)io latenil regions, it i^ 
to liave the hands rest npon tbe head. If the arras aie held ii^j^- 
musyk'S stand out so prominently tluit they xutcrfere with obtuinin^ 
|»uInioMiiry resommcc lii percussing the posterior regions, the tir*- 
should be bent forwurd mid the arms eruttfied in front. 

In jHtrciiHsing the chest, compare i-orresponding portions of tlw "^ 
Gid;.a. If irhuiiges from the uorniiil are slight, they can he detected 
no other way. Ordinarily it is snfiipient to repeat a series of strokes Q.^* 
on one side, tlien on the other, or to percuss both sides repeatedlv' -* 
quick succfssiou. Howi-vlt, the ptTcussion soniids thcv sliglilly at tli-^ 
ferent periods of tho act of respiration; therefore, whenever tl»* 
changes are so slight as to require great care for their discrintinatiuii^ 
the sides should ho compared dnriiig the same sljige of the respiratory^' 
act. The best period at which to make tlie coiupariso?! is at the closff 
of a forced expiration. 

£AXcytional. — Iti Imultli the two siiles are not ulwava uliku as re^rtls OU* 
parily |i<>twi>cn the noU- «>licite<l in Full inspirutioti und Diat ehcit«tl id forced ev 

In applying the finger or the pleximeter, be rareful that it presses 
evenly ujion the surface and disphices all thy air beneath it. Otherwise, 
tho resonance of the pleximeter is obtained instead of that from the 
cliest, and at the same time the air is suddeuly forced out, causing a 
sound very similar t<> cnieked-jfot resonaucf. 

Tlic force of tlie stroko should be moderute, never grciit enough to 
cause the patient pain, and alike on both sides. In percussing super- 
ficial portions of the lung, the stroke should he very gentU', but to 
oht^iin the resonannu from dee])er jtarts it must be more forcible. Bf>- 
ginners commotdy strike much too hard. 

The stroke should be from the wrist ulone, whether made with the 
hammer or with tho lingt-r. When striking from ihe elbow, we cannot 
control the force of tlie blow. Some diagnusticiana are accustomed to 
strike ti siugle blow, first npon one side, then upi)u tho other; but I get 
better results by making three or four tiips in rajiid succession. 

The din^ction of the stroke shouM always be perpendicular to the 
surface of the uhest. If we percuss obliquely, insteail of obtaining the 
rosonanco from the lung immediately beneath the pleximeter, we get 
that from a ril) or from more distant tissue. 

In percussing near the sternum, in the upper iwrtioii of the chest, 
we obtain resonance from the trachesi instead of from the lung, unless 
care be tnken to direct tlie blow toward the central i>ortion of the apex 

The stroke should be a simple tap, the finger or hammer being al- 
lowed to rebound instantly, instead of resting a moment on the plcxi- 
meter, which has an effect on pulmonary resonance simibir to thai pro> 
duced by touching » vibrating tuning-fork. In percussing with the 
fingers, strike witli thoir tips, instead of with the pulpa. 


As tlio signs iu 11 htuiihy chest viiry in iU dillercnt regions, we 
must lake special puius to familmrize oarsclvcs with ull the beulthy 
sounds. Tlu're uru no two litallhj |ieo]>le vUoao cheats iiro uxactlj 
ulike, therefuro we can tako no oue peraou as a staiitlanl for cmnpari- 
Bon; but after percussing many heaHhy cliosts, we may form an ideal 
Btand&n! from which txo ^rrcat variation can occur without indicating 

Normal vesicular rfwnance is obtained most perfectly in the left 
iiifrn-cluvicnlar region; and this, bo in? tho sound obtained overtho puT- 
monary air vesicles, id taken as the i-tandurd for compuriaon in piihnu< 
niry percussion. 

In the riglit infra-clavirnlur region t!ie percussion note Is nearly the 
wme lis in the left, hut is slightly harder or more tubular in finality, 
owing, probably, to llic greater size of the bri>ncliiul tubes. 

Ill tlic middle of the supra-oIuvicuUir re>;ivu ilio resonance la soft or 
vciieular in f^unlity, but toward the inner ]iart of this region it becomes 
liardor in quuUiy or tubular and higher in pitch. Austin Flint called 
'iiii nn approaLl-. to tympanitic rviiunance. Kxternally in this region 
tbe vehicular quality is diminiiihed. In percnssing over the centnil por- 
tion of the clavicuhir rejiioti, tlie souml is fairly vesicular, but it bccomee 
IfM and less so toward either end of the clavicle. 

In the mnmmury regions the Bounds are altered on one side by the 
prcMtnco of the lici>rt, and on the other t^ide by tlie jiresence of the liver 
(Fig. 1). Iu the np]ier ]>art of tht- right niauiuiary region we obtain 
Tf-«iculu.r resonanoti extending down to llie line uf he[mtic dniness in 
tlie fourth intersjmcc. Helow this, where the lung overlaps the liver, 
dolneaa is apprec-i:J.ila on forcible porrusnion, gradually becoming more 
nnd more distinct as the lung decreases iu tbicknesg, until wc reach the 
lower border of the lung ut the sixth rib, the line uf hepatic flatness, 
U'low which wo lose all pulmonary n-^onanco. 

The lines of hetuitic t/ufncicf and of liepatic rfff/wp.-**, tlie flret along 
the upper m:irgin of the liver, the second at the lower margin of the 
lung, are ordinarily a'bout two inches apart. 

Extf^itional. — In d(>t>p inspiration the lowpr line may be carried ud Inch aod 
a li:iir or two inchps lower, and iu ftiri-'il>le expiniiion it may hv elevultnl ti-oiii one 
to tive iDch(» ; thei-efore the ar«a of hepatic diiluoss, IwIw-lmju the two lines, may 
v.Lry from two to seven or even eight inches. Thi^ wide ran;;e is not conimoo, 
but its DCGOsioDiil occiirTeni.-e shows tlie necessity for btudyiug the client in Uotli 
inspimtion and expiration. 

In the left mammary region pulmonarj' resonance exists ovpr the 
outer part. Near the middle of the region forcible percussion elicits 
curdioo dulncss. Near the etemuni the heart is superficial, covered only 
Ity the pcricitrdinm iind by cellular tis.siie; here there is a small, triangu- 
lar space yielding flatness. It iu about an inch and a hulf wide at ita 
bue, which corresponds to the eixtli rib, and extends from the fourth 



to the sixth cosiiil cartilnge. The ajiex uf thiti triangle is looat«d at tl 
margin of the ttlernvini en a level with the fourth rib. 

The rcsoimnc^e of tlie mammary region is modifled more or less by 
the thickness of the muscles in men and by the mammary glands in 

In the infm-ranmraary region, on the right side astmlly, there is 
nothing but the liver to ufTect the percus&iou note, hence we h%V9 a 
«onnd termed flatne^g, like that obtaintMl by percUHAiug the thigh. If 
the colon be distended by gas, ue obtain tympanitic resonance if> I tie 
lower part of this region. 

In the left infra-mammary region flatness caused by the left lol> of 
the liver extends a couple of inches to the left of the median line. In 
the outer portion of tiiis region we obtain n similar sound from the 
Bpluen. and between the^e two orguus we elicit tympanitic resoD'-jied 
from tlitt stomach. 

In the upper sternal region, as low as the level of the second costal 
cartilage, the sound is tubnlur, or, according to Flint, tympanitic. 
This is due to the presence of the trachea, the sounds of which are 
modified by the anterior borders of the lungs which are in apjiosition 
throughout this region. Below the level of the second ribs, uii light 
percussion, pulmonary resonanco may be haird, though modified by the 
timbre of the bone. But deep percussion gives dulness, resulting from 
the presence of the great blood-vessels. 

Over the lower sternal region, by light percussion, pulmonary reso- 
nance is obtained to the right of the mediuii line, while on forcible per* 
cussion there is dulness. Left of tbc median line, the heart is super- 
ficiu! and yields flatness. At the inferior portion of this region, flatness 
is duo to the left lobe of tlie liver. 

Over the scApula, the vesicular sound is indistinct from the thick- 
ness of the muscular tissue, but above the spine of the scapula it is 
much more marked than below, and in the upper purl of this region it 
is quite clear. 

In the inter-scapular regions the sounds are hard in qnality and 
high pitched, because the clipst walls are thick. There is, however, in 
all cases some pulmonary resonance. The pitch is a trifle higher on the 
left side on account of the aorta. 

In the infra-scapular regions the vesicular resonance is well defined, 
though not quite so cloir as in tbc infra-clavicular region. It extends 
downward to the tenth or eleventh rib. On the right side we find the 
line of hepatic dulnetiii at tlie eighth rib and tlte line of hepatic flatness 
at the eleventh rib; but these vary from one t<> two inches during forci- 
ble respiration (Fig. 2). 

On the left side the resonance is slightly modifletl near the spine by 
the nearness of tlie liver. Belnw the tenth rib the intestinal canal, if 
flUed with gas, causes a tympanitic sound. In the outer i>art of this 



region, bctirccn the ninth and clevonth ribs* dulness is obtained over 
the spleen, and for a short distance about this dull region renouunco ia 
rendered more or less tymprtnitie by the stomach and intestines. In the 
lower piirl of tho left infra-^cupulur region, close lo the spinal column, 
dulnesfi is found over the kidney, and it occurs in a similar position, 
though a trifle lower, on the right side. 

In the axillary regions the resonance is often more marked than in 
the infru-clnTicuIar. 

In the iufni-Axillary region the resonance is modified on the right 
eide by the liver, and upon the left by the stoniuch and spleen. 

In this region the margin of tiiu lung passeu obliquely ilownwiird 
und hiickward from the anterior boundary neur tho sixth rib to the jk)»* 
terior near the tenth rib. On the right side, heputic Hatnesji is funnd 
below this line, and hepatic dnlness a wmple of inches higher. On tho 
left side, below this lino, we find tympanitic resonance in front over tho 
atonuich, and dulne5$ posteriorly over the spleen. In this locality the 
pulmonary rcsouunce is often modified by the stomach, aa high as the 
fourth rib. 

The SIM of the spleen varies eonsidorjibly, even in health. The area of 
dnlne^swhich it raiises seldom exfeoils twoand nn«-hal( inches in height 
by about four inches in width; about half of this dull space is in the 
infra-Bcapalar and half in the infra-axillary region. 

ExvrptiwicU, — la fri-c cases the spleen rises as high ns the lower Ixiundary of 
the axjllai*y regiun, or tho stomach may yield tleciiled tympaoitjc resonance as 
high ati tlie fntirtJi rib. 

In the irtf rA-scajiiilar rrcnon, upon tim H^ht side in children, dulneu is some 
times very pronounced, due to the disproportionate size of the liver in early life 
This ia not infrequently niistakea for the consolidaliou of pneumonia. 

The percussion sounds in different regions of the chest are modified 
by age, sex, and various idiosyncrasies. In old age, the chest walls are 
leu elastic than in middle life, and the lung has undergone some change 
which renders the sounds Iiardcr in quality and higher in pitch. In 
children, the lungs are very resonant, and the costal cartilages are elas- 
tic; consequently we obUun a low-pitched, intense vesicular sound. In 
men the percussion note over the upper portion of the chest i« not 
nsually so reeonant as in women, bnt it is more distinct over the lower 
portions. It will be seen, from wliat has already been said, that there i« 
notable dissimilarity of tho jwrcussion sounds on the two sides in the 
mammary regions, as also in the infni-niammary, infra-axilbiry, and 
iufrHrBcapular regions. In all other portions of the chest the resonance 
U nearly identical on the two sides, bnt the slight normal disparity in 
the infra-clavicular regions is a point of great importance 


In disease, the percussion sounds may occur in every gradition from 
normal to tympanitic resonnnce or flatno&s. These Tarieties h;ive been 
varioutily clufsiliud. I(. E. Tbonipsou classifies tlicm as t:\cuT, dull, tym- 
puiiitiu, amphoric, und cracked-pot rcsominco. Flint itrniuircd lliem 
ucidyr six heiuis; and A. I*. Looniis under seven, «s follows: Kx;iggeruted 
pulmonary resonance, dtilness, llntness, tynip»nitic resonance, vesiculo- 
tjmpuuitic rosonimce, amphoric resonance^ find cracked-pot resonance, 
or the crackod-metnl sound. 

ExACGEiiATKiJ PiLMJNARY BESONAycE differs from tbo normul 
vustculur sound only in ils intensity. The pitch and quality are the 
Biinie as iu health, but the intensity h increiuted. This sound is obtained 
over lung tissue which is rpcciving more air than uHUHl,and which mighl 
therefore be said to be in the highest degree of hejilth. 

The sign is therefore only negative, as it is indicative of no disease 
whatever iu tbu place where it is obtuined, but ntthcr points to deficieuC 
action in some otht-r part of tho respiratory tmct. Exaggerated pill- 
mouai'y resonance, in adults, is very nearly the same as the normal reso- ■ 
tiAuce iu children. Tin- sign results from obgtrucliun to the entiiince of 
air into sonic portion of the reapiratury tract, wht'tiier from filling up 
of the air culls by intlanimator}* exudation as in pntniraonia, from nar- 
rowing of the bronchial tubes, or from collapse of the air cells. Pneu- 
monia of one lung or of a siuglc lobe of a luu^ causes exaggerated 
resouance over lieuUhy portions of tlie lungs. Compression of the luug 
from air or tlutd in the pleural sac giveti rise to exaggerated resonance 
on the sound side. If one main broncluis is oocluiicd, from causes 
vithiii it or external to it, resouance u exuggerated on the opposite side. 
In extreme aniemia exaggerated resoiiauco occurs on both sides, duo 
probiibly to a diminished amount of bloud in the pulmonary circuit. As 
the chest is practically a cavity with unyielding walls, diminution in its 
fluid contents musi cause a curre-jponding incrcitio in the amount of air. 

DtJLXESS indicates a small amount of air beneath the part percussed. 
It can always he uhtuintd in the lieatthy chest wlicre the lung overIa|>8 
tjie liver. Tlui sign ilitfers from normal vesicu'.ar resonance in having 
high pitch, hard quality, and comparatively short duration. Its inten- 
sity [•>■ usually less than that of vcbicuhir resonance. Varying degrees of 
dulness should be carefully studied on the healthy cheat. Over the 
liver, on forcible percussion, slight dulneas is fuund iu the fourth iuter- 
costul splice, becoming mure distinct, higher in pitih, harder in quality, 
and shorter in duration, as examination extends downward, toward the 
lower margin i>f the lung. 

ThiH sign, when obtained in a position which should yield vesicular 
resonance, indic^ites that something has occurred to diminish the nor- 
mal amount of air in tluit part of the lung. It is obtained over co/tsvli- 



wSd luagt from aimple inflammfltion or from phthisis, from com- 
prea«ion of the lung or from collapse of the air cells; orer coUcciivna 
of/tjitl in tho bronchi or in the «ir vesicles; over wotlcraie vxiidaliofni 
in the jjlcural sac separating thu luug from tho cliest walls, but t-ffutiions 
of Miy conaidcrablL' umouut deatroy pulmonary resonance entirely, giving 
flittnc;^. BuhifSH lA ulst> ohtaiiiciJ over intni-lfKrrfiKtc linfwr», wlicUiur 
*oliJ or flujilf jtrovidoil n small portion of lung tissne containing air 
intcirencs between tlicm and tho thontcic wall. It is one of the signs 
found in pttcumonui, jfhurifi^, jjhlhisvf, atelectasis, and in irttrfhthoracic 
abtKtJUoitf tittcunstits, and tumtyrn. 

Exceptional, — Dulness rei«ults ocutisionully from pulmonary apojileicy. In 
ftuvh cnM^s it is usuully fouml ut thu lower angle of tlic Kt^iimliu II ttmy un.>u 
fonn bn>wii jnt)ui':itton oT iJie Inn;;, due to a vuric(Wf> conilition of tlie |iiilinonai'y 
witLt. lu Ihis diseaBe it in found near tlie middle of tli4 luti(pi on iMttJi fvides. 
It may arise from eiilun^od bronchiul ^IudiIs, anti in a Tew iiititanres it in 
found in Ikroncliitis over the apex of the Itingii, or more clearly at the lower pes- 
tvhorii .rtoftlie clieiit, due to u collection of secretions witlitu tJio bronchi. 

Flatxess differs from dulness in complete absence of vesicular res- 
OHKnce. Dulneea indicates that there is some air bcuoith the point at 
fbicli the titroke ih nmde; fhitne^!!, ihiit there is none. Duliietis i^ oh- 
lined over that ]«>rtion of the liver overlapped by lung tissue; lljUnegg 
over that portion hL>1ow the sixth rib, which is Kuperticinl. Dulness 
occurs in pleurisy wlicrc the exudation has «opiiratp(I the lung a short 
distance from the cliest wall and caused u corresponding diminution in 
the volume of air. Fhitne&s will he found in the &ime disease, when an 
eSuiiion of scrum lifts the lung above it, removing all aii'-oontiiiniiig 
tissue from benciith the potut percu>?sed. 

Fbttness is found bijikuri^y with effusion oftencr than iu any other 

Excti^iontil.^Xn rare coros of pneumonia Uh: iiiClammaliun nms to k< toll n 
height Ihiit not only the air celU, hut also the bronchia) tubtv are tilled with the 
exuOution, iini) in nuch caaes absolute tlatue<t» in found over the lime tiKxiie. 
Aj$atn, whet) ihc lung become« completely collapsed from pressure or obstruc- 
tjoo w( a large bronclius, flatnes* results. 

Tumors or ubscesees within the thorax> when thoy rest ngainst the 
cbest walls, cause Qatiiess. 

Tympanitic resoxasce ia the luiine given to the sound which may 
be normally obtained over the stomach or the intestines when filled with 
air or gas. It indicates a quantity of air enclosed tiy walls thin and yield- 
ing and not too tense (Oa Costa). 

Under certain conditions, this sign is met with over the thorax. 
Tyniiutniliu resonance is usually described as of higher pitch than the 
vpsiculnr sound. Its duration may be longer or shorter, und its quality 
IB hollow, conveying the idi'U nf more or less tension; it is nisu somu- 
vhat bard, metallic, and ringing. Statements of diHerent authors 



oonBict concerning tho pitch of this sign. 
othGrs that it is lov. 

Samo hold tluit it 13 hi^h. 

It seems to me tUal tlie (luK:i'e|>uucy Iiiu urisvii f row tiiistukini: X\m riogiaff 
tnetalUc quulity ol the sound Tui' a hj^li jittclii wlicii it may reully be luw. I flod 
the WL-ii,-lit of opinion in favor of a. lii^lt |)itch. R. K. Thom[>so», in Ins UttJe 
work on iihynit'nl <.-x»iiiiik:ition of tlie L-liest, Matesttiat the pitch of thU fti^n niay 
be eitiier higli or low : biL^li when the tension uf lliu volimiu of air b grcati aad 
low when it is sli<;ht. 

This variety of resonance is never found in thfe healthy chest, nnlo?a 
it bo transmitted from some of the orginis hencath the dinphn^gm ; it i* 
frequently obtained below the fourtli rib, on the left side from gitseons 
distention of the stomach or the iTitcstines and occasionally ovtr the 
infra-nianmmry region on the right side ■nOien the colon is distcudetL 
W)ien obtained over jiortions of the chest which ahoiild yield a vesicular 
sound, the i\gT\ usually indicuteti a collection of air ur gas in the pleural 
sac, i)8 in pnenniothonix. Occasionally it is found over a large cavity 
in the Iting tissue containing air. 

Pulmonary cavities are generally produced by phthisis; hence the 
rule, that there arc only two dii^eases of the chest, pucuniothoi'ux aud 
phthiais, in which this sign is found. 

S-rcejitionnl. — Ttiittnian, Geo, and some others claim thnt this voiiMy of 
remnani-e ftoiiiftlmes i-esults from diminished leu&ion of the j>ulmuiiary (wrsii- 
cliytiia, and may hi! found m aay condition causing' parlial (-oUjipse of the lung", 

Pe)Ti>ct tymitanitic resonance may be obtained in tliat very rai-e coatUlion la 
which air or gas collects in the pei-jcaidium. ]t is said to be found io some cases 
of emphysema and of acute tubeix-'ulostti. Accunliii^ to Da Costa, it is som^ 
times found in pulmoaai-y ccdema. 

Tympanitic reconanre from the stomach may be elicited far a1>ore !t8 
normal seitt, wlien the Itmg is retracted and tlic stomach and intestines 
are correspondingly elevated. 

Vesicclo-tvmi'Axitic resoxance is a quality of sonnd midway be- 
tween the vesicular and the tympanitic. 

This sign occurs in extreme emphysema, where the air cells and the 
chest walls are distended. 

Amphoric besoxaxce is a modified tympanitic sonnd which Hiiiy 
bn closely imitated by tapping the cheek gently when the mouth is filled 
witli air, bnt not mnch distended. The sound is liollow and somewhat 
metallic It is obtained in very much tho same conditions as cracked- 
pot resonance — that is, over an empty pulmonary cavity with yielding 
walls; but to producctbis sign the cavitymust communicate freely with 
a largo bronchial tube, so that the ulr can be driven quiclcly from it by 
tho ]>ercussion stroke. It is found also over collections of air in the 
pleuntl sac, when this cavity 0]>cii8 through tho luug into a large bron- 

Pulmonary cavities are generally caused by phthisis, but they mvf 


result from ulisccss. Amphoric re^biiitnce Utherefaru ii&ign ut pneumtf 
Ihvrax, jfhfhiifi'', uud jKissibly of abscvas or ijnntjrene. 

Bill Sound. — ^^^ltl^ listening' over a lur^ |iulnionuiy cavity. If percuKkin 
tie iiiutle on the opposttit Hide of lln* cliebl, tvilli one lat^o coin utrUtiag upon 
anoctier usod us a plcxtmeter, a ringing Wll tiounil will l>c heard, wliicti is S'Jiue* 
times \ery laud. 

Crackep-pot RF-rtoxAXCE {hruit tU }H>t fvh) may bo imitate*! by 
placing' tlio hands lonsely togellicr, psilm U]kiu palm, mui utriking upon 
the knee. It is doscribml ns rosembling tlic clinking of coin or tho 
iimhi^ of ft cracked metallic Vcttle. Generally the sign seems to be the 
resnlt of forcing air sudilenly from a |iiilmon.'iry cavity Uirough a small 
opening. It has been considered by some us diagnostic of n pulmonary 
cavity, but tbi* sign may occasionnlly be obtjiinod when no cavity oxistb, 
ftnd aomctinies even in healthy individuals. Something closely reijcm- 
bling this resonance is apt to be heard diiriug jiereussiou if the plozim- 
eter is placed lightly against the surface, fiu that air remains beneath 
and is suddenly forced out by the blow. 

It l<i ftaid that oc'OAsionaily tliiH &oiinil may Up oliritotl iu tlie bronchitis of 
ciitldreo, or just above the level o{ the fluid id pleurisy vrith etru^ion. 

As arule,oruckcd>pot resonance is significant of a cavity, bnt the ma- 
jority of cavities do not produce it. When found, it can seldom be 
beard more than two or three times together, and it requires on interval 
of re^t before it cm bo reproduced. This is probably due to the finmll 
opening into the cavity — the air, having been driven out, returns slowly. 


In pvrcuaskin with the onlinnry plexiinetei'i no matt^^r what fts material or 
Hk form of conslntction. all the lifwuo b«iioath it is thrown ftito vihratian. Tliis 
rvntters it n^xt tu iiii)>o«vtibIe todcdiie MJiarply tUo oittHiics of tlubu-vt wlieu solid 
tissue is ovcrl«ii|tf<l liy the hmp, lirN^atise iho pKixiiuoler covem too miich si>ace, 
uid tlic MiuiidR fi'oin the tLNsu(>!t containing uir ;ind froai thoKe whieli do not are 
blended. For instaDce, in attcmplinj^ to ileterniioQ the lower border ot the tiuip, 
overlapping the liver, wo coniniencc above udJ ]>ercuBs downward to tile point 
of complete flutoess, then upwurd U{:uiQ to a point where the vosieutar rviionuiiee 
is clear, and thus hack and Tortli, until two U4lj:iccnt points uro reached where 
vre olitain on the one hand quite (>errect pulmonary rcsununce, and on tlto oUier 
flatness. Then we judge that the border of the luug lies midway between the 

To avcid throwing too much liMue into vihi-ation, the si?^ of the pleximcler 
muftt he aiiridft'd ; but us the si/a' )h diniinisliod, unless ciMti>ou*atcd (or in some 
way, lite intensity of the tionnd is eorn>«poniliu>fl>' lenwrned. These dlHi^ullies 
•eem to have heea overcome in tlm construotion of a little instrument kuuwu vtA 
the ptesslgraph devised by M. Peter, of I'aris. 

It consistAof a small cylinder of wood about four inches In length and flv«> 
eighths of ou inch in diameter, withadiscut one end upon which percujwioaUto 
be made. Tlie other end cnn-<>tslA of a truncati^d cone, the plane sui-raue of which 
Deasurett neatly an eighth of au inch m diameter. In uniag' tJtc :u5lrumeut, the 



small end {» plucvd on the surface of tl»e cliest^ and percu!»Iou is made u(H>n Ui« 
other end with Tl>t> |>iilp of a singli^ linger. Care must W toUon tliat llic iiistnt. 
nicnl t^ hflil iter|HMi>iicLilar to tiiL> siirfacd. On a<:-coiinlof tht* ftnLillUMsn «>r tli4 
surface whioli r^sX& against tho rlie^it, llie Kound obtaiiiG<l would bo very Teeble, 
were it not in a int'asure mtoiLsiliuU hy tlm body of the instrutiieaL actin;,' as » 
8onndin^>l»ur<). Trouss«uu claimed that it is not necessary to strike upon ths 
(liw, but titat wo may simply tap upou it with the y\i\\t of thv Ihtg^r. nnd that 
by means of this inalninnjiit even students miiy rai»idiy map out the liver or 
heati, when witli ordinary pcrcu&sioa this mi^hl he impossible, even for ii skilled 
diaKU<^''*~'i^"- '^''*^ inslniiiieat iis constr tided by Peter luid upuo the siile an 
ermn;;friii_-iit holding a crayon wliivJi could bu pressed down to murk Uie&kin 
a'Ik-ii (hi- border of the or<{an had ho>?ri fouud, »u> thai ti dotted line would l)c left 
corresponding to the otitliiies of tlit> solid viscns or tumor. I liiivr; found thr^ttp 
fttrnment very natisfiictory in det^L-miiitiig siipcrndal dulno^i, so long as it if 
employed only in the intercastal spaces, but not when applied over the ribs. 


Aascaltutory percussion was iiisiltnted by Camman and Clurk in 
184C. It consiets, a« the name impliee, of combined nutionltiitiun and 
pernusflion. In praL'tiHiiigit, a Btethoscope is needed. For this purpose 
tha originators of the method dovised a peculiar instrument, which gqi 

Tm. It— CuuuM's Srarsoffcopc rent Amcn-TATom fKBcrmoiL 

sists of a solid cylinder of wood formed at one end into a tmneated 
wedge, and at the other into a disc (Fig. 11). The wedgo-shdf>cd ex- 
tremity is placed in an intcrroHtul spuct*, ovi^r the mnBt superllctjtl porw 
tion of the organ or tumor to be examineil, and the examiner's ejir i(» 
placffi upon the (Use. An iissisUiiit then percuseee from the healthy 
lung tissue towiird the instrument. The moment percnsniou is made 
over solid tissue^ the changed sound reveals the fact to the listener, ar<l 
thus enables him to determine the deep outlines of the solid mass mnr h 
more accurately than by simple percussion. Tho ordinary binaural 
stetho8(»ii>e with the smallnr chest-piece may be used for the same pur- 
pose. The advantage claimed for this method is that It enables one 
*fl determine the outlines of iiitm-thoracic tumcn! or organs much more 
accurately and rapidly than by other means. Outlines of the liver, the 
spleen, raid tlie ki<lney may also be lutcertained with coiisidorRble neca- 
racy, even when ui^cites is jnTseiit. 

In the practice of this method, a secoml person has been necessaty to 
make the percussion, anu it is nften impossible to get a skilled assistant 
at the time needed. To overeome this difficulty, I have devised an in- 
strument known as the cmtKiIlometcr (Fig, 13). It consists of a hoi* 



low cylinder abont three inches in lenfjth by five-eighths of nn Incn to 
diAmbit^T, trithin which plays a metalUo phingor. Tc tlie objective end 
of tbe indtrnmflnt is tittofi a soft-rnbber chest-piece, ngiiinet wliich the 
plnngcr strikes. To the other end is attached » rubber tubo about 
ciglu«(>n inches in lengch* couueccing it with a rubber bulb. Conipres- 
sioo ol the rubber bulb drives the plunger nguinst the chcst-piiH^e; fit 
the instant the pressure is removed, the bulb expands und the plnnger is 
lorced npward by atmospherio pressure. In practising auscnltatury 
percussion by the aid of this inglniment^ the stethoscope ie held with, 



Flo. 11— IfOiLS' ZMSAhUtMWrtK. 

the left hnnd; the bulb of the embullomcter is held in the pnim of the 
right hand by the liut three fingers, and the cylinder by the thumb :ind 
fon'finger. This enables the physician to move the instrument without 
restraint, to strike any point as rapidly or as slowly as he chooses and 
with wbatev<»r force may be desirable. Ry means of this little instru- 
ment and the binaural stethoscope, auscultatory percussion can be sutis- 
Inctorily pructised wtthuut the aid of aa assistant. In using the bin- 
ftnnil stethoscope for this purpose, tbe small chest-piece should be 
employed. Probably one still smiiller or flattened, so that it might b» 
^plied between the ribs, would give even better results. 




Auscultation, the art of listening to sounds produced within the 
cheat, originated early in the present century. It ranks first among the 
methods for physical exploration. The sounds to be studied by this 
method are produced during either inspiration or expiration, or during 
both portions of the respiratory act. 

Auscultation may be mediate or immediate. In the former, the 
sounds are conducted to the ear through an instrument known as the 
stethoscope; in the latter, the ear is placed directly on the surface of 
the chest, or on the chest but slightly covered. 

Id this connection, a brief notice of Laennec, the Inventor of mediate auscul- 
tation, is of peculiar interest. He vfas bom in an obscure province in France, 
and at the age of nineteen went to Paris to obtain his medical education, where 
he very soon attracted the attention of the profession by his diligence and atten- 
tiveness at the hospitals. 

From the time that he entered Paris until his final departure, about five 
years before his death, his whole Hfe seems to have been given to careful clinical 
study and verification of the results by autopsy. The fruit of his labor we find 
in papers writteu on inflammation, melanosis, encephaloid cancer, and numerous 
other topics, but especially in the great work of his life, his treatise on ausculta< 
tion, published in 1816, when the author was about thirty-five years of age. This 
was the introduction of auscultation to the profession. So thorough were the 
author's observations, so accurate his conclusions, that subsequent writere have 
been able to add but little to the information upon this subject gathered by him. 
Not long after he published this work, close application began to undermine liis 
health, and in a few years the very method which he had introduced disclosed 
the signs of phthisis in his own chest. Realizing fully their signidcance, lie re- 
signed his work in Paris and retired to his native province, where he died at the 
age of forty-five, leaving a name which will still be remembered when most ot 
those noiv prominent have sunk into oblivion. 

Since Laennec's death, the method known as immediate auscultation, 
according to him first practised by Boyle, has received great favor with 
the profession. Many physicians now consider this the only proper 
method of auscultation, while a few others rely entirely upon the medi- 
ate method, "Whatever the advantages of either, we must familiarize 
ourselves with both to become accurate diagnosticians. 

The stethoscope has some disadvantages. The first and main objec- 



tion id tlmt it has :l peculiiir ringing Bound always confusing to begin* 
ners. Until wo l>t;t;unie sufticit'ntly familiar with the inetrunjeut to ig- 
nore this, we shall be nnablo to appreciate the pnlmonai-j* Bonnds. Many 
of these inatniments are poorly constructed. The aiethoscope is of very 
little valne in examining children, because it is likely tu frighten thcni; 
besides, the respiratory murmur in them ia so loud tbut it cun be easily 
beard with tlie unaided ear. 

In examining the lungs, the ear alone is usually euSicient; but to 
differentiate between the souuda jirodnceil at the viirious orilico of the 
beart, wo must employ the stethoscope, the small chest-piece of wbicli 
excludes in a great measure all sounds excepting those produced imme- 
diatoly bcueath it. 

Mediate auscultutiouhas, however, the advantage of greatly intensify- 
ing the hitra-thoracic sounds, so that signs which could not be heard by 
Ihe unaided ejir may he readily recog7iized through the in;^trnment. 
JSomo portions of the chest cannot be easily examined by immediate 
iiDScuItAtion— for instance, the axilbiry space and the supra-ciuviculiir 
region; therefore the instrument becomes necessary; someliines it may 
be uuplousuiit to uj'ply the eur to the cbyst, and somelimea for the 
sake of delicacy it is not advisable. 

The advantages chiimed for immediate anscultation are: It yields no 
humming sound; it obviates the necessity uf carrying nn instrumeut; it 
does not frighten little children^ and the results obtained arc usually 
Bufficioutly accurate. 

If the stethoscope moves slightly upon the chest, it produces a gral- 
(ng sound much more intense than the respiratory murmur. The t^nnie 
ibiug occurs if the finger maves u]M>n the instnitnent. if the hand is 
ilnwn over the surface of tljo chest, or if the patient's clothes move 
upon the chest or upon the instrument. In some cases neither mediate 
■lor immediate auscultation alone yields ucciinite results, while the two 
tombined enable us to make a proper diagnosis. 

There is now a great variety of 8tethoaco|H«. They maybe classified, 
(lowever, as solid and flexible, some of which are binaural and otlicrs 
(4ngle. The binaural instrument is provided with two tubes which con- 
duct the sound simultaneously to both ears. The single stethoscope is 
designed only for one ear. The solid stethoscope most in use is u tubu- 
lar inatrument about six inches in length, exjMinded at one end into a 
bell-sbnped chest-piece about an inch and a fourth in diameter. At the 
other extremity is a disk or eiir-piece about two inchejs in diameter (Fig. 
13). Some of these instruments are so made that the ear-piece may be 
removed for convenience in carrying, and a soft-rubber ring encircles 
the disk, m> that it may be useil ns a hammer in percussion. 1 
think physicians generally find more difficulty in exauiiuing the chest 
with this instrument thau with the biutiural stethoseojie. A binaural 
stethoscope deviseil by Lcnred, of Loudon, was made of gutta-percha and 


PHYSICAL mAoifoaia. 

oonsieted of two tubefl* one for each tmr. The oiirionlitr extremiiieB of 
these tube4i were ditik-ehaped, and the other ends were fitted into a hoi. 
low cyHndrical or cup-shaped chest-piece. The elasticity of the tubes 
kept the disks in firm iip|>o&itiou with the care. Thiij iustrumeut was 
exhiltited iu Loudon in the year ISol, but it uttrActed little ittt<'i)tion. 
About the S!ime time Ciinimiin, of New York, iritroductd the biTuiund iu- 
Btruiiieut that bears his mime. This consists of two met4d tubes so curved 

FtO. IS.— ^UD WoODCy 8TITBn»COPt. 

as to fit into both enrs, and connected with cftch other by a hirigc-joint. 
These, wheu jdaoed iu tho eiirs^ nro held in position by jin clastic passing 
from one to ihe (iiher just iibove tho joint, or by springs of viirions con* 
trivtinco. The luiricuhirends vt these tubes lire tipped with gutta-percha 
or ivory of sufficient size to close the externiil mcjitus iind prevent tho 
entrance of external sounds. To the other ends nro fitted two flexible 
tubes which connect them with the body of the instrument to wliich 
the chcst-pier-G is attached (Fig. 14). Each instrument has two ehest- 
piecea, one about an inch and a quarter iu diunioter, for exuminatioa 


CxTSKBtoN Thh «>!tu>n«kin tiihe rmdim ft tttxy tor tb« 
I fnwt coDTvaifliuM la examliitLiK |>fttleat(i Iti hml. 

of the lungs; the other five-eighths of an inch in diameter, for the ex* 
amination of the heart. 

Of the various modifications of Camman'a stethoscope, Knight^s is 
the best. It possesses all of the essential points of a good instrument, 
viz.: the metallic ear-tubes are curved at the proper angle to conduct 



tlir 0ouD(l clirwtly into the auditory canal; thfcar-tipe nre of proper size 
U* exclude bsU'i nal sotititU, auil ure not so small us to puss into the audi- 
tory oiuii] aud occasion pain; the tubes nrliich connttct the ear-pieces 
with the cheat piet'e arc very pliiiblc iind have a calibre equal to that o£ 
other portions of the inslrnmcnt ; tlie chest-pieces are of proper size, 
anil the whole instrument is thoroughly finished. 

With many instrumeuts a soXt-rubbor attachment is fi:raished which 
may be fitted over tiie end of the enialler clieat-inecc^und is desi^icd for 
the examination of emaciated patients. Tins chest -piece, however, is 
practically worthlc&s, on account of tlie creaking which is produced, dur- 
ing the reepiratory movements, by friction with the wooden chest-piece 
ou whioli it is adjusted. 

Charles Denntsou, of Denver, has an excellent modiGcAtion of the 
binaural inatriiniciit: the cniidiictiiig tubes are of large calibre, com- 
poseil of gulta-perclitt and unite in a cuumion tube with flaring extremity 
abont an inch across; nito this three other chesi-pieccs may be tightly 
6tte4l, two uf the same material, one of medium size and ohl- three inches 
in diiimeter. The latter '\& e*i]iecirtlly valuable when it is desired to hold 


FiQ. 15.— ALtjROff'a DtvrBRCinrtAL SrcntnAtorc 

the chest-piece of the stethoscope before the patient's open mouth 
vhilo jMjrcusBion is being made on the chest as recommended when tho 
signs of consolidation of the lung are indistinct. The third cbesC-ijiece 
is of poft rubber. 

The differential stethoscope invented by Allison is essentially the 
le ftS Cnmman'a, excejjt that the ilexible tulie^ are each fitted with a 
jlinct chest-piece^ so that sound cxn\ hv conducted to the two ears 
cimnltaneously from different portions of tho che«t (Fig. 15). 

A stethoscope whicli will tit one person perfectly and allow tho 
sounds to be conducted without obstruction into the auditory canal, with 
another may rest ugain&t the e.\terual ear in tiUch u ])ositiou as nearly to 
oivlude the orillce of the ear-piece; therefore in purchasing, one should 
see that tho tubes are so bent that the instrument fits the mrs accu- 
ntely. The larger chest-piece ought never to exceed one and one-fourth 
mches in diameter. If larger than this, it cannot be accurately applied 
to nn emaciated patient; consequently air passing beneath it will pro- 
dace a hamming sound, which will drown the pulmonary wigns. 

The apparatus oo KniRlit's stetlioxoopc Tor ailjufvting the pressure of the ear- 
pieces works pt-rft'L-tly. uuii is otlen \-er>- useful, thouijrli a simple rubber Iwind of 
proper length would aniiwer tlie purpose, if only one person were using the in- 
3truincat. A rubber band, which could hu letiKthened or shortened by a buckle, 
would allow the iiistfunicnt to be cuiiily udjut>lcd to uuy huud, and tvould be 
Je^s expeiiiiivti tliuu Ilie nictul attuclitncuL 

ConsidornbiB practice is required to perform auecultaiion properlj. 
Ab guides, ti Xuw rules niuy be liiid Jown: 

lu mc'iHate uuscultJitiou, the chest must be bm-cd; i» iumiediato 
ansciiltiition, the covering uiust be us soft, thin, and smuoth ua jiusslble. 

The iJOBition of both paticut and cxamiucr should be cosy and unre- 
strained. If the ]mtient is in bed, it is prefenible to Imve him gitticg 
if hcultb will permit. If the examiner ia in an uncomfortable position, 
he canuot properly concentrate his attention uixin the soiindg. 

In examining a child, or a patient in bed, it is :i good pbin l-o restoit 
one knee, &o that the lioad will not be on a plane lower than the body, 
otherwise gravitation of blood to tho brain will cause fulness of the 
head, <iizzine8s, and Impaired sense of liwiring. 

We must eitrly le:irn to coucentrute the whole attention on the 
souud to which we are listening. 

It is desirable to Imve tlie room qniut, especially in practising imme- 
diate auscultation, for the ear which is not iLpplied to the chest catches 
every extraneous eound, unless it is stopped with the finger. 

The ear or tlie stetJioscopo should be applied liniily, bub not with 
great force, to the surface, and ill such manner that no air can pa^a 
beneath it. 

Compare corresponding portions of tba two sides during both natural 
and deep respirations. If one Bide is examined during ordinary or for^ 
ciblc respiration, the other must be examined under the same condi- 

The pulmoimry sounds are not exactly alike in any two individuals, 
nor are they the same in different regions of the chest in tho same in- 
dindunl; therefore it is necessary to study healthy cases carefully, in 
order to become familiar \rith :dl varieties of healthy sounds. This 
iamiljarity must be so jwrfect thnt no effort of the mind is required to 
remember the variations in different localities. This canuot be urged 
too forcibly, because until wo can easily recognize the healthy soiinda 
it is absolutely useless for us to attempt to detect the signs of disease. 

When the blood leaves the right side of the heart, surcharged with 
carbonic acid and other debris of tissue met:imurphosis, it makes a pecul- 
iar impression upon the respiratory nerves, which is transmitted to the 
brain as a r^ll for more oxygen. Instantly a message is flasljed back 
over tho nerves, to the inspiratory muscles, causing them to contract 
By this action the diajdinigm is shortened and its convexity lessened; 
the ribs are lifted, and by rotation on their articulations with the spinal 
column, they are at (he same timu curried forward and outward. Thua 


(he diamoters of the chest nra incruneocl in every direction, and air rusb- 
ing- in through the open glottis distends the ebatic lungs as the chest 
expands. Immedint<.*Iy tho resplmtory act ceases, the nuiscles rt'Ins, the 
elutic tissue of the lung asserts itself, and the nir is expelled from the 
pnlnionary vesicles. This hitter is a passive movement, in wliich the 
Mjiimtory mnsoles take little part, excepting in forcible expiration. 

While inspiration is tnking place, we hearu soft, breezy, or rustling 
wnnd, known as the inBpimt()ry murmur. As eoon ns ii ccaRcs. a sound 
foft and breexy, lut lesa intense and mncH shorter, occurs, which U the 
expiratory ninrmnr. Tbi^ is follovcd by a period of rest, which com- 
pletes tho cycle of respiration. 


A variety of signs may be obtainc<l in the normal chest owing to the 
position of sorronnding organs, and the difference in tlio force and vol- 
nme of the air current produonig the sounds. 

Auscultatory sounds arp possessed of elements similar to those of the 
percnufiiun sounds, viz., intensity, pitch, quality, duration, and in nddi* 
tion, rhythm. The latter refers to the relation between the different 
portions of the respinitory act. The intensity of the sound varies in 
aifferent people. Tho jiitck and the /junlifrf are practically the same in 
all healthy cjises. 

The duration of the sonnd also varies in different cases, but is about 
equal to the durution of tho respiratory act which produces it. All 
modifiaitiuns of the respiratory murnnir which may be ubtjiined in dif- 
erent regions of the chest are simply alterations in one or more of these 
elements. Tims In the different parts of the respiratory tract we ob- 
tain the normal vesicular murmur, bronchial reppiration, and trachea! 
and laryngeal rctpinUion, eacli of wliich differs from the others more or 
less iu intensity, pitch, quality, duration, and rhythm. The clearest 
vesicnhir murmur is cbtuined in the iufra-chivicuhir and infra-sciipular 
regions. Tjirvngoal respiration and tracheiLl rr^piration are obtained 
over the larynx and the tracliea, and are essoTitially the same. Bronchial 
respiration, or more properly broncho-vesicular respiration, maybe heard 
over tho bronchial tubca, au'l for an inch or more about them in every 
direction upon either tho anterior or tho posterior surface of the chest. 

The VERlcrLAR siriiMrR, which is the sonnd obtiiined over the 
pnlmnnnr}* pnrenchynni. is taken as tho standard of comparison for nil 
others. This sound may be best studied in the infra-scapular region, 
though it is more intense in front, below the clavicle: bnt in the latter 
position the heart interfere with its easy recognition. The vesic- 
ular murmur, like all other respiratory sounds, is possessed of two pnrts. 
The first of these, the inspiratory, begins as a soft and distant blowing 
sound, and gradually increases in intensity and approaches more nccrly 
to the car toward the end of the act, when it is breezy or rustling in 



character. It varies iu iutensitr in clifferehC iiiJividaHls, but is gcucr- 
ally easiily heard. Its pitch is low; hi durfliion it corresponds with the 
inspiratory act. Its quality, called vesicular, cuuiiot be accurately de- 
Bf'ribed, though it may bo easily learned bypmctice uj>on a healthy cluut 
This sounil is followed iniinedijitely by a geiitlo .•ustliug suuiid. the cj:- 
piratory imirnuir, which passos off gnidually into a low breath or puff. 
It is leas intimsc than the preceding, being usaolly so feeble that one 
must, listen for it very attentivoly; it is of thu samu low jjilub, and about 
one-fourth the duration of the iiispir.ttury sound. Though termed vesic- 
ular. Its quality is nt-ither strictly vesicular nor bronchial, but aligluly 

The normal vesicular murmur is modified in different regions of tlie 
chest, by the size of the bronchial lubes, and more or less by the thick- 
ness cf the chest walls and by the position of other organs. It is heard 
in perfection in the left i.ifra-claviculur region. On the right side iho 
snniul is more intense, and tho expiratory si»und genendly slightly pro* 
lungCil; this disparity being due evidently to the dirccCiou and ehiu of 
the right bronchnsascompsired with the left. There maybe averrsliglit 
intcn'ul between the inspirator}* and expiratory murmurs, and the qual- 
ity of both is usually slightly tubuliir. 

Over the upp(:r portion of the st«mum and the inner third of the 
infni-clavienlar regions, the i)ro.\iriiity of tbo ti-achua uud of the l-irge 
brt>uohial tu'>es renders the normal murmur sumewhat tubular or broils 
cho-resicnlar in quality. 

In the inter-scapular space, owing to the thickness of the chest vti 
the vesicclar sounds are less distinct; owing to the presence of the main 
bronchi, they are nioi^ tubuhtr in character, so that in this position ul»o 
we lind a sound which might properly be termed the broncho-vcsjcular 
murmur, but whu^h i^ uitually calletl nornml bronchial breathing. 

In the scapular regions, the thickness of the chest vuU renders the 
vt*j< sound indistinct. 

In children, the vesicular mtirrour is much more intense than in 
B'lult^. Over the u)jper portion of the chest it is usually mnch more 
intense in women than in men. In the aged, it frequently Iosps some- 
thing of it* ioii quoliiy, and becomes slightly more tnbnlur. and is 
itltercd in its rhythm, the eipintory sound being occnjiionaUy preceded 
by a short period of silence, and having a duration nearly or quite equal 
to the inspiratory murmur. This change scents due to partiiil atrophy 
of lung tissue and to changes in the elasticity of the chest walls. 

In extreme anaemia, the vehicular murmur is intensified over the en- 
lire chest. 

In lisieninc |o fhere^idrationof muscular subjects, a continnons. low- 
pitched, superficial, rumbling murmur is heard where the mnscles are 
'htckest, whirh la due to the contraction of mnsculir fibpp?. In tare 
cises this is sn marked as closely to resemble the vesicular uurmnr. 





lijLitTKGEAii AND TRACHEAL ItESPiRATioy. — The respirator}" murniur 
ere: ihu laryiix asd the truclteu difTcrs from vosiculur respiration in its 
inteosityj pitch, quality, dnmtioa, nud rbytlim. The inspinitory sound 
Umuch more intense than in tlie vc^iculur niurniur, itd pitch ifi higher, 
}U quality tubular, and there is a marked iuterval betweeu it and the 
expimtury auuud. 

Ttc expinitory sound is genendly more intense than the inspiratory, 
ID(I ereu higher in piteh. It has the bunie tubular '|ualily and iibout 
tbeeuiie duration. To 6Uiu up these points of distinction, lari'ngcikl ar.d 
tr^cknU. respimliou diHers from the Tesieular in being laoro intense, 
hijtlier pitched, and tubuhir in rjuality: in having an interval between 
die ivo portions of the act, and tht> expirator}* sound is as long as the 
iDf|iinttory, or even of greater duration. 

ItBONCMiAL REfii'iKATioK, or, pcrJmps Hjore properly, kroxc no- 
TESiccLAR BESPiKATiox, IS noxt iu iniiiortance to the vesicuhir. It 
•Mj- always bo found iu the healthy chest, but is only heard in a limited 
irta, immediately over and fcurrounding the large bronchial tubes. The 
Iftltcr term seems more aj)propri;ttt', as this combines hotli the bronchial 
uul the Tesicnlar varieties. True broni-hial brealbiug is the same na 
tnche:d, excepting that it is usually It-.BS intense- If is the sound ub 
tim-d in pulmonary diseases where the air vesicles are completely filled 
It; iLflammatory lymph or other products. Bronelio-resicnlar respira- 
tioa holds a place midway between broncliiul and vesieuhir, and is the 
MUiid obtained when only a portion of the air vi'sicles are occl'ided. 

Tlie sound heard over ttie main bronchial tubei> in the hcaUby chest 
is more intense than the vesicular murmur, and its pitch is higher: its 
qtrality is a combination of the vesicnlur and tubular, and a slight inter- 
ml laav l>e noticed between inppiratinn and expinition. The expiratory 
loutid is of nearly equal dunitiou with the inspiratory. 

We shall at once perceive the necessity of being able to recognize 
these normal soundi* and of knowing Ihe localities in which they ocenr; 
iw some of these, when heard in uhnornial ])ositions, are the aigna of 
gnve diseases. 


The on«cnltatory sounds are altered by disease, princip-jilly in thpir 
intensity, rhythm, and quality. 

The intensity may he increased, giving rise to exaggeuted, compen* 
Kniory. or supplementary respiration. It may he diniinish<;d, and is then 
railed feeble respiration: or thcaonndsmavte entirely suppressetl. The 
rhythm of the murmur may be interrupted. It is then termed jerking, 
irary, or cog-wheel respiration; and the interval between the two portions 
of the act may be lengthened. or the expiratory sound maybe prolonged. 

The qnality of the sound may be rude, termed broncho-vesiculi.r. 
or bronchial, cavernous, or amphoric. 


ExAOOERATED RESPIRATION differs froiii tile nonnnl innrmur in fn 
tensity and dnrdtion, both the iiiKpimtory and the expiratory sound 
boingintoneifiod and Bonicu'lmt prolonged. It ieprodncodin lungtusu 
which is jiorforming inure than ha nrdinar}* fnnntion. When ob 
over the chest of an adult it closely resembles the natural soand 
child, and hence has been termed puerile respirntion. It is nlso termed 
pupplementary or compcnf-atory rcspirAlion. Like exaggerated percus- 
sion resonance, it may be siiid to iiitjiaiie tlii' highest degree of Iiriilt}i iit 
the organs where it is produced; bnt it also points to diseaso of aom* 
other portion of the respiratory tniet, and is therefore a valnable nega* 
live si^. It results from any condition which, by interfering with th» 
entrance of air into one portion of the respiratory organs, may caoM 
more afitivity in the remainder. Thus, purtial mnnoh'fliittoti, rolfajjsgj ttr 
cotuprex-sioti of tJie /wi/y gives exaggerated respiration well market] in th» 
sound portion of the affected organ, and more or less also on the sound 
sido. So also obetrnction of a bronchial tube by secretion or dimitiuiion 
in ihcalibre, by compression from tumors or thickening or contraction ol 
its wall, may givu rise to this sign in the portions of the lung not that 

(E'Uma vf the lungjt may also cause exaggerated respiration over their 
apices; and in hemiplegia, more or less panilysii* of tlio respiratory mns* 
cles on one side caugcs exaggerated re«pii*ation on tho other. 

Feeble nEspiiuTios differs from the normal vesicular murmur In 
being less intense and shorter in duration. The inspiratory part o£ 
the sound is most affectud. The sign may be occasioned by anything 
which iuterferea with the perfect tninsmission of sounds to the surface,, 
as thick chest wallti whether due to muscular or to adipose tissue; it ifl, 
also caused by small quantities of air, fluid, or inflammatory lymph, 
the pleural sac. 

It may result from loss of elasticity of the Inng tissue in conseqn 
of dilatation of the air vesicles, as in pulmonary fuijihi/^ema, or from 
lubercttlaf or infiftmmntory consolidation of the lung; also from defi- 
cient action of the respiratory muscles, occurring in jmrahfMi^; or it may 
exist in ritsatfifa tit" the fiMmuinal or thoracic, ort/aiijf which give rise to 
pain and canao the njitiont to restrain muscular movement. 

Collections of ^(/i'(/ o;* ^w.-* in the pleumi cjivity, tumors in the chest 
or abdomen or a pregnant uterus may interfere with the fnnction of 
the lung, and prevent the descent of the diaphragm by mechanical pres- 
snre, thus causing feeble respir-ition. 

Obstruct ions of the Uirif>u, trachea, or broftchi also cauiie feeble respi- 
ration resulting from collection of fluids, the presence of foreign bodies, 
thickening of the walls by infUimmation. diphtheritic or croupous de- 
posits, UHlema, and neoplasms ; from contraotinn of the walls, as In 
asth ma, spasm of the glottis, or paralynis of its dilators ; or through com- 
nroasion from witlmut by inflammatory growtlip, tumors, and the like. 



^hen this diminUhed murmur 'u found in tlio upper part of ono 
hing, it often uidirates phthisis; 'if found in the lower piirt of the lung, 
it is very often an indication of pucumouia; found over the lower por- 
tioQ of both lungs, it i$ suggestive of a>dcina, 

SrPi'KEssED RESPiKATiox 15 due to the aimeoflusos which, occurring 
In a leea degrcCj give rise to feeble respirution. It is often ohscrvud 
over the diseased portion of a lung, the remainder of which yields the 
exaggerated re/tjtinuory nuirmur. 

bf 1>*TEBUU1'TED KESPIRATION*, olsO known 06 COO-WHEEL TlESrifU- 

Tios, either inspiration, expiration, or both may be broken into two or 
ntnri' pnrts, tht; sound being suddenly interrupted, to return nguiu, and 
[•erhiips agsiin iind again, before a einglo respiration ie complete. Thu 
julerrnption take* place most frequently with iiiifpiration. The sign is 
imt\ under n variety of circumstances, not only in discaiie, but also in 
lealtli, BO that it is not of much importance, though sometimes helpful 
ia confirming a diagnosis based on other evidence. It is sometimes 
pn^rut over the whole chest, at other times confined to a limited 

TThcn occurring in healtli, it is often heard over the whole chest; but 
wlien resnlting from pulmonary disease, it ia more apt to be localized. 
lathe incipiency of phthisis this sign is frequently obtained directly 
CT^r the dieeiued lung, especially when the lesions are in the left 

It may be produced by any disense which renders respiration painfnl, 
u inUrcosfal jieumhjin, phurt'ni/f and ph-nriidtftiiit. It also occnra in 
ctnuufl ^KTsons when agitated by the examination, and is very apt to 
be found in hysterical fmlieiih. When due to nervousne&s or pain, the 
lign will be found over the whole of (jue or both lungs. 

As an indication of disease, interrupted respiration is a sign of very 
little value, excepting in the early stage of phthisis. 

In iactptent phthisU the iaimediutc cause of this sign soems to be forcible 
coDtrociioD of tlie heart, whereby an abnormal amuuiit of blood is forced into 
ibe pulmcmary circuit, tbcruby cuubiiig suuiu narrowing of tJie calibre of the 
broncliial tube*. 

A PBOLOXGED IXTERVAL bctwecn inspiration and eipinition may be 
ciused by shortening of the inspiratory murmur, or by a delay in the com- 
loeneement of the expiratory niui-mur. 

Shortfncd htfijnrah'fni. — The insi)inttory sound in this condition 
teases before the act ia complete and is consequently shortened, in par*ial 
consolidation of tho lung due to inftammulory or tubtrr.uhir deposits. 
It is deferred in its commencement after tlie inspiratory act begins, and 
thus is shortened where the air vesicles are dilaied. 

Deferred Expiration. — The expiratory sound is delayed when the air 
foaiclei are distended, as in pulmouary emphysema. 

PSrSTCSL DiAoyosis. 

pKOLONnEii KXiMRATiox rwsultH ffom :i losBofelosUcitrof tbelnngs, 
eitliur by coiisolidatiun or by distention. 

Wlien tlut» torntiec)H(Iutioii,iiproIongo<l expinitory mtrnnur is usnally 
more intense than nomiiil. It is high pitcliwl jinil more or le*s tnbulur 
in quulitr, iiud usiuitlj p.>8se86ed so mucli of the brouchial clement us to 
bti termed broncho- vesicular. 

The prolonged exph-utory nim-mur which is Rometimes round fn healthy 
€>hests posnesBea the »&ms pitch ami (juatitv us the nonriul vehicular soimtl. which 
enables us to UiatinguLth it rroiu tlic prolouireU expiration orcoasolidution, in 
wliicli the pitcli is always )ii^h und the qua-lily soiuewtiat tubular. We must 
not lorget llittt io heulth the vesk-ular murmur ovue Hie right ap.x is soin«liMie$ 
nion; or Icbs lubulur n.ti<l high in pitch, au<l tli:tl tliu expiratuiy k^-uhkI Lt pro- 
loni^Ci), a^ cotii{>ari.>il nith the ktt i^idc. Thercfur*.-, i» this position the t<y^n ran- 
Dot olways be considered as itidicatlveofdiftense.iinleu it be taken In connection 
vitJi other Kij^na. 

When obtained on the left side, jirolonged expimtion is nearly nlways 
duo to phthisis or to emiihysenisi. The difference in the two is that in 
consumption the expiratory sotind is liigh pitched nnd more or less 
tubuhir ill quality; while in umidiyscmu, it is usually even more pro- 
lunged — it may be two or thr^^ times us lung us the inspiratory murmur 
— ^ud it h:is a low pitch, it is not tubul-ar Imt nitlier vetiicular in qn.ilitr, 
and is apt to be cousideiubly less intense than the insplnitury sound. 

Ocoa^Jonallj prolonged expimtion may he cause<1 by inlerrerenee with IImi 
free exit of air rrom the lungis, as by obi^tructjon in the hirj'tix or bronchial lubeft. 

[ii these caaeH it is iDiiially usHociated ^vilh i\. d<^ferred ini>|^ratory murmur, io 
w!iii.'li the liound doi.-s not b*.'t;in wjili the insjiii-ulury iwt. 

B^vcei>tioiial. — Pi-oloa^i-il exi>ii'utinn huvin;^ Ihi* ptU-h and quality of the 
healthy iiitii-iiiur M ohtaiiied with oavcnious rf««))ii'ati»ii in rai-e nast-^^. tii stich 
ii)*ttati{vs ilA sij^niricance is ascertained by the character of the jnspiiutory sound 
• ml by other sijjns. 


oloselv resembles the sound which can be obtained directly over th© 
broneliial tubes in n healtliy chc^t. 

The respiratory sound is raised in pitch in proportion as the tubular 
•upplants its vesicular r|uulity. Tlie expiratory sound is always higher 
in pitch than the inspir;Ltt>ry, its quality is more or loss, .:nd it 
is prolonged. The alteration in })itoh and dunttion is in proportion to 
the prcjiondemnce of the tubular over the vesicular quality. 

Disease may furnish all degrees of broncho-vesiculurreapinition from 
the normaf vesicuhtr mttnmtr to perfect bronchuU hrenfhint/, acconling 
to the amount of consolidation. 

This sign is due to the better trnnsntiasiou of the vibrations from tho 
larynx, tnichea, and broucliial tul>es to the surface of the ehcst, in con- 
Buqucnce of the eon soli da tint i of the air vesicles, making the imrcnchmni 
ft bettor uonduetor of souud-nuves und rendering tho bronchial tubes 



more rigid, so that they transmit these wiive« from the apper nir pftssagea 
vith less resistance. 

The sign is obttiinod in ineipt'enl phfhui-if over the upper part of tlie 
lung, and in ^JHfi/Hi«HiVr, uBually over the lower lobe. It is also he^rd 
xaiomBcus^sotpuivumnnj (ijiOjikTtf,:\r\\\ oy&T n hing piirtiul]j collapsed 
from any cnnse or whirh hiis been compressed for a considenible time 
hj^uiif or (lit in the jtlcurat mf. It is luoet vuluiiUe aa a sign of incip- 
imt phthisis. 

Exceptional. — Occnsioniilly in c-isM where bronchA- vehicular rospiralion oo- 
nntt ejtiior tlio inspiratory w t>x|>)rati)i'y murniur may Im> absent ; Then, an in 
limiLir tn^taiifcs of bronchial respirution, its detection will depend on \\\f pitch 
RDil qualHy ol the soumls which are preseotf and U|>oii concomitant aigna. 



Bboxchul REsrtKATiox is one of the most important varieties of 
the healthy eonnds, which may sometimes be iudicutive of disease. Its 
nnlity uud its other elements excepting its intensity are mucli the same 
tbo^e u£ nomiul trachi^al respiration'. The intensity of this sound is 
DffUitlly greitter by far than that of the vesicular mnrmnr, bnt sometimes 
very fevble; the pitch is high, the quality tubular, and the duration of 
both inspiration and expiration is prolonged, the two being of uboiit 
eqmil length. There is an appreciable iutcrvul between the inspiratory 
and expiratory sounds. 

£.rcf}4i<mal. — In bronchial rei^piration, either portion of the respiratoiy 
murmur may sometimes be al>st^nt. 

Loexmec taught that the bronchial pound was iilwaya prorluced in a 
healthy chest, but that it was not usually h&ird because of the interven- 
tion of air vesicles between the tubes and the chest walls. When ol^ 
tiiined in disease, he considered the sign due sinijdy to the better truns- 
miesion of the sounds tu the surface. Skoda believed that consolidation 
of the air Tosicles stirrounding the bronchus was necessary for the pro- 
dnction of the perfect sign. Whichever of these views is correct, or 
whether both are in part true, matters little to us, so long as we knov 
that the sign always indientes consolidation of lung tissue (Fig. 27). 
The tnbular sounds in tins variety of the respiratory murmnr are 
transmitted for a considerable distance beyond the consolidated lung, 
which accounts for the lict tliat the bronchial and the vesicular elemenla 
are frequently combined in the regions immediately surrounding that 
which yields simply bronchial respiration. 

Tlte greater intensity of tha expiratory sound in bronchial respiration ne- 
oounta for the fart that occasionally we obtain a venicular init|>iraton- and a 
bronchial expiratory sound, as the intensity of tlie bronchiul sound drowns tlie 
vesicular tn expiration. 

Bronchial respiration is fonnd in greatest perfection, in pneumonia^ 
over the consolidated lung. It is obtained also in some cases of p/t/tit.\i% 
but in this affection we are more apt to hear broncho-vesicular respinition. 



Exci:}itionat. — In rare cases cancer of the luog jrieldg bronchial breathing. 
Pulmonary apoplexy sometimes causes the &\ga ; it is heard over ihe eotira 
chest, tliougli more distant than in coiuoliJatioD, in a few cases of pleurisy with 
ejctensive ettiuiioo. 

CAVERN'ors HEsrinATlOJ.' has been likened to both bronchiul and 
vesicular. We aro tolil by ouc uulhor tlmt it closely reacmblt'S the forniKr, 
and by another that great care is iieceaajiry to distinguish it from the 
latter. This discrepancy is probably due to confusion in theapplicntioa 
of tbe term to different signs. Flint made the distinction cletir by in- 
troducing the tcrui broncho-cuvemous to desiguntc those hollow, high- 
pitched sounds which, although conveying the idea of a cavity, do not 
correspond with true cavernous respiration. The iuteusity of cavuruoua 
reapir»tion is usually feeble, so tbut, unless searched fitr carefully^ it will 
be oTerlooked. The pitch is low^und the quality, instead of being vesic- ■ 
ular or tubular, is soft and blowing or puling. The expiratory portion ■ 
of the sound ia prolonged to about the same length iis the inspiratory, 
and is even lower in pitch than tlie latter. The fiiiUire of some diagnos- 
ticians to appreciate the quality of this sound has caused them to deny 
its existence. I have occasionally heard the true cavernous niurniur as 
just described, but 1 think it a very rare sign. It is iirodueetl in empty 
pulmonary cavities, the walla of which are so flaccid that they expand 
readily in inspiration and collapso in expiration (Fig. 16). It is a sign, 
therefore, of any o£ those diseases which might eansc snch a cavity, vij,, 
congtiinptioiitjmluionarif ab^icesSf or t/auijrenf.iiflhe lung. 

Bro/icho-caivrnous rggpiralion is made np of both the bronchial and 
the cavernous sounds. It is usually described as cavernous, but it is 
higher in pitch and more tubular in quality than the latter. Its quality 
ia not entticiently tubular to bo called bronchial, nor ret snflicicDtly gott 
and puffing to hv termed cavernous. It la produced in pulmonary cav- 
ities, surrounded by lung tissue more or less consolidated; the tubular 
element being dependent upon the amount of consolidation. Somctimca 
'the first part of the iuapiratory murmur may be tubular in quality and 
the hist part cavernous; again, we may obtain cavernous inspinitiun with 
Lronchial expinUion, due to the presence of consolidated lung tissue 
bear the cavity. In the latter case the tuteusc expiratory bronchial 
murmur probably drowns the euvernous sound wliich was heard with 
the feebler inspiratory murmur. 

Broncho-CJi-vernous respiration is the characteristic sign of the later 
stages of coMumption, but it may also be produced in the cavities duo 
to aftscejtjt or to yungrene.. 

Amphoric respiration- resembles tho sound prodnccd by blowing 
Into the mouth of an empty bottle, hence the name It is of a metallic 
musical quality, and may be heard during either inspiration or expira- 
tion, or during both portions of the respinitory act, but is generally most 
marked in expiration. The expiratory sound ia lower in pitch than that 




la brouchial ruspimtion. In this couiiection it is well to cmpliasizo the 
Boceaiitv of stuilving Ihe pitdi uf the rcspimtor)- sounds, fur m some 
iBiUnces thtre is abdolutely no otiier iiicaiiij of diatinguishiiig between 
the sounds transniitteil from the bruuL-liial tubed iu coniiolidated lungs 
lod thoflo heard over pulmonary cavities. The diatinclion in theso cases 
hdeur if wc remembor that tlio expimton- sound in the former instance 
isalvayH high in pitch, in the hitter nhvuya low. 

Amphoric respiration occurs under the same conditions iis amphoric 
nKiiianoe, and is frequently fonnd in connection with cnicked-pot reso- 
■anoft. It IB due to the passage of air in and out through an opening 




Tto. 10.— PnTifni& 

from a bronchns into a largo pulmomiry cavity or into the pleural sao 
(Fig. 26). Tbo sign is obtained most perfectly in j/niittmoihortix or iu 
pntumo-htfdrothorax. In the latter it disappears and retnrus again, as 
the qnaniity of fluid rises so as to cover the opening or falls below it. 
This sign is also heard in ]iht)iisis when the pulmonary carity is largo 
and its walls are firm, so ihat tbey will not collapse In cxpimtiou. 

Canities may exist wilbin the lungs without yielding cithur of tho 
rarielies of respinitioii M-hich may be caused by » vomica; for example, 
if a OHvity be filled with fluid, or if the fluid in the cavity rise above tho 
orifico of the bronchial tube, none of thei?e sounds will be heard {Fig, 
IC) ; but if the patient's jiositiou bt> changed or the amount of fluid de- 
eraased by coughing, the signs return. 




The anscultiitory sonnrls wliich we have thns far been studying are 
Buch as miiy be obiitineii, in more or less perfection, over the healthy 
chest. Certain accidental or adventitioua sonnds occur only in disease. 
These may acconipuny normal sonnds or take their place, and will vary 
according to their origin. Those produciKl within the lungs are called 
rdlefi or nmchi; tlioae upon the pleural surfaces are '.emied frtctiun 

Rales. — Rdles are na numerous and as different in variety as the 
shades of color, but they may be grouped into a few distinct classes, 
which are generally L-apuble of some peculiar iuterpretntion. All of thera 
are either dry or moist; hence we may group the different soands under 
one of these heads, according to peculiarities in their pitch and quality, 
as shown below: 

or rhooehi, 



Sanon>iiK rAles. 
Sibilant r&les. 

Mucous r&1» tlargB and small). 
Suhci-epiUint rAles. 
Crepitant riil*»s. 

Gurgles (lurgfc and small). 
Miirous click. 

Rdles may originate in the larynx, trachea, bronchial tubes, air 
cles, or in any cavity connected with the brnnchial tubes. They are pro-' 
ducetl by various conditioTis which interfere with the passage of air 
through the tubes and into the air Tcsiclee, and may be heard in inspi- 
ration or expiration, or during both portions of the respiratory act. 

Dry k.Iles are distinguished as sonorous or sibilant according to 
their pitch, which depends on the size of the bronchial tube In which 
they are produced. 

Sonorous rnkx are nsually musical, or snoring in quality, resembling 
the sound produced by blowing through a tube; they are sometimes 
cooing, sighing, or moaning in character. Their intensity varies from 
a aonnd which can be scarcely recognized to one which may be heard at 



ice from the cheet, and their pitch is alwayu low. They nmy be 
beard during both inspimtion and exptrution, but are most frequent ia 
expiration. They wu produced in bronchial tubes esccc^ling one-eighth 
of AD inch in diameter. They are caused by the vibrations of viscid 
mucus ur by a fold of mucous membrane^ or by anything which con- 
BtricU the calibre of the tube, iis pressure upon its cxtcrnul surfuco by 
tuinore, bin<l8 of cicatriciMl tissue resuUiiig from former diseiises, or 
coDinction of the circular muscuhir tihres causing a uniform narronring 
of die tube (Fig. 17). These soundfi nre not removed by coughing, un- 
lea ttust'd by tenacious mucus adhering to the side of the bronchial 
lobe. Though in Ihc great majority of instances after coughing or 
■fterdeep inspiration an individual rule may disappear, other nUes will 
remain in some portion of (be chest. This sign ia obtained in greatest 

• SoDoroui rilM 

Snlonpllant rUes ■ 

Iboota rAlM.. 

■Slbllui rilM. 


FM. 17.— Bhokchui. Kii-n, l>Ry axo Hoiar. um SvacRKpiTurr RXun. 

penection In the early stages of actiie bronrhitis and in a&thma. It is 
also heard iii some cases of chronii: bronchttiitf occasiuually in phthisis, 
and rarely in pneumonia, iM^ing in theso latter instances associated vith 
other adventitious soandtt. 

When obtained in phthisis, the dry rtiles are few in number and are 
:iated with moist rales. 

In the early stage of asthma, sonorous nllee may be heard in great 
imbers over the entire chest. 
Siftifnnf riihfi occur both in inspiration and in expiration, bnt are 
heard mostly m inspiration. They are not so intense as the sonorous 
Their pitch it! high, and in qaality they vary almost as much 
>rous n'lles, being sonietimt!s wiiistling, sometimes hissing, and 
sometimes almost creaking. They are caused in the smaller bronchial 
tabes by the same conditions which give rise to rales in the larger bron- 
chi (Fig. 17). 

They are heard most frequently and abundantly in agthma and in 



capiUart/ hromhiti/t. In ordinary acute bronchitis they may bo lieardj 
tboDgh iu limited nomberii. 

Sibilant i-Ales are hearil ocouivaaUy tu phtbiaia, due ttieu to loculuKtl bron- 
chitis or tu tubercttlur tW]K>siU. Tlicy are suiiii.*li)iK's, lhoiij;b itoL uiWn, buui-d 
in pneuinoniu. Occusiouatlv, even in healtby or apiiaifiitlv lieallliy clursts, wo 
Diay hear txvo or lUrcc of thew fine souodit ii«ar the bonlei-a of ihe liiug«. 

Sibilant riiles may be altered, but tliey are seldoni removed by caugh,- 
ing or by forced in8piniiii>]i. 

Mol»T RALES are groni>od aa mncous, large and small, sabcrepitaitt 
and crepitant, according to their characteristics. 

Minous rdfe9,aho produced in the bronchial tubes, are large or smaU 
according to the size of the tubes, and are caused by air bubbling 
through fluid — niucuii, pus, 8er\im, or blood (Fig. 17). If the bubbling 
bap{>cn to be iu u large bronchus, we get a largo, coai-se, mucous rale; 
if in a smaller bronchus, the rale is much finer. 

These niles are hriird during both tnajiimiion and expiration, and 
Tary greatly in intensity. Sometimpa, like sonorous nilcs, tliey tn.iy be 
hejrd at a distance from the chest ; they are at other times lundly i.ndi- 
ble. Their pitch depends upon the condition of the surrounding lung 
tissue. In simple inflammation of the niuouus membrane, the riiles are 
luw pitched; but when consolidation surrounds the bronchial tubes, as 
in pneumonia and in phthisii^, the pitch is high. These sounds are ob> 
taiueil in greatest perfection in rfiruin'c hrtmchitis, but may be heard 
in acute bronchitis after the dry 8taj;e has passed. They are present 
in greater or less degree in nearly all cases of cnnxumpihni, in the third 
gfny nf pneumoititif iiatX in pnlm'ninri} tfdeimt, trnd are humorous when 
hi'inurrhfKjr has taken plaee into the bronchial luben until coagiihition 
occurs. In phthisis they are found over a limited ^psce, due somo- 
timea to associated bronchiiis> at other times to the escape of fluid from 
a cavity into the bronchial tubes. These, unlike dry rales, are usually 
much affected by deep inspiration and coughing, by which they may 
be considerably altered or entirely removed. 

Siibcirj>it(tnl rtVea are moist sounds, which are prodnceil in the very 
fine bronchial tubes, probably In the ultimate brouchi and lliuse a size 
larger (Fig. IT). They are rauseil by air bubbling through fluid, and 
may l>e hejird during either or both portions ot the respirator)' act, bat 
are most fre<jnently heanl with insjiiration. They are of companitirely 
feeble intensity, vary in piteh acconling to the condition of the surround* 
ing tissue, and arc distinctly moist and crepitating or crackling in 

Those rdles may be heard moat perfectly in rnfnllrtrtj hnmrhHis and 
the third xtnge ofpneuuinnia. They are often found in asthma shortly 
alter the paroxysm. They are present in conrfpsllon of the htw/, purn- 
lont hroHchifiu, and pulmonary oedema, and are found over a limiced por- 



*MXi of the lung in tnuuy cuses of jihtbisii^. They ocanr in brow^n indu- 
ration of the lungs, and ure hciml after hemorrhage into the Bmallcr 
bronchml tul*^, limited to the position of the huniorrhuge. 

The Biilicrepitjint rale, due to circumscribe*! oiiiillary bronchitiB, U 
a sign of great value in the early diagntittig of phthisis, in which it may 
uf tun be found at the a{>ex of the lung before any other Bif^na can be 

7'he rrfjiitani rdle is largely like the subcrepitaiit, bnt diflerB frxim 
the latter in two rt-specta: it is not so moist or liquid in chnractor, ao 
that it is sometimes dusked as a dry nile; an<I it is never obtained in 
expiration. Crepitant rales are very well imitated by rubbing together 
a lock of hair close to the ear. They were compared by Laennec to the 
■ouud produced by throwing salt ui>on a fire. 

These rules are produced in the resiclee, iiiterceilular spaces, and 
oltlmuLe bronchi (Fig. K). There are two hypotheses m to their 
mode of production: one is that they are caused by ntr bubbling 
tfaroogh fluid within the air vesicle, juat as mucous r.iles are produced 
in the bronchial tubes; the other, that they are due to the sciwiralion of 
llio agglutinated surfaces of the capillary tubes or of the air vesicles. 
Which of llieye if true, or whether both are in part correct, has not been 
decided, T(i nie they seem to be produced by sej>anition of the sticky 
surfaces of the air vesicles, and the capillary hrunclii. In some cases of 
pneumonii), for instance when associated with inflammatory rheumatism, 
DO crepitant rdle can be obtained whicli may he accounted for by slight 
Tueidity of the inflammatory lymph; for if the sounds were produced 
liy air bubbling through fluidj they would occur regardless of the nature 
of tliut fluid. 

Ctwpitant Hllc^ are much morv nunierotis than tbo 8ii1>ci'v|Mlant. In listen- 
tnf; to Bi(bci>'pii.'nit iAIt»s. »c ^cldnni spt>iii to tieni* murt? xUnn \i-u or fifliTn at 
one* ; tvlnfreas willi tlie crupitatit rAlt* we seem to heiir a Imndi-fMl or moi-c with 
«ttcli inspiration. 

Crepitant rflles are obtained in perfection in the eaHy atatfe nf puev- 
wH'mift. of which they are considered diagnostic. This Hti\^o lasts but a 
Jew houre>: consequently in many cases of inflammation of the lung the 
hUea hiive disnp|ieared before we see the patient. 

A few crepiliiiil nilcs are ^tnielimes heard in congestion of the lung 

'and in pulmonari' n>dema, and they are frequently found in phthisis, 

in a small zone around the consolidation. In this latter case they seem 

to n^ttlt from gradual extension of the pneumonitis, which often pre- 

oetU*s tiilrercular deposit. 

Crepitant rAlcs.snbcrcpitant rille8,and friction sounds arc sometimes 

'so much alike that it is ditiicult to distinguish between them. If dry 

crepitating sounds are numerous and heard only on inspiration, they 

are crepitant nUes; but if dry crepitating sounds are few in num1)er and 

PUrSlCAL niAtJNOiilS. 

are heard in expiration or in both inspiralioii and oxpimtiou, they are 
likely to be friction sounds. Subcrcpituiit riiles arc more moist and not 
ne:irly ho numerous as crepitant nllcs, uud thuyaro usually hoiird in both 
inspiration and uxpirutiou. The moist cliaraetor, the number^ and iho Liiuo 
of occurrence of subcrepitant riUes witl enable ue to distinguish Lheiu 
from the crepitant; and their deeper seat and their cionstiincy will nsu- 
tklly emible us to distinguish them from tine Irictiuu tiounds — which are 
still fewer in number — even when the latter are moist in character. 

Crepitant n'llea are not much uiTt'etod by cough or forced rcspinitiou 
wlien due to pneuinoniii, hut In nthur instances two or three full inspi- 
rations will frequently dispel theui. 

Exceptional.— Either oiP|)ilant or siibcropitant rAles may be someti.niM 
licought out direclly after coiighinjj whew they ven absent a inoiiipiit pn*. 
vlousJy. A tuntnd closely re-wmblins' tlie MiWri^pitant or tliR civpitjint rille mat 
frequently be obtained owr ilit? tliiti border of the lifuiithy lung-; in these in- 
8taac«s, unly a. ft^w oC the rales are beard, und tliey dUiappear after three or four 
forced ioiipt rations. 

GuBULKS rojiomble lar;fe mucous rdles, but aro generally higher in 
pitch and possess a hollow metallic quality; though occurring during 
hoth portions of the respiratory act, tliey aro most frequent in inspira- 
tion. They are produced by air bubbling through fluid in cavities wliich 
communiimto with the bronchial tuWs (Kig. 10). If cavities are com- 
pletely filled with flnid or entirely empty, or if the level of the fluid 
does not reacli above the opening of tli« bronchial tube, no gurgles will 
bo producttd. These soiimls aro largo or small, according to the size of 
the cavity in which they are produced. 

This sign is usually indicative ot phlhinii, but may occur in any pul- 
monary disease which causes excavations. 

The siucora click resembles an isolated atibcrepitant rtlle, and is 
heard during inspiration only. The sign generally consists of n singlo 
click, or, at most, of two or tbrec clicks. It is a sharp crackling or 
clicking sound, supposed to be produced in the smaller bronchial tuboi 
by sudden se]mration of their agglutinated surfaces during inspiration; 
it is not usunlly affected by cou;;h. Wlu-n heard over the a)'cx of one 
lung, it is a *ign of L'onsiderable value in the early diagnosis of phOitjnn, 
Such sounds are sometimes heard over a considerable portion of the 
lung in acute tnfM^rrnhm.t, in extensiveMro«iV7>w(»MWOMtff, or in the later 
stages of intcr^ititial f.r ratarrhol puenmonta. 

Frictios Sounds. — Fi*iction eonuds are produced by rubbing to- 
gether of the two pleural surfaces, which are either dry from diminu- 
tion ol their natural aecretions or roughened by exudation of inflamma- 
tory lymph (Fig. 18). These sounds are grazing, rubbing, grating, ra8i>- 
ing, or crejiking in character: sonietimes dry. sometimes moist. They 
may be simulated by rubbing the b:i(;k of the hand, while listening with 
the stethoscope on its palm, or by rubbing the fingers on the iutegnment 



»hen auacnltating the chost. They are usually fow in number and 
transitory, being beurd for a few respiratious, and then disjippouring to 
return again in a few minutes; thpy miiy be heunl just at the eiul of 
inspimtion or at the beginning of expiration. This is thi- characteristic 
sign of pleurisy. The gmzing friction soumi is only heard in tho be- 
ginniog of the inflammation, and can be detected most frequently in the 
circnmacribed pluurisv accompanying phthisis. Some one of the other 
Tarietios, of whicli the quality is of no importanro, may be hoard iu the 
first and third stigea of pleurisy. Care must always he taken nut to mis- 
take for this sign the sounds produced by cnickling of the hairs beneath 
the instrument, or by the rubbing of the slothoscope, the fingers, or the 


PHldvot rMptnOory 
oturmur uid iIuIbhu. 




rnspmiorr •outKis.f ' 

Tta. IBl— AcPTi PucTRHY. Tho upper partor the (uiiBiBlnji normal con'trtlon.oriheslroelto 
■UghUrdlMMided, Tho k>w«T imrt of tlM lung la [wrtiaJly collapoML Tti<> uirper curtac*- uf Uie 
llrid Is aot borisootal, but kt cootoi-ms luon or ka iNTfi>ctl; u> tlM> imtural ouUluv of ilie lung. 

tlothingou the eurfaco, or of the clothing or fingers nn the iriBtrument. 
Bounds closely rcBembliug the friction murmur aire often heard over the 
false ribs in a healtliy cheat. They seem to be produced by slight 
moveiuents of the shiu beneath the rim of the stethoscope. 

Cnakimj or rrutHjtUmj sound«i are sometimes obtained over tho chest, 
the Bigniticaiion of which is not ftilly nndcrstoocl. The creaking sounds 
are most frequently heard at the lower part of the tliorax. and lUf siiji- 
posed to bo due to old plt-uritie adhesions. Hoth creaking or craekling 
and crumpliiig sounds are sometimes obtained orer the upjier portion 
of the chest. The crumpling sounds which are heard in inspinition re- 
senililo those M'hich may be produced by inflating a dried bladder, and 
are supposed to be produced from similar onuses; that is^ the inflation 


of dry emphveematons air cells. Thompaou considers these sounds Jtt- 
dicative of sypliilitic diseiise of the lungH. Vi'beu confiued to the apex, 
they are nearly nlwaya nasocintt'd with phthisis. 

Metallic; TiNKLiNfi is a clear, gilrery, tinkling sonnd, like that pro- 
duced by dropping n pin into a glass. It seems to bo caused by the 
fjilliiig of u drop of fluid from the upper part of a large cavity ou the 
siirfjiee of fluid Iwlow. It can 8onietim*'a bo heiird over one entire si<3e, 
but it is usually moei distinct ou a level witli the nipple. When llio 
proper conditions are present within tlie chest — that is, a large cavity 
contaiuiug uir and Huid — it may be produced by any a^t«tion, such, for 
example, as sptviking, coughing, deep inspiration, or occnBioually by the 
act of HwaHowing. The sign occurs most frefiuenily in the pleural cav- 
ity in pneumo-hydrothonix; but in exfcptionul instances it is produced 
in very largt) pulmonary cavities. A t^niiiid very eimilrtr to this may 
sometimes be heard over the stomach when diet^uded with gas. 


Considerable information regarding the condition of the lungs can 
be obtained by studying the sounds of the voice as transmitted through 
the chest walls. 

If we listen over the healthy chest while the person is speaking, an 
indistinct, distant.and ninttled sound will be heard, termed normal vnonl 
nmoiifince. It is due to the fact that sonnds produced in the larynx iire 
transmitted not only outward througlj tlie month, but also downward 
through evciy branch of the bronchial tree. Vocal re^orijince, like moat 
of the other pulmonary sounds, varies greatly in different healthy indi- 
viduals and in different portions of the same chest. If a person has a 
low-pitchwl intense voice, the vocal resonance will be more forcible than 
in those who have high-pitched or feeble voices. 

In studying the voice-sounds by immediate auscultation, it is desira- 
ble to close the ear which is not applied to the chest, in order to exclude 
sounds (Turning from the mouthy and it is better to have the patient 
count one, two, three, than to ask him questions and listen for the an- 
swers. Ky the hitter course the examiner's attention is distracted from 
the sounds within the chest iu the attempt to catch the piitient's reply. 
The varieties of vocal resonance which may be heard o^*er different re» 
gions of the normal chest are named from the piirts in which they are 
produced; over the larynx and trachea we Imve laryngejil and traclieul 
resonance; over the bronchial tubes, bronchial resonance; and over uir 
vesicles, the normal vesicular or, as it is usually termed, normal vocal 

LAltTKAopHON'V 18 the vocal resonance obtained over the larynx, and 
TnAcnEOf'iloN'V that obtained over the trachea. In these varieties the 
words are imperfectly artirnliited, but the voicii is tmnsmitted to the 
ear ** with a force and intensity almost painful.'' The sounds are con* 




rvDtrated or, in otber words, seem to be produced witliiu a small area 
irami'«Iuttel y bciivuth the litetho&cope, and necessarily vary in pitcli with 
the jillch of iho iudividimra voice. 

XoUMAL iiROXcuopnoXT is obtftined while the person is apeuking, 
by lieleuiiig oNt-r tlie broncliinl tubes, near the border of the sternum 
from the first to thu third rib, ur more espeeially directly over the main 
bn:>nehi on a level with the t«ecoud costid cartilages in front, or on ii level 
with the fourth dorsal vertebra in the inter-scftpular region. Tliis 
occopiea u position midwiiy between normal vocal resonance and luryr.- 
gophony. The eounde thus obtaine*! are transniitted to the ear with 
coneiderable intensity, thougli with miifh less force than over the larynx; 
they appear to bo produced immediately beneath the etethoscope, but 
the -words seem very imperfectly articulated. Whenever this sign is ob- 
tained uver any other portion of the chest, it indicates consolidation of 
the pnlmouary parenchyma. 

NoBiiAL VOCAL RESOSANCE 16 obtained by listening to the voice over 
,e vehicular portions of the Iniig. This sound, liaviug no ajtproacb to 
ieulatiun, is di> and diiTused, seeming to come from the deejier 
portions of the Inng two or three inches beneath the sarface. As a 
rtile, vocal resonance is always more intense upon the right side ihan, 
upon the left, especially in the iufra-clavicular regions. 

Bxteptional. — ^la a fenr instances over Uie right apex, even in liealth, the 
re«ooance very naaily approaolies broncltophony. I( the foiindit havo this 
chanu-ter upoD tnith sides, as lliey have la mre iostaaces, they will be found 
mofttinlen&u upon the right side, but higlt«r in pilch on the lett — a disparity 
due U> the difference in c;Uibre of tlic br<mcliial tubvn ; tlio»e upon tbe n^cUl siile 
btttn^the larger niusl net.'esvarily ^ive the mom iuteose au*! luwer-pitcbcd sound* 

The normal vocal resonance is generally obtained over the entire chest 
in men, but only over the upper part in women and children, in whom. 
it is a sign of little value. 

This sign is modified by disease, principally in its intensity, which 
^oa; be cither diminished or increased. 


Diminished. •[ Vocal sounds feeble or supprewed. 


Vocal sounds exaggei-utcd. 

Resonance whicb 'fi termed bronchophony. 

■ '* " (e^opbuuy. 

*• ** pectoriloquy. 

" " " amphoric voice. 

'DrMixisHEn H7.<?0KANCE. — T)innniHhed resonance is usually due to 
mncb the same canses as the diminished respiratory murmnr; that is, 
eepuratlon of tbe pulmonary from the costal pleura by air or flnid, as in 
pneumothorax or pleurisy. It also occitrs in cases of extreme i-Hf/iA/yw mo, 
in jiulmontirif eedema, in bromhilis with free secretion, and occasionally 
where there is extreme puhuonnri/ cutufoUdaliotu 



The Tocal sounds are niofitly Bupprosscd over fluid in the pleural sac; 
but just libuve ihu level of the fluid the uir cells are [uirtiully eollapsed^ 
BO that vocal resonance h increased. For an inch or an inch and n half 
below the level of the fluid the resunance is dimJuiAlied in intensity, and 
A little lower it ia nwirly suppressed. TUlih we are able to ascertaia 
the height of the fluid by means of the vocal resouunue as well as by 

This sign is principally of value in the diagnosis of pleuritic effusion, 
by ennbling us to distinguish bi^tween it und CDnsoIldation of the lower 
part of the lung. 

Exceptionat.—ln some cases the vocoJ resocance may be lieard disLincUy alt 
over the pleunlic elTusion, lliuiij;li llie (>outiJs ure dtstuut und iiioro ur \<^s* muffled, 

iNcriBASEi) Vocal Resoxance. — Exaggerated vocal resonance differs 
from the normal voice-sounds simply in its intensity. This sign de- 
notes more or less consolidation of the lung tissue or coihipse of the air 
vesicles, and ia usually iissoeiated witli broucho-vcsiculur respiration. 

It is a sign of considerable impdrtanrp in the diagnosis of the early 
stage of phthisis and in discriminating between pneumonia and pleurisy. 

ExcejHivtial. — lu very run* caiws llie vocal resouuiice u exaggerated in pueu- 
motltomx and in cniphy&fiiia, 

Bronchoi'Hoky, as already noted, consists of more or loss intense vocal 
pounds, usually imperfectly articulated, which have a itccujiar degree of 
concentration, or, iu other words, seem to be produced immediately be- 
neath the stethoscope, instead of coming from the deeper ]>urtions of 
the lung. The intensity of this sign, which may be greater or less than 
that of normal rcsunanuc, is an unimj)ortunt element; so also is the dis* 
tinotness of articulation. Its recognition depends chiefly on tlie chorao 
terislic concentration. 

The significance of bronchophony depends upon iU location. If 
board over the main bronchial tubes, it may be simply u healthy sound; 
but if heard over vesicular j)ortions of the lungs, it is indicative of 
COQsolidiition. It Is usually associated with a tubular resjunitory mur- 
mur; but as it oci^urs with a less amount of consolidation than is nece»- 
Barv- far true bronchial breathing, it may frequently be obtained with 
broncho- vesicular respiration. 

Exceptional. — Bronchophony ain.illy poMeeses the dtarax^tcristic coQcontra- 
fion : but wi-ln^n Uie coiisolidat«!d lun^ is 8ei>arat«d from Uie chest wall by fluid, 
it uiuy Kuuud distuiit. 

This sign is of special Tolue in the diagnosis of the second stage of 
pneumonia (Fig. 37). It is seldom obtained perfectly in phthisis, 
because in this disettse consolidation, is nut usually complete. 

Krw^ffoual.-^Bronchophony ftt occAsionally otttained fa narcinoma of (he 
iung, though usually tlita diaeaso involves Um whole tissue, air vesicles and brou- 

VOCAL sov^'oa. 


ctilml tubcM alike, or It crowds the pulmoniu-y tUsue before it, thus IiindeH ng tlie 
transmission of tlie voici;. But when ttie uir vusiclei uJoae nre lllled and the 
broncliial tubes rtiiuain patent, vjt ocelli's in i-ure cases, bi-unchoithuny may be ob- 
tauoed. It in aino present in liumorrliagic infarctioits which fill the air vuiolea 
but tvave the brondiiai tubes oi>cu, and may therefore be a si^n ia pulinotiaiy 

>£aoruoyY is a variety of bronchophony. It is u tremulous sound 

which ImB been eomjNtre^ to the blfiitirig of a goat; hence the name. 

Ijike bronchophony, it conveys to the listening ear the impression of 

haviug boen produced within a very limited portion of the long; unliko 

the lattor, it i>eeins to come up from a considemblc depth, and to trem- 

hlti about the end uf the i)tetbosco{>e. Wlien present, it may be most 

resdily obtained in the inter<Hcapnltir or uxillarv regions. This sound 

t« generally iimluced in coiiMuliduted lung tissue nhicb is septiratcd. 

trom the chest wjill by a tliin layer of lluid. Jt is a sign ot phitro-pnen' 

v\OMi(t — that is, pnc'utnonia and pUnirisy with ettusion; but even in this 

'lieease it is present only a short time, and is a sign of little value. 

Egophony is most frequently produced when the pleural cavity is about 

luilf Glled with fluid. 

In ordinary pleuritic effusions, the lung just above the surface of tho 
llnid is more or less solidified by collapse uf a jwrtion of the air vesicles; 
under such circumstances regophony may bo produrcd providing tho 
pleura-)ii)lmoni\lis and the pleuni-costalis are agglutimiteU just above 
the collapsed lung. 

Pectoiiiloquy differs from bronchophony in that the articulated 
speech is more completely Iransmitttid. In broneliojihony the voice ia 
lieard, but the words are not distinct In pectoriloquy articulation is 
nearly perfect. There are two varieties of pectoriloquy: one in which 
the sounds are concentrated and near the tar like bronchophony, but 
arc heard over a consJdenible portion of the lung; and another in which 
the sign is conBned to a limited spiice and has not the degree of concen* 
tration found in bronchopliony. The first of these, which is high in 
pitch and cbinging or metallic in quality, is frequently produced by sim- 
ple consolidation of lung tissue. The second, whieli is low in pitch and 
softer in quality, is always a trnstworthy sign of a pulmonary cavity 
with smooth walls and a largo opening into n bronchtiil tube. Well- 
deGncd pectorilminy is not a frequent sign, but when heard the first 
variety is a sign of pUthistM or pneHinunUi, and the second of any of tho^e 
diseases which cause vomicae, viz., phlhisigj pulvmnary alKicess or jraw- 
grttU!fM%Ci brQiichierlasix. 

Ampuosic voice is hollow and more or less musical iu character. 
The musieul quality follows tho voice and is termed the amphoric echo. 
The words are not articulated, as in pectoriloquy. This sign occurs 
tindor the samo conditions as am[>horic respinLtiun and amphorio per* 
cuMioii resonance; that is, over the pleural sac when containing air iui43 



commuuicattng freely witk a bronchial tube, uad over very large cavities 
in the lungs. 

Excvptional. — There ure j^ooit ivaaotis for belie\*ingr t!iat, in rar* cASttf »m- 
plioric voice, as wdII o-s Liiiiplvoric iY^ft|iinLtion, may be beai-d over a layer of air 
in the pleura) cavity wliicli cIo««t not commanicate with the bronchial tubes. 

Amphoric voice is » sign ot jnteumo-hydrothunuy in which disease it 
is associated with tympimilic resonance over the upper part of the che^t, 
and ordinarily with the sueeussion sound. K'the latter sifrna arc absent, 
the amphoric voice is probably produced ill a phthisical cavity. 

Whisi'ERIXr Vocaj- Resoxaxce. — Flint describod the whisper reso- 
nance witli ounsiik'rable niiuuteue&s. He considered the signs which it 
furniithes of equal value with those from a loud voice; I find them uf 
even greater importance. 

Thk nokuai, uhon'CUIal tvniiiPERisa term applied to sounds of 
a blowing or tulmltir chanicter, very closely resembling the sound of 
forced respiration, heard in listening over the upper portion of the chest 
when a penon is siteakiug in a sharp whisper. It4 modifications by 
disease are classified as exaggcrate^il bronchial whisper, whi.tpcring bron- 
chophony, cavernous whisper, whispering pectoriloquy, and aniphorio 

ExAOGERATED BRONcniAL WHISPER is more intense and higher in 
pitch than the normal sound. It is pruduced in lungs which arc slightly 

Whisi'ER1s« iJKOscnoPiiONT is higher in pitch and more intense 
and blowing than the preceding. It has the same characteristic concen- 
tration and nearness to the car \\» bronchophony with the loud voice. 
It may be obtained over lungs so slightly solidifiei] as to yiuld only ex- 
aggerated vocal resonance Mhen the patient is sjteiiking aloud; therefore 
it cjin be appreciate*! sooner than bronchophony with the loud voices 
This (act renders whispering bronchophony a moat important sign in 
the early stage of phthisis. 

The cavernous whisper is a low-pitche<l, blowing sound, confined 
to a limited portion of the cheet. It is produceil within pulmonary 
cavities under the same uonditiuns us cavernous respiration. This sign 
is principally of value in the diagnosis of phtlnRis. 

WiiiriPEiaxo PECTORiLOQiiy differs from whispering br-onchophony 
only in its more perfect articulation. When obtained over a small space 
only, this is a sign of a cavity. It is most frequently found in phthisis. 

AsiPHiiKic WH16PER occurs Under the same conditions as tho am- 
phoric voice or amphoric resonance on i>ercuBsiou; that is, over the 
pleural sao filled with air, or over very large cavities in the lung tissue. 

Aphonic jtecloriloquy is a term which has been applied to the voice sounds 
when th^ patieiil is Mpt^nkin^ in a low tunc. It has been stated that th^e 
sounds caa be distiocUy heard Dot ouly over coasolidated or coUup»ed lung^ 

bat also even when the oritan Ln this condition is geparated from tbe thomcic 
wall bv u collection of air or Ji<rrtii>i : however, these vihnitiotiK are not conducted 
through jj«*. By studying I hi:* vuriely ot voeul rt'souiim-'e, it is clainieil that 
may determine whether pleural ptTusions are of a serous or of n. purulent 
character. I have been able to verify this statement in u Tow caites, but aoi in alL 

TrssivB Sios s. — The reaonance of cough may Hometimes be stodied 
with advantage, especiiilly in childron. Tlic act of coughing is often ol 
special value in dislodging obstrnctions in the bronchial tube^ or ptil- 
monury cavities, nnd also in causing u subsequent deep inspiration which 
I will freely inflate the air cells, thus bringing out signs which might 
^K4)therwi>te bo overlooked. Tbe ditlerent viirit<tie8 of cough are classified 
^^mth laryngeal^ bronchial, oavernons, and amphoric. 
W Labtkmbal cough is usually more or less hacking in char&o- 

I tfir, and often spasmodic. [L is indicative of larytigitis. 
I BROKcutAL rorr.H is quick, harsh, and bniasy. It is accompanied 

I by a thrill or fremitus, and if severe is nearly always attended vith pain 
^^a beneath the sternum or along the Inferior ribs, corresponding to tbe 
^^P attachment of the diaphragm. It is generally indic-ative of bronchitis. 
Cavernol'8 col'uh is produceil under the same circumstances as 
cavernous respiration, and ia generally associated with gurgles. It baa 
a hollow quality and is usually very intense. 

Amphoric coron is more musical and hollow in quality, isgeneniUy 
lower in pitch, and seems to penctnUo t)ie car witli less force than the 
cavernous. It is heard over very large pulmonary cavities or over the 
pleura when filled with air. 

Sometimes largo pnlmonarycaritieeare traversed bytrabecnlte which 
yield a peculiar twang when the patient coughs. This is of special 
Talue, as these strings prevent cavernous or amphoric vaice>sounds. 

Tussive signs are usually, though not always, transmitted through 
consolidated lung, but seldom through collections of fluid. 

We may obtain considerable information about the condition of the 
lungs in children who cannot be induced to speak by studying tlte cry, 
which ia subject to the same variations as vocal resoounce in adults. 




Pleurisy consists of an inflammation, more or leee extensive, of the 
seroua mcmbrano covering the lungs and lining the thorucic walls. 
There are three recognized varieties of this disease: the acute, aabacate, 
aud uUrouic or suppurullve, tUso culled empycuia. 

Anatomical and Patuolooical Cuauacteristics. — There is first 
hyperwmift and reddt^ning ut the pleura with Urjiiesii from checking of 
its normal secretion, tlieie is swelling from tnui'^udution of serum into the 
perivAScular spaces, and multipliciition of connective-tissue culls vritb 
loss of the normal glistening of the pleund surface due to degenerattoa 
and exfoliation of superficial endothelial cells. Then follow exudation 
of iuflaaimatory lymph uud Lfluslon of scrum to a greater or less extent; 
the foniier clinging to the pleural liurfaoe presentji a rough, sbaggj 
HppearHuct-; the latter gravitating tv the lowest part of tin- pleural sue, 
UKually holds in suspension shreds of fibrin, leucocytes, and endolheliiil 
cells. Thickening of thu serous membrane results from muItiplieatioDy 
in it and iu the fibrous exudate, of new conncctive-lissu» cells; these 
mature, ni^vr bluud-vetssels furni, making couuectiun with the original 
vessels of the pleura, and organization of the exudate is the result. 

Adhesions more or less extensive may form betwoeu opposing pleural 
sarfoces, which become bound together closely by the plastic organiza- 
tion, or more loosely by fibrous bands and false luenibrnnes. 

Thejileural surface early in the inflammation may present irregular 
spots of ecchymosis surrounded by the more dJtfused redness; later, 
whitish spots of fibrous organization appear on the free surface. The 
effused aernm is generally of a light yellow or greenish color, has a 
specific gravity of from 1,010 to 1.024, contains four to six per cent of 
albuRien, and coagulates readily u|>ou exposure. In iUt'se respects it 
differs from the fluid of hydtuUturax, which cuiitHini> but one per cent of 
albumen, its specitic gravity being below 1,015. Tho amount of fluid 
varies; iu acute pluurisy, it is nut utiually great, seldom occupying more 
than one-third or at most one-half of the pleural sac, and U very rarely 
sufficient to fill the cavity. In subacute pleurisy the quantity is often 
sufficient to fill the cavity and cause great distention of the side. In 
empyema the amount is seldom greater than iu acute pleurisy. 



The proceases of pleuritic inflammation vary with the unuses aud 
■everity of the ul!cction. The effusion takes its chnracterfrum the preg- 
anco of serum, fibrin, endothelial eolls, blood, uiid pus in vwryiux quantity 
nnd variously combtuud. The products of iDtUtniuiAtiuu. in mild rueeB 
may be chiefly fibrinous with little or no serous effusion; hence Lhe so- 
called plastic or dry pleurisy. M fibrinous exudute and pleural thiek- 
«niiig i»re marked and serous effusion is copious, wo have the s^ro-M'nn- 
aiiJi form. If infective innamniation ocnnr pus results, imil we CidI it 
rinfit/rrna. The purulent uccumuliition in these cases swarms with the 
clmructeristic streptococci ami staphylococci of stippumtion, und iu 
some instances the so^4dlcd diplooooci of pneumonia and biicilli of 
tultcrculoflis may bo fonod, though they are difficult of deinoustrutiou. 

Hemurrhugic pkurisy occasionally conipHcates purpura hemorrhagica, 
can<t*r, scorbutu?, mid tubt-milosifl, or may result from the lighting up 
of * new iuflainnmtion in an old pleurttit<. 

Seroufl pleuritic effusions after remaining for a time are usually 
gruduidly absorbed, lint ]mrnlent accumulations never to any great ux- 
ItMil. In tlie latter the lluid temls to perforate the surrounding wall 
«itber to ap^jcar externally or to empty itself into an adjacent cavity or 
»rgaii. The solid portion of an effusion may be absorbed after under* 
^uiug fatty metamorphosis, but not infrequently, sooner or later it be- 
comes the seat of tubercular degeneration; or it mayWconie incupsiilated 
ind remuin so for years; or it may be the seat of calcareous de|KH!itian. 
L'ases ore reported in which the Hbro'us exudate covering an entire lung 
liad been the site of such deposit. Asiilu from tht'^e characteristics of 
fcn inflamed pleura, certain pathological conditions result from the 
rffect of the process upon iidjneent structures. Inflammation usually 
entond^i to the lung tisbue immediately beneath the pleura, giving riise 
to exudation which uccliideii some of the alveoli. It may also by ex- 
i«naiDu eaiise pericarditis. The plenritie effusion may be sufficient to 
otusc complete collapse of thu corresponding lung. 

The compressed lung, npon disappearance of the fluid, tends slowly to 
re-exiKuid unless pressure has been too long eoutinuefl, in which cose car- 
Tiiflcntionof the organ results, and it remains as a small, compact, leatherv 
moss, II suitable nidus for subsequent dispose. Its comjilete expansion 
in any case is apt to be limitml by the formation of cicatrieiul bandsi 
,And the great vessels may suffer serious compression. 


For convenience of description, acutt- pleurisy has been divided into 
fear stages by some authors: First, a dry stage; second, a plastic stage; 
third, a stage of effusion; and fourth, a stage of absorption. I prefer 
the division into three stages analogous to tbc three stages of j>neumo- 
sia, calling the first the dry stage; the second, the stage of effusion; the 
third, the stage of absorption. 



Etiology. — Acute pleurisy may be primary, or becoudary to some 
other dieeu^. 

PredixfMsin'j fViH.<fjr.— It occurs ni03t frequently in w-iiiier ami 
spring, iu adtiitd rather thiui childrcu, aud attnekei preferably tlit- male 
sex. MidiiutritioQ and poor hygieDio conditions furor iUs uecurrence. 

Estitiny Vavses. — The uioat coninicn causes are exposure and rlieii- 
matiam. In a weak person mental depresfnion may be an exciting caniio. 

It may result from traumatism, €!vcn (»f alight character. It arises 
not infrequently from pneumonia, phtliiaia, pulmonary infarction, ab- 
aceBS, gangrene, or tumors; other cauium are fuuud in hemorrhage into 
the pleural ravity, pt'rlcarditis, costal or vertebral caries, absri'ss of tlie 
nicdiastiuuTn, [H-riti>nitis, and hydatids of the liver; also in infective i\U- 
eases, Urlght's disease, pya;mia aud septicfemia. 

SvMiTOMATor.oov. — The usual symptoms of this disease are: A sharp, 
cutting paiu iu the side, aggravated by general and respiratory uiovo- 
nients; rapid nnil hicoroplvfc hispiraiioH ; a aliort, di'y cough and a 
hard, rapid pv he, with more or less distnrbauco of (he digestive organs. 
Pain is especially severe on inspiratiou aud apt to be located ju^t l>e< 
iieath the nip))Iti, though in children frequently it is less circttnisi'rilied. 
It is a more constant symptom in adults, but variable in dunitton; it 
usually diiniuishcs as the general pyrexia appears, or vrith the occurrence 
of effusion. 

The tcmpcTftlure is usually but slightly elevated the first day, 09'' or 
100** F. in adults, but in children 102'' or 103'' F. In pleuritic effusiou' 
of children, surface thermometry may reveal on the affected side Jiigher 
temperature by one or tivo degrees, rising aud falliug with the increase 
and decrease of the efTneion. AVhile iu very mild cases the subjective ■ 
symptoms may bo bo slight as to attract little or lo attention, in rare * 
case-8 they may be so severe as to suggest pucuuioniu. Pleuritic synip- 
tomtt are apt to be less marked iu the feeble ami cachectic. When a 
largo effusion occurs, nausea and vomiting are frequently present aud 
(]yapn(i->a becomes a prominent symptom. 

The most imfwrtant ;ft>//i5 of jileurisy are: short and catchinj? respi- 
ration, friction fremitus on palpation, and friction sounds heard oa 
auscultation. Over the collection of fluid after effusion has taken place, 
there is flatness and loes of vocal fremitus and respiratory mnrmnr. Tho 
upper line of flatness changes with the position of the patient (Fig. 18). 

In the Jjri>t ntnt/e we have in the beginning simply dryneas of the 
plenra, and ehortly afterward an exudation of inflammatory lymph. 

liy inspection we obaeT%*e jerking or interrupted and incomplete res- 
piration, with diminution of the expansive movements of the affected 
side. This catching respiration results from the patient's efforts to 
limit inspiratory movement, in order to prevent pain. This sign, 
though nearly always present, is not diagnostic of pleurisy; for in inter- 
coitnl iu'Miral!.ria and in pleurodynia may l>e found similar muvemeuts. 

patient is sitting or in a aomi-recurobent position, his body 

Yfn be indined tovud the mffecied side. If reonmheat, h« u Uk«]T to 
be lying on the anaifected side. 

OocadbnaUT, e^iecullv io childiva. the patienl's effv-»ns to iw^iniiit ibe nk^T*- 
~ at the affected skie result in t«iupo(miT spinal curvature t^^m-aixi tliat skK 

On palpation, no signs irill be obtained in the early ]vtrt of thU 
stage; but a little later friction fremitus may frequently bo detected, 
and the Tocal fremitus may be found diminished. Pre^sui* usually 
elicits deep-e^ted tenderness. Mensuration yields no additional $igns. 

Percussion yields no signs at first; but vhen plastic exudation haa 
taken place, dulness, in projwrtion to the amount of exudation, will 
be elicited. The dulness i? always less marked at the end of forve*! 
expiration than during normal respiration. 

Auscultation early in this stage discovers a feeble respiratory mtir- 
mnr with jerking or cog-wheel respiration, and in some instauoes, 
just at the end of inspiration, a feeble, grazing friction sound. When 
plastic exudation has taken place the respiratory sounds are still mor\' 
feeble, and the friction sound becomes distinct, on both inspiration and 
expiration, but usually most intense with the latter. This may have 
any of the characteristics of friction sounds, as rubbing, grazing, creak- 
ing, or crackling. It nmy not be obUiinable except on congh or deep 
inspiration, and will not be heanl if the inflammation is confiniHl to the 
mediastinal or diaphragmatic pleura. At this stage the vocal resonanoo 
is somewhat diminished. 

In the second stage of pleurisy by inspection we still observe dimin- 
fahed respiratory movements, but not the interrupted respiration noticed 
in the lirst stage, perhaps also an apparent increase in size of tho 
affected side; but sufficient fluid to dilate tho side of tho chest is excep- 
tional in acute pleurisy. 

In palpation the vocal fremitus is absent over the effusion. Itarely. 
distinct fluctuation can be obtained. The apex beat of the hoiurt will 
be found crowded to the right or left, according to the seat and amount 
cf the effusion. If the pleurisy is upon tho loft side, tho heart is 
crowded to the right; if upon the*right side, it is displaced in tlio oppo- 
site direction. 

Exceptional,— In very rare instances of serous effusion, the vocal frcniltuH in 
not lost. 

Percussion over the lower part of tho chest yields flutnesfl, extend- 
ing upward to the surface of the fluid. Tho height of this surface ih 
not altered by deep inspirations or forced expirations, but its relntions 
are changed by alterations in the patient's position, unless the effusion 
entirely fills the pleural sac or there are complete adhesions abovo its 

Above the fluid the resonance is exaggerated, and in exceptional 
cmses it may have a vesiculo-tympauitic or amphoric qtulity. 

InvestigationB by Danioieean, of Paris, and more recently by the late 
Dr. Ellis, of Bfwtoji, show th«t usually, when the pleural sac is no more 
than one-fourth or onc-tUird filled, the upper surface of the Uuid corre- 
sponds to a curved line knowQ as the letter S curve, termed by Ellis 
the curved lino of flatness (Fig. 19). 

O. M. Gurliind, in his monograph on rneiinio-dyuamics. describes 
this curved line as folluws: " Its lowest point is found behind, near the 
spinal column. From thia point it cnrves upward and outward across 
the lateral region, where it is highest ; and from this point it jiroceeda 
almost horizontally forward to the sternum," The experiments of 
Garland demouistrate that, instead of a gradual rising of the fluid id 

■ttrve; A, U, 

Ci'RVBD LtiiK or PuTXiiM IK Plsdbibt, PoaTBiiiuK Vuiw (Uiiu.4)fD>. C. B, Lcttvr S 
C, irtasRl* of dulMM. 

the lower portion of the chest, carrying the lung above it. and main- 
tuiniu^ a horizontal surface, as is usually supposed, iia upper line nearly 
corresponds tu the natural outline of the base of the lung. This Is sup- 
posed t-o be due to the elasticity of the lung, which holds the fluid in 
this unnatural position. I refer thoao intcrcstod in this matter to Oar- 
land's monogntph for a complete exj)osition of the Hubject. 

If a line be drawn horizontally Ijjickward from the highest point of 
tho curved lino of flatness in the latcnil region to the spinal column, a 
flomewhat triangular spjtce will be loft butween it and the posterior p»rt 
of the curved line of fljitness. Thi« space is ternieU by Oarland the 
triangle of diihifM (Fig. 19). It is bounded l>elow and externally by tho 
letter S cune, internally by the spinal column, imd above by a lino 
drawn backwurd from the highest point of the curved line in the lateral 
region. This superior boundary is not necessarily horizontal, but it 

jirrr pif:rii*r. 


mmT be so ctatBAtrtd for ibe akv of illiistnuon. In this trungular 
■pttce ve hsTe oo fi&id. b=x tie 7«eoziuic« is :eii$ (has aVove i;. Thij 
dalneu is dae :<• puml (x-nipresdos of the is::^ &pu::si ;he spinal 
colnip"- In order W T^cc'gr.ixe ihe carriii line thiv^u^houi iis eiuire 
extent, ve muft not c*L'ii:i«r« i^e aJected viih the so'j::d side pv^teri- 
orlv, as it is not the distinciion tieiweea nesonanoe aiiu dalr.fss wh:*h 
ve wish to obtain, bet the ui=tinet:*:.ii l-eiwe^n culness and £aice$«. 
PeTtmseion should be m»>ie in perpendioclir lines at several placeis. 
either from above downward or from below upward. By ihis mt'thod, 
we easily distingnish between the dalness over the compressed lung and 
the flatness over the fluid, and Wtween the chaRioter of the resonance 
in these positions and that of the lung above them. Failure to recc^- 
nize the true character of the percussion note in these dlffervnt localities 

Fio- so.— CrKTD Lm or Flat^km in Plctribt, Anterior View (.ELLnt. 
•Btcrbtr Ttew. 

I<ett«r S cum?. 

has caused authors to describe the appt-r surfuee of thr fluid ns corre- 
sponding to a horizontal line. If we recollect that the fluid in the 
pleural sac conforms itself more or less perfectly to the niiturnl contour 
of the base of the lung, we shall understiuul why the line docs not iimlcrgo 
greater changes with alteration in the position of the puticnt. Suppose, 
for instance, that we find the level of the fluid, in front, at the fiftli rib. 
when the patient is in the erect position; upon causing liiui to lie on his 
back, according to the genenilly accepted opinion, the line of flatness 
should still remain horizontal, and would then he found running longi- 
tudinally along the latenil region. In fact, however, this never occurs. 
On the contrary, the line of flatness is not likely to he dei)rcssi'd in front 
more than one or two inches by this change in the patient's position, 
and it will bo found running more or less obliquely downward and 
backward, instead of longitudinally. 

When the pleural cavity is nearly fllled with flnid, we frequently get 
tympanitic resonance over its apex, especially if the patient is recum- 

... . ,,, ,^p|aiu thfe phenomenon, we are onco more 
;^ «t:kteiiienta tliiil tvmpanitic resonance u 
,U vtutL lb w high piloheU. t'riieulzcl — who bfliovea the 
..uutitHJ 10 bo low ill pitch^iu givhig the rcHSoua (or IbU 
oiu WiulrJoh ami Truube, wha cluim that the pitch in 
i.tit i» tli<pi*nilent upon two t^lctneuts: fir^t, the volume 
.... p»»int pon.'u8sed; second, the tension of tho lung tis- 
uUu that the pitch of tho percnssion Bonnd is directl}' 
'..tio lit i\w tension and inversely proportionate to the tolume 
;^Lillatliii{ oohinui of nir. lu other word^, u3 the lung i^ dimin- 
wl tn vi>luuio tho pitch iamiHed; or as it again approaches the nor- 
a\ h|ii<<, the piti'h Is lowered according to the amount of uir whicli it 
iiilalh*; kihI i\b the tension of tiie Inng is increji«e<i tlie pileh is eli-vated. 
'I'ltnrtiforo if Ihu dimination in volume which raises the pitch and the 
illiiilmitluu in tuuBion which loweris the pitch be equally IjfllanccJ, the 
pilt'h nill remain unaltered. It therefore follows tiiut in moderately 
Ui'Kii pleuritic efTuaioiia which yield tympanitic resouuuce in the infra- 
rhivi(!ulur region, the diminution in tension (htc jfihh) must e:[eeed the 
dlniiiiiition in volume {!n'ijh pitch). Flint, and f)a Costa (Medical Diag- 
lioniii IS'.fO, p. 205), who consider tympanitic resonance to be of high 
pitch, bttlieve that thia sign in ph-urisy is due in great part to tlio condncte<I 
ri'Honanoe from the trachea and the bronchial tulles. Both of these 
reasons may be in part correct, but,iis 1 pointed out in a oomniuuication 
to the Chicago }fe<lical Journal and JCxnmintr, Marcii, 18^ I, it is more 
than prol)able that this sign results mainly from u collection of watery 
vapor above the fluid in sac. Va])Oriz:ttiou of water occurs even 
Ht ft low terapcrutnre, but at a temperature of one hundred and one or 
two degrees Fahrenheit, under ordinary pressure, it takes i>lace rapidly. 
This process must therefore bo going on constantly when ttnid collects 
in the pleunti cavities, and as soon as ttie serous surfaces bocDDie so 
altered by inflammation that they are iumpuble of absorbing the vapor 
as rapidly as it is formed, it will collect above the fluid until the tension 
becomes sufliriont lu prevent its further formation. A cavity so formal, 
filled with watery vapor, must yield tympjinitic resonance. I am con- 
vinced of the correclneJiB of this tlieory by experiments not only with 
fluids outside of the body, but also on patients with the pleural cavity 
almost filled with fluid, and in whom when recumbent tympuuilic refi- 
mutncc was plainly discernible, just lieneath the claWcle, while on ill- 
version of the patient so that the bai<e of the chest was the highest, 
tympanitic resonance would be found over a small area at the base of 
the pleural sac. 



Bie^uski (Schmidt's Jnhrhnch, Auirust, 1889) calls attention to a new B(gn of 
right-«ided pk'uriHV ; mcreo!»eO cardial- dulneM laterally appeani with effusion 
6Ten in itiuall aniouDt, catued. Ik Uiinlu, bv ateleotaniis of tlie nitddle lobe of the 

lung. 8u exposing more of t)ir> lieart, Tbi» idcreawnl dulncss u said to remain 
[04- a year ur more alter absot-fttioD of Uie etTusiuD. 

B)' auscultation the respiratory murmur above the level of tlie fluid 
i» often found slightly cxaggeniied. The vesicular murmur ciuinot be 
heard uver the ilul-i excepting in a small zoue ueiir its U])per level, where 
ibosotinds are feebly transmitted from thu lungs. Over the fluid, vocal 
n'ioiiauctj i^ either lust ur the voii;u-souiuls iire iudistiiict ami (listjint. 
.Someiimes coiifolidjition uf the lower part of ihe lung euuges legoplionv 
Tiear the upper Rurfane of the fluid. Often a few friction Bounds may 
be beord in the same position, but none over the rest of the fluid. 

[turiiirf Uu- third ifiii'je of pleurisy the signs denote gradual return to 
hwlthy eundliion. Distention becomes less, respiratory movements 
freer, and the voeal fremitus gradually appeiirs first at the upper 
urLion of the ehest. The upper limit of the- liquid, as ascertuitie<l by 
trra&sion, slowly fulls until tlte tluid is entirely absorbed. Sometimes, 
rwlhe lower part of the chest, mure or lees dulness persists for a long 
kime, or the resonance may not again become nurnial, uwing to the re- 
aining inflammatory lymph or to thickening of the pleuni, which 
^lD%y permanently aepamto the lung a sliort distance from the chest wall. 
The respiratory sounds gmdually return, at first feeble and distant, 
tiDt groning more distinct, until they finally become normal. Ocea- 
tJoQaUy the respinitor}' sounds remain harsh and tubular in quullty. on 
lUDt of the imperfect expansion of the air vesicles, and bronchial 
ithing may remain near tlie vertebral column for some time, t'su- 
SVf as the two surfaces of the pleura again come into contact, friction 
waiidfiare obtained, which may continue for a short time only or for 
eprrral months. 

The heart and the abdominal orgims gradually return to their nor- 
mal positions, us shown by percussion and auscultation. 

in ioine rare coacs, howevor, wh^n tbe lieart is crowded to lite ri^ht of the 
mill liy nil efliikiun into the left pletmil nnc. a()be!iion<t take place which i«r. 
kdpntly retain the or^n in its al>iiorinul siluutiun. Sometimes the absorption 
ta l»rge and luii>:^-i.'Oiilinued etTu.siuri in llio ri^bt &ac is fuHuwed by a pennanent 
location of lb<! heart tu the rii^tit of tJic sternum, due tu thi> tetuk-ticy of the 
nuTDundiri}; parta to fill theii|iace which should b« occupied by tlie unexpiuidsd 

If the air vesiclps cannot fully expand, owing to the partial disnrgan- 
tion of lung tissue from long-continued compression or because the 
ig has been bound down by intlflmraatorj' adhesions, the chest may 
again utuin its normal condition. There will be consequent loss of 
>tion and retraction of the affected side, with more or less dulnesi 
on percussion iind feeble or suppressed respiration. In the most pro- 
tracted cises the ujiper portion of the lurj^ bt-comes oidy partially ex- 
panded, and in this region there will be dulness upon percussion, with 

I unLI1AV^14f 

deficient vesicnlar murmnr and bronoho-resicitlar respiratory soands, 
together Tith exaggerated vocal rosonance. 

DiAONosis. — The essential points in the diagnosis of acute i)leunay 
are: the iudistinct chills, the sharp pain in the side, friction frumitug 
and murmura; flatuess on percussion with chaDgo in the lorcl of fluid 
by changes m the patit-'nt'a position, with absence of vocal freniitng and 
absence or great diminution in the iiiteusity of all respiratory and 
Tocul signs over fluid effusions. 

The differential diagnosis of pleurisy is usually easy, yot various dis- 
eases have been mistaken for it. The affections liable to cause error in 
diagnosis are pleurodynia, intercostal neuralgia, pericarditis, pneumonia, 
phthisis, collapse of the lung duo to pressure on a main Ijronclius, can- 
cer of the lung, aneurism of the aorta, and onlurgeinent of the liver or 

Pleurisy is only likely to be mistaken for jikurodynw or intercostal 
neuralgia in the first stjigo of the acute variety, when the pain and con- 
eeqnent impairment of the respiratory movements and murmur are the 
same as in the latter affections. The distinction may be made by ro- 
momboring that the paiu of pleurodynia is apt to be fugitive, shifting, 
and often hilutcral, and is likely to be increased by slight pressure and 
by muBciilar contractions. The pain in intercostal neuralgia is confined 
to one, two, or three tender points along the course of the intercostal 
nerves; the neuralgic diathesis is coumionly to he found in this ufffction 
and fref|nently coincident uterine disease. On the other hand, the pain 
in pleurisy is deep-sealed, and although there is tendomesa on pressure, 
it ifl not fonfineil to isolated points along a nerve; and by nuFioultation 
we deti-ct a friction sound wliiob is not obtained in pIeuro<h*nia or in 
intorcostal neuralgia. In these latter there is usually no fever. 

The diagnosis botwe»^n pericardilis and pleurisy affecting the left liido 
is iMised upon the locality of the pain and the friction sounds, and the 
relation of tho latter to the respiratory movements. 

The pain of periwirditis is located in tho prseoordbl region; that of 
pleurisy more laterally. The friction sound in pericarditis is hoard 
most distinctly at the loft border of the sternum near the fourth costal 
cartilage; that of pleurisy upually farther to the left and lower down. 
The friction sound in pericarditis is independent of the respiratory 
movements, and does not cesise when the patient holds his breath. In 
pleurisy these sounds are not heard except during respinitiou. 

Srce/idomi/.— The action ot the heart may raus« a friction Boun<) betwi-en 
tite antoiior portions of the Ml pleura which will not fliiuppear when respiration 
ceases, but tlii» is extremely uucoinuion. 

The diagnostic points of pleurisy as distinguished from pneumonia 
arc as lollovs: 



PuuRisT. Pneumonia. 

Chill absent or slight Onset with marked chiU. 

Temperature low, rarely above 103° F. Fever high, 102°-105° F. 

blitflit prostration. Marked ]irostration. 

Cough hacking, dry. Cougli followed by tenacious, often 

bK>ody or r\isty sputum. 
BespirutioD jerking. Respiration panting. 

Stitch-like pain, usually below the Pain iisually duller and less intense. 

Aspiration gives additional evidence 
of effusion. 

CouDteoanue notably pale and anx- Countenance apt to be flushed. 

ious at the onset. 
Decubitus often on the affected side. 

Vocal fremitus diminished or absent. Vocal fremitus increased. 


Flatness and sense of resistance over Dulness rather than flatness. 

the fluid. 
Displacement of adjacent oi^pans. No displacement. 

Vocal sounds feeble. Vocal sounds exaggerated. 

Inspiratory and expiratory friction Crepitant rales and later numerous 

sounds prior to effusion. moist rales. 

Bespiratory sounds feeble or absent Vesicular murmur feeble or absent, 

over effusion. but bi-onchial breathing distinct in 

second stage. 

The moBt distinctive sign of pleuritic effusion is absence of vocal 
fremitus over the a£Fected part, instead of increased fremitus as in pneu- 

Pleurisy is distinguished from phthisis by the history and by the 
same signs which ditferentiate it from pneumonia, also by the fact that 
phthisis, affecting the greater part of the lower lobe of one lung, will 
usually affect the apex of the opposite lung, whereas the signs of pleurisy 
are usually confined to the lower part uf one side. In phthisis the signs 
usually progress downward; in pleurisy, upward. 

Many signs similar to those of pleurisy with extensive effusion maja.- 
appear in collap-tp of n hnig from compression of its main bronchus, t!i^ 
loss of motion of the side, absence of vocal fremitus, dulness or flatness 
on percussion, and absence of respiratory and vocal signs. When these 
signs exist, the diagnosis must be based mainly on the position of the 
heart. Moderate pleuritic effusions, where no adhesion of the pleural 
surfaces has taken place, would be easily ditferentiated from the condi- 
tion under consideration by changes in the level of the fluid. IJut 
where the effusion is circumscribed, or when it completely fills the 



pleural cavity, this eign would not be preeeiit. In pleurisy with consid- 
erable eflhiaion, the henrt is more or less displaced toward the opposite 
side. This does not occur in eollapse of the lung. 

The essential difTLMi-'iiee in the signs of these two conditions may be 
seen ut a glance in the following table: 


Ueart usually more or less dUplacvO 
to opposjto side. 

Side often tlistendeil. Side not re- 
tracted excepting iu protracted oases. 

Collapse of lvsh frum coMpnessioM 

Heart iioC displaced. 

Side not distended, may he retracted, 
and would always be i'<>lract«l cxr-opt 
Uiat coUuptte of ttii> air vesicles t*auKeti 
diminisiicit prosaurcoii tlieoi'gaii. Tliia 
favors ditatalion of the btood-ve»«l», 
and sonietimes causes congestion wilh 
oxudatiun whtcti fills the air vesirles 
and distends Uio lung to its normal size. 

Dnlness usually begins near the middle of the \x\n^ in pulmonary 
cautery and progresses irregularly in different diroctions, leaving here 
and there patches of normal reBoniince surrounded hy tlatness. In plpu- 
risy flatness begins at tho base of thu chest and is uniform. The consti- 
tutional symptoms of the two diseases are usually different. 

The occurrence of empyema *vith perforation of tlie chest walU, jii the course 
of the aorta, might cause a pulsating limior which would closely Mmulnte 
an«urijtia of thf aorta. It would be distinguished from the latter disease by the 
presence of signs of empyema iu ttie Iowkf part of the chest. 

Pleurisy of the left side is distingnished from enlargemftU of the 
9;if0«n by the following points. An enlarged spleen seldom encroaches 
much upon the thorax, and therefore causes little or no distention of the 
side, and no bulging of the intercostal spaces or displacement of the 
heart. Upon percussion, dulness is found to extend in front higher 
than behind, and the level of its upper surface does not materially 
chnnge with changes in the patient's position. There isolso a largo area 
of flatness below the diaphragm. 

Even skilful diagnosticians have frequtMUly mistaken f.nlnrtjement of 
the liifr for pleuritic effusions. The differential signs will be seen in 
the following table: 

Plkuritio EFnjsiONB. Htpertrofky of the lfvkr. 

Frequently, bulging of the mterco»- There may be bulging of thecliest. 

tol spaces. but the intercostal spaces are not espe- 

cially prominent. 







Dulnos extending higher behind 
Uk»n fn front. 

Tbe line of alnoliite Hatoom iiHttally 

voriuit with chaii^e*i in the jxiAJtion of 

tlic patient, and U not depressed or ele- 

Lvated du ring' iQBpi ration or expiration. 

Duln^ss extending- in froiil higher 
ihau iK^hind, because the shelving U»r- 
der of tbe lun^ (iditeriorly inlcrvenes 
hetween tlie liver and tliQ ihoracio 

The line of natnc«s is not materially 
aiTect^id by ohangrei in the |>aticntV 
l>OBition, hot ia depresGed und elevated 
by inspiration and expiration. 


Ttw rwpirutory nmmiur is heard in The respiratory niurniuritt heard b»- 

tront^at a lower level than behind, and hind at a. lower level tlian in front, 

tJiis level is not materially afTceted by and this level is depressed during; dvep 

dDepioKpinttion. inspiration and elevated in expiration. 

pRotiSOBiH of acnte and snbncnte pleurisy. In ordiniiry esses of 
aeuie plouriBj- recovery ueually occurs witliiii two or three weeks, but 
t)iey miiy lupse into tbe subacute und chronic forms. A permanent 
lesion usunlly rt-maius in some purt of theplcurul sac .iftcrstiro-fibriiious 
pleurisy (Louiuts), frequently in. the form of thickening and adlit^sions; 
these predispose to repeated attacks, resulting in greater pleural thick- 
eningj connective-lisaue liyiierplania and t-ou tract ion, thus limiting tha 
function of the lung and favoring attiu:kd of bronchitis und the inroads 
of phthUis. 

Diaphnigmutic pleurisy in tho dry form is cummun Jiud generully 
resoUs in iidbe^ious, which may fijt the diaphragm uk high in some cuseti 
a« the fourth rib, usually at the eovonth or eighth, thus greatly dimin- 
ishing the vertical diameter of tho chest cavity, reuderinfr subsequent 
thoracentesis, if necessary, dangerous, and favoring rupture of the dia- 
phragm in tho sudden strain of severe bodily exertion. 

Subacute pleurisy may be protracted for months, resulting in per- 
maneat crippling of the lung from compression, and it may be in 
emphysema of the opposite organ; or the Htiid may become purulent, 
especially in children. Pleurisy complicating grave disorders such as 
pyfcmio, septiceemia, or Hright's disease is obviously unfavorable. In tho 
latter affection and in very acute pleurisy, effusion may be so rapid ond. 
copious OS to cause death in a day or two. 

Extreme cnmpreitsinn of the lung in any case invites sudden conges- 
tion or o*<lema of \U fellow, and eonseipient death. 

Danger of sudden death from compression of the heart, according to 
Loichteustern {Deutuchet Arvhiv fur klinuche AMicin^ Band IV), is 
greater if a large effusion occurs on the right side, prolHthly oving to tho 
greater weakuees of the walls of the right ventricle, liowever, in chil- 
<)ren a large effusion on the left threatena euddeu fatal syncope from iU 
ejicet in twisting tbe great vessels. 


Treatuext. — The patient should bo kept quiet m bed,Hnd put upon 
nn nnstimu lilting (3iet iinlesa great weaknetig demaud llit- oi>jH)sita 
Talking siiould bo proliibitfd, and all volunUrj' motion uvuided. The 
Tcspirntoiy movements may be restricted by strapping the side with 
6Crii>s ot adhesive phister niniung diagonally, from above downward 
and forward and downward and backward^ and also borizonU>11y; a 
broad strip of rubber phistor applied during expiration, or u wide f laAtio 
buiidiige, may be employed for th« same purpose. When these are nut 
used, hot poultices iiuiy be beneficially «mpl(»ycd. 

Opiates or some of the more recent analgesics, such as antipyrine, 
ftcet-milide. or phenacetin, which are to be i>referred when there is 
mnch fever and in most rases where the pain is not extreme, should be 
given in suftirient quantity to relieve pain, l^omis recommends the 
application of a constimt galvanic current to the affected side for the 
rclii'f of pain, which continues after the subsidence of friction sounds.- 
Souiutiutes the pleural i<uc rapidly lilU with serum, and the question 
of aspirutiun will be suggested. With regard to this, the following 
rule is important: Do nut aspirate in acute pleurisy until about the raid* 
die of tho second week or until all acute symptonis luive passed, unless 
compelled to do 8o to relieve great dyspntea. In the lliird stage of the 
ditwaae, tonics and potsissium iodide, with counter-irritation by blisters 
or iodine, are indicated. Absorption of the fluid may also be favored, 
by free sweating brouglit iibout by the use of jabonindi, pilocarpine, or 
the hot-air buth. and by such diuretics as squilU, comp. spts. of juniper, 
und potassium bitartrate, acetate; or iodide. Sodium ealicyhite, or :<alni 
in large doses, is* rcconimcndtHl ais sometimes iircdiieing prompt sub- 
sidence of serous pleurisy where other remedies prove ursntisfactory (J. 
Drzewiooki, Medical Jitfordj July, ItiSU). 



Subacute pleurisy, also called chronic pleurisy by some authors, con- 
sists of a low grade of inflammation of the pleura, most fre<jucnlly char- 
acterized by mildness of the symptoms, absence of pjiin.and slight con- 
stittitionid ()isuirb:>nce with the effusion of an excessiveamoantof somm 
often completely filling the pleural cavity. 

ing been already dcs<.Tihed under the geucnd title Pleurisy, it only re- 
mains to be said that this is pre-eminently the "pleurisy with 
L effusion." The morbid processes occurring in the plonri are less rapid 
than in the arnto variety; the pleund thickening and formation ot 
jlbrouA tissue is more extensive; tho effused liquid larger in quantity; 
the results of pressure more gmve. 
Etiology, — The causes are similar to those of the acute form, but 
malnutrition and tuberculosis arc the most frequent. 


Sykptomatology. — The priucipHl symptoms are dyspntNit Iob9 ofap* 
p^itt, em/triaiion, vomUing, and more or leas cough. 

Fever of from one to two dt^reea ia common. Pain may be slight 
or altogether absent. 

It is surprising how great the effusion may become in this affection 
before the difficulty in breiithing beoonies noticeable. 

The 8i</n» are thniie of the Hcrontl und third iitiiges of acute pleuriaj 
vttb extensive effusion (Fig. ^1 ). 

BroBcblal bf««lhlsf .* 

i: ahwooe of nwpW < 

Flo. 21.— 8i;BAi.-mt Putt'Kur. 

DiAONOSiB AND Prooxosis.— The subject of diagnosis and progno- 
lis of sulMicute pleurisy has bei'ii included in that of acute pleurisy. 

Trbatmest. — TheindictUionsarefor imprvif/i nutrition and remoml 
of /Ac rffusivn. 

Very moilcrate catharsis, diuresis, and diApboresis, if employed short 

of exhausting depletion, especially in the more robust^ are advisable, not 

M much to influenoo absorption of the pleuritic effusion as to favor im- 

proveuicnt of the general nutritive pr(M.>esiu.>s. >tild counter-irritation is 

sImi useful. The diet should be nutritious, easily digested, and moder- 

ttaly stimulatiug, composed uf animal and farinaceous broths, beef pre]>- 

arations. eggs, and in some cases such spirits as slierry iiud port. The«e, 

ssd hitter ionics, as the various ])repAriitions of liydrastis, calisaya, 

columbo, and gentian, combined wiili ferruginons remedies, and the 

employment of mercury and potassium iodide in alterative doees, beat 

meet the first requirement. 

If iu u couple of weeks the fluid has not materially diminiahed, it 
should be withdrawn by an aspirator, providing there is sufficient to 
more than half fill the pleural cavity, or even when the collection is 
jmitll if il 'Siui-es dyspnim or dit-conifort in the side. AStienever the 
rarity ia completely filled Vud the heart displaced, even though no urgent 



a^'mptoma occnr, no time shoaM be lost iu {icrforuiiug the opcratiou. 
Ill uusi'S of liilukTul etTudion, especially where ilicre is c^uoosis or great 
tlygpniiii; wlieu erunt-iattoii occurs with iiuligeatiou &n(l feeble circuU- 
lioii; wlifii plenrsil effusion complicutes periranlillii, he:irt disease, pneu- 
monia, soTcre bronchitis, or Brighl's diacuse; or when the fluid beeumes 
purulent— aperutive proce(inr»i must not be ilehiyed. In operating, it ia 
most coDTenient to Iwve the paiient sitting astride of a chair with the 
arms folded and rcwting uiion tlio buck of the chair, and the bodv in- 
clined slightly forward; but if the patient h too wc«k to sit up, bo* may 
remain in the recumbent postnro, lying clo«e to the edge of the bed. 
(ieneral anspsthctic* are seldom used ; the pi^ rid may he thoroughly be- 
numbed by injecting deep into the intercostal 8[mce, and jost beneath 
the skin, with a fino needlo, a few drops of a two ]>or cent solution of 
cocaine, or of the solution recommended for local amesthosia (Form. 
140). It is well to tull the patient that he need have no fear until told 
the plunge is to bo mjide, in order to save him much anxiety and enable 
the physician to make his examination more deliberately. The surface 
to be punctured should l>c surgically clean and the instruments aseptic. 
I liml it convenient to dip the thoroughly cleansed needle into a mix- 
ture of equal parts of carbolic licid and olive oil. Any of the uspiriLtors 
in common use may be employed, but the simpler are usually the best. 
It is generally best to use « medium-sized needle, and the cocks should 
be closed and the air uetirly ex!mu8ted from the aEpimtor before it is 
introduced. The puncture is best made near the angle of the ribs in 
the sixth, seventh, or eighth interspace. It is my custom to make it 
high. When the pleural sac is only partially filled with fluid, we aacer- 
tain the upper surface of this, uiui nmke tlie puncture about au inch 
below it. If the operati.m is at the lower part of the chest, the needle 
is apt to strike the liiaphnigm, or, if this does not occur, as soon as a part 
of the licjuid has been withdrawn, the diapliragm is forced npward 
against the needle, causing pain and preventing further withdrawal of 

The akin should be drawn upward about half an inch by the ends of 
two fingers, which are then pressed firmly into the intercostal space; 
between them the needle is thrust inwanl and upward in the direo- 
tion corresponding to the slant of the adjacent costal surfaces, to avoid 
the danger of striking a rib. AVhen all is rejuly the patient should be 
forewarned of the sudden coming pain, and the needle plunged in until 
it enters the pleural cavity. The air cock is then opened and the fluid 
slowly withdrawn. During this procedure, if cough, pain, or dyspnoea 
or a feeling of constriction of the chest or weight upon the sternum 
occur, the iispiration should bo discontinued at once, whether the fluid 
has all been withdrawn or not. The amount of fluid removed at one 
time is exceedingly variable, being from a few ounces to several pints, 
and not infrequently rapid absorption has been known to follow removal 




of even a few drachms. The operation should be repeated within from 
five to ten days if the fluid reuccumu lutes. Usually after these measures 
the patient immediately improves, the appetite is better, weight in- 
creases, and the fever may entirely disappear. Subsequent treatment of 
the case should be of a tonic nature, and should include systematic and 
carefnl exercise of the muscles of the trunk, and breathing exercises. 
Recovery is sometimes greatly aided by a sea voyage or change of climate, 
especiall;f to a high altitude when mountain-climbing will develop the 
respiratory muscles and the air cells will be expanded. The patient 
should be told that he must expect pain in the affected region on- pul- 
monary and general muscular exercise, for some weeks or months. 




The term empyema is applied to pleurisy when the inflammation is 
protracted and pus instead of serum occupies the pleural sac. 

Anatomical and Pathological Chakactebistics. — If sero-fibri- 
nous pleurisy become suppurative, the plastic elements undergo degener- 
ative changes by the action of various micro-organisms, and are found 
to consist of pus cells and shreds and flakes of semi-purulent coagula 
immersed in serum. If the empyema be primary, leucocytes, round cells, 
and endothelial cells, more or less degenerate, appear on the pleural sur* 
face, to be washed by the serum to the bottom of the pleural sac. The 
lymphatics, cells, and pericellular spaces — in the serous and subserous 
tissues — contain active micro-organisms in greater or less number. The 
effects of pressure upon the heart and lungs in empyema do not differ 
from those which occur in pleurisy with serous effusion. 

Etiology. — Empyema, according to Bouveret, is most prevalent dur- 
ing the first five years of life, and pleuritic effusions are more apt to be- 
come purulent in children than in adults. Whether idiopathic or not, it 
usually occurs in those of hereditary weakness or those who are debili- 
tated by disease or irregular habits. 

It may follow trauma or opening into the pleural sac of an abscess 
in the liver, lung, or thoracic wall. Pneumonia and typhoid fever are 
frequent causes, or it may complicate rheumatism, or scarlet fever and 
some other contagious diseases, or pyaemia or septicaemia. More recently 
influenza has been assigned as an occasional cnuBe. 

Symptomatology. — The symptoms of empyema denote serious con- 
stitutional disturbance. The most importantare: rapid pulse, dyspncea, 
cough and pain, high temperature, dry brown tongue, hectic and night 
sweats, with loss of appetite, vomiting, and rapid emaciation. 

Tke signs of this disease are much the same as those of subacute 
pleurisy, but usually the displacement of the heart and of other adjacent 
organs is greater in proportion to the amount of fluid. Contraction of 
the chest occurs when compression of the lung has so impaired its elas- 
ticity that it cannot regain its original volume after partial absorption 
of the fluid. The cliest is then flattened on the affected side, the nipple 
depressed and nearer the median line. 


Occn&ionally accompanying curvature of the spine may exist, wilh con- 
Tesity toward the soiinil KiUe, ThU phettomenon rciultii because the donal 
inuiK:te« of the sound utile are nu longer couul*.'rl)alunL'<.il by those of ttie aiTected 
Aide, wtiicii iMcume purulyzvd by Uu* pcrsisU'Ut pn.-»stiiv. 

Ordinarily the level of Ihe fluid does not vary with changes in Lhe 
poaition of the patient, owing to the agglutination of the jtleurul Bur- 
facos inimediittuly above tlie et!urtion. \n thi8, as in other varieLics oX 
pleurisy, iluctuation is occasionally detected by palpation. iSumotimes, 
irith large effusions, especially in the left pleura, pulsation of the side is 
obsenetl syuchronously with the conti-action of the heart. This condi- 
tion is callcHl pufstttinr/ empyema. If the pU8 breaks through the ohe»t 
wall and appears beneath the integuments, the tuniur thus formed gen- 
erally pulsates etrungly, and it might easily bo mistaken for an aneurism 
if located in tho course uf the aorla inetoad of being at the lower part of 
lhe chest. Tumors of thJH kind often enlarge with inspiration and 
diminish in size with expinition. 

E^fxptional. — Rarely, empyema, iDKtt^adof occupying' Its URual posJtioo otthe 
Jbnm of the chest, may be contined to Uie upper part of the sac, or to a 
lull space about the root of the luQg, or it may occupy two diffe'rcnt aud widely 
L'pttruled l^K-alitiea. 

Uisgeaeratly cotusidert>d impossible to ditferentiate between serum and pus 
in ^le pleural vim ; but Gnidu Bocelli. of Hotue. cluiniH that the dislitictjoD cau 
btt made by atu-ntion to tit'.- whis|RTinjf vixrul resonance. Tlic wliisjK-r resonance, 
bo ckiiiu»( may be licai-O at thu bioie uf serous plenrtlio clf iisiouti, but will not be 
ooflduct^id through pus. In luakiuj; Ihia duilmHtoa, two conditions roust be 
secured: First, iiiHiit:diute uust-ullaUun must be pracliHeil. (be var bein^ presiied 
flriuly a^iiiKl ilie nukvd c)ic»t, ami all L-xt«rtml sounds excluded by clu^iu}; the 
otiicr vnr ; Bvtioml, tJif patient must ho. &o placed that tlu; vibrations produced by 
whispt-'ring shall proceed from his uiouth in a direction diametrically opposeil to 
tlie listening: ear. 

DiAUKOHts. — Empyema may be suspected from the physical signs de- 
nying pleural effupion, together with the symptoms signiUcant of puru- 
lent inflammation, but tho diagnosis can be made positive only by explora- 
tory puncture. 

Pkognosis. — Tliis is generally considered uufavorable. Chances of 
rcwovery lie in spontaneous opening and discharge of the pus, a very 
teaious process, or in its removal by operative procedure. Without such 
relief, the dangers are : death from sepsis, pyemia, exhaustion, or from tho 
efftn^ts of pressure upon the thonicic organs. In acnte empyema, death 
moy result witliin one or two weeks, but in the more chronic forms the 
patii-nt may live for months, or even three or four years, or posaibly 
longer. Children recover much more satisfactorily after nperaiion than 
ndultis but snccuDib more quickly without it. Lelch leu stem considers 
tho es('a|W of piia in the empyema of ehildren as an ahntist infallible 
indication of recovery, lie believes that the eases of Bii-ralled sponta- 
neous cure in children can be explained by tho theory that the pleural 



accumulation in these oasee disappears by discharge through an opening 
into a bronchus. 

Luumis stales that when spontaneous opening occurs, abont twenty 
per cent recover; but that when the pus has been removed by operative 
procedures, only about twelve per cent recover; but I have seen quite a 
series of cases in which evacuation of the pus by the methud here recom- 
moudcd has been followed by recovery in about seventy-five i>er cent of 
the patients. 

Treatment. — Pns in the pleural cavity must bo removed. To this 
end various operations have been advocated. 

Aspii-atiou of the cavity repeated two or three times has In a few 
oaaes proved sufficient. 

L. G. Fiitteror, of Chicago, reported to me by personal letter six cases 
perfectly cured by aspiration of the chest and washing out of tlie cavity 
with a three-fourths of one per cent solution of clove oil in water that 
had been filtered and thoroughly- boiled. This was injeoteii and drawn 
off and followed by a permnncnt injection of a second quantity of this 
fiolation nearly etptal in amotmi to the pus fii-st cvacuiitcd. 

Another method of treatment ia by pkurotomy. An incision is made 
in tho iixilUiry region between tho fifth and ninth ribs and pantlltd to 
them; donble drainage tubes are inserted and u Listi^r dressing is ap- 
plied. A convenient apparatus recommended by A. T. Cabot (Cyclo- 
pedia of the Dist-asts of Children, Keating, Vol. 11, p. 715, I*it>*i) is 
readily made from a piece of tuhing cut half in two, folded upon itself 
and held in place through a shield by safety-pins. 

.Still others advise rr»evtion of the ribs either subpenoslcal or not, and 
performed with various iuoigious and mitior pointjt of ttvchnique. 

Authorities differ as to the iuvariablo advisability of washing out the 
cavity. Bowditch {Miiluiil yetcs, January, 18yu) claims tliat in two 
hundred and ninety-nine o{>eratiou8 ujwn two hundred and fifty patients 
he fouud it necessary to wash out the cavity only once, and he considers 
Udangerons. lJcCerenvitIe(.y'//w)V//V./riArA«c/;<'r, Band 318, lleftl) re- 
ports six cases of e])ilepsy in children, following mechanical irritation of 
the pleural surfaces, as in irrigation, sounding, and probing. Equally 
high authorities favor irrigation. 

A. B. Strong, of Chicago, strongly favors resection of the ribs, and 
reports thirteen cases {Chiratjrt Mr^iUral Iferord, October, ISHI) with only 
one death. Of these, however, twelve were acute and eight were in 
young children in whom tho prognosis is usually favorable, whatever 
method of evacuation of the pus is adopted. Ue uses htrge drainage 
tubes (Fig. a3) well iidupted for the purpose, readily made and easily worn. 

W. JI. Striekler, of Colorado Springs, Colorado (Mcdiml Xen'», 
Mar. 1S8T), a(lvo(;ates rest-etion of the fifth, sixth, and seventh ribs, 
thorough digital examination of the cavity, removal with the fingers 



of all fibrinous nmsses, separation of fidheeions if necessary, and eopiout 
hot-watt-r irrij^utioii, fuHowod by duily flushings, lie reports exceileut 
rc(itilt« in Qvi,- uduU ciiscs. 

ZimnierniiLa and olliera consider aiplum drninage as the must effeo 
tiva A long, aseptic rubber tube is pa&sed into the cavity tbrongU tha 


. K— CuoT's nKAiNAOB Traoi. 

Put, %— Stroxo'b Diutyiai Trscs. One-b&U siae. 

canula of a large truc-ar, a clamp closing the outer end of the tube. Tlie 
cannla ia then slipped out, the tnbe is clamped between it and the chest 
wall, and the first clamp and the canula nro removed. Connected to this 
tube is a glass one U-aiding through a rubber stopper t^ the bottom of a 
bottle containing some antiseptio solution. 

To secure a constant air-tight joint at the round in thin patients 
where thetissucjt retract, the tube nmy |mss through a rubber shield bound 

SL— IxoAU' Plat Tkocab. One-hAlt «tae. For totroduclBg draiUBfr* lubo In nDpjrnna, 

cloHely to the chest. Powell {Ciinnilian Prarlltwner, 1887) successfully 
treated six cases by siphon drainage, nsing Kt'Iaton's catheter }Kisscd 
itirough a rubber bandage fastened around the chest, and irasbcd out the 
cavity by alteniately niiaing and lowering the bottle coutaiuiug a weuk 
solution of carbolic acid. 

WithusinglcexcoptioQ, I have never found resection necessary. The 
radical oiH-Tutiou which 1 have t'tnpluyi''l with much suttsfm'tionfnr many 
years is i»c*rforincd by means of a broad, tlat trocar (Fig. HA) suftieioully 
Urge to admit the ]>a6stige of two drainage tubes at once. If on ames- 



Ihctic is tkonght necessary, iiitrons-oxide gas may bo advanbigeously 
uscii, tis its effocta are quickly over; but it will usually U- sufficient to 
inject ijoep into the iutercoelul tlHUues, us well u£ just beiioiitii the skiu, 
% few drops of » :four-[icr-ccnt solution of cw»ino sucli as recom me tided 
for local ana'slhesiii in tlieiiuuc. The skin having been mnde thoroughly 
clean, it is punctui-ed by a sniull eicalpcl. which itiukea un iiiciaion ahout 
a quarter of an inch in lengtli, the point of the trocar is entered into 
.this incision, and then the instrument is plunged boldly into the chest. 

Boon as the stiletto is witlidmwn, the thumb of thu operator is pkced 
OTcr the mouth of the cuuala to prerent the escape of ]ms; and tbon tho 
tubeSj which have been previously prepared, arc slippcfl qnickly through 
the canuhi to the required dcjith, the canula ie withdrawn and the tubes 
are left in tbe chest. A bit of she*^t rubber about three incbes eqaare, 
with two bniiill u^jeningii near the centre un<l i-lo»e togoitier, is now 
slipped over the tubes and down to the chest wall. Next* a section of 
the same tiibiug about half un inch in length, thruugh which have been 
tied two loops of stout thread each about uu iuch in leugth, is passed 
over a canula and slipped down over the drainage tube to the chest wall, 
where it i.s furceil off ujion tiki; drainage tube cluKt^> lo the Htirfuce. Both 
tubes arc treated alike, antl tlirough the luops are iiiu-ised lung stri^w of 
a4l)iceive plaster, by wliieh they are Infund firmly to the chest wall. 

Tho drainnge tube is now perfectly under the control of the operator; 
it cannot possibly sliJo into ilie chest, luul the udhesivc straps keep it 
from being forced out a few ilays laU>r when the tissues about it have 
retracted. The section of slieet rubber placed next to the cheat wall 
acts as » valve prevcutiiig air from entering the chest at least for the 
tirst eight or teu days; 1 1 Kit is, until tlic retractio]i of the tissue occura 
about the tubing. A ruller bundagc is ujjplicd over the whole, the drain- 
age tubes being allowed toprotrmie through it. In preparing tho drainage 
tube, I take a piece of ordinary ptiregnrn tubing about two feetiu length 
and one-eighth of an inch in calibre and cut It half ncro&i near the 
middle; it is then folded upon itself, *oue of the tubes is perforuted in 
sevend places extending about tliree incties from this cut cml, the other 
in a eo[i]>le of place::, extending ubout one inch. About an inch and a 
half from this end the two tulK?s are stitched togctiier at a single point 
with strong Bilk. The stitch is nmde through one of the perforatious 
and knotted within the tube; tlien, If by any meims it come loose, it is 
likely lo be waslied out. When fo)ded ujnm itself nnd fiisteued in this 
way, one of tlie tubes is cut about half an inch liliorler than (he other, 
Ro that the operator may know snbseqneutly which tube is perforated the 
greater distance from the end. Abovit Pix inches from the end of the 
lul<c which is passed into the ehest, a bit nf thread is tied closely about 
it as a mark, in order that during the operation the surgeon may know 
how far it hns been pushed through the nannla. Finally, the outer ends 
of the tuUa are tied tightly, and tlie whnle is made luteptir by soaking 
in a strongly curbolized solnlton. By tiiiis cloHng the ends nf the tubes, 
n-e Hjv cnablvii to slip tiwm through the cauuhv, w.iUulv;v\v the latter, and 

•vtA vhcn th« chasl » mttdi dHtaadad, viAont 
^ OMp* «r ■at* tkaa floe or KVD 4MUMH oC poa. 
After tba di mi^fti «n eooiplvtcd, the drmiaa^ tebca may b« beat 
ta ami Umb hcrawtimlljr, wbO* th* MMis an opcavil 
lyfhortglHB tabes to loader nibber tabw* tbron^ wUiA 
^nitj Baj be vaehed or drained acccvdmg to indJoatJona. It baa 
ij ewton to vaeh oat tbe pteonU sac immedUtt^v with as aoti- 
laahitwn^and to bare ibe wash- 
ing Tvpsaltd afterward OBce «r ^'^ 
tvine dail J for a eo«{de of weeks, and 
■alwBqamtly hai frvqaentlr antil 
theoc is oUii«fat«d. Thissolotion 
sboold be nsed at a teimperatttro of 
101*" F. B«tw«cn the waahing* tbe 
«iids «f tbe tabes nur be bent upon 
and tied, or tbe j mar be 
^*— f "g in a bottle containing 
taatiaeptic solnlion, as thought 
When the patifiit is able to 
walk ahoai.I asuollr allow drainage 
togooD consianclr inti^A bottle which 
tbe patient curries iu Lid pocket. 
In cases of empyema which have 
lasted fur a long time, it is very im- 
portant that ultoat the lifth or sixth 
ireek after the operation the phy- 
siciso shonld ascertain whether tho 
carity is decreasing in size, wlitoli 
can be easily done by measuring 
from time to time the quantity of fluid requlrrd to All it, Usually tho 
pleoral Shc rapidly rontnicte until it will not hold nion? tlutn fntirurllvu 
<mnees; bat after this, especially in nduli cases of long standing, xUv mtn- 
tnction may be very slow. Here it becomes necessary to nw> tttimutot- 
ing injectinne, such as aqueous solutions of sine sulphstc, gr. ij, to iv. 
ad z i-; ir<;>n sulphate double ilu^ strength; compound solution of iodine* 
3 80. to3 i. od 3 i. ; or copper sulphate, gr. v. to gr. xx. ad ^ i. If 
iodine is used it will Httnck the dntinago tubes so llnit they tnnst be 
renewed every two or three days. Hydrogen |teroxide, the cununeieial 
solution diluted with an equal volume of wutcr, has been highly recom- 
mended to chock supi>nriitiou, and a solution of tho oil of cloves or 
emulsion of i<Hloform may be tiaeil for the uime purpotw. AVhcn tho 
CAvity lias so far cuntracteil as to hold nut niorii than two or thnio 
draobms, the drainage tubes may be withdrawn ubouL half an ineh. lefk 
in this position for two or three davi), tliHTi withdrawn its niiioh farther, 
and 80 on until they are out of the pleural cavity, wluin tho extiirniil 
wound readily cloaes. 

(IiirTKiu. A, ia#M rtihlir: K rH*lnins 



The aim in the trcatuiuut of enipyeniu is tu give free exit ft>r pus, 
and socare oblilBnilioii of the pleiinil hic by agi^lutitiiiLiun of its wnlls. 
llcnc© W0 eiicouruge as far as possible the esjwusiou of the lung, in 
eome oases nlloving the rihs to fnU iu. by resection, aud bring' the pleiirr.l ' 
Biirfaec'8 together. 

The importance of careful medical and geneml treatment adapted to 
the iniproremeut of tho patient's condition need hnrdly be em])hafiizod. 


The following forms of pleurisy, though not entitled to he considered 
as distinct varieties, need some special consideration: 

CirciifH^criled jthurisi/ usually occurs during the course of phlhiais, 
uud is responsible for nuiny of the acute pains sufTt-red by i-onsuniptives. 
Tliia inilunumitidU is gfiiemUy limited to tho siii-il jiorti'in of pleura 
in testing the lung where the lesiuus are superGL-ial. The signs indi- 
cating this condition are sume varit'ly of friction sound, or a drj', ci*cak- 
ing sound, prolKibly duu to old iidhesions. 

Ph'itrUif of fhe Hjiex, unnssociated with phtliisis, is said by J. Burney 
Yoo to be a fi-ctpient discjise, wliirh ho believes to be tho cause of many 
coughs, usually called hysterical, or srumach coughs, lie li;is observed 
it principally iu vronieu who have been accustomed to wcur lon-neckod 
dresses. Its chief symjitoni is a harsh, dry, shidloii', or incomplete cough, 
occurring in a person a])piireijlly iu good health. 

The only physical gtffn to bo detected is friction limited to the supm- 
clavicnlar region, or to the upper third of thy scjipular region, 

Diaphratftitofir jihun'i'i/ or inlhininuition of the pleuni covering the 
diaphragm is not easily detected. According to Noel Gueneau, the fuU 
lowing symptoms render its di:iguosis more precise. I>c:jidcs the pain 
elicited by percuasionoverthe liiiseof the client uu tliealTi-cted side, there 
is a point of hypera-stliesia, due to irriuition of the phrenic nen*e, found 
at the intersei'tinu of two lines, one of which corresponds to the bi rder 
of the sternum, and the other, perpendicular to it, follows aud prolongs 
the border of the ribs. At the same time there is liypenesthcsia found 
between the sternal attachments of the steruo-cleido-masloid muscles, 
and pain in the shoulder and in the iiifru-clavicular region of the eamo 
aide. These are reflexes from irritation of the phrenic nerve. Nennilgia 
of the last intercostal neno is also frequently present, and there is likely 
to be increased obliquity of the hist rib on the afferted side, and immo- 
bility of the h\'pocliondrinm. If the inflammation is on the riglit side, 
the liver is usually slightly depressed. 

Percussion gives a high-pitched note over a narrow space, correspond- 
ing to the lower margin of the lung contiguous to the eltusion. 

On aus<!uUation, the vesicular sound at the level of the collection of 
liquid is usually feeble, and accompanied with crepitant or mucous 
rdles. Weakness of the inspiratory sound and prolonged expiration may 



exUt over the whole Umg.due to cumpreii«ion of the bronchi bj enlarged 
gluiiUs, which are iwid ordiimrily lo acfoiniKinj? thU diaeflaa, 

MttltiUK'tihir pienrisy \a rarely objiervecl. lu 1854, Wintrich wrote 
thut it was impossible to ilistiuguiah, in the living snbject, between ««i- 
iacvhir, hihcular^ and innUilnrulnr plt-iirisy. und this proposition ik still 
genonilly aocojitcd; but in a con»murirtit)on to the Auidi'mio de Mi-di- 
ciue, of Paris, iu 1870, Jaccoud dt'flared the diagnosia jkoaeible when tlie 
following ^oups of eijrns are found coiucidently with the ordinary 
c<ymptom8 and signs of pleuri.-^y. TIp has observed (wo distinct scnieio- 
logit-:;l types of the affection. 

In the first, added tu the ordiiiiiry signs of complete pleuritic effu- 
sions, tlie viical frtMnitua, tliuugh lust over every other portion of the 
affected side, is found to be preserved along a line running forward from 
the spinal t-olnmn, in ii more or Icb8 reguliir spmicinMiInr course, toward 
llie stenuiin, at a variable height. Vocal reHoniince and bronchial respi- 
ration are heard in the «nne Io«ility, tbongh wanting everywhere else. 

Tills lino indicates the position of the band of i>leuritii' adhesion 
dividing liie jdeural siic into two cavities. In these eases, ho has fonn*! 
in the infra-clavicular region feeble and distant respiratory murmnr and 
Toice-sonnds, with no tympanitic resonance; 

In the second type, vulviI fremitus, Ihnngh more or less eiifeoblcd, U 
obt.iined over the wliole effusion, excepting sometimes a narrow zono 
of the brKidtli of one or two fingers, at the lower posterior part of the 
chest. Marked bronchial respinition and broiicliophouy are aljio fuund 
over the fluid, with perfect flatness ou ]>ercusBion, and no tym}tanitic 
resonance under the clavicle. Iu txvo ciises he h;is been able to hi*: to 
the fuudainentui partitions, by finding one or tv.'o zones where the 
ribraiions were manifestly stronger limn in other locjillties. The value 
of this diagnosis depends upon the proftosttion airpui-eiitly establish^I 
by Jaceoud*6 observations, that Ihonicentesis is not well borne in multi- 
lorulur pleurisy, but tliat it seems rather to add greatly to tlie patient's 
danger. The essential points in the dilTcrential diagnosis between ei- 
tensivo pleuritic efTusions of the unilocular, bilocular, and muUilocular 
types are shown in the following table; 

Uxir.ociXAH pLRumsv. Bu.ocrt.\B plecbist. 5liaTii.ocn.Att puccKiBr. 

Lou of Tocal fremitus. 

Vocal f rem Hub prtwcrved 
OD a line corre^iiMJUtUn^ 
with the band of adhexEnn, 
ttiou^i lt>st above luid be- 
low this liae. 

Vocal fr«mjt4iK, though 
onfoplilwl, is prcHout ovvr 
the wliolo of the alTei^lvit 
side. exc<>pting' a small 
tf.mQ nt the I)asft, Vnoal 
frenritiij} is occaHlooally 
we'll nmrkvd in one or two 
limiteil KODtts cormspODd- 
faig to bauk of adliofioD. 



Usually tyn]|>an)tic rci^ 
onaoce under the clavi- 

Abaeooe of respiratory 
murmur and voc»l rv^f>- 
nancc, «xr«|itin}(over Uie 
oomprf^fUbHJ lung in the 
upper part of tiie tbortuc. 

BiLOcnaR pletbist. 

Fiatnesa ov«r the whole 
chest : no tyiupuniiini. 


BronL-liial respiratioD 
and brom-hopliony licunl 
over a linp corr*>spoi»ling 
to the pleiiritio bnml, hut 
waatinj; in other plac-es, 
except over tlw ai«x, 
where tliey are indistinct. 


Flatnoss over the whole 
cbesl; do tympanism. 

BroDcliial respiration 
and bronchophony mai-k- 
ed over the !>ettl ol tlie 
whole effusion. 


Hydrothorai ia a term applied to the prMence in the pleumi cavity o! 
a dropsif^al elTiiiiiou, which is non-iullammatory iii character, ihiu, clair, 
yellow, or greenish. It haa a low specific gravity, contains relatively 
little albumin, ami coagnlateH lesd readily than an inflammatory effusion. 
The affectinn is uHunlly bilateral, but nmy be contined to one side. 

Etiology. — Hydrothomx may arise from any condition wliieh im- 
pedes venous circulation, producing extensive passive congestion, as heart 
disease, notably mitml affection; diseitses of the liver or kidneys; pres- 
sure of tumors and the like and venous thrombosis; it may also be the 
result of malignant disease, chruuic blood-poisoning, exhausting dis- 
charges, or other morbid conditions producing general hydra-mia. 

I'ho symptoms, of which dyspnmi is most marked, come on insidi- 
ously and are due to pressure of the tluid. 

The /ligm will bo similar to those of an jn6amnmtory effusion. 

Diagnosis will be based upon the sijins and symjJtoms of the cau- 
sative disease, the absence of inflammatory symptoms, the character of 
the fluid, and its usual bilateral position. 

pROOXOsis will depend upon the cause. 

Tkeatmext will be directed tn tbe primary morbid condition and to 
the immediate relief of the lung by iispinUiAU. 


Pneumothorax consists of a collection of air or gaa in the pleural sao, 
resultiug from perforation of the pleura or from decomposition of pleu- 
ritic effusion'. (Fig. 2(i). 

Etioi.ooy. — Air may enter the pleural cavity through a traumatic 
openiu^ in the chest wall; through communication established with the 
stomach or tesophagua hy ulceration or ruptnre; throujjh openings into 
the lung from exploratory puncture, fracture of the ribs, or nlceralion 
due to phthisis, empyema, abscess of a bronchial gland, or gitugrene; or 



through rnpturo of an emphysematous sac. Abont ninety per cent of all 
iicaaes are of iiiltorculur origin. 

SvMPToMATni.or.y. — The nsual *//JH/i/ot«« are sudden acute pain in 
the eide^ with serere dyupuu-u uutl lividity of the lips and face; ^oat 
prosirution, at-'Conipunied with anxiety of countenauce ; a chimmy aur- 
,&ce, imlpitnlion, uccelemtrd pulse, and in some oiacs coUupfiu followed 
by dejith witliin li few hour8. In other oases the symptoros are mani* 
feeted insidiously, only becoming marked n-hcu caneidoroble fluid accu- 
mulution l»aa followed the entmnoe of air. This ia the cjise in pneumo- 
thorax from emphysema. If it re6ult from phthisis, the diyiuptonis, 
especially pain, are very marked. 

The most imjKirtaut fifjun arediminiHhctl niovt-ment and enlargement 
of the allected side; tynipunilic rusonauce; re8]iiratory murmur feeble 
or amphoric in character or wanting. 

Inspection and mensuratioii reveal distention of the nlTected side, 
diminntion or lo^it of the rei<jiiratory movements, with widening, and 
nometimes bulging of the intercostal spaces. 

Palpation shows the vocal fremitus feeble or wanting, and the apex 
beat of the hourt displaced toward the sound side. 

Uy percussion, lynipanittc or amphoric resonance is obtained over the 

rCoUectiun of air. When distention of the side is extreme, the ndjucent 

i»rgan« are displai^ed, and the tympanitic resonance, 8(m)e what muffled 

l-iind motlified in (iinility, may be obtained for a considerable distance 

"beyond the uorniul limit* of tlie pleura. 

EixwpUonaf. — Occwiouully when the htiuioa is very f^i'eat. the pervussiuQ 
Bote is M> nuiUliMl an to seem almost dull, The b^^ll i>otiii(l may be ohtameil by 
fercuwiitiu witli two coins on odh eide of the cavity while the car U pliii;e(l 

In auscultation; the respiratory murmur is feeble or absent according 
4o the uniuunt of air. The vocal sounds arc nltered in like manner. 
'Pbe respiratory murmur on the sound side is exaggerated. The heart 
soundit are feebly transmitted through the collection of air. Bronchial 
VreJithing may be heurd over the compressed lung, in the inter-scajiular 
I'pftf'e, and nsuitlly over the apex anteriorly. Amphoric rettpiration and 
voice are also oHiiiined when a bronebinl ttiW- connects freely with the 
cavity of the pleura. The differential diagnosis between pneumothorax 
and emphysemn.theonly disease with which it is likely to 1>ecoufounded> 
will be given under the latter. 


Pneomo-hydrothorax signifies a collection of both fluid and air in 
the pleural sac. When the former beromrs i>urulent. as is usually the 
case, the condition is termed pyo-pneumothorax. As the effusion of 
ffuiil is almost sure to follow in u few hours after the admission of utr 


iulo till? plcuru> the signs und symptoms of this disease and of pneumo- 
thorax are usually coiisideitd together, but the prcseuco of both air and 
fluid in the pieurul cuvity euu^es some signs which are not found in 
piieuiuuthorax. The splushing sound obtained by suceussioti Is diag. 
uoiiliu. MetiilUc tinkling is ulsu found in nniny inslanc:>H (Fig. 2(i). 

Inspection, piiinition, and iniu:iiirutiun fnrnisli the s:(mo signs as 
in pneuDiothurux or in extensive pleuritic effusions. There is absence 
of \ocal fremitus, and displacement of the heart and adjacent organs, 
with distention of the side and loss of motion. 

On percussion, tympiinitic resonance is obtained over the air in the 
upper, and flatness over the fluid in the lower, part of the chest The 

Rlirht lunr (HinipiwMeil hy tir uid fluM. Heart crowded far 

to the Mt. 

line of flnlness corresponding to the surface of the fluid changes wit 
the position of tliu patient. Tympanitic reoonance is not iufrctiuoull; 
transmitted a short distance beyond the limits of tlie pleura, and even 
below the surface of the fluid, so that if only a small effusion is present 
this sign may be heiird over the entire cliest, and thus the presence of 
fluid cscajie our notice. Amphoric resonance is sometimes heard over 
the upper part of the cheat. 

Upon auscultation below the level of the fluid, the respiratory mur- 
.nur is absent ur very feeble and distant. Above this level it may be the 
same, or amphoric respiration may be heard. This hitler may be limited 
to a small space near the i-Dint of perforafion, Mhich Is likely to be 
locjited just in from of the angle of the fourth or fifth rib. Amphoric 
respiration may disappear an<l reappear apiin during the conrae of the 
disease, in consequence of the variation in tlio amount of fluid from day 
to day. 



TTsiUilK broDchia] ni*pinitioQ u b«sirU over the compvvssed Inn^ 
-vhen* it lie^ against the fpinal column. 

The Bigtii of phihisis, which in nine cwws oat of ten precede those of 

rotithonu, are fre^nently found at the apex of the luug on the 
te Bule. MetAllic tinkling is one of the sigufi of tbid disease. It 
«ealt from agiution of the flnid in oonghing. The splashing 
fioaud obtained on saccasjion is characterieiie. Voval resonance is feeble 
or wanliug, or amphoric, upon the affected side. The percoision reso- 
nance and the respiratory murmar upon the sonnd side are exaggerated. 
I>lAOSOi-l5, — i'netimothnrai and pneumo-hydrothorax are not likt;ly 
lo be mistaken for other diseaets, tbongh they are suid to be closolj 
eitnaUtcd when there is complete catarrhal obstnictiou of the main 
bronrhtis on one side. They may (tos»ib1y be mistaken for emphysema, 
chronic pleurisy, or diaphragmulic hernia. 

Comparison with tmphgntna presenta the following distinctive foA- 




Ptomioeiuv or balfnatf of one sitl?. 
with loaa of movemeoU e»pw:ially at 
tiw luwer part MrHjeclitr!*!. but no fall- 
iut; ID of the mfenor ribs or intercostal 
Spaott duno^ nupiratioo. 

Promiaenoe of the anterior superior 
porliuQ of Uiecbeftt, tKUolly uftoa buth 
!*i»li*». Willi A chanicl«ri»tic lifting 
iiivv>;uient of the upper purt and lall- 
iojj in ol liif lower ribs :inA inteivofttal 
st«u.-vs durtu;; iospiraUon. witli fre- 
tltieotly |H-i-iiiiuieiit c-ontrsction of the 
lower part ol tiiu cbesL. 


Tympanitic resonance over the up- 
per port o( the cbes! «ith flatness ov^-r 
the fluid, tlie line of (latnefis vao'*n); 
with changes in the patieat's position. 
TIte heart \a displaL'etl tu the riifhl or 
I. acconiinip to the «eat of tlie ilfs- 
Nearly always these sigiu are 
found on one side only. 


Ve>iJculo tympanitic lesoiuuice over 
the entire lung, but most marked at 
ilie superior portions; no flatnen b«> 
h»w. The heart may be covL'rcd by 
lun^ tissue, but it is not greatly dis- 
placed. The signs are usually found 
on both sidesL 

Renpiratory murmur feeble or ab- 
•eot: irhpard. tlie expiratory mumiur 
ia of normal ditratiun. unless prv)luiii;ed 
coosolidaticn of tbr Inn;;, in wliti.-h 
it will Ik> litf^h pitclied. Atii|th')nc 
respiration and voice are observed if a 
bronchial tube connetn* freely wtUithe 
pleural cavity. Metallic tinkling. 

Splaahing sounds if fluid is present. No splashing sound. 

Respiratory murmur usually feeble 
and generally ikSvocioted with bronchial 
r&leii. The expiratory sound is pro- 
lunyed nnd low pitched. The re^pir*- 
tun.' MiunilH lire sometimes harsh und 
tubular, but never aniphonc. N'o mo- 
tallic tinkling. 


These diwiases can be easily difitinguUhed from chronic pteurUy by 
tlie physiciil signs obtained on percuseiou nnd auscaltation. On iuspec- 
iiou, jmlpation, and mensuration the signs are simihir. 



Tympaaitic resonance over the up- Tyinpanilicix'aonuncv, if heanl atall^ 

per iwrtiou of tbe chest, tlatuuss over is liniiti-d to n Hiiiall s|Kice at. \\\n a[>ox 
the Uiud. of tlie lung, usually inimediateiy be- 

neatb the clavicle : llatneMt over thft 
remuinder of the ulTecteU side. 

Often amphoric respiration aud Never oinphoric i>espiration or voice. 


Diaphragmatic hernia is, fortunately, a rare disease. It possesses 
many Bvmptoms and signs in common witli pnRumothonix, like which it 
causes distention of one side, displacement of the heart, diminished 
motion, tympanitic resonance, aud feeble or suppressed respiration vith 
metiillic tinkling. The dlfffreutjal diagnosis depends mainly upon the 
history aud the eym[>toni8, us seen from the foIlDwing table: 


Uistory and Sgmptmnt. 

Uiaally followtt phlhuisor&ccidcntal Often congenital; at times dyspnuea 

perlorution t)f pleiim ; tlie ilyspnuta comes on Auildeuly, and us suddenly 
may come on suddenly or gradually. diBappearB. 

Amphoric respiration and metaUtc No amphoric renpiraHon, and th» 

tinkling. metallic tinkLiu^ occurs independf^iuly 

ol thi; i-espiralory niovenienis, and is 
u»su(-ialetl niiti ruinOiinj; uf ga^ in itie 
sloniacli or iiitor^tines. which usuiiUj- 
fonn the contents uf Uic hernia. 

pROoxosis. — I'nenmothorax without pleuritia is rare, but when it 
does occur recovery not infrcriuently takes place. TI»e prognosis in 
pyo-pucumothorax is very unfavorable. Death often occurs within a 
few hours or at most within a week or two. Rarely imtients rtnrover. 

Treatment. — Pneumothorax and pneumo-hydrothorax call for es- 
sentially the tuunc treiitment. At first an opiate should be administered 
to relieve pain. When flnid has collected and dyspuwa is great, free 
drainage is ndvigabie, especially if the fluid hns become purulent; subse- 
quently the case should be treated in the same manner »s emi>yenin. 

Pntain recommends replacing the flnid and air by sterilized air, and 
Tta favorably {Gazette d€s Uopitaux, April, 1889), 




BHON'CHiTia is au iuflanimation of the membrane lining tho bron- 
chial tubes. It ufTec-U buth sides at tlie suinc timt?. and is therefore 
(*alled 11 bilateral diiicusti. Five varieties of broucbitis ar^ recognized, 
vis., Hcut«, subacute, chronic, cupillarr, and (ilustic bronchitis. 


Tiie syniptoma and the signs nf acute and subacute bronchitis are 
BubBtantially tho siinie, except that in the latter variety thpy are less 

Anatomrai. asi> PATaouKiii;Ai. Chakactekistics.— Tho morbid 
peculiuriiies in aoutt* bronrliitis are those of ncute caturrlml iufiamnia- 
tiuri affecti?ig the larger bronchi. There is congestion, tiiickcning. Mnd 
softening of the mucous nicmbniue; slight exfoliation of 8ii)iern<-iat 
epilliLdi:il cpUs, and bypci'seeretion of ibiu tnins|mrent niucns, frulliy 
from admixture of air. This gnidualiy becomes translucent, and finally 
yellow and vise-id as more leucocytes escupe from tlie engorged veseels. 
Slight ccchymost'8 may iipiwar in severe cases, and theexpeclopalion may 
show minute points of blood. This affection, usually confined to tho 
larger tulu's in adults, has a tendency in children and the aged to involve 
the capillary bronchi. The same conditions arc jiresont in subacute 
brouchitis, but less marked. 

Etiolody. — Old peojde and infants and those debilitated by disease 
or vicious habits or subjects of the gouty or riieuniatlc diathesis are 
most disposeil to attacks of bronchitis, especially if exposed to improper 
hygienic conditions, whether of poor ventilation, defective drainage, or 
deficient food and cli»thing. It is more previlent in climates exhibiting 
frequent and sudden atmospheric changes in humidity and temperature. 
Exposure to cold, especially when tho body is overheated, or to cxces- 
eire heat lu a badly veuliluted room Is a frequent cause. Inhalation of 
irritating gases, i)article(i of dust, or larger solid bodies frequently gives 
rise to bronchial infinnimutiou. The Decisional occnrrem^ uf the dis- 
ease in seemiag epidemics also suggests as the muse in some cases a 

SYMrrouATOLOBT. — Bronchitis is ushered in sometimes with a cbiU; 
asaollj with pain in the back and extremities, attended by a Bensation 

FUlSWyA R T mSEA sss. 

iBas or constriction in the chest, soreness beneath the sternnm, 

igh and frothy expectorition gometimos streaked with blood. 

lost important /ii;;inf are absence of diilness and the presence « 
smali, dry or moist rales on both sides of thy chest (Fig. 1*7). 

)tion ill acute bronchitis shows the chest luuvemeuts uormitl 
lat rtcoele rated. 

)n palpfttioii^ the voc-al fremitus is normal. If tiiere is conside] 
-etion in the tubes, brouchiul fremitus will be obtained, especial 

ptionai. — la a few caaes the movements axe deBcient ia those parts 
supplied by broDuili ttmt ui-e [lartlally occluded by a coUectioo of t.^ 


ercussion, the resonance is normal. 

rtional.—la some caws diilness is Tountl, especially over the lower po 
e chest, due to accuniulnliuu of the Quid secretions. This dulnes 
ttiay be removed by cuughiiig and free expectoration. 

ascuHatiou in snimcnte bronchitis we frequently hear simply 
lomcwhut bronchial sound without rales. In a<-ute, imd ir* 
I of subacute bronchitis, sonorous and sibilant nilcs (Fig. 7^ 
lied in the early jiart of the disease, aud the resicnlar uiuf" 
Store or less obscured by these nigiis. After from twenty-four tv 
Igbt hours, the setrrelions from the mucous membraiiu become 
it, and then the dry give place to large and small, mui:9t, mucous 
he iutensity of these nUes varies; sometimes they are feeble, at 
cs they nuiy bo heard at quite a distance from the chest. 
jigns are seldom continuous. Often they are heard during a few 
tiotis, and are then displaced by deep inspimtion or by forced 
ion or cough. Mucous rales, even when numerous, may somtv 
le entirely removed by free expectoration. 
le of the brunchial tubes may become so filled with mucus as 

diminish the intensity of the vesicular murmur, or even to 
it in thoso portions of the lung supplied by the occludeU bron- 

^foRo/.— If the dtftcase affect the smaller tubes, the vesiculartnurmur 
.udible over the entire chest. 

1 reaouance is not altered. 

CHKONic DROjrcnms. 

:Cal ,\no Patholouicai. Charac.tekistics. — Continned 

;dn of the bronchial mucous membrane produces thickening 

larity of its surface. The surface is occasionally (wler than 

d of a grayish color, hut is usunlly of a deep pink or red and 

■ of u purple hue. The congestion may be diffused or in 

_ J 




BftoxcHlTis is uu inflammation of the membrane lining the bron- 
chial tubed. It affects both sidca at tlie fuiinc time, ami is therefore 
called a bilati^ral UiHcase. Five varieticit uf bront-hitis arn rt»C(^iiized, 
viz., acute, subacute, chronic, capillary, and plastic bronchitis. 


The syniptoma and the signs of acute and siibacnte bronchitis are 
substantially the same, except that in tlie latter rariety they are Icm 

Anatomical anu Patuologu al Cha«a< tf.kistus. — The morbid 
pecnliiifitiea in acute broncliiii:^ are tliuse of ucnto catarrhal inflamma- 
tion affecting the larger bronchi. There is congestion, thickeninjr. nnd 
8ofl*ning of the miioons memhnine; slight exfoliiition of superficial 
epithelial cells, and hypersecretion of ihin truiifiparent mucus, frothy 
from admixture of air. This gmdnally bt-conics truutihicent.aud finally 
yellow and viscid as more leucocytes escape from the engorged vessels, 
Slighi ecchymoses may appear in severe cases, and the expectoration may 
filiuw minute points of blood. This affection, usually confined to the 
larger tubes in ailults, has a tendency in children and the aged to involve 
the capillary bronchi. The same conditions are pre<*ent in subacnto 
bronchitis, but less marked. 

JCtiology.— Old people and infants and those debilitated by disease 
or vicious liabits or subjects of the gouty or rlienniatic diathesis art 
most disposed to attacks of bronchitis, eepecially if exposed to improper 
hygienic conditions, whether of poor veniilation, defective drainage, or 
deficient food and clothing. It Is more prevulent in climates exhibiting 
frequent and sudden atmospherii- changes in humiility and temperature. 
Exposure to cold. esj>eciany when the body is overheated, or to exce^ 
Bive heat in a badly ventilated room is a frequent cause. Inhalation of 
irritating gases, pjirticles of dust, or larger solid bodies frequenily givea 
rise to broucliial inflammation. The occasional occurrence of ihe dis- 
ease in seeming epidemics also suggests ns the cause iu some cases a 

SvMPTOMATOLOOY. — Brouchitia is ushered iu sometimes with a chill; 
nnialiy with pain iu the back aud extremities, attended by a sensation 

lu other subjects of bronchitis, cough and expectoration are more 
00D8tJiutIy preseiitr but ure variiible in character. In certain citiiea, aptly 
termeil bnnieborrhci-a, exjiectonitioii is vory profuse, amounting soiue- 
tlmc-s even lo two {juartB in twenty-four hours, more or letw serous in 
quality^ but occasionally purulent. On the other hand, in so'called 
dry catarrh, expectoration is Branty and viacitl; small, tough, tmiiB- 
luceut nuiBses are expelled with extreme ditficulty during severe par- 
oxysms of cough ac'cumpanied with great muscular effort, refiex laryn- 
geal spiism, choking, venous congeetion of the face and neck, and perhaps 

The siffus of chronic bronchitis differ from those of the acute affeo- 
tion principally in the greater abundance of mucous nUes and in the 
scarcity of dry rales. 

Diagnosis. — Thti different varieties of bronchitis may be readily 
distinguished from each otlier by the biati>ry. They are liable to be 
mistaken for lutbma, emphyiteTiia, pulniouary beniorrhage, and phthisis. 

Ki*om aftthtna, bronchitis is distiuguished by the «ymptomR and by 
the hisUiry. Tlie spuamodic character of asthma, its sudden appearance, 
the great dyspna-a, and tlie history of former attacks are sufticiont to 
establish the diagnosis. 

The physical signs in these two diseases differ rather in degree than 
in kind, as shown in the following table: 


lu the early staj^e. dry rAles, oompar- 
atively few ia number. Later, cluhng' 
the second or Ibird day, IhcKc i^ive 
place to large and Hmall raucous rales. 


Durln^^ Uie jMii-oxysm, sonorous and 
sibilant i-Ales are ven- aliiintlunt. Tli« 
foUowinff day eitlier tlic i-ef>piratory 
murmur may be nortiml, ur an abun- 
dance of moist rAles. duo lo tlie utl«a* 
dant bronchitis, mcy l>e pi-esenU 

nd \ 

Simple bronchitis can be easily distinguished from well-marked cases 
of emphyaemn, but the latter disfuse is nsinilly ussociuted with more or 
h'ss inflammation of the bronchial mucous membrane. The distinctive 
points in the two diseaseii are as follows: 

BRONcurrta Ewhtseka. 


Form aad movements of the chest Prominence of llie upper portions of 

iiaturaU Uie chest, barn;I-<thai»ed. witli more 

or less constant cxpnnhion of iIh; su- 
peritir ril>s, whit-li are *«levaled In in- 
spiralioii as thoiitrli united in asinela 
burn'. DoT)n>s8ioii of tl»e soft purls in 
iiLHpii-ation, n<.>tal>ly uliove ibe cluviL'l»fs 
and viernnin and at the lowttr portions 
of the eliest. 

ACUTE jtJioxcmn^ 


BRONcmns. Ejcphtsema. 


Resooanoe normal. In exceptional Vesiculo-tyiiipaaiLic reaODaocemorfe 

ln>itaac-es Blight dulnesH, especially or less marked. 
over the lower part of the diest. 


Vesicultu* mumiur Rom^times incom- 
plete. The expiratory murmur not 
prolonged. Numerous rdies. 

The respiratory sounds feeble, buv 
expiration gro»tJy prolonged. Com- 
paratively few rAles^ 

Bronchitis is distin^Uhed from pulmmwry hemnrrhage by the ])if-- 
tory »ni] churacter of tho eputa. The pliysiml signa are ideiirical, ex- 
cept tho abseuce in. the latter of dry nUes. with the harsh qtmlitv of 
rcspinitioii often found in bronchiti}!. 

Before the days of auscultntion Hiid percussion, chronic bronchitlB 
was often mifttaken tor phthixijt, bnt at present the physical si^s render 
Lheir distinction com [»a rati rely easy. They differ in the following par- 

Bao.NCHms. P11TUIS1& 

Pomi iU3(l movemenia of the chest Ver>' early in the diseaw more or 

oaturuL less depression over \\w uffected re- 

gion, with lessened expansion. 

Rhonehial fremitus, 
voL-ai fremitus. 

ficBooance aormaL 

Rale« found in ttiisdiseoAC are e<|uully 
diffused ovvr both liin^. Expiratory 
murmur not notably prolonged. Res- 
oaauco natural. 

with normal Vocid fr«mitu» exaggerated. 


Store or leas dulness over the affected 


Kales and otlier signn of consoUdar 
tion loc'ilized. tintiled to l\ve ixirtioo 
of lung airected. Untnol 10- vesicular 
respiration and exo^crati'il vocal res* 


No bacilli of tuberculosis in tli« spu* Tubercle bacilli ; elastic dbres. 

turn, nor elastic fibres. 

pROGSOSis. — Acute bronchitis generally terminates in recovery with* 
in a few days or at most two weeks, even without treatment. It is 
dom serious except in iiifnnts and the aged, or very feeblo patieutK in 
whom it not infrequently develops into the capillary form. In tJ»e dia-, 
ihetic or cachectic, oft-re|>eute(l acute attacks are apt to occur and leal 
to chronic bronchitis. This latter form, though in itself rarely fatal, it 


not easily curublc and groilnally tciuU to the derelopmcnt of bslbma or 
more serious couditions, such us einphyscnin, brouchiecttwis, alclecUiaia. 
and fibroid phtliisis. Kmphysemii is peculiarly liiible to reiiuU from 
dry uHliirrh of the bronchi. 

Tkeatmest. — In many cmscs the riru/e dlse^ae miiy be iiborted, if 
Been early, by ;i bol HLiinulating dniugbt ut bed-timo and the Applicntion 
of siunpisms over the chest; or ti ten-grain dose of Dover's powder, 
quinine, or pheuacetine, eight gniius of untipyriue, five of acetanilide, 
or a moderately full doue of jaburandl or its active princ;iple piluoarjiliie. 
Failing in this, we may Ui^e nitli adv:tntuge smiil] Unscn cf opium ur of 
aconite: or troelierf u( morphine, anlinionv, and ipecac fonipound (Form, 
Hi); or aeomhination of morptiine, amiuouiuin chloride, and tjirutr emet- 
ic (Form. 1); or troches of compound licorice mijcture (Form. 34) until 
the exiiecturation beeonu'j! free. .Subser|nently for cough it will be 
found beneliciul to iidminister extract of cauualia iiidiea (AUfU'e) gr. j| 
to i, extract of hyoeeyamua (alcoholic) gr. i to i., extract of nux vomica 
gr. ^ to i, f|uinine hydrobromate gr. i. to ij., mouol)romaled camphor gr. ij. 
to gr. iij. every four to six ho[u>. Animonium earlMJniite with email doses 
of morpliiue (Form. 5) h also U)<efnl. If the cough is not very trouble- 
some, we may give poiiifiaium clilorate, 3 as. to 3 i. daily in divided doses. 
Tonifa may be reqnircd until resolution is complete. 

The subacute form of the disease is treated iu essentially the same 

Chronic bronchitis is often dependent upon some constitutional dis- 
onsf or diatliesia which should receive our firat iitteiition, together with 
inipruvenicnt a^ far as jio^^iblc of the hygienic iturroundingK, and the 
correction of vicious Iiabite. If it is due to the dnrtrou» diatht^ii;, ar- 
fionious acid, gr. ^^ to gr. ^ three times a day, ia esjief-'ially in<]icatetl. 

For the rheumatic or gouty diathesis, oue or more of the following 
remedies uiuy be giveu from three to five times a ilay : Potassium acetsta 
gr. XV., resin of guaiac gr. x. to xv., or its animoniuted tincture " ss. to 
3i., polasaium iodide gr. v. to x,, tincture of colchinum ilix. to xx. 
Even in these chronic conditions, salicylic- acid or sodinm Hilicrlate is 
sometimes very beneficial, as also salol. In some iTistnnoes undoubted 
bonctit is ilerived from phylolaeoji. In a large percentage of these cases 
the digestive organs will be found at fault, ant) the greatest good will 
follow a judicious use of hixatives and the administration of remedies 
which will correct gastric and intestinal indigestion. 

Many patients having the gouty or rheumatic diathesis are subject to 
eructations of giis or sensations of weiglil and fulness of the stomach 
shortly after eating, or to flatulence. The indications here are to hasten 
digestion and prevent decomjMwition of food. To this end I have often 
found of grejit service a c:ipsu]e containing the following, given before 
meals and at bed-time or before and after meals according to the sever* 
ity of tlie case : 


B Capftici i;r. ss. 

Uydi-iistinae hydrochlorat.. .- gi'- f . 

Extmct. HMC\s voiiucu; tir. i. 

AciJ. juilk-ylici. Sr. ij. 

Pupain (Carku p:i|Miji-uJ gr. iij. 

M. Incliwe in Oiipsule. 

The liydru<.-ltlorutc uf hyilrajtUric here u«(h1 is tlie article comtuooiy kaovrn 
ms ftiicU in modtcine. but in pbarmacy and cheinistr}' it is mure Lvrrvvtiy i«nu«d 
bjrdrochlomte of bvrberine. 

When the dipcrtive troable is mninly jpistrie^ the salicylic acid is 
preferable to prevoot dccompositioa; bat if flutulcueo i« u jiruiuiueiit 
sjinptum, sulol will be found efficacious. Of the digestive agi^iits, pa- 
paiiit: ia tu lue must sitlisfactory, but somotimeif pepisiu, {»uncr(»iLiii. iiud 
iiigluviu arc useful. 

If tliL' iilTcctiuii ori^inute^ in syphilis, potiiRftiuni iodide in full doses* 
with mercury hicliloride, will have the lw«t effect. 

When the disesise ia of simple ciitiirrhal origin, potussinro chlorflte, 

3 L daily in divided doses, ia one of the best Iniemal remedies. I'rej>- 

arations of »c{Utll, senega, ye rba santa, and cncalyjilui^ are i^umelinies 

beneficial. Vegetable and minenil tonics, cod-liver ui), and prejianilions 

of malt are indirated for debility. 

Peraiiitent' counter-irritation sometimes aids greatly in promoting a 

LocoUji, inhalations similar to those recommended for diseuiics of Iho 
throat {Form. fi2, ^3, 'it, 09, 72, and 73) aie beneficial, and in some 
instances, particularly where there is free secretion, great relief is oh- 
taiueil from the inhalation of thymol gr. ss. to i. to 1 i. of liqnid ulbolene. 

Cou^'h niay i'c relieved by small doses of mori)hine and iinimoniitm 
curboufite (Form. 5), by troches of morphine, or cannabis indica and 
terpin hydrate compound (Form. 33), and often by setlative inbalaiious 
(Form, 53--5i»). For dyspniiea, the nitrites in some form ai* specially 
bencticiaL Great caro shonld be taken on the part of the piitient to 
avoid damp feet, exposure to night air, cold drafts, overheated atmos- 
phere, and the inhalation of irritating substances. 

Wlipti pnu-tinable, chanjie of climate is often highly beneficial. When 
the lironchiat secretions are profuse, the patient is likely to ohtitin most 
benefit in a higher altitude with dry atmosphere: if the secretions are 
scanty or t-enacious, a moist climate with an eqnable temperutnre like 
that found at the sHtshore in .Southern California or along tlie coast of 
the Gulf of Mexico is raoro salutary. 


Capillary bronchitis consists of an acute inflammation of the mucous 
lembrane lining the capillary hronrhial Lubes. It usually results from 
"extension of inflammation affecting tlie larger bronchi, and it affects 
both lungs at once. 

Anatomical asd 1»athoia>oical Charactkkistics. — Evidence ren- 




dered by aatopsies indicates thtit capillary bronchitis without accom- 
l>iiiiving inflammation of the air vesicles is very nire. In most cji8e« tho 
inucuuB membrane of the larger tubes is tirst involved, and during tho 
|trugrc8;3 of tho disease the small tubes becoino more or less blocked with 
Beereliou; this bus ii valvc-like ucliou, which preventu nir from entering 
aomu of the alveuli during inspiration, but aUuw.<i it lo escape in expiru- 
lion, so that these air colls collapse, and as a result the cells in adjoining 
Jobulcs are correspondingly disteudeil. The lung consetjueutly lias an ir- 
regular mottled iipiieamnce, from interspersed sunken atelecljilic patches 
and ele%-atcd distended air sacs. 

Etiology. — The etiology of capillary bronchitis is that of acuta 
bronchitis, it usually resulting, in childrcu and the aged, from extension 
of int1:immation from the hirger tubes. 

Symitomatology. — The principiil symptoms, in addition to those 
found in acute bronchitis, are severe dyspno>a with lividity of the sur- 
face and great prostnition, following marked febrile reaction and accom- 
pauied by rapid respiration and a weak pulse. 

The principal sujiut are: absence of duhiesa, iiccasionallv exagger- 
ated resonance and sibilant or subcrcpitunt rllles on both sides (Kig 

By inspection, respiratory movements are found to be rapid, and the 
countenance shows the effects of imperfect aeration of the blood as the 
disease advances. 

Palpation occasionally yields a rhonchial fremitus, dne to disease in 
the larger bronchial tubes. 

I'ercussion obtains a resonance normal or slightly exaggerated over 
the lower portions of the chest. This exaggeration is duo to emphysema 
of a portion of the air vesicles, which results from complete occlusion of 
some of the smaller tubeii, with collapse of their terminal vesicles, and 
consequent dilatation of the surrounding air cella. 

Auscultation usually furnishes signs of general bronchitis, and in 
addition to these, wirly in the course of tho affection, sibilant niles are 
found iu great abundance, which a little later are n-phioed by aubcrepi- 
tant rales. These subcrepjtant rales, when numerous and attended bv 
the symptoms ah'eady mentioned, may be tjiken as a jKt^itive sign of 
capillary bronchitis, but a few are frequently heard over the lower por- 
tion of the chest, simply from gravitation of fluids, or of the products of 
indammation from the larger bronchial tubes. 

Occasionally a few subcrepitAnt r&les are heard, near the borders ot tho lung. 
even In h<>altl). 

Subcrepitant niles, when confined to the apex or to the base of one 
lung, usually indicate that the capillary bronchitis producing them is 
either of tuberculous or of emphysematous origin. 

Diagnosis. — Capillary bronchitis is attended by signs similar to 



«uiiie of those fouiiil in ustlima, pueumoiiiu, or piihiioniiry UMlema. This 
disease uiaj be Uistinguishcd from asthma by the history. 

Capillary bronchitis cuunoi be mistaken for the first or uecoud etago 
of M»rr /tiieuiHonitt if we bear in miiitl that ueither of ihese stages cauees 
many sibiknt or suberepitaut riileti, which are abundant in bronchitis^ 
and tbut both sUges are iittcnUed by marked dnlness, while in bronchitis 
resonance is either unaltered or exaggerated. From the tliird uUige of 
lobar pneumonia this disease is distinguished by iho signs obtained by 
palpation, pereussion, and aascnltation, as follows: 

Capiuoay BRON'CHms. Lobar pkeumonu. 

No increase in the roeal fretnitiiB. Vocal rrcmitus increased. 

PervHAgion . 
ND<]nlnes!i;occaaionaUyexaggerut«il .More or less duloess. 



Subcrepitant rAles over botli luogn ; Subcrapitant rAles conllDeil to one 

4tiese rAles are of low pitch. Ktdv, uver the ulFected lunf; ; these rales 

nre hijfli in |>ilch. 

It is difficult to distinguish between c^ipilhiry bronchitis and hhtlar 
ptuumoHWt with vbich it often coexists; but the diagnosis may be 
made fairly certain by attention to the following points: 

Capillary bronchitis. Lobular PNEiniONtA. 


Moderate fever. Moderately accel- High fever. Very ra]>id respiration, 

^erftted respiralioa. 


No dulne«s. but possibly exaf^gerated Limited unchanging spots of diilness 

resooaiice. """y »'(im';tinit'« be delected, tlioiigb, as 

the disease usimlly (Ktcure in children, 
in whom dulne«s is diflicult to detect, 
this sign is lialde to escape observation. 


UiUtitudes of One dry or moist rAles The r&les are limited In area unless 

over every part of the chest the two dtMOiies coexist. Bronchial 

breathing can occitsionally be detected. 

Capillary bronchitis is distinguished tram, pnlmoiiary isdetna hy ih^ 
following symptoms and signs: 

Capillary bronchitis. 



Febrile symptoms. 
Usually shows an antecedent acute several days in duration. 

No febrile symptoms. 

This ulTeclion usually follows some 
protracted diseaite, an typhoid fever, or 
aflectious of tliu heart or Icidnevs. 



Capillary bbomchitis. 

Hesonance normal or exa^erated. 


DutneBB over Ute loiter part of both 


Usually aumerotu r&les in Uie larger Signs of general broacbitis Ire- 

tubes, queatly absent. 

Capillary bronchitis is distinguished from phthUis by the historj' of 
thp case, and by the fact that the subcrepituiit rdles of the latter affec- 
tion are liuiitud to u smaller portion of the ehest, which is usually over 
the apfx of uuu luug. 

pROitNusis. — This diseiise iu severe casea may j>rove fatal withiu 
eighteen hours, but uaiuilly it extends over tour or five days. Tlie rate 
of moitality, though difTerently estimuted, is extremely high, e«pecinlly 
for the aged !*nd for infsints under one year. When following whooping- 
cough or measles, or complicjiting any serious organic Trouble, or occur- 
ring in delicate chilUreu, the prognosis is also unfavorable. CoUTalcs- 
cenco in any event is apt to be tedious and recovery iucouiplete> 
attended by more or less permanent crippling of one or both lungs by 
collapse of the alveoli and hyperplasia of the connective tissue. The 
prognosis should therefore always he guarded. 

Death generally reeultg from ai'iihyxia, ariil its approach is indicated 
by signs of extensive involvement of the kings, difticult e-xpeetonttiou, 
cessation of cough, dyspncea, cyanosis, or the symptoms of collapse. A 
temperature of 105" F. or more, if long continued, is very uufavgmble. 

Tre.^tment. — Opiates should not be used in tiiis disejisc excepting 
in very small doses. Early in the disease, ammonium chloride with 
syrup of ipecac will bo useful; but after two or three daj's, more benefit 
will be derived from ammonium carbonate. Inhalations of steam, or 
steam impregnated with sedative remedies, have a soothing effect on the 
ioflamod bronchi (Form. 5:^-20). Ammonium iodide iu snntU and often 
repeated doses is sometimes a most eflicient remedy. Strychnine, gr. 
■^ to •^, is a valuable remedy in this affection, as sonn as symptoms of 
exhaustion supervene. Alcoholics should be used tostistain thestrength, 
if the ammonium carbonate doe* not seem sufficient. Oongli and any 
BpasnuHJic tendency may be relieved by camphor or the bromides. 

In childi^u it is necessary to wutch carefully the secretion of urine 
iu order to avoid a freqiicut cauue of dyspiuea: digitalis intenmlly and 
cataplasms over the kidneys are usually effective in promoting free renal 
aecretiou (Simon: Medical .»!/Tjr, January, 1800). 

The most efllcieut remedies are ammonium rnrbonateand strychnine, 
with large jacket poultices kept constantly warm and moist and cover- 
ing the whole chest. The diet mnst be nourishing. 




Symmjvis. — Pscudo- membranous, croupous, exudative, or fibrinous 

Broiicbitia issometltneacomplicHted by exudation of fibrinous mntcer^ 
with the formation of falsw mymbniiie or pluHtJc cadts in the smaller nir 
tubes und their ramiticntions nud ocragioniilly in the larger brouchL 
This affection may be acute or chronic. 


is generally chronic, and usuiilly involves the smntltT brouehi only. It 
ta most frequently circumscribed, but may be diffuse in ucute csecs, and 
is marked by exudation from the surface of the bronchijil nmcous mem- 
br»ne *>f fibrinous nrnterial, forming casts, which have a laminated 
structure, ilie layers being eepjimble wlien dry. Thi? pubstance is com- 
posed of conj^hited alhnmin (soluble in alkali), ooittuining leucocytes 
id fotglobulcRj fometimes octahedral crystaU, a few red cnrposclcs, 
I and epithelial cetle. It is Urm and of a white, gi'ny, or yellow color» 
occasionally spL'cked with blood. tSccmingly the mucous menibrane 
beneath it is not seriuusly implicated, but may be either cougested 
or pale. 

Btu)I.o(iy. — The ultimate cause of plastic bronchitis is not as yet 
known. Though poverty, exposure, and feeble health are mentioned as 
favoring its occurrence, excepting diphtheria, no particular diseases or 
conditions have been aseertuined to bear special causal relation to it. 

Authorities differ as to its comparative frequency relative to age and 
sex. Ac<-ording to I'eacook it more i»ften uffcctd meu (Transactions of 
the Pathological So<:iety, Vul. V, Ijiiridoij). 

SvMlTOSiATOLOOT.— The prominent symptoms are: hacking cough 
with aciiiity expectoratiou, followed, after a varying interval of from a 
few huurs tu several duys. by n sense of constriction in the chest, aud 
dyspntea wbicli may be very severe. The cou^h gi'adually increases in 
severity, the expectonttion becomes uiore abundant and perhapii tinged 
with blood or accompiinied with profuse luemoptygif, and finally small 
fmgnients of the fibrinous matter are brought up or, after severe parox- 
ysms of cough, complete Gists of the bronchi. These ca^ts maybe solid or 
hollow, varying in diameter up to half an inch and in length from a 
fraction of an iuch to six inches, the counterpart of the bratiching bron- 
chial tree. 

The physical nignx are those of ordinary hronchitia. superadded to 
which are the signs due to partial or eomplete obstniclion of w)me of 
the bronchial tubes, via., weakness or ahsenue of the re8i)ir:itory mur- 
mur, with dulness where portions of the lung are collapsed. These 
signs may lead to an erroneous diagnosis of phfiriaif or of ptuumonia. 
From the former, plastic bronchitis is distinguished by absence of catch- 
ing respiration, pains, und friction sounds; by the speedy occurrence of 


dulness with loss of the respiratory mnrmar and vocal signs, and hy the 
preRenee of signs of hronchitis in other parts of the chest. 

We distinguish it from pneumonia by the absence of bronchial 
breathing, and, when collapse of the Inng occurs, by the sudden acces- 
flion of the signs of consolidation. The differentiation from ordinary 
bronchitis rests entirely upon the expectoration of fibrinous casts. 

pROGSosis. — The mortality in the acute form la about fifty per cent, 
death occurring in from five to fifteen days. Though complete recovery 
from chronic plastic bronchitis is rare, death simply from this form is 
equiilly so. 

Treatmext. — During the acute attack or during exacerbations of 
the chronic form of plastic bronchitis, the treatment should be essen- 
tially the same as that for membranous croup. 

Stirling recommends inhalations of lime water, strong or dilute or 
combine'! with a two to five per cent of sodium bicarbonate, in which 
the casts are soluble. Turpentine, cubebs, and copaiba tend to render 
them more plastic. 

At other times, potassium iodide will aftord some relief. The gen- 
eral health must be maintained and all causes of cold avoided. 

A warm climate is advisable, and if possible a sea voyage. 


Synonyms. — Bronchiectasis or bronchicatasis, knife-grinder's rot, 
filer's phthisis, cirrhosis of the lungs. It is sometimes termed fibroid 

Axatomical and Pathological Characteristics. — Dilatation of 

the bronchi is usually associated with fibrous induration of the lungs or 
With vesicular emphysema. It is generally found in the smaller tubes 
over the middle or the lower portion of the lung, more frequently on 
the right than on the left side. 

The affection may be general or partial, single or multiple, and may 
oe fusiform, cylindrical, or saccular. The bronchus so affected may 
continue of normal calibre on each side of the enlargement; it may be 
narrowed or obstructed on either the distal or the proximal side; or 
obliterated on both. The walls of such a cavity frequently show atrophy 
of the mucous membrane, with its secreting glands, or they may present 
H surface more or less irregular and granular. The submucous elastic 
tissue is liypertrophied, the muscular coat normal, atrophied, or its fibres 
widely separated. The cartilages may be thickened or may have par- 
tially disappeared, but the connective-tissue elements are greatly hyper- 
trophied, and the adjacent interstitial lung tissue is involved in the 
flame process. 

Etiology. — Bronchiectasis may arise from increased pressure within 
the bronchi or from weakening changes in the walls or surrounding lung 



tissue. It may be the result of alveolar collapse or ntelectasU or stenosis 
of the bronchi from any cause, but chiefly from chronic bronchitis, also 
from phthisis uud occaniiouully from ohl pleuritic ttdhesious. 

SYJirTOMATOLOOT. — Puticuts affcctccl with bronchiecuaia often have 
the gcnenil ajtpc^iniuce and symptoms of phthi^ieui subjects. The prin- 
cipal distinctive synijitom i^ the expectoration of opaque, purulent, and 
extremely offensive sputum, which is very abundant, measuring some- 
times three pints in twenty-four hours. 

Theprinc-ipa! »r<7»>'nre: more or less duhiess.. and a hiirsh inspiratory 
murmur with numerous nilcs, all of which signs may rapidly change. 

Inspection shows imperfect expansion of the chest, prolonged, labored 
expiralion, with more ur less lixity of the chest walls, and depression of 
the intercostal spaces. 

The signs obtained by palpation, perenssion, and auBPullation vary 
greatly at different times, according to the amount of fluid in the tubes 
or cavities. This variation in the signs is of itself almost diagnostic of 
the disease. 

By jHilpatioD, the rhonchial fremitus may or may not be obtained. 
The vocal fremitus may be normal, but it is sometimes incretised, at 
other times diminished. 

By percussion, some dniness is usnally obtiiined over the affected 
Inng. This is sometimes removed by free expectoration, and may then 
b« followed by vesicnio-tympanitic or perhaps a craclced-pot resonance. 
Dulueea is apt to be located at the middle or lower part of the lung, and 
is most common on the right side. Light percussion nsunlly elicits dni- 
ness. when a more forcible stroke would produce a somewhat tympanitic 

On auecnitation, M'e sometimes Cinl the respiratory munnur sujv 
pressed over a considerable portion of the Inng, while round nljoot it the 
iiounds may be harsh and loud. A little later, free expectoration hnving 
eraptietl the bronchial tubes and cavities communicating i\ith (hem, 
reapinition may become hroncho-vesicular and intense. M-here at tirst it 
could not he heurd. The respiratory murmur is often associated with 
numerous ndventitions sounds of every variety from the dry, sibilant 
rdle to gtirgles. 

Vocal resonance is subject to similar changes, and from the same 

DiAONosis. — Bronchiectasis is most likely to be mistaken tor pHthma^ 
from which it can only be distinguished by attention to the expectora- 
tion, and to the mutability of the physical signs. The distinctive 
feAtordS between the two are as follows: 

Fremitus changeable. 


Elxuggerated vocal fremitus not unl- 
rei-)ial, but when pi-ewnt uyuatly con- 




BRoscHiecTAais. Phthisis. 


Dulness, orvesiculo-lympanUic reso- More or less dulnesis, which remaitiB 

nanoo, often clianfiiDjr tvoiu one to the constant. 
other during llie «.xaniinalion. 

The signs aw usually found over the Tlie signs for several months are 

toweror middle i)ortioD» of one or both 
lun^, and chansf vapidly as the re- 
sult ot deep inspiration or cough. 

UBually confiiieU to tlie upjwr portion 
ot one lung. They are not loalfrially 
altered by cough or by deep inspira- 
tion. They are confiiittl to a inore 
Ifmittid splice than Iht; signs of dilata^ 
lion of the bronchi. 

Prognosis. — Bronchiectnsis rnng a chrouic conreo, and, though not 
£Eite] in itself, is iuductivo of other pulmouarj disease, especially predift* 
posiug to putrid bronchitis, and gaD^reno or abscess of the liin"^. It i«in- 
rurnhle and, Ixting secondary to fhronic bronchitis, old pleuritic adhe* 
siondiuid thickening, ateleccasis or libroid phthisisjit^proj^uoeiti depends 
npon that of the associated disease. 

Hectic, rapid ptdso and {>rogres8iY3 enmciatiun with uight sweats are 
unfavorable i<yniptoins, but thustj syni]itoni(<, aLteuded by must abundant 
fetid expector.ition and great aathenia, giving thfi iippeamnce of the hitit 
stage of consumption, sometimes disajipear in a partial recover}*, ro thut 
the patient lives iu fairly good health tor a year or two. 

TaEATiiKNT. — In bronchiectasis, cod-liver oil, calcium cbloridf, and 
vegetable tonics are generally demanded. Some of the preparations of 
eucalyptus globulus or griudelia robusta are opcaKionally beneficial, as 
are also copaiba, turpentine, senega, and stjuillR. Potjiaaium or ammo- 
nium Iodide aud arsenic aro also useful. Inhalations of turpentine, 
caniphur, iodine, aud carbolic acid uro frequently useful in checking or 
altering the secretions (Fomi. 60, UT, 68, 70, 71, 73). Counter- irritation 
should he tried. 


Asthma is a spasmodic ailcction of the respiratory apparatus, chieflj 
characterized by paroxysnml attacks of dyspnoea. 

Anatomical and 1\vthological Cji.\.kactebistics, — There arc no 
recognized morbid changes peculiar to a^tthnm. It is a functional dis- 
order or neurosis dependent upon some physical condition not yet thor- 
oughly understood. Many hypotheses luive been advanced to explain 
the mechanism and ciiuse of asthmatic dyspno^t. 

Though none of them have become entirely adecjuate theories, tha 
bronchial spasm hypothesis in the one most commonly accepted. Ac- 
cording to this, the dyspncea is due to spasm of tliu annular muscular 
fibres of the bronchi which narrows their calibre aud obstructs the pas- 



eagfl of air. That bronchial constriction occurs m asthtna ie proved by 
the constant presence of sihilant niletu 

Som«>, with Wintrich, cougider Bpasm of the diapliragm ae acconnt^ 
ble for tho diftimlt brenthing. 

Weber and othera hold that it is due tt) vasomotor relaxation pro- 
dncinjT congestion and tumefaction of thu brouuhiul uiiicaiiij mL-nibnnio. 
Crystals and ejiirals found in the sputum by Ijcydfii ami Curtu^'limiinn, 
and supposed to lie causative, as irritants to the bronfliial nincous inein- 
biiiiie, have be«n tisoertained to be present uot alone in afthnia. but also 
in many pulmonary disorders. 

Etiiilovy. — Altliougli tho nltimatf cause of asthma is unknown, 
certain predisposing conditions aro recognized; according to Sidter^ 
horfdity is to be traced in forty per cent of all cases; others claim 
a etnitller {wrcentage (Lazanis tn Deutsche tnediciHt^iir ZcitHtigt 

Tho neurotic temperament seems to favor it, jMirticularly if coupled 
with plethora; also the rheumatic ami gouty diathesis. It is common 
to all ages. Its victims are most often males, those preferably of tho 
npper class. Soltmnua thiuks it especially common among the Hebrews 
<8hattuck: Cyclopedia of Diseases of Children, Keating). Asthmatics 
nsually suffer must in wiiit4?r, ami the attacks occur generally at night. 
Its exciting causes may be considered iw those acting directly a£ irritants 
to the terminal fibres tif the vagtit^ or sympathetic? in tho hroiichial 
mucous membrane, and tluise acting reflexly from a greater or leas dis- 
tance. Bronchitis is the most frequent exciting cause uf :LSthma. An 
asthmatic attack may arise from itdialation of dust, smoke, fog, and 
other vnpors, pungent fumes, odors from certain plants, pollen, and 
emanations from animals. Indeed, the list of substances capable of 
exciting an astlimatic paroxysm is long. 

Different patients are affecte<l each in his own peculiar way, one 
by the pre^ienee in theatmosplien'of one substance or condition, auuther 
by one totiilly different. The diseases and conditions which by reflex 
impression upon the bronchial nervous mechanism excite the asthmatia 
paroxysm are also very numerous and varied, Not infrerjnent imuscs 
are found in irritation of the upper air passagoe by impalpahle particles 
diffused in the atmo^^phere or by such deformities as septid detlectioDj 
exostoses, naaid polypi, and hypertrophy of the tonsils. 

Asthma has bec^ii attributed to the pressure from a hypertrophied 
thyroid, an aneurism or other tumors, or from enlarged bronchial glands. 
]t is frequentlydueto somo disorder of thealimeutiiry tn!<;t. such as (gas- 
tric indigestion or neurosis, duoilenal catarrh, hepatic torpor, constipation, 
intestinal worms, or hemorrhoids. It may be duo to abdnminal tumors 
or derangements of the gen ito- urinary system, as for example calculi, 
prostjitic enlargement, enuresis, 3pemiatorrh(£A, sexual abuse, and. in 
women, ovarian, uterine, and vaginal disease. Diseases of the heart, of 



the kidney, or of the brniii may cause iisthiiia, as iimy also cerUin iskiu 
diaeasea — eczema, iirticitria, miJ bur[>c*ti, fort'xaiiiplo. Puiik't ile»'i-it>e.>iau 
epileptifonn variety of luthnia {Journal de Midecine de Paris^ IbbO). It 
8oeni8 somciimes Co occur from j>re$i-itce in the blood of poison, such :;» 
the CI ramie, gouty, rheuiUHtic, or iimlariiil (Hobinsoii, McUU-al yvK'n, IWI'O), 
or certaiii ehtMuieaU presumably at-tiug through the circuUriun upou 
the respiratory eenti'eg, Uut back of all these favoring conditiouH uiid 
exciting cnuses is something, as yet unknown, which is nn iniportflut if 
not the chief otiologioul factor in the production of the disease. Cases 
occur iu which the most careful examination fails to Gud any predispos- 
ing or exciting cause. 

SvMPToUATOLOGT. — Asthuia is characterized chiefly by jKiroxysms of 
dyspncRa, with striduluus respinition und the evidences uf deficient uen> 
tion of the blood. In some indtamrcs ati attack may l>e foretohl by sen- 
sations of mental deprcjwlon, drowsiness, or iiritability, or iheir oppo- 
ailes; or by byperfusthesia, heiuliiche, a sense of constriction of the 
throat or chest or frequent desire to gape or sneeze. Some attacks begiu 
with coryza. which may develop iuto bronchitis. Usually the onset is 
sudden: llie jmtieut awakes from sleep, wheezing and perhaps gasping- 
fur breath, with a sense of thoracic constriction, and if it be bis first 
attack he fears inimiueut suffocation. Brejithiiig becomes more laborei1„ 
accompanied by venous turgeacence, congestion of tlie face and neck, 
bulging and suffusion of the eyes, dilatation of the nostrils, and profuse 
perspiration. The pulse decreases in strength with the severity and 
duration of the paroxysm. The ])aroxyem8 usually last from two to 
four hours, but the attack sometinicii terminates iu a few minutes. It 
may occasionally continue for weeks. Recurrence of the affection re- 
sults in some patients only from certain exciting causes, in othei's more 
or less poriodienlly — daily, weekly, monthly, or yearly. 

Diurnnl attacks arc rare. Frequently the paroxysm terminate* in a 
mild bronchitis, iietween attacks the condition of usthmiitic patients 
varies in degree from a conditiou of apparent liealrh to the state of 
more or less constant suffering from the disease or its sequelie. 

The principal ."I'yjf.f are labored and wheezing respiration, attended 
by numerous sonorous and sibilant rules, which may b? heard, and 
often felt, over the whole chest. 

The imtient is usually found in the upright position. Respiration is 
labored, inspiration being short and jerking, and expiration j)rolonged. 
Thedyspncon is chiefly expiratory. The respinitory motion of the chest 
is greaitly diminished. Severe cases show the signs of deficient oxygeuih- 
tion of the blood. 

Inspection, palpation, mensuration, and percussion yield no distino- 
live signs. The resonance may be normal or slightly exoggomted. 

Uy Kuscultatiou we obtain jerking or cog-wheel respiration, with a. 
groat variety of sonorous and sibilant rAles. The respiratoiy murmur 



u usually harsh and more or lesa tubular, tirn reeicalar element being 
auppresaed. Vocal resonancu ia normal. 

DiAONOKis. — ^During a imroxysm, astlima iriav Ir' miatnkon for 
eardiac ilygpntpa, capillary brouchitU, or spui'iiioilif laryugeji! iiirectioiis. 
From the first, it may be distinguished by the lii&torv, hy tlie al»ence of 
cardiac signs and by the preeeace of a grejit number of ijonornug and 
eibilunt riiles. 

Asthma differs from rnpiikiry broncbitiH in its history, and in some 
of the eigne obtained by inepection und auscultation, as shown in the 
following table: 


A sudden attack, willi usually a hU- Dyspaceu comes on ^-adually, usu- 

tory of former jtaroxysras. Febrile ally preceded by acute or subaouto 
symptoms not nmrkeil. bi'oriubitis. Febrile eymptouis pro- 

Re&piraUon labored, but not greatly U^spiratiou not only luboi'ed, but 

•oMlerated. also rapid. 


Sonorous and sibilimt r&les, usually Mucous rdles likely lo precede tha 

followed by large and small mucous sibilant i-dle?>, niul tlic silijlaot to bft 
rAlefl. followetl by ibesubcrepitant. 

Spa^f/wdic affections of the larynx are distingniehed aa follovs: 

Asthma. Spasuodic labynoeal AFFEcnons. 

Dyspnoea expiratory, 


No loral lorynjreal signs. 

No cliango m voice. 

Dy^pacea inspiratory. 

No tiles. 

Laryngeal si^s sometimes positive. 

Voice a1teii*d. 

After the paroxysm, the signs of asthma are tike those of bronchitiB> 
bttt tbey last only a few hours. 

Asthmatic symptoms often occnr during the progress of pulmonary 
iphysema; but these two diseases may be easily distinguished from 
''eAob other by the history. In ertipffyAeutti,tiS in cardiac disease, dyspnoea 
is permanent, and aggruvntod by exercise; while in asthma the dyspnuea 
usually ironies un during the hours of rest. 

pBO(tso8ii% — Aaliimatic paroxysms arc very rarely fatal. One at- 
tack predisposes to others, and the disease is usually obstinate. Hope of 
complete cure is good in jiroportion to the youth of the patient, absence 
of organic disease, short duration of the attacks, infrequeuce of recur- 
rence, immunity from distressduring the intervals, and the presence and 
discoTerT of a removable cause. Chronic asthma tends to the develop- 
ment of emphysema, chronic bronchitis, and dihitatiou and hypertrophy 
of the right cardiac ventricle. 



Tkbatmbnt. — During tlie puroxysm, the most efTcctual iuieriial 
treatment cunsi»U uf the udniiiiistnitionof uiorpliinetiiKl chlonil (Form. 
2) reiiwite<] every half-hour or overy hour tinti) relief \a oblained. Thia 
may be comhined with half u ilriu^hm of 11. ext. uf ^riiidelia rohiista^ 
which issometimoa bcncticiiil. The nitrites in the form of nitroglycerin 
gr. jjjf, or nitrite of amyl "lij. to v., reneatcKl evory twenty minntos for 
two or three duses, or iipouiorpliiuf gr. 7^,, internally every two houre, 
frfqaently provu efleutive. Weill {Irtt Frnmre .Uifliaile, March, 1889) 
through experiment)!, confirmed hy others, found tluit inhahilion of car- 
bon dlaxi<Je greatly relievwl iiongh und ilyKpna^ and cut the paroxysm 

Two or three cn{\8 of strong hot collee will frequently abort an 
attack, if taken when the first Bymptoms are noticed. The seTority of 
the paroxysms nmy be greatly moilitied by small doses of belladonna, 
hyoscyamus, or hyoscyamino gr. ^1^ to yjs Iiypo'lcrmically; or by po- 
tassium bromide or camphor. Fuming inhahitious of arseuious acid or 
potassium nitrite alone or eombinL-d with other autiBpatimoiJlc:i such u8 
etniinonium^ Iiyoscyanius, or tobucco, give 8p«?e*Iy relief in some cases 
(Form. 132-138). Galvanizing the pneumogiwtric nerve, with the poa- 
itire pole beneath the mastoid procoBs, and the negative pole on the 
epigastrium, will promptly relieve aome cases. 

If either bronchitis or pneumonia supervenes, it should receive treat- 
ment similar to that recoinmeudcd when it occurs i\a a primary disease. 
The general treatment of asthmatic patients should be supporting. Be* 
tveen the {MiroxyBins an effort should be mudo to prevent their recui^ 
rence. The most effiracious remedy for this purpose is potassium iodide, 
but in some cjises aninioiituni iodide, grindelia, eucalyptus, arsenious 
acid, or resin of gnaiac will be found useful. 

In all cases a complete history should be obtained and a thorough 
txamiuatiou made to ascertain, if possibh', the existence of any disorder 
which might cause a reflex brouchial spasni. Such disorder should 
be correctoil ; thus, it will often hei possible to prevent or care an attack 
by attention to the alimentary canal. 

It ahonid be remembered that asthma may result from the rhcnmatio 
3r dartroug diatbesis, and that it is often caused by bronchitis or emphy- 
sema, as well as by purely nervous affections. The treatment must 
therefore meet the conditions of each case. 

If all nicJicinos fail, a change of climate should be tried. The cli- 
inate of Colorado is perhaps the most frequently beneficial to these 
patients, but very slight changes tnay be sufficient to prevent a re^.-tar- 
rence of the attacks ; therefore "each patient must be a law unto him- 
gelf " in this reganl. By repeated trials, most cases will find localities 
where they will be free ^m asthmatic attacks. 




Fnlmonary einphyBemu is an abnormal inflation of tho lung, due to 
over-ilidtention of it^ air vesicles or acc'uniiilatiou of air in tho tissnea 
nbont them; in tho former cases it is commonly termed vesicului', in. 
the lalti-r uxlru-vestoular ur luterlubutur uniphyeuiuu. 

Ktiologically it is also called primary or secondary, comjvenKiitory 
and vicHricins. 

A.vATuwicAL AND Patholooical Charactekistics. — I'ost-mortcm 
opening of the che«t in a welt-markeil ease of genera) emplivscma re- 
reals the Inngs abnormally p:ile, much iliitteiided so as to meet or over^ 
Iiip anteriorly, their surfaces bearing the imprint of the ribs, their bor- 
ders rouiideil. They do not collapse. The heart may be displaced down- 
ward and toward the uiediaii line. The lunj? feels softer than iiurnml 
and pufly to the touch. Indentation mado by digital pressure rumains 
for some time. 

There is loss of elasticity, diTuiuished crepitation, and greater buoy- 
ancy in water. Dilat«d air sacs may be seen proti-nding from the sur- 
face as ronn<led, hemispherinil, or spherical elevations and of a grayish 
line. Air may bo presided from the distended sites, which upon section 
appear i\& cavities scattered through the lung, rarying iu size from a 
millet-seed to a hen's egg. In mild or beginning emphysema there may 
be simply extreme distention of the aUeuli, with little or no destruction 
of their walls. As the process continues, two or more air cells coalesce 
by the rupture of their common aejita, forming cavities of vnriablo size. 
The walls <if. these are hero and there constricted and roughen ?d by 
ragged projections which mark the location of former alveolar purtiliona. 
The capillary plexus is conaetiueutly partially destroyed. In the inter 
lobular form, secondary to vesicular emphysema, uir escapes from tho 
vesicles into the interstitial connective tissue forming other cavities. 
The process may extend along the blood-vessels of the interlohnlar septa 
to invade the mediiuttinnlj, cervical, and finally the subontancons connec- 
tive tissue. 

Probably rupture of the alveolar walls is dependent iu moat cases 
upon a primary fatty or fibroid degeneration. Senile emphysema, so 
called, results from atrophyof lung (issue: here the lungsare diminished 
in sire and generally pigmented. Kmphysema is gonendly bilateral, but 
may be confined to one lung or to a single lol>e. When due to forced 
expiration, with obstruction in the trachej*. larj-nx, or glottis, it is moat 
marked along the anterior border uf thenpper lobes. In addition to these 
morbid changes, the bronchi communicating with the cavities are the 
seat of more ur leas bronchitis and bronchiectasis, Vireliow, as reported 
in 1889, had never seen tubercles in an emphysematous lung and uidy 
me case of pneumothorax {Bertimr kliniache Wocliejixhrift, 14^811). 


But both these conditions may accompany it. Pnenmonift oecft5ioiia!lj 
compUcutes it^ and dilnt^itioii aiul hypertrophy of the heurt, with re- 
Bulling cbuiigofl iu ihe lungs, lircr or kidneys, iire not uncommon. 

ETiOLOfi\'. — Emphyseiim may occur at uny ugc. It is, liowever, 
most coniutou in those heyond middle life, uthI more frequent in men 
than in women. Heredity seemn to play an important part in the eti- 
ology: but whctlier tlic ilisoiiso is largely dne to hereditary transmission 
of u special weakness ot Inng tl^ue, or to primary maluutritive cliauges 
of a fatty or fibroid nature, is an open question. It occurs iu the aged 
from natural atrophy accomiMinying geiicml senile decline. Forced in- 
spiration may cause over-dlstention or rupture ul air vesicles, whose elae- 
ticity is alreaily inipai.v^d. Tlie usual cause is the exertion, after deep 
inspiration, of ]ii)werful expiratory efforts with closed glottis or with 
more or leas obstruction of tlie respirator}- passages from other ciiuses. 
Uonco, the disease not infre<jnently complicates asthma and the cough 
of chronic bronchitis or pcrtnssis, and may result from oxccfisiro nse of 
certain wind instruments, or from straining efforts as iu lifting, child- 
bearing, or defecation. Local conipensjitory emphysema occurs in the 
air Tcsicles adjacent to lung tissue that is collapsed or consolidated or 
whose larger bronchi have been olistructed. Obliteration of tlie iiir vesi- 
cles of one lung wholly or in large part, from pneunumia, phthisis, in- 
farction, and the like, or from prossurc by pleuritic effusion, may produce 
compensatory emphysema in the opposite organ. 

SvMPTOMATouinY. — The proitiiiteut symptoms are constant dyepnona, 
increased on exertion, associated often with the symptoms of bronchitis 
or asthma, or of both. 

The prominent signs are: lifting of tho sternnm in inepiration, 
barrel-shaped chest; vesieulo-tympanitio resonance, and prolonged ex- 

Inspei^tion jn well-marked cases finds the countenance dusky, the 
eyes prominent, the nostrils dilated, and the sterno-cleido-mast-oid mus- 
cles standing out like whip-cords in their efforts to aid in respiration. 
The shoulders are elevated and drawn forward, the neck is apparently 
shortened, anil tho individual seems to stoop, which gives hlin the a]>- 
pearaucc of old age. The margins of the scapula; sometimes stand out 
like wings, and there is an increase in the anteru-puiiterior diameter of 
the chest, giving the rounded barrel-shaped appearance. During inspi- 
ration, there is no expansive movement of the upper ribs, but they are 
elevated as if the chest walls were composed of a single bone. In marked 
oases of this disease, there is with inspimtion fulling In of the soft ]iurts 
of the chest above the clavicles and sternuui; the intercostal spaces at 
the upper part of the chest are wider and more distinct than usual; and 
there is retraction instead of expansion of the false ri1>s during inspira- 
tion. Early in the disease, these signs are not present. Vouous pulsa- 
tion is sometimes seen in the jugulars. 



Oocaaionally omon;^ old people, in cases known as atrophous emphysema. Ui« 
inter^''>8U:ijl»r itepta are dentroyetl hy atrophy and the vesicles coalesce. Th| 
volume of llie luc)<; is tb<>reby more or less diminished, !io that the duwase cnuMsl 
no dlatentioa of tho I'liesl. In ^ucli otues. no sit^s wotdil be obtained oit in> 
vpecliou, except f»crlia|»s retraction luid an increavetl obliquity of the lower rih», 
Willi conRidpniblu diminution ut tlie Hpace between them and the cre«t of the 

Rt palpntion, the apex beat of the heart ii freqnentlj fonnd btilow 
its normal position, and nearer the median line. 

Vocal fremitus may be e3cuj^«;Qrated, diminisheil, or normal. 

Mensnmtion shows us the exact increase in theantoro-posterior diam- 
eter of tho chect, and the deficient expansive morcmcnt in inspiration. 

Percussion yields Tcsicnlo-tympanitic resonance, nsurtHy most marked 
over the ui>per part of the left lung. Percussion over tho pnccordia 
may show diminished urea of siiperfici:*! cardiac dulness. or the entire 
region may yield pulmonary resHuiuuce, due lo tlie expansion of the 
border of the left lung, so that it completely rovers the heart. 

Deep inspiration or forced expiration will not materially affect the 
pulmonary resonance^ as it wotild in he-alth. 

On auscultation, the vefiienlar murmur is impaired, the inspiratory 
ind being deferred, and con8c<|nently shortened, and tlie exjdratory 
sound being prolonged, so that the ratio between the two may be ru- 
versed. making the expiratory sound espial in length to the iriHpiratory, 
or even three or four times as long. In typical, uncomplicated niees, 
both sonnds are low in pitch; but hnrsh, blowing sounils from the bron- 
child tabes are often beard, especially dnring ins^n'ralion. A peculiar 
dry. crackling sound, closely resembling fine pleuritic friction, is often 
heanl jUHt at tho end of inspiration or at the beginning of expiration. 
It is produced in the walls of the air-vesicles. 

Gerhanlt iBfr/iwc r klintsche WoehtH«chrift, 1888), in four cases of einphy- 
semu, li«ai-d flne bubbling, crai kling KOuads in the cardiac region synchroaous 
with tlie heart-beat, eridpotly from displacement of air in the mediastinal 
coDoective tis^uo by the cardiac impulse. 

In rare ca^^es, especially in tlie u^fed, the inHpirutory and the expiratory^ 
ids are of equal duration, exajjgeratcd in intensity. hurEli and tubular ia' 
quality, and high in pit<^i. Tliis is probably due to atrupliy of a portion of the 
lung tiKwie. 

Vocal resonance may be either increased or diminished. 

The heart-sounds are usually feeble, and thoee at the apex are dio'* 
placed downward and inwanl, by the intervention of the emphysematons 
luug between this organ and the surface of the chest. The cardiac 
sounds and impulse are often abnormally distinct in the epigastrio 
region, due tu displacement of the heart and to dilatation of the riglit 
ventricle. Dilatation of the ventricle may cause tricuspid regurgitation 
with a valvular murmur. 

DiAONtisis. — The iii8«u!c« likely Ui lie mistaken for einpIivKema 
are: ililatnlion of the Iiiiig from acute titljerniilosis, uud imeiuno- 
thornx. When confined to «ne Inng, fni[iliytfeinii niiiv he niiMiikeu 
for any of the dieeasee which usually causo foeble respiration. In 
Buch cases, the normal ninrmurof tht> tiound si<lL< is liahleto bo mistaken 
for exaggerattid ret^pinilion, and llic ft-eble niurnnir of ihe enij^hyiiouin- 
U>U8 lung fur the normal sounds. Error may be avoided by remember- 
ing that tho feeble respiratory murmur of emphysema is chnracterized 
by prohriffcti expiration, and that resonance over the affected lung la 
more marked than tliat of the soimij i^idu; whilo in nearly all diseases 
eau.sing feeble respiration, from obstrni-tion in the iiir paiu>ages or frum 
inti-rferenco with the free expansion of tlie lung, the cspiratory sound 
is jfhorlrr than the inapinuory, unrl ihe resonance i« less intense thiin on 
the sound side. Emphysuraa of one lung, or of a single lobe of one 
lung. 18 a rare nffeotion; but when it does occur, great care is necessary 
10 avoid en-ors in diagnosis. 

Bilateral emphysema \$ differentiated from pnetumlkornx by the signs 
furnished u])on inspoction> percnsMon, and auscultation, as foUows: 



Usually bilateral. Very rarely bilateral. 

Promjueuce of both sidos, especially Uaiforni distentiua of one itUie, no 
of th^ anterii-ftuporior portion of the sJnkin? in of the soft parts during in- 
chest, witb fulling in of tlio soft partA spimtion. 
during inspiration. 


Vcsiculo- tympanitic resonance on 
botli stdc^. 

Tymjtanitio resonance on one side 

Tho ro»pimtor>* murmur vesicular The respii-atoi-j' murmur feeble or 

In quality, and expiration prolonged. sitppreti»ed, or amphoric. 

Kmphysema of u single Inng is distingnished from pneumothorax bj 
the following signs; 


Vesicado-tytiipanitic re«oDancc Tt'inpanitic re&onunce more or ieoA 

int«nfte, willi atisence of the veslcul&r 

Theinspiratory murmur delayed, the Tlie vesicular murmur feeble or 

expiratory Butind pi'olon^'ed. absent, but, if tieunlt reiTular io 

rhj'tlim. Tilt* respiration may W am- 

E. Thompson states that in acute tnltfrrnhms, as numbers of the air 


-vesicles become filled with the tubercular deposit, the adjoining cells 
become distended so as to cause physical signs, especially in front, al- 
most identical with those of emphysema. The distinctive features of 
the two diseases may be seen in the following table: 

Emphysema. Acute tuberculosis. 


AffectioD gradually developed. Comparatively rapid accession. 


Constitutional symptoms often slig:lit. Constitutional symptoms similar to 

those of typhoid fever. 

Cyanosis ; labored expii-ation ; chest Pallor ; respirations rapid but not 

enlarged. labored : chest not enlarg^ed. 

Vesiculo-tyrapanitic resonance more Vesiciilo-tympanitie resonance in 

or less marked over whole chest. front, but actual duloess behind. 

Expiratory murmur prolonged and Expiratory niiu-raur not much pro- 

low in pitch. longed and higher in pitcli than normal. 

Some signs produced hy fibrosis or fibroid disease oi both lungs are 
liable to cause it to be mistaken for emphysema. The distinction may 
be readily made from the following signs : 

Ehphyseha. Fibroid disease of both lungs. 

Fixity of the chest with bulging, ex- Fixity of the chest with flattening, 

bept in the atrophous form. 

Vocal fremitus usually diminished. Vocal fremitus markedly increased. 


Vesiculo-tympanitic resonance. Usually dulness, but occasionally 

resonance approaching tympanitic in 
Beart covered by lung tissue, as Heart uncovered, causing increased 

shown by resonance. area of superficial dulness. 

Low - pitched respiratory sounds, Absence of respiratory murmur at 

though sometimes considerable harsli- times. In other instances, rude res- 
ness from affection of the bronchi. piration. 

Emphysema and bronchial asthma are not likely to be mistaken for 
each other, especially if the following points are remembered : 


Dyspnoea constant. Dyspnoea paroxysmal. 



Chest barrel-- bui>etl. 
Heart displucutl. 

Emphvsema. ASTIIIU. 

CliP-st normiil. 
Hvnrt not displaoetl. 


Few rAUfi |iri.>HVRt imli^ss t>roiicliilis Abundant ili*)' r&les, tubilant and BO- 

compliciite, when rales are moist. mii\ju^. 

pRoaxosis. — A lung onoo cmphjsomutoug never recoTcrs. Mih] cases 
dejietiilent upon causes which may be eiirly removed may be gretitly re- 
lieve<l ))y tlie geneml improvement of tlie patient nnd the comjwnsa- 
tion offere<l by the remaining normal hing tissue. Though in itself not 
a dnngerons dificase, wcll'mnrkod emphysema insures the patient muoh 
distress, unfits him for ftctive life, and ^roatly jiredisposes him to more 
serious disease. Bronchitis, though frequently a c'tm!>e of the disease. Is 
a eummou effect. Bronchiectasis, asthma, and pleurisy are likewise fre- 
quent complications. 

Heart disease with disorders of the liver, kidneys, spleen, andalimeu- 
tary tmct which are its common sefiuolae, naturally resnlts from chronio 
obstruction to pulmonary circnlatioii, and is therefore an important cle- 
ment iu prognosis. Pneumonia, tuberculosis, and hemorrhage arc rarely 
observed in emjihyscmatous foci, but may occur 'u\ parts not so affected. 

Treatsien'T. — As the changes iu the lung tisane iu this disease are 
due in part to general malnutrition, our first aim in treatment must be 
to improve tlie general condition. Ttemedics of most sen'ice for this 
pnrpose are tincture of iron, cod-lirer oil, and occasioually small doses 
■of quinine and strychnine. 

Chronic bronchitis usmdly coexists, and should receive treatment 
similar to that alreaily mentioned under the head of treatment of pneumo- 
thorax and pneumo-hydrothorax. Potaesinm iodide is the most eerriceo- 
ble single remedy in this disease. It should be given in doses of gr. r. 
to IX., three or four times a day for a long time. Arsenioua acid long 
continued has been found beneficial. Asthmatic symptoms are to be 
treated as spasmodic asthmsK Cough may require anodynes. Expira- 
tion into rarefied air has benefited »ome cases. 

The patient must avoid all causes of cold or asthmatic attacks, and 
should live if possible in a climate where he will be most free from dysp- 
iicQfL High altitudes are not to be recommended for those cases. 




Si/noutfmx. — Peripnoumoniii, peripneumonia vera. Popularly known. 
as king fever or inllaniniiition of the Inngs. There are two rw-opiiizeii 
Tarieties iif this disease: /oM/-y);i«»mDnm» in which the greater partorlhe 
whole of one lobe, or the whole lung-, is affected, and lobitlar pnr»ritontft, 
in which the inflammation is confined to « single lobule, or to groups 
of lobules scattered through the lungs. According to tho origin and 
character of the disesise, Ita various manifestations collectively have also 
been termed prinmry or secondary pneumonia, or bilious, gastric, ty- 
phoid, latent or walking, intermittent, hypostatic, tubercular, scrofuloua, 
rhenmatie, gouty, puerperal, or metastatic pneumonia— varieties, ao 
called, which require no special description. Though different cases vaiy 
more or less in their origin and anatomical charactcritttics, as well as iu a 
few of theirclinieal features, to attempt to differentiate between them hy 
their physical signs would only lie confusing. I shall therefore consider 
at length only lolnir and lobular pneumonia, and but briefly mention, 
nnder their respective headings, special variations of the disease, and 
the signs which are accounted valuable in enabling us to differentiate 



Sj/nontfms. — ^Acnte pneumonia; croupous pneumonia; acute sthenio 

Lobar pneumonia consists nf an inflammation of the vesicular struc- 
ture of the lungs, with accumulation of inflammatory exudation in the 
air cells, whereby they are fille<l and rendered impervious to air. 

Anatomical and PATHOLOfjirAL Ciiaractekbticb, — Croupous 
inBnmmation of the lung is e-hiinioterizcd by threo stages — first tuf/orye- 
went, second red hnpfttizfr/io/i, third yellow or ffrny htpnthntitm; it may 
terminate in reaolntion, in suppuration iliffuse or circnmflrrilied, in gan- 
grene, in chronic pneumonia, or in tuberculosis. \)wT\t\fi fugorgctmnt 
the lung is incrensed in size, is of a dark red or bluish color, with per- 
Imps faint patches of subploural occhymoscs and the affected tissue does 
not collapse. It is dougliy in coiinistency.pitaon pressure, and is lic:-vier 
tbftu normal. From the cut surface oozes a reddish sero-albumtimur 


fluid, with darker blood from tlte CHpillarios. Microscopuafhf the vefi^ols. 
liuing the alveoli are foiiiul oron-ded nitli blood corpusrli-s and so uia- 
tcnded a^ to encrouch upon the Innitn of the iitr »ir^, whieli contain 
serum, oorpuscles, and n few epithelinl cells. 

lu tht' Btflgo of ffii hrfintizaiioH the organ is darkly mottled, in coloi 
reaemUliug tho liver; the serous snrfuco may l« markedly crchymotio 
Hnd tiic 8eat of fibrinous exudation. The lung is larger, heavier, and 
firincr than iiunind; it sinks iu water, is friable, uou-crcpitant, uud may 
show the iui}jritit of tho ribs. The cut or torn surface ifi Ixithed in a 
re<Idish s^Totii! Uuid. and appears granular from the projection of small, 
dark red masses uf coagiilum from the alveoli. These become more 
prominent on pressure imd are easily removed upon scraping tho (-urfacc. 

Micro»coj}icnfhf iXwse masses are sc-eu to oonsitit of granular epithelial 
cells and rod and white corpuscles, lu-hl within a tlbriuous coagulnm. 

In tho third stiige reil hepatization gradually given plat^o to ifelfnir or, 
iu markedly pigmeiite<i lung», to (frai/ hepatizaiion. The rwi colnr of 
the former stage ili^ippeard owing to fatty degeneration uf the alveolar 
contents, to amemia produced by the pressnro within the alveoli, and to 
breaking up of the red corpuscles with some ak^iorption of their hasmatin. 
The lung in this stage is stiil larger and heavier tlian in the preceding 
stuge, it is more mottled with gray and yellow, more fragile, and is uon- 
erepitant. Section reveals a surface more uniformly gray or dirty 
yellow and less granular, from which exudes a viscid fiiiid of like color. 

Microscopic examination shows pus cells, fat globules, pigment, 
miero-organisms, and a detritus of librin and rod corpuscles. The 
morbid conditions causing thesi* appcaranuea are loc-ated chietly in the 
air sacs. In addition, the nuu-otts nienibrnue of tlin smaller hroneln is 
usually congested and not infrefjiieutly these are the scat of plastic, 
fibrinous casts sometimes extending to the larger tubes. (Edema of the 
|wrt8 adjacent to the inflammatory focus is usually present and may also 
involve the upi«>sito lung. Acute oompensjitory emphysema is likewise 
occasionally present. The bronchial glands enlarge and aometimea 

IMeuritis occurs if the pneumonia is superficinl. Pericarditis is most 
common in pneumonia of the left lung, evidently from direct extension, 
but it is not an uncommon accomi>animent of right-sidod pneumonia. 
Inlliimmiition or at least markeil congestion of more remote structures — 
the alimentary tract, liver, spleen, kidneys, brain, and spinal cord — are 
not uncommon associate morbid phenomena. Under favorable condi- 
tions, resolution oconrs, incident to rapid fatty degeneration of the 
idveolar contents, which become more fluid and disappear larliy by 
expectoration, partly by absorption. Gradually air re-enters the vesicles, 
which resume their function, congestion snbsidee, and pulmonary a^dema 
slowly disappears. In unfavorable cases suppuration may supervene 
upon the third stage; the lung then becomes more uniformly yellow, 
boggy, and very fragile, and the llnid from the torn surface is decidedly 




purulent. There is also more or less |Hirtileiit innitnition of (liu peri- 
Tesieulur tismmK. Reimltition inuy slowly fullow tbU difTuee siipiruratinii, 
or niiiiierut:.s iihscei?}te!< iiiuv form 1>y rupture of tliti iiitemlvuDbr wpta 
Htid furniiition of limiting walla of granulation tituiie. Tlit^se in turiii 
l.y progrefflive uliieratton in tho line of least resistance, may t«>rmi[uit« 
in perforation of tlie plenra or pi'ricanliiun, <»r may empty themselves 
into the bronclii and cinge hy cicatrization; or their content* remaiuing 
encapctulateil may nndergo cascons change and roceiro enlcareons deposit. 
Diffuse or circumscribe<l ijitni^renf oe<'nsionHlIy occur*, invited in some 
cases by nnteccdent Ijronchi ectasia or pntriil tirnnohitis (Orth, l>iagiio«is 
iu Pathological Anatomy, J). 145). In rare cases arnte pneuninnia termi- 
untes in a chronir fonn^ eharacterized |>athologirally by large increase in 
tho interstitial connective ttssne which oblifcrutes the alveoli and smaller 
bronehi of thealfecteil part, making ir firm, denstt, and airless. Kinaily, 
the pneumonic area is liable to infection nith the ttiben-le Ifacitlue, Jn 
order of comparative frequency pneumonia afTects the right loner, the 
left lower, and the right upper lolw. Arccrding to Miiuft, the disease 
in children originates oftenest in tho right upper lolic-. least frefjuently 
in the right lower. Double pnenmonia occurs in from tire to fifteen 
per cent of all cascA, but most frcfjnently in the aged { Ldomi?' Practifal 
Sleilicine, p. Ht'i; fyelopiedia of Disetwes of Children, p. ,^sii). 

Ktiolooy. — (.'limates and soasons most subject to sudden marked 
changes of temperalnre, occn|uitiona subjecting the individual to abrnpt 
changes from heat to c^ld, and such hygienic conditions as bad ventila- 
tion and sewerage, poor food and clothing, and habits which enervate 
are all favorable to the occurrence of pneumonia. Though robnat health 
anil a fine physique seem at times to offer to it no Ikarriers, yet most 
diseases which exhaust vitality and diminish local resistance predisiinso 
tu pnetunoniu. In this category are included a previous attack of pneu- 
monitis, the acute infectious diseases, alcuholisiu, nra>mia, acnte rheu- 
matism, and disorders of the blood. Diseases of tho hciirt prodneing 
chronic pulmonary congestion, and severe traumatic injuries to the 
cfaeet, are also predisposing factors. 

Kec^nt InvMti.iraiJotut by Fraenkel, Weichselhaum, FrMlAnder. Netier, 
Sleriiherir and many otli«r careful ot»<ervers suggest that pneumonia i!4 an ia- 
feetioii» disease, tho priiimry exc;itin^ cause of wliicli isa specidr iiuci-«>^'rtpuiii-sni ; 
and titui in most iastanoei^ Uie diplococcas pneiMUonin-* of Fraetikel i» timt >ronu. 
Ao(*«ir(liiiK lotbesewHlerR, it can be proved lOt_'xisl iiiovpr OOpor centof all«, 
io ttif tUftucsand dotikof Uie loml pubnotnu-y inHaniniation ; and it has alto 
liecnfiiuiiil ul Ibeiu^'it of ceniplicatiiig lueningilis, plenritU, peri(^rdiUs. synovitis, 
and utilis. Frieillnntter'tt microi-oi.'cus ibe lyplioid )incillu<i. and other spei'itlo 
ffeniu may a\^*t in some oawts excite pulmonary* uiflamnintion. DeJafield <,NfW 
York ifed. Jour., 1890) re^rds pneumonia as an tnrective iDdainnuvtion de- 
pendent upon individual euscvptibility, a primary er^cciting; cause of iaflainmatioB 
and a palttofranlc bacterium someonr^ of whioh facton; takes precedence at differ- 
«Bt tint«i>. FaLts r«cor<lea by Wolff iZtUgchrift rfer Bakt. . 1900), Jaworak! 



{Jour. Am. Med. Am.. Dec. 1S»0>, Kiihd {Berlin ktin. Woeh., April, 1S89), 
JiniUetutn {Brooklyn Med. Jour., April. l^Hft). Wii^Tier {,(4711. Jour. Med. Hci., ItwO), 
Wells [Mfd. Itegiiit.. Feb.. 1«1KJ : y. Y. Mrd. Jour.. March, 1800), Moslcr (/it-iiJ. 
med. M\Kh.. Nos. 13 tiud 14, 18O0 ; Mt:d. PrtM tmd Circ. Hv\>\. 23. 1800). luid 
others stronm'ly suggest iU contajfioiis ohumi.'U'i' uiuler Htiine comlitions. 

SYMPTOMATrtLOOY, — The chief ayrtiptnms jire ii severe initial chill, 
folldweil bv fever which attniiis ji;reat intensity in a few hintrs and hb 
sudtk'ulv subsides Itctween the tifiii kikI the tenth 'Inya; these wre iiBiiiillv 
alti'udeil by paiu in tho sitie, dyspjui-n, congh with eler»r teiiaciona and 
subfiequeutly rusty sputa, great prnittration, and frcfjuenti} delirium. 

lu some eiises these active fetimres are preceded eeveral days by dull 
pains in the he»d, back, and Hmbii, dizziness, hissitude, iind perimpe ali- 
mentary disorders. Usually the onset manifests itself abniptly by scvore 
rigors, which may lust for two or three hours. In children tliere may 
also be initial convulsions, ilGlirium, aud gastrio disturbance. The tem- 
perature in uucompliciited pneumonia is uliaracterized geiiei-ally hy a 
riw) to 103" or 105" F. at tlio invasion, followml hy slight morning ro- 
missiong and evening exacerbations till the day of crisis, when it either 
declines gradually or falls suddenly to normal or one or two degrees 
below. The highest point is commonly reached on the second or third 
day, but may occur just before the final fall. 

The pulse ranges from 100 to 130 bents per minute, or much lugher 
in serious coses, and is the most important index in pneumonia. It 
becomes rapid and feeble depending upon tlie severity and dui-alion of 
the atUick, and may be intermittent, especially in old age. 

Sharp lancimiting pain below the nipple, increased by cough and deep 
inspinition, is a common symptom, probably due to concomitant pleuri- 
tis. It may be absent or slight in old age and when the pneumnnia is 
dee]) seated. It tends to diminish and disajipear by the third or fourth 
day. Very severe headache during the fifRt two or three days is an ah 
moat constant symptom. Pelirium, uHvially of themild, int^oherent type^ 
18 most frequent in old people, chihlren, and drunkards; in the latter it 
may take the violent form. Muscular tremors are common in oonvt^ 
lescenw. Convulsions often occur in children either at the beginning 
of the disease or just before death. Ho^piration is shallow and increased 
in rapidity, in severe ca?e8 even to sixty or seventy counts to the miunte. 
Dyspnu'tt is usually an e«riy and prominent symptom, bnt may l»e absent, 
even with greatly accelerated breathing. 

Cough of a short, hacking character is commonly an early symptom, 
but is exceptionally absent. It may disappear just before death. The 
expectoration, at first frothy, Iwcomes translucent, tenacious, and viscid, 
and later of a red or browniah-red brick-duat or rusty color from ad- 
mixture of blood. In some grave cases the sputum is more watery and 
dark pnrple. like prune juice. Uusty sputum commonly appears within 
the first two or three days, but may bo absent till the tenth or twelfth. 



ami thtu prcsuutiu but slight degree. Barely, it isfntiitly ubsenl. Dur- 
in;: rciaoluliou the sputum \i inure prefu9e»ud yelt(»w or greenish. Diges- 
tive tliatjrdcrs, vouiiting, aiul ilturrhu'it ocotir suinetinies at tlie invaainn. 
The esscutittl aujttti in the order of their occurrence arc; diminished 
movement of the side, some duluess and crepitant rdles, followed by 
marked dulueHa. bronchial breathing, and broni'hopbony. These signs 
are succeeded in fnvornble cases by suburepitaut rales and a gradual re- 
turn of the healthy signs (Fig. 37). 

HonnftI slfBl. ' 

BiDDChlAl bTMthlng ) 
anil imjuubopboojr. f 

Subcrepuuit riUes. .. 


Tmk ST.— The upper lobo iaAicm* bMlihr lung Uhq« : cb>e ntddlo lobe ropreMOti lh« atoood 
ilaC« of pneiiinopU (red bepaUxaUon), Mid tbo lowvr lobe lUuaAfmtKs Uttt third «ta^ (CTOT b^p- 

For convenience we describe tlie signs in three groups corresponding 
to the three stages of the disease. l^\\e first stage, beginning with the 
inception of the disease, continues until the air vedicles are completely 
tilled. From this point the sku/k/ stage continues throughout the i)enod 
of consolidation or nn\ hepatization. The fhir// stitge, that of gray 
Itejiatization, continnes from the beginning of resulution until couraleft- 
rence is complete. 

As signs o^ ///p /iV.*/ Wa*/e, inspection Gnds the niorements of the 
chest soiuewhut diminiitlietl over the affected organ. 

Pal|Nttion in tlie early part of this stage yields only negative resnlts; 
later, the voc«l fremitus is increased. 

Poreuesion early in this stage elicits slight dulncss. which gradually 
incroases as the ^tugc advancci<. 

Ou auscnitatiou, while there is congestion only, before inflammation 
bos become fairly established, the respirator)* murmur is feeble. As 
GXtidiition takes place, crepitant rules occur iu great numbers at the end 
of inspiration. When tlieso rdles are well roarke*! and persistent, they 
may be regarded as pathognomonic. 

Wlien pneuinoDta is Associated with inQainmatory rhcuniatifim, the crf^pilaiit 
ledoes twt ovcur. Siilioiepltant are sonwtinMS associated with the crepitiint 
"iNUes, but the latter greatly predominate. 

As conBoiidfttion progresses, reapiratiou b«:t>meH broncho- vosicular 
and finally bronohial. 

As ((/'//(j< f;/" ^A<r «*(■'>'«/ «/rtf/^, inspection anrl palpiition slinw that the 
moveniQiiU ure still de^cient on the uflucted side, und cxiiggemtod oa 
the u)>i>uBite side. Vocal fremitus is exaggerated. 

Exeeptiamtl. — Consolidation ia rare inslancea iUmiQisbi>s the vocal fremitus^ 
in conseqiiencti at complete occiuHion of the bi-oacbiol tubes. 

lu percussion there ia marked dnlnesa over the affected area, with 
«xugnuniled resouunce over healthy portions. The lina separutiug dul- 
ness from vesicular resoiiiuico ustuilly corresponds to the position of (he 
interlobular fissure, and is not altered by changes in the position of the 

/Cj'ceptionui.—la i-ai<a cas«s the density of the lung- h so great timt tlic per- 
tius^tun suuiid cuused by vibruliun of air in llie broncliiul tubt-s is tnirisinTtli*<l to 
the Burfatw with such pet:uliiLi-ili!iliui:tue»s as lo Jutttify lh<> itp^KrUulinii of tabular 
resonnnce. In some Jn^laiRVH of f xtr«,'[ne consf>li(irtliini. tlin ivsoiiiinti! w^enw al- 
iiiustutnpboric. In such Ciises Ihe-iohd soiimls wuiiMof twuessity be mistaken for 
hollow !«ounds, were it not for tht<ir pitch, whiih it nl w.-iys lii^li instead of low 
like ihu proper re&ouiiuce of cavities. In nu-e coses, flatness is found instead of 

By auscultation there are fonnd no crepitant rdles, but in their place 
we (ind brouchiul or broncho-vesicular respiration, varying in degree 
with the amouui of cousolidatiun. There is alsu coexisting bronchoph- 
ony and whispering bronchophony. A few moist and dry bronchial 
idles ure upt to bo heard in tliis stage. 

Excrptional. — In rarecosps a f»w crepitant rfllen itwiy bo hoard tn IbissLige. 
In other instanctiS, tiie bronchial tnbos of Ijirger Hize may be tilled by the intlamma- 
tory lymph, so that the vot-al reMinanc^ tsdimini-itted instead of being* iDtensitled, 
and all respiratory sounds may be suppi'esaed. 

Early in thfi third stage, the signs are the same as iu the second stage, 
with the addition of a few subcrepttant nlles. As the stage advances, 
vocal fremitus becomes gradually lessened, dnlness diminishes over the 
inflamed portion of the lung, bronchial breathing slowly gives placi; to 
broncho- vesicular breathing, and this iiually to the nonnal respiratory 
mnrniur. Subcrepitant nllos appear early in this stage, and continue, 
often associated with mucous rales in the larger bronchi, until resolution 
is nejtrly complete. 

The crepitant nile also occasionally reappears; it is then known as 
the crepitant nile redux. 

bronchophony, which was present ju the second stage, gradually 



gives plm.*e lo cxuggeruteil vocul rc-soDanco, iind thia, in tiiru, to tbe 
uorniul suuihIs of the voice. 

I>iA';si>sis. — rneumonia is to be tliagnosticntod from |ileiirodyuia, 
iiitt'rft«stiil ueuralgin, pleurisy, pulmoimry unleina, colliipse of the iiir 
vesiclM, liydrothornx, pbtliisis, iiiul bronchitis; also, in c-hilUrcii, from 
ineninxitis on account of the delirium, ocoasioiiul otiiunictionB of tbe 
posterior cervical muscles and other convulsive plienoincna. In tlie aged 
or debilitated, ou account of thu fypboid syniplonis and ocrational 
absi'ni-c nf the usual symptoms of iiiHauimatiun of the Uing, it may be 
mistaken for typhoid fever. 

It is not likely to be mistaken ior phnr<Hhptia or inkrcrmtal neuraU 
gift bv any one fumiliar with physiciit diagnoiiiii, ua thosi3 diseufles yield 
no signs excepting those duo to piiin. 

Ttovd. pieurUi/ it is distinguiabed by the following features: 



Beep-seatc^d, comparuttvelyduDpiun, Paia superflciul, and lonu'lnn tins', 

marked chill, hii;h temporatiira, coiijfh usually absence of market) ctiiti and 
vitb \*i9cid or rusty spnttini. hi^li teuipeniUire, absence! of rusty 

and visdd Mputuro. 


First Stage. First Stage. 

federate diilness n'ith Te^^hle n>Hpi- ResonutK-t; □orniit). Respiratory 

ratioa. Nunieromtci'vpilaiit r&lesualy nntrniur tt.>cble or ub^enl. Ordinarily 

on m«]>iratioQ, ami cxag'^rated vocal ^nizin^ or crenkin;; rnction »uunda, 

wMaance. Itntli in«pirnlaiy nnd oxpimton,' ; but 

oeco^iioitally traiutilory cr(>|ii1atinp 
friction Tnurmurs few in niiniher as 
C'ompittvi) witli crepitant rAleti dso* 
ally l>ear<J during ttin.*« or four iostpir^ 
tions Ihen disuppearing', lo return id 
a few moments. 

Second Stage. 

Vocal ri-pTiiitiis absent. F)ulne»9 in- 
Mend of duliicss. Tliolinc of llatness 
chanK^'*^ with changes in the patient's 
post I ion. 

UBiiully ftl)8eti<'*> or marked feeble* 
ooaKofnll i-PApirulDni'nnil vitcalaounda. 

Third Stage. 
Friction freiuittis and murmur ; ab- 
fteni.*e of Hilcty. Ri;Hpii-atory and vocal 
Ki^'iis ffHilite or nearly noroial. More 
or less dulness. 

Second Stage. 

Vocal froroiltu exitggcrated. Dul- 
Bess iDurked with no change of th<> np> 
per limit by cliaiigeit in the poKition of 
the pnlir-nt. 

Bronchial n-spiration aad bron- 

TTiird Stngt. 

Subcrepilarit iaU*s in iidditioo to tbe 
bnrsh respir.vlion. ex.ig)r»?rated vocal 
fremitus, and rt>iK»nnuctf, anddulnessof 
the second stage. 

There is a liability to mistake puhmmary ivdema only for the first 
luid ihird stages of pnetunouia. The diagnosis is generally easily made 


if we recollect thut oedema is usually u bilateral, and pneamoDiu a uni- 
lateral disease. In cetlcma, thedalneasiBeligltt^aud occurs ou both sidoa; 
while in pncutnouia it is marked, and commouly found only on one iiide. 

Crepitant niles arc few iu u?dcma and nearly always associated with 
larger moist niles. In the first stage of pneumonia crepitant niles are 
very abundant, aud seldom associated with other moitit iiouuds. 

Sulwrepitant niles in o&dema are heard upon both sides, and are not 
high in pitch or motalHc in quality. In pneumonia they are found only 
on cue side, and arc high in pitch and usually metallic. 

(Edema usually follows some protracted disease, as, typhoid fever. 
Pneumonia is generally u jjrimary affeiJtiou, and is attended by marked 
febrile symptomH which are absent in a-deraa. 

Pneumonia is distinguished from pulmonary collapse or atflectasii by 
the history and ensemble of physical signs, rather than by any pathog- 
nomonic c]iaract«ri8tics. The points of distinction are shown in tho 
following table: 



Usually a primary affection inrolv- Generally a sequel of broachitia, 

lag ooly one luag. oftea involving both lungs. 

Harmed duluess. M(Nict-ut« dulness. frequently vesicti- 

lO'tympooitic resonance in the vicinity. 


Id the first and thlnl stoees. crepitant Few if any crepitant or subcrepitaat 

and subcreiiitant rAtes. rd]e!i. 

Second sU^;e, bronchial brcathiug; Tlrouchial br&atbin^ over collapsed 


exaggerated respiration over healtliy 

RAIes and other abnormal signs usu- 
ally conflneil to one lung or one lobe of 
tliat lung. 

lung; prolonged emphysematous ex- 
pimtioD near it. 

RAles due to bronchitis over both 
lungs. Other signs due to collapse 
more apt to affect both lungs and not 
likely to involve an entire lobe of 

The distinction between pneumonia and hydrothorax is shown below: 


Unilateral duln(»». and the respira- 
Xavy aud vocal signs of cousoUdaUon. 


Bilateral llutiinHi, with absence of 
respiratory and vocal signs. 

To distinguish pneumonia trom phthisin, a knowledge of the histori- 
aud the symptoms is frequently essential. Many jihysicians. where the 
aigne of pneumonia have continued for more than four or five n-f»ek8» 
consider the case one of consumption; but this ntle will not always hold 
good. The distinctive features between these two diseases, as they ordi- 
narily present themselves, may be seen in the following table: 





An acute airecUoa usually involviog 
(lie g-reut«r porltoQ of the lower lobo 
of uiic lung- and giviii>; rise to the sig'o» 
of ct'iDwlJdatiou. 

A prolniclcHl diMiiuM) coming' on fn- 
Hidiuusily, newly ulwayn Utiginnmg at 
the 0]iex of th« luii^:. iintlut lint In- 
vul%-in{; only u limitvO amount of 
tlHsu>< : (giving' lisp, ni-xr. lo thv flifibft 
of »liKhl uml )tiih<w.-(tuuiiily to tbuHc of 
grvator coiiMiliiJntion. 


Breathing paoUng. Harked pyrexia Brvailnujf hurried hul natural. Ir- 

terminating in crisis. r<>pularundint«rmitli'nt temfMrature. 



TubenMii bucilll. 

Phthisic following upon pneumonia will be distinguished from pii/- 
longed cases of Ihe siifi|il« iiif1J4mniution by the history and by Ihe 
phvi^trjil signs oblaint'd ou r(.>|M.-utt'il uxaniiuiitioiis, and in most cases bj 
finding tulHTcle bacilli in llie i^juitum. 

Any one funiiliar with jdiysint) diagnueis cannot mistako brouvhtiis 
for the early Htngeit of ]>neurnoniu. Tliu t&Xh* of tim resolving stage of 
pneumonia inigltL U? mistaken for thoau of brondiitis; but thcriMK no 
danger of «rror if we remenibor that the latter is a bilatfral disvafi' and 
caiisvti littlo or no diilness ou jiercuesion, and tlial, Sf\wu dnlneiM duu_ 
occur, it disapiK^urs after cough and frett expectoration. 

Though in some traces the eyniptiims of pneumonia are like tho 
symptoniii uf mcninfjitis and ii/phoid fever, the diugnu«is is readily niadi} 
by careful physical examination. 

pBOciNOsis. — Uncomjilicated pneumonia usually runs its artlvo 
coarse in from five to ten days. The eymptoiits increase till the day of 
crisis, when they suddenly remit or sulfide by lysis. The crisis, usniilly 
occurring anywhere from the 6fth to the ninth day, is murkM by a 
■udden fall of temperature, often to one or two degrees below nornml, 
accompanied by decrease in seTerity of the other symptonis, and Cnllowetlj 
by sleep, or in children by »tupor. There U also not infrerjuentlj 
SI critical hemorrhage from the kidneys, bowels, or nasal njurouA mem-] 
brone, and usnally a profuse perspiration occurs. In the feeble or age 
the critical discharge may occur as diarrhiPa. 

The mortality in pneumonia ranges from ten to twenty jwr oenc, 
varying in different aeaeons and yean, bot in the weak and aged averag«j 
ing mnch higher. The prognosis is worse for women than for men, U 
infants than for adnlta nnder sixty. In persons over sixty, and in tboae 
addicted to the exoesiire nse of alcoholic stimnlante, the disease is ex- 
ceedingly fatal. In general, fatality is pro|K>rtionato to the extent of 
Inng tisBoe involred and to the severity of the fevtr. Doable pnea* 
Bioaia nsaally terminates in death, and pneamonia n( the apex is said to 


be vspociull)' nuluvurublc iu tho aged uud iti children. Complieatiug 
|H>nc&rditis, valvular dis^eose of the heart, Rright's Jiscme, dialx-ics, 
pleurisy, tiibiTculosis, eiupliystiua, and pnlniunary abscess or guugreiio 
greatly lessen thechauces of recovery. The most jirooiiueui iiufavurable 
symptoms are m follows: A pulse iu adults above liO beau to the 
minute, in children above IW, or marked irregularity in its rhythm; 
rapid respiration with low temperature; fever above 104" F. for more 
tliaii forty-eight horn's; a gradual rise of lfiu[>t'rature after thr fourth, 
or eontinuwl fever beyinul the tenth day; delirium and ronia, or in 
children convulaionit occurring late; signs of collapse at any stage of the 
disease; haemoptysis or eopiond prune-juice expectoration; suppression 
of t)ie s)mlum iu the third s^tuge or its becoming fetid. Deatli occurs 
from ufipbyxia or more frequeutly from heart failure. 

TitKATMEST. — Within the first ten or fifteen honra from Ihe incep- 
tion of the tittiick, a blister will sometimes prevent further development 
of the iullammatory process; but patientd are seldom seen by a physi- 
cian early enough to allow of the use of this agent. Calomel adminis- 
tered in grain doses every hour until its purgative effects are produced 
is 9aid to abort some eases, but it should not be given to debilitated 

For the first two or three days, small doses of aconite or reratrum 
viride are very useful. They should be given often, iu just Buflieioiit 
doM*s to keep the pulse nearly down to its natural mte; they must not 
be continued after the third day. During the aanie period fluid est. of 
ergot, in doses of n^xx. to xxx, every three or four hours, is often very 
nseful, relieving congestion and checlitng the inflammation. 

After the second day quinine in doses of three to five grains every 
three to five liours is the best antipjTetic. In the inception of the dis- 
ease, phenacetine, gr. v. to %., or antipyrine in similar [loses are often 
productive of the beat effects iu relieving fever; buta« soon as the heart 
begins tfl weaken, they should be emjtloyed, if at all, with the gresiteet 
caution. It is unsafe to use them continxionely, and seldom desimhic to 
administer more than three or four doses of either in the beginning of 
the disease, or more than one or two small doaes during any twenty-four 
hours after tho second day of the attack. It should be remembered 
that iihenacetine is less depressing to the heart than antipyrine, but 
apparently possesses only about one-half the antipyretic power. 

During the active stage of inflammation, large, hot jacket ponltioee, 
enveloping ihe wh(de side, are beneflciid if they can be kept constantly 
and thoroughly applied; otherwiae tlicy do harm. When poultices can- 
not be managed satisfactorily, an oil-eilk jacket should be eniployed, with 
warm clothing. The constant application of heat or oold prodncea the 
same reaults in acute inflammations; therefore, in some instances when 
the temperature is high, excellent results may be obtained by tho appli- 
cation of cold over the affected organ ; preferably by means of the coil 



of rubber tabiug through which » cnrrent of ice- water is kept uirciilat- 
iDg. From the very rirst, the pjitienl should ke«p perfe<?tly f]iiiet, 
neithiT mo^'ing nor speaking excepting tvlien nbanhittOy nccesgary. 

Very small doses of opium or nioUenite doaea of chloral are soma*! 
times necessary to reHeve puin tiiid restleganess, hut eith'er mnst be gJTOsJ 
Vci7 carefully, uiui opium 13 espe<'ial]y ohjectionabic when the evidence 
of imperfect aerntion of blood Is distinct. 3fany patients ImvcTindoubt- 
edly been linrried to t]ie gruTc by the injndiciona use of opium in thia 

Where there is much prostration, and the heart is weak, fttryohnise 
gr. ^ to jij or tincture of nux vomica in full doses with or without tinc- 
ture of digitalis every three or four hours is very important. Alco- 
holics or amntonium carbonateare required in the same condition ; and if 
oedema of the lungs ap]iear8, alcoholic stimulants in large and oft- 
re|»fale4l doses are of the utmost, importance. 

The ammonium salt is evanescent in xU effects, but acts promptly. 

Auimonium iodide, ammonium chloride, calcium chloride, liquor 
pot:Ls&H5, ur potassium acetate :u'C Utsefui in the later stages to favor 
rusolutiou and prevent ea^eulion. Lute in the disease counter>irritatioQ 
is beneticial. Cuthurties and hluod-letting should not be employed ex- 
cepting in rare instjtnces, in robust patients. When patients are much 
prostntted and delirious, great care should be taken to prevent them 
from sitting up or getting out of bed, for this will aometimes cause im- 
mediate death. 

Liquifl diet should be given regularly during the height of the at- 
tack ; as n rule, a half piut of milk or ita equivalent being given ever; 
three hours. 

The ex|>crimenUof G. and F. Klemperer ( Berliner hliui»ehe Wochenaehrift) on 
tJtR riinitive <>(Tf>ct« oT the hlood-Keruin oT ittiniuni' animals, or anti|tneumoU>xm, 
are extremely iuteresUog, but aa yet the results are Dot uuUieDlicaled. 


Synofiymit. — Catarrhal pneumonia; broncho-pneumonia; dissem- 
inated pneumonia. Ohronic, interstitial, or interlobular pneumonia is 
often included in this term. 

Lobular pneumonia is an inflammation of single lobules or groups of 
lobules scattered through the lung, preceded and accompanied by bron- 


of a lung, which is the seat of catarrlial pueumouia, if the disease ia 
superficial, pre«euts rounded, isolateil, reddish-brown or gray spots, ofteo 
slightly raised, varying in size up to that of a walnut. The^e may be 
coDfinod to a lobuto or may be scattered over ono or both lungs. At 
these poiuta crepitation is diminished or absent, the lung is more fria- 


ble and cjinnot bo inHuletl. Section reveals a Dioitlod appenratiCi: due to 
isolutcd dark brownish areas of consolidation, intersperBedj iu advanced 
slagca, with others of u lighter line; from the former, thick, reddish, 
scvretioii e8caj)e8, from the latter, it \\i\i more of n milky upjHmnince; 
pue may also be preHsed from the bronehiolet!. The gnmular formations 
characteristic of the red hep!iti?Jitioii of crou|iout) pneumonia are ab- 
Beut in the catarrhal form. Here the nuclei of consolidation are com- 
posed of scattered groups of bronchioles with their immediately related 
Teiieles. Iiiflaninintiun comnieneing in the brnnHiioles involves the air 
Tnaielcs by direct pxtensiou or by aspiration into them of irritating seci-e- 
lions. The microscope i«how« some of the alveoli collapsed, but the 
majority are more or lees tJlleil with serum, leucocytes and epithelial cells 
with varying degree of fatty degeneration according to the duration of 
the disease. The local effects of this intlammation are similar to those 
of croupous pneumonia, t-xccjit tliat the prtMlucts. of catarrhal pneu- 
monia contain much leas fUjrJn and fewer red corpuscles. The walla of 
the brunchioles are thickened and infilt rated witli i-ound cells, and their 
epithelium is largely exfoliated. Their Ciilibre is in some iduous con- 
tracted, in others diluted. The small tubes are always blocked with 
catarrhal accretion. There is also usually present more or less neri- 
broncliitiij. The alveolar walls are congested. 

The alveoli adjacent to these areas of consolidation may be emphy- 
aematous and are often the seat of congestion and o'dema. The pleura 
over them may be inflamed. The pulmonary lymphatic glands are com- 
monly enUrged. Catiirrhal put-umouia terminates in resolution, suppura- 
tion, gangrene, or in chronic tibrciid Indiiratiou, or the products may un- 
dergo tjiseous or tubercular degeneration. 

Etiolooy. — Lobular pneumuiiia is most common in infancy before 
the third year, and in advtiuced age. Bad sanitary comlitions, poor food 
and shelter, and debility am pretJisposing factors. It is always second- 
ary to affections of the smaller bronchi, and hence arises from exposure 
to the exciting causes at bronchitis. It is apt to follow influenza and 
the brunchicis which complicates contagious diseases, esiKcially meaitles 
and whfxjping-cuugb. 

Symitmm.xtuux.y. — The eaaeutlul symptoms are rapidity of the pulse 
and of respiration, usually with lilgh tomperature and troublesome cough 
and emaciation, occurring in the course of a bronchitis. 

The pnlse, at first strong, frequently becomes feeble and compressible 
and runs up to from 140 to ItlO per minute, and the respirations from 
60 to SO. The temperature gradually rises with irregular exacerbations 
andtfemissions to 104" or lO.V F., anil in fatal arute cases may go trro or 
three degrees higher. The cough loses its bronchial cliaracter and be- 
comes hacking and painfid, and is followed by but little expectoration 
which may be streaked with blood. 

The most important *iyj<s are deficient respirnt^iry movement*, slight 



and occusioimlly "patchy "dulncsfl, with deficient vesicular nuirmtinnKt, 
on forccil inspiration, Dtimerous poorly dcilMed loucuus dicke. Wlicn 
only H limited number of lobuk'» iire nfTei-ied, a flia^osia cannot be uc- 
euratoly mndo; but if several lobnlea are involrpil, the signs bpcomo 
quite distinct. 

By inspection we slml! ueually observe rapid bnt imperfect res- 
piratory movements, with very slight expaueiou of the ribs during 
inspiration, but considerable elevation of the chest walls, I'spe- 
cially at the upper part; and at the aarae time falling in of the sufl 
parts of the cheat and retraction of the lower ribs, as in pulmonar^'l 
emphysema. The inspiration is often shortened and the expiration 

When several inflamed nodnles exist, eBpecinlly if they are locritc-d 
near the surface of the lung, palpation will discover exflggerate<l vooul 

Upon percussion, dulness will be found, varying in degree with the 
nmount of coiisoliiliitlon. Thi^ h nearly always limited to the inferior 
and posterior portions uf tlie chest, and usually occurs on both sides; 
bnt the disease may be confined to one lung or to the upper lobes of 
the lung?. 

By ausonltution more or less broncho-vesicular or bronchial resplm- 
lion with exaggerated vocal resonance and moist high-pitched rAles will 
uenally bo found over the lower part of the lungs. Likewise, over the 
upper auil anterior portions of the eliest we ordinarily tinU the signs of 
pulmonar}- cmphysetna, viz., vesioulo-tympanitie resonance, with a pro- 
longed and low-pitehed expiratory murmur. 

After protracted or repeated colds, the occurrence of a feeble vesicu- 
lar murmur, with several illy di'tined mucous clicks on forced inaplni- 
tion, should cause us to suspect lobular pneumonia. The mupoiis clicks 
in these cases are due to retention of the catarrhal pniducts in the ajf 

Uigh-pitched bronchial niles are uldo significant of coui>olidatioii. 
lu children, some of the alveoli are often oompletoly choked, so that 
few rdles are produced. In adults, the iunumiuatory products are mora 
fiuid, and conse<piently rales are more abundant. 

Dl\oko81b. — The diagnosis of lobular pneumonia is very difticnlt, un- 
less a considerable number of lobules are affected. Even then, the disease 
ctuinot always bo deteeted by the physical signs alone, bnt, as in some 
rases in other pulmonary affections, the history and symptoms must bo 
weighed with the signs, before a positive opinion can be forme4l. For 
example, in a i^hild sutTrring from bronchitis, if the respiration sud- 
denly becomes accelerate*!, the temperature elevated, and the cough, 
which may previously have been loosw and ea^', becomes dry, hacking, 
and painful, we have good rea^mn to think that the vesicular p>ortion of 
the lung h*s become involved in the intlammatory process. If, in addi- 



tion to these symptoms, thesij^'-ns of consolidation which have just bccu 
enumerated are jireseat, tbti Uiaguoeis may be considered certain. 

The disttnetivo feutiircs ln-tween iftfiflnrt/ brour/iifin and lobular 
pneumonia may bo found under the JttTcrential diaguo»is of capill:iry 
bronchi titi. 

Tiobulur pneumonia is often prect-ded and accompanied by collajise 
or atelectasis of many of the air vesicles; for this reason the si^jns of 
the two diseases arc nsually considered identical. If any considerable 
amount of tissue is inrDlved, and the two conditions are not eomliined, 
a difrercutlal diagnosis can be made by attention to the following ityntjH 
toms and EJgns: 




Tem]H;ratiire suddenly incre.isod 
cough becomes dry and paroxysmal. 

The elevation of tempe ratine, nnd 
llie cxiuyh. wliicli are incidental to the 
.iMoci-ativl broarhitis. ar<* nol mate- 
rially utTected by collapse ot the air 
Fatltng in of the lower portious of Tlio inverted aclion of the Inferior 

Ihechesl. wliich may liavt^hoen tiotioetl ribs is increjispd in pro|H>rtion to the 
to bronchitis, partialty disappears. exteat o( atelectasis. 

Palpal itm, 

Tocnl fremitufi It increased. 

The vocal tremitus is not likely to 
be iacreaMed. but, on the coalrury, it 
luav be dimiaiitlied. 


Cnironn dulncss. or distinct patdbos 
of dultiess, usu.illy marked over the 
lower portioDK of tbe cbest. 

The dulness tit not »o distiuct, aud 
there i& occasiouatly ve^iciilo-tym|ia< 
nitic resonuuce. 

The dulne^ usually occurs flrel nt 
the l>order of the left \\mg. where it 
overlaps the liearl ; anil shortly after- 
ward al the base of the lungs. From 
tlie latter |Kisition it has u tendency to 
spread upward ia an elongated, sonie> 
what pyrontiilal fonn n.Inng' the hn&t 
of tiic intervei-tebraJ grooves, in which 
poRition it may reach as hif;h as the 
apex of the lun^, 


The respiratory sounds >renerally 
banh or broncho- vesicular In quality, 
never wholly tubular. The nmcoaa 
r&lr« of bi-onctiitis usually heard over 
the entii-e chest ; but, in many in- 
■tances, Hner moist rAles are obtained. 

Tlie respiratory sounds uiuaUy 
feeble. The rAles of bronchitis are less 
likely to be pre-sent tlian in It^ular 
pneumonia, and are seldom heard over 
the collapsed lobules. Sometnnes deep 
inspirations may bring' out a few crep- 



limited to a small spnce ininie<ltalt>)y 
ever the iaOiimeil lohiilen. When tlw 
finer bronclii are tlilatetl. a$ suniutiiiiea 
bappens in thin (lifteas«, the rdles be- 
come foarse and nomewhat motaltJc if 
the dilatations aro siirrotiniied by con- 
Aolidnt^ Itins*. 

itant r&)««. which are heard with three 
or four iusph-ulurjr aou, aud then dia- 

The difforontini <)ingno8is between lobular pDonraonm and hbar 
pneumoniit appears below: 


Begina with a bronchitis. 
No cbiU. 
No crisiA. 



Bc)^ns with ihill. 
Pain in the side. 
Terminal crisis. 

Usually conflDed to one side and to- 
one tai-£e unuL. 
Duhiess iiiurkKl. 
CrepiUiul am) Rubcreiiitant rflles. 
Bniiii-iiial voice u ml bi-eatJiing. 

Orten over boUi 1ud>;s but in siaall. 
Bcatten^t) areas. 

Duliu-vi not markeil. 

UucouH with Ktiialler rAlus. 

Bront-liy-vesicuUir vuicw «iu1 breath- 

The following is the differential diagnosis between lobular pnen- 
moniii and acute tufKrcuIar phthisis: 

Acute ttberocuar pbthisis. 

Id youni^ adults. 

Initial pyn.-.\ia precedes Itie phj-alcal 

flsmioptysis common. 
Emaciation less rapid. 



faclkildreu and the ajjed. 
Initial bronchitis. 

Uaemoptj'Bis not common. 
Emaciation and exhaustion 

Most mailed in lower and posterior Most marked at apex. 

No tubercle bacilli. Sputum sometimes contains tubercle 


pHUUNOfiLS. — Thia disease may termiDate fatally within two or three 
days, or uiay extend uvcr muuy weeks or uiuuths, ending in re^ulutiuu 
and recovery, or in purulent infiltration, or in cheeriv or tubercular de- 
generation and death: or the intiamuiutiun may cauBO exteuaive new 
connective-tissue fornmtion in the inleralveolar septa and about the 
broucbial tnbea, eventuutiug in fibruiil phthifiitf. which may extond over 
aeveral years. 

The disease is most fatal in infants, eetpecially when following whoop- 
ing-cough or tneasles, anil in aged or greatly debilitated subjectt^. Death 
results in from '^0 to 40 per cent of all casea. M>me authors placing the 
mortality even higher. Among the grave Byn:.ptoniB ore: e.\teusiuu ul 


the bronchitis aud increasiag cyaDusiii; irregularity of the reBpimtiooi 
and inefficient, feeble cough with cessation of expectoration; a nipid, 
feeble pulse ; temperature exceeding 104" F. , and stupor or conrnldions in 
the later stages of the disease. 

Treatment. — Lobular pneumonia is nearly always a secondary affeo 
tion, due to extension of the inflammatory process from the bronchi^ 
mucous membrane in consequence of debility. Bearing this in mind, 
we avoid all depressing remedies such as antimony, aconite, or Teratmm 
viride, and very early commence the use of stimulants. 

Quinine is the best remedy to moderate the fever. Alcohol shoold 
be given according to the amount of depression. The rule is to give aa 
much as can be borne without causing head symptoms. Ammoniam 
carbonate or ammonium iodide are very useful, not only for the stima- 
lation which they afford, bat also for their beneficial effects ia removing 
the products of inflammation. 

Sedative inhalations are useful early in the attack, and at a later 
period stimulant inhalations and counter-irritation are beneficiaL If 
the patient emaciate, calcium chloride, tincture of iron, and cod-liver 
oil are indicated. A change of climate is advisable if recovery does not 
take place within eight or ten weeks. 


Several somewhat peculiar forms of pneumonia merit passing consid- 
eration, though they are not distinct varieties of the disease. These 
are: interstitial pneumonia, typhoid pneumonia, bilious pneumonia, 
pneumonia due to cardiac disease, and pneumonia from BrighVs disease. 

The treatment of these forms is essentially the same as that for 
the diseases with which they are associated, combined, as occasion may 
eeem to require, with the resolvents and expectorants indicated in lobu- 
lar pneumonia. 

Chronic OR interstitial pneumonia (sometimes termed catarrhal 
pneumonia) will be described under the head of Fibroid Phthisis, 

Typhoid pneumonia is a term that may be applied to a certain 
complication. If pneumonia complicates typhoid fever, or vice versa^ 
the symptoms of the one disease are associated with and somewhat 
modified by those of the other, and the resulting prostration is marked. 
The secondary pneumonia is here indicated by increased rapidity of the 
pulse and respiration, with signs of consolidation. Cough and sangnino- 
lent sputum are rarely present. 

The expression typhoid pneumonia also refers to pneumonia of a 
sthenic and usually fatal form, frequently epidemic among soldiers and 
others subject to unhealthful sanitary conditions. The chief features 
are extreme exhaustion and constant tendency to collapse, although the 

4BSCS:i:S OF TUB 1.UN0. 19a 

IooaI jmlmouary aigiia nmy be but slight. Symptoms liko those of sep- 
tic-wmia mny be prolonged for months. 

Peculiarly viscid gubcrepitjmt nilos may be heard, few in number 
and found irregularly at (he Ixise or apex of the lung. 

' BiLiova PNEUHoxiA, which is most common in mftlarial districLa, is, 
in addition to the symptoms of typical croupous pncunionia. chanicterized 
by jaundire, greenish, rlseid, and inodorous stools, with other evidences 
of liepatic and gastric disonler, and a fever record interinitt«nt in type, 
the febrile exacerbations being sometimes preceded daring the early 
part of the day by chilly sensations and coolness of the ends of the nose, 
fingers, and toes. 

Pneumonia arising from disease op tub ueart, especially from 
marlted mitral lesions, presents many features similiir to those of lobular 
pneumonia. The iuvusiuu is usually slow, seldom pr^retled by rigors. 
There is a chronic cough, with experloration which seldom becomes 
rusty or tenacious. The signs may appear in scattered palcbes, which 
change their seat from day to day, but are usually found over the lower 
lobes of both lungs. 

There is some exaggeration of the vocal fremilus, slight dulnees, and 
blowing though not strictly bronchial respiration, with exaggerated 
i Tocal resonance. 

Pneumonia from Rriuht's disease mnynot differ mnterinlly from 
ordinary iicute pnewniouia, or it imiy begin in collupsi' of portions of 
the vesicular s-tnicture, and present characteristics similar to those of 
lobular pneumonia. 


Ahflcees of the lung consists of & circumscribed collection of pus 
within the pulmouury pareucliynia. It is usually characterizwl by pain, 
rigors and fever, and later by expectoration of a small amount of blood 
•miuediately followed by a large quantity ot pus, which escapes within a 
few hours. These nbecesses are rare excepting when secondary to tuber- 
culosis, pyiemia, or embolism, in which cases they are usually multiple 
and muBt bo considered as incidental to the primary disease. They may 
also result from the entntnce of foreign bodies into the air passages, 
obstruction of the bronchi by tumors, or from suppuration of the bron- 
chial glands; also from perforating abeoesses from below the diaphragm 
or from the mediastinum. The pulmonary ali^cesses which chiefly 
interest ua are those rt^sulting from acute pneumonia. 

Symptomatoloot.— The abscess nsually follows within a few days, 
upon some exposure, and occurs during the acute st&ge of the infiaroma- 
tion. being preceded by the chill and fever of acute pulmonary intlum- 
mation; but aometimes it occurs after the pneumonia has subsideil. 
The formation of pus is commonly attended by rigors which are followed 

pvutoSjkMT »nr§9Wt 

IB* 4lf tVO 



in«f«tar ciulit. tm 
tfciwacpitt. la 

fqcpwted m thtf coone «C « fr« 

t'okM ikc yriit dia of 
wtUkb lea ta tnsl^ <§?•, th»fraft» 
Wing pnenM by « fr* dnfB a< UMd c 
a peat to a piat of raBovMh or gn«iiii| 
pctt u tipTloratoJ witkia a tern IwaiL 
fWTgr**** or abnv it 

OooMBBaU J the ftbana Ta|«am xat* the 
The ipataM w—anly eoofena aaill nOeviih 
laag tans Tinfafe lo the naked eta, vfciefc apM 
tiflB are fionnd ta fwiteln eJMtie fttft. 

Tltf jifaf an: itnlnfii vith toabhnua or afaanwe «( the nspintorj 
amraar orcr the afaena^ c wlaa e J vith indisltnei lAle* and niwiliiiiiii 
branchial hrwathiay ia tha fau^ tiane abont k, and a&er caca^ of piu>^ 
forachort time the sgna oi a csritj. 

DiifiKiaf*, — ^Th3 afWtion it liable u> be ■iiraVea tar fannu^il 
pnaaiaita, cr aent* or ^raaie pteorisf . The Bflai iapenant fieatni 
in the diagaoM kki tbr «jmp«o«a of aeaie pnrnmonia ftilWved 
inegalar chilb and feTirr: dalneM laoR cr Ich circ Ma cribcd, bat a| 
to be mon dialiact than tha*. of paeanonia and Um than that iif plea- 
riff ; atjptc inspiratory aad Tocal sipw, and ftaatir adden ^xpccunatiun' 
of a large qnaotitj of poa in vhid macf be fonnd dastie ftbre. 

BnaekUia b diatingaiihed faj abnaoe of the initaal chill aad sabaa- 
qmint ngen, lUght fercr, a im ma of dolaeH on |wrnnrifm, and the 
f t iatn ce of faSatMal rdba; and by the character of the expectovatioii. 

Pmenmemia jiehie Terr dmilar rfnptoms and qgaa, bat aeldoro 
nniri the bn^alar ehilb aad ferer. In {itwaiaoaia the dalncMB ma^ 
be loB or son sariEod a ecord ing to the atse of the aboecBi aod the 
amount of healthy bug tinoe between it and the aniface ; but erentaallj 
tba dnliw in caae of abaees beoomea noK dtcttnctij ciirtuascribcd. 
Jn pTwuiafftita dtttiiwi crepitant and aabcrv[MtaBt rAles or btonchinl 
breathing are praetieally alvars preeentt while orer a polmonary abeoee 
there maj be a feeble aomtal mormnr or abaence of ravpitaionr aouuda^^ 
or there maT be irregular broDrbial rAIes, which are lielj to be 
duitinct in a zone sarroonding the abetsen. 

AruU pUurisy maj be difliBTeatiated br the pnanoe of fncti« 
BnandM and fremitu, but absence of rocal fremitos. In it there ia mt 
decided dolnem. and leat distinct re^tratorr and rocal sigaa than ii 
abooMi, and there i« do hectic ferer. TMien there ia mach effnaion, 
duage of the terel of flatneas by changing the patient's position and 
d i tp la cewent of the heart differentiate it fnnn afaeoeeB. 

Chr^uie pUmrUjft or empyema, when general, ran be easly dlsiin- 




guished from u))6ce88 of the luitj?, btit tvlan circumscribed the Eigns are 
not characteristic uutil u niicrus^-u^tic t.-xuiiiiiiatiuu of ilic ptis reveals 
elastic tibru in tho case of abscess but none in oiripycnm. 

I'KooNosis. — The affection may prove fatal within two or three 
weeks or may be prolonged for mouths. If the abscess opens spontane- 
onsly it will usually do so within tlin-e weekB. Many cases die of ex- 
haustion, Honie by infection of other parts, und still others by rcjiealed 
pneumonias developing about the purulent c&vity; yet b considerable 
uuml>er recover. The cases caused by pytemia, gangrene, tuberculosis, 
eiubulisni, are necessarily grave. 

Treatsiekt. — Commonly the profession favors expectant treatnieut 
with tonics and uiuple nourishment, hut when the aliscL-ss can bo located, 
especially if near the che^t wall, the question uf surgical interference 
ptust be couaideretl. Knowing the danger of the operation and remem* 
tering that many cases recover spontaneously, I believe that the greutoet 
good to by far the greatest unni!)cr will be obtained in most casus by 
pursuing the expectant plan for at least tlirce or fonr weeks; but when 
Ke have rcaaon to believe that there is a single abscess near the surface 
of the lung, when sufllcient time has been given for BpoutaneouB ojieu- 
ing, and when progressive emaciation and hectic fever indicate the 
retention of pus, it is sufer for the patient to open the abscess from 

Aspiration alone or combined with wustiiug out the cavity with a 
disinfecting solution will prove curutive in a considerable nnmher of 
cases and should bo tried first, but if it fails the surgeon, with antiseptic 
precautions, should cut down and resect a portion of one or more ribs. 
If the lung is found not adherent to the jjlcura it ehonld U' drawn up 
and stitched to the external pleura, where it will become firmly attaclieil 
within a few hours. Then (or at once if the two surfaces of the pleura 
vtv adherent) an opening should l>e made through the lung tissue to the 
cavity by means of the thermo-cautery, and a large-sized drainage tiiTjo 
introiluced. Strong's tubes spoken of in treating of empyema (Fig. 33) 
»re well adapted for this purpose. The cavity shonld subseqnently be 
Managed as iXwm of other abeceveu, and the patient etistaiued by tonica 
ftod nutritious diet. 



■e Iiyperajmia are redder, shglitly heavier, inid lesa 
i. Au unusual amount of arieriul blood escapes on ■ 
riosiiredistomlod, thonlvijolurepitlieliuin is swollen, ™ 


Pi'LHONAKY hypcrffimm sigiiifieu an excess of blood in the pnlmonary 
ressitlft. It may bt- gi>nc->riil or local, active or pas^iive. It possesses no 
distinrtive piuiiical figns unless associated with puhuonary oedenm or 
bronchial henuirrhage. 

Anatomical ask PATHOLtMiUAL CHAKArTERisTUs. — Lungs which 
are the seat of acfit-a hypenvmia are redder, i^liglitly heavier, and lesa 
crepitant than normal. 
section. The cjipillarios i 
and tho bronchiul niuoouet membrane may be injected. (Kdcma may ac- 
company a local active hypermniia. Active hyiicrffimia may speedily dis- 
appear or it may terminate in iuflaninmtiuii. 

\i\ jHisitire hyper.v'niia or congft-tion, llie lungs are of a dark red or 
purple color, the dependent parts shttwiiig marked post-mortem staining 
of a darker hue; the organs are heavier und less crepitant than normab 
and the tlow of blood on scL-tion is copious and dark, but mixed with air. 
The aipillaries are engorged, distended, and tortuous; the atr s:ics con- 
tain scrum with blood corpuscles, leucocytes, and epithelial cello more 
or less granular. The connective tissue is usually slightly (edematous 
and shows small extravasations. In severe and continued congestion 
these changes are exaggerated, there is greater thickening of the alveo- 
lar walls, engorgement of the vessels, wdema. collapse of some of the 
air sacs, and, decrease in the amount of air in the lung, which is of daik 
red color dotted with lighter points oX extruvasutiou, partially decolor- 
ised. The fluid from the cut surface is more watery. This condition 
is termed splenization. Prolongwl obstruction to the pulmonary cir- 
culation duo to mitral ditteafle results in hrmen induraiioa. Here, 
iu addition to the capillary engorgement and alveolar changes, there is 
extensive pigmentation of the lung along the lymphatics and vessels 
and about the connective-tissue cells, from de^wsit of brown granules of 
hfematiu derived from the degenerate red corpuscles and carried thither 
by the leucocytes. There is also marked connective-tissue hy[)orplasia. 
Tbe luug is consequently dark brown in i^olor with yellowish and red- 
dish (Mttrhes due to extravasations in various stages of decoloration. It 
is larger, heavier, firmer, lei<s u^deniatous, and drier than asplenoid lung. 



Iiy}}ostatic. eongention signifies jKiiwive liyp^rasmia of dependent pnrts, 
usually btlateml and due to curtliiic weiikne8s in those long confined to 
bod hy exhausting (Jiseaaes, 

Etiology.— Jr/iif bypersmiamuy bedne to increased cardiac aotioa 
from violent exercise, medicinal etimuliUion, mental excitement, and cer- 
ttiin neurottes. or to local irritution from iutuilmiou of pungent gasei, 
foreign budiei, and hot or cold air; or lo iliminution of inter-ulreolar 
pressure in the rar«6cd atmosphere of high altitudes or during inepira- 
torj' expansion of the chest nith olwtriu'ted air pnssageB, as in croup, 
uedi-ma glottidiH, and tumors of the liirynx. Lastly, interference with 
the circulation in one part of the lung may cause compousfttory or col- 
hitcral hypera'mia of the other parts. 

Pamre pulmonary hypera?mia is due either to ineflicienl propulsion 
of the blood through the lung from weakness or inefficiency of the right 
heart or to obslructiou iu the pulmonary artery or to interference with 
the outflow of bloud from the lung owing to valvular disease or weak- 
ness of the left heart or pressure on the pulnionarj- veins. 

Symptomatology. — We can best recognize pulmonary congestion 
by considoring its history and symptoms, iu connection with the physi- 
cal signs. For example, if a patient is attacked with sudden dyspncea 
after extreme physical exertion or cxiiosurc to the influence of a ntrcfied 
atmosphere, as in high altitudes, pulmonary congestion should be sus- 
pected ; and if the dyspncea is attended witli a profuse watery and blood- 
stained expecloratiou and the signs of wdema, we may be positive of oar 

In Huch case* percussion reveals slight dnlncsa over the lower por- 
tions of the chest. 

Auscultjilion rcTeals a feeble respiratory mnrmur» crepitant rillea, 
and usually an abundance of large and small mucous r&les. 

Acrrntmition of ihf- Mcond hoiiikI of the. heart, at the pi)ln)on.iry onflrp, has 
been coitMidoieil by somt> antlioi-s diaRoostic of pulmonary irontrextiuii ; but t)il8 
Bicn cannot he i'«lieel on. an it tuav be oDl,r relative, duo to fi'ebleae&s of the 
aorlic nonni! ; nioreover. lhi» accentuation is a common si^ in citrdiac disease. 

In the conuestioD of tlie bm^ ^^)>icb immediately pr^cedi^fi pneumonia, 
phi:fii«-:il examination reveals vt-rj- slight duhiess, with feeblem-ss uf the respira- 
tory murmur aod. possibly here and there, a crepitant or ntilKrepilant rfile. Thb 
condition, however, is nut usually include<l under the head of pulmonary con- 

Pboonosis. — Active pulmonary hypertemia maycause death within a 
fewhonrs from oedema or homorrhsgc, or it may terminate in pneumonia. 
It is ordinarily amenable to early and prompt treatment. Mild cases 
are usually of short duration and recover spontaneously. Passive hj- 
periemia is more serious, but the prognosis depends largely upon the 
gravity of the canse. Chronic cases due to heart disease are liable to 
•udden fatal attacks of oedema. 

154 prtrntNAnr mssASSs. 

Tbeatmext.— Wlien tUe congestion oomes on suddenly, fnll doses 
of ergot should be givtin. Bleeding will be found useful in aiaes of ex- 
treme plethora. Dry or wet cupping over the chest is sometimes bene- 
ficial, A blister will ot'cahionally prevent the supervention vS inflnmnm- 
tiou. If the heart is weak, it rihould l>u stimulated; und if pulmonary 
oedema coexist, alcoholir stinmlauta should bo given freely und ft hydru- 
gogne cathartio may be administered. 


The 9t/tnptmn» of brown induration are those of the causative initial 
disease, with cou^h and Im'moptysis, 

The principal sitjH is dulness, limited mostly to the second intercos- 
tal space near the sternum. Tliero are also exapgorated vocal resonsnoe, 
brom;ho-vesicular or broncliial breathing, bronchophony, and occasionally 

This iifTection may bo dlfTprentiated from other pulmouiiry iliseasea 
by the position of the dulness and the presence of the symptoms and 
signs of mitral diseitse. 

Tkeatmevt will aim to relieve the cai-diao affection. Aramoninm 
carbonate and chloride, moderate doses of digitalis and tinctnru of nux 
vomica^ are especially indicated, and couu tor-irritation may be boneBcial. 


Pulmonary hemorrhage includes hemorrhage from the bronchi 
(bronchorrhngiM) and from the parenchyma of the lung (pneuinonor- 
rbagia). The chief symptom is hemoptysis. This term, used loosely, 
in a broad sense denotes spitting of blood, whether in large quantity aa 
from the rupture of an iineurism into the air {Kisuages, or in small 
amount, merely streaking the sputum ol chronic bronchitis, or us found 
in the msty or prnnc-juico expectomtion of pneumonia. Pro|>er]y, it M 
aigni^cs the mising of more or less pure blood from Teasels bleeding V 
into the larynx, trachea, bronchi, or alveolar structure. 

Anatomical axu Patiioujuicai, Chakacteristics. — The appear- 
ance of the lung after pulmonary hemorrhage depends upon the extent 
of the hemorrhage, its cause, and the time at which the orgun is in- ■ 
apectad. If post-mortem examination is mjido soon after broiichini hem- 
orrhage, the lung in general may be ana>mic, marked by isolated bright 
red spots at points whore blood has gi-avitated or has been drawn into 
anperficial alveoli. On section, coagnla may also be found blocking the 
bronchi. If these collections in tho uir sacs and tubes are numerous or 
large, the lung to that extent will be heavier, less crepitant, and less apt 
|io collapse. Its cut surface will show red, firm patches or nodules re- 


les r^- ■ 



seniblmg iularots, from which sero-eanioiis flnid escapes. The bron- 
cliial mnoons membrnne niiiyaiipfiir uliiinsi uorninl, or i-ochyiuoiic, rcl, 
swuUt'ii mill sofU'iioi. li the exuniinaUou be mmle long iifter death, 
there may be liitle or do remaining evidonee of un abnominl cundition; 
or the coiigulu in the air snia may l«* imrtiftUy decolorized. The heni- 
orrhage may in sonio oases give rise tu lohuliir piieuiuoniu. 

If heniorrlmge has come from an abscess or tubercular cavity, un 
ermled tcswI or ruptured unonrisin may be found in the wall of the 
cavity or in one of the trabcculae trftvei*8ing its space. Brown indura- 
tion :tt the hing also will often bo found, with the evidence of hemor- 
rhage due to mitral disease of long standing. 

In other caseH, atherumuluus, fatty, or amyloid degeucration of the 
Tpssels may mark the seat of purenehymatoua Iicmorrhage. Rarely sub- 
pleural litematoma and htemotborax are present. 

Etiology. — All those conditions which weaken the walls of the pnl- 
lonary blood-vessels predisj>ose to ha-moptysis. They inolnde tubercn- 
losis, abscess, anil gangrene, which diminish the local support of the ves- 
sels; also changes in the vascular walls, such as atheromatous, fatty, or 
amyloid degeneration, and atrophic changes incident U* liieniopliilia, pnr^ 
para, scorbutus, and the infectious diseases; also heart disease and other 
conditions which produce clironic over-disteution of the pnlmonary 
Lvessela. The usual exciting causes are musL-ular exertion, coughing, 
r^lond speaking, or concussion from a blow or fall. Other crises occur from 
penetrating wounds, but in quite a largo percentage of cases, no exciting 
^oauso can be discovered. 

SYMPTOMATotoov.— The chief symptom is expectoration, usually 
of arterial blood, more or less frothy; perhaps immediately preceded bj 
a sensation as of warm fluid trickling beneath the sternnm. This maj 
follow severe congh or strain and without premonition, or may be pre- 
ceded by coldness of the extremities, congestion of the face, headache, 
dizziness, thoracic oppression, or palpitation. 

Uarmoptysis may be followed by nansea and vomiting, and is apt to 
[Occasion considerable mental shock. Large and small bronchial rales 
Are present in must cases during active hemorrhage, and may remain for 
several hours. Feeble respiration is sometimes noticeable and dulness 
may be present, thongh frequently no signs whatever can be detected by 
the most careful examination, 

DiAONOsiB. — Ilfemoptysis may be mistaken for faiematemesis, epi- 
staxis, or hemorrhage from the gums or the pharynx. The distinctive 
Matures are as follows : 

H.EMOPnrgis. IIveUATEHEais. 


tTsually history of pulmooary or Usually gastric or hepatic disease. 

heart disease, especially phthisis. 



A preceding thoracic oppreaaioa or Al«<**iiigs«seof pain orfalB*« 

premonitory sensation of uicfchng^ ftuid "xnesa. 

beneath the sternum. 

Blood expeUed primarilT by cough. Biood expelled primarily by vomits 

Vomiting secondaiy if present. ing: ^ *«nn_ 

Subsequent cough »nd bronchml Otest agv ^^^dv^ 


Character o^ Mood. 

UsuaUy bright red and trOthj from tTsuaUly dark ciocted or Kmntam - 

admixture of air. may be mixed with food. ' 

Alkaline reaction. Acid reactioii. 

In epistaris iMpection of the mms and poet-nans with rdl«cted light 
reveals the course of the blood and perhaps its origin, ffemwrkoffe from 
the (jHtm or the pharifHx can generaUj be readilv recogniwd bv carefal 

Prognosis.— Pulmonmry hemorrhage, though rarelj immediately 
fatal, is in most cases indicative of phthisis. A single hemorrhage may 
amount to a pint or more^ and continue from a few minutes to seTeral 
hours. As a rule it is followed by others. In most instances it is fol- 
lowed by the occasional eipeetoration of a small amount of clotted 
blood for twoor three days. Freqnent recurrence, or severe hemorrhage 
if not fatal, results in anaemia or may cause lobular pneumonia. When 
occurring in phthisis, hwmoptysis seems occasionally to check its course 
temporarily; commonly the patient expresses a feeling of increased 
well being. Rarely, it is followed by a more rapid progress of the dis- 
ease. It is a fatal symptom if due to ruptured aneurism, and serious if 
complicating pulmonary abscesses, gangrene, malignant growths, or 
when accompanying the infectious diseases or grave dyscrasia and occa- 
sionally when resulting from heart disease. 

Death may occur from depleted circulation, asphyxia, or from grad- 
nal exhaustion dne to ansemia or to secondary pneumonia. 

Treatment.— The patient should be kept perfectly quiet until ail 
bleeding ceases. 

The most efficient remedies for checking the hemorrhage are full 
doses of ergot, gallic acid, or lead acetate and opium. 

The hemorrhage may sometimes be checked by the inhalation of a 
spray from a weak solution of liquor fern subsolphatis — "Ix-.aqnaad ' L 

In estimating the value of any remedy for this purpose it must not 
be forgotten that the bleeding will asnally cease in a short time wheth- 
er remedies are used or not, Loomis relies more npon aconite and 
opium than npon styptics. If ice is applied to the obest. it should be 
Vreat care, as it seems to favor the supervention of broncho- 
(er hemorrhage (Loomis* Practical Medicine, p. <i5). 




Sjfnonyms. — Diffuse puUnotmr}' Ucmorrhugt!, pneumonorrlmgia^ 
bemorrhugic infnrctus. 

Piilinuii:irT apoplexy is ;i rare iilTe<?tian. cansiMiiig of extrava»itioi) of 
blood into tlie lung tisitue. It iiHually ooi'iirA in tlie lower lobes. 

Siucc apoplexy etvinologiwilly refers to loss of tMiiBritnisne^B inci- 
dent to rapture of n cerehml iirtery, llus term is not iiptly :ipplie<l l(» in- 
tcrstitiul i>ulmonary hemorrhuge; nsajro. howevt-r. lias authorized it. 

Anatomical ami rATiiOLu(;uAL Ci!a»ai.teristics. — I'ulmunai'y 
apoplexy consists of uu csejpe of blood into the pttronchyma of the lung 
from a ruptured vessel, uttenilcii by more or le«s luoeratton and iutiltm- 
tion of the iisstics, itL-coi-dlng io the size of the daiuuged vessel, the cause 
of the injury, uud the condition of the lung. 

Tho Inng ig rrrljitlvely heiivier iirul firener thiui norma], and c<intain8 
no nir in the iifTectcd portion. Not infrcriuently several extmvasHtions 
exist from the bursting of vessels in different parts of the organ. 

The resulting clots or hemonhagic infarcts, as distinguished from 
embolic infarcts, arc of pymmidal form, the bases of the pyramids ap- 
pearing superficially beneath the pleura us dark red or almost black 
jKitclie^, the sides ourre^pDudiug to the iuter-lobular boundaries ; occa- 
sionally tho pk'unv is also torn, and blood esnipeB into the pleural sac. 
The cut surfiice is firm but moist and of uniformly dark color in the 
early stages, but later the clots gnuiually become decolorized. Hemor- 
rhagic infarcts somewhat resemble true embolic infarcts, but arc usually 
larger and more sharply deflned. Apoplectic extravasation may canse 
death immediately or from subsequent snjipuration or gangrene. It may 
end in resolution, complete or aecom{HinimI by ciratrii^iiU contraction, or 
may undergo cuAcation, udcitication and encapsulation. 

Etiouiov. — Hemorrhagit; tnfarctus in the lung is usually the result 
of pulniotuiry hypenemia .-irtlng njion vessels already the seat of degen- 
erative changes. Such changes frequently give rise to multiple iineu- 
risms which give way on sudden or prolonged intra- vascular prt^ssurc. 
A severe blow or a wound of external origin may cause diffuse hemor- 
rhagic iuGlcratiou or it may resnit from erosion of a vessel by ulceration, 

SysiPTOMATOLOOY. — This affection is usnally, though not invariably, 
attended with dyspntea and btemoplysis, the expectorated blood con- 
taining small dark clots. 

The principal siguA are: more or lees dulnesa, feeble or bronchial 
respiration, and mucous ntles. 

When the coagula are few in number, and small or deep-seated, per- 
cussion yields no signs; but if they are numerous, or He superficially^ 
dutneaa will be more or less marked. 





CpoD auscolbition^ diqcous, subcrepitant, and possibly well-niurkec 
crepiutic riles will be detected in and about the extniTasations, until 
ooa^lation of blood has uken place. Aftenrunl, respinitioQ will be 
feeble or suppressed over tbe extraTumtions; or bronchial breatbin| 
ftud exaggerated tocuI resonance may be obtained, if a large dot lies ii 
apposition with n bronchial tube. 

DlACN'Orii^ — I'hc diugnoiig of pulmonary a|>opIexj must be bajsed 
Dpon the history and the character of the sputa^ in connection with.H 
tbe eigns fonnd npon percussion and anscoltation. It is not likely tof 
be mistaken for any other diseaee except pneumotiia, from vluch it can 
easily be distingni&hcd by the history and bjr the expectoration. 

T&£ATUE>*T.— The treatment should be mainly directed to the cause 
of tbe hemorrhage. Kcmuvoi of the blood-clot Is probably hastened by 
the administnitiuu of potassium iodide, or liquor potas^as and other 
alkalies. Counter-irritation iii useful in some caees a few days after the 
accident. Quiet must be nmint&iiietl for two or three week? to jireveul 
a recurrence of the attack. If pneumonia ur pleuriiiy 8ui>erYene, thoyj 
should be treated essentiallr the same as when ther occur alone. 


PrufoxARV THROMBOSIS coosists of the gradual obstruction or » 
blood'Tessel in the lung by a coagulum formed in «i7m. It occurs ia 
the pulmonary artery or some of ita branches, as a reenlt of local non- 
inflammatory vascular degeneration or of intlanimation in the surround- 
ing long tissue. 

PrutoNAKY EMBOLISM cousists of a suddcu obstruction of a ressel 
by a foreign body, usnallv a fragment of a cardiac volvaUr vegetation 
or of a thntmbus in some of the systemic veins. Emboliam muy occur 
in the imlmouury artery by lodgment of a thrombotic fmgir.eut from 
the veius of the abdomen or lower extremities or it may occur in th« 
bronchial arteries by an obstruent brought from the mitral or aortia 

tmMic infarcts are usually multiple and occur near tbe surface of tbe 
lung, especially in the poaterior part of the lower lobe. In form and 
gross appeantnee they resemble itrmtrrrkntjir infarcts, but they depend 
Ufton obstruction of a blooil -vessel, instead of rupture. At the apex of 
this infarct, usually at the bi^l^cation of an artery, an emlMlns is gen- 
crallr to be fonnd about which a secondary thrombus has formed. The 
conical form of the infarct correeponds to the distribution of the branches 
of the occludeil vessel on the distal side of the obstruction. These being 
no longer supplietl with bj-wd ^y the main vcmoI, become engorged, ac- 
cording to Cohnheim, by regurgiution of bliMjd from the veins, but ac- 
cording to Litten this is due to a small amount of arterial Mood still 





supplied to the port by arterioles, wliicb, however, are not sufficient in 
size arid number to lifford udetpmle collaterul circulatiou. The chuuges 
iu the part, conscfjuent upon engorgement and atasU, urc: migmtioD of 
leufocytej), deterioration of the tunica intima, diapodosie of red corpus- 
cles and engorgement or collapse of the air cells with thinning of their 
val]». About the iniarct is a zone of active bypera^min. Kiiibolic in- 
iarctuti may terminate in rewlutiuu or eicatrizutlon, but if infected in 
ibscesa or gangrene. Harely caseation and calcification with encap»ula- 
ion occur. 

Etiology, — Thrombosis may be due to local vascular degeneration or 
iiiflanimatiuii extending from tlic adjacent lung tissue, oepecially in con- 
nection with ft't'blu hujirt power. 

EmftoHum may be due to loosened fraginenta from the cardiac ralrea 
or from systemic veiions thrombi or to fat-grannleii dniu-n into the open 
veins at tlie site of a fnicture or crusliing injury to the long bones. 

Symitwmatolooy. — The principal symptoms are sudden, severe, and 
sometimes paroxysmal dyfipnoea, turbulent heart action, and puliation 
of the juguliirs, from yieUling of the tricuspid valve. Exnggt-rateil res- 
onance is sunietimes ileteeteO, owing to cutting off of the blood supplj 
fruni some uf the jmlmoiuiry lobules, and conspquent distention of the 
air i^ells. In the same locality, the respiratorv murmur will be feeble 
or suppressed. 

DiAONcisis. — Neither the symptoms nor the signs of these conditions 
are sufficiently well understood to enable us to make a positive diagno- 
sis in evi.*ry instance. Most reliance must be placed on the syniploins 
and hist<iry. 

Pkognosis. — The prognosis is unfavorable in proportion to the 
amount of lung damaged hy the emboli or thrombus, nn<l is always 
very grave if the emboli be infected. SmuU infarcts may undergo rvso* 
lutiou. Death occurs from collapse, apua'a, or from secondary pnen- 
monin, sepsis, or pbtliiHts. 

Treatment. — The treatment must be exj^ectant 


5ynont/m«.— Apucumatosis and atelectasis. The latter term, though 
referring to the same anatomical couilition as the former, is mure prop- 
vrly applied to air cells which remain in the festal condition after birth, 
not becoming distended with air. 

Pulmonary collapse is a condition of the lungs in which nir cells 
which have formerly been inflated have collapsed, and returned to a 
qnaei-fcctjd slate. 

AxATOMUAi. AND PATnoLOCiCAL Charactehistics. — Both the ao- 
ijuired and the cuiigenital forms may involve the whole or part of one 
lung or a part nf eiich: the collapsed air cells being en masse or in iso- 
lated lobnles or groups of lobules scattered through the organ. In 



order of freqncncVtthu pirU iiffectud nre: tbe lower margin of the lower 
lobea of both Inugs, the tongue-lIkc pruloiigatiou of tbe loft upper lobe, 
and tbe posterior portions of the lower and iip|>er lobes of hnth lungs 
neiir tbe spine. Tht' ci^llupBed parts correapond externally to Kmall irreg- 
ular ftre^ns depresaod below tbe general surface of a reddish-bine, violet or 
gniyish-blueoobjr. The crosA-«ection is dark red, smooth, tough, airlegg, 
and the part rejidily sinks in water. Kueently collapsed uirsaog may l>e in- 
flated, l>ut if this condition long persists, distention becomes imposKihle 
and the parts subsequently undergo fatty or fibroid change or become 
thf) teat of tuberculosis. The surrounding lung tissue is not infre- 
quently em]>hysenmtons or oedematons; the bronchi which are still per- 
vious are frequently dilated. Permanent and ettensive collapse from 
prolonged compression results in a dense, solid, fleshy condition of the 
lung, termed Ciirnificaiion. 

Ktiology.— The affection is most freqnent in early childhood. It is 
always preceded by inflammation of the bronchial mucous membrane, 
the secretions front which collect in some of the smaller bronchial tubes^ 
where, acting us ball valves, they obstruct the entrance of air during 
inspiration, hut ])ermit its esc:ipe in expiration. Ultimately the air 
cells to which the obstructed bronchus is distributed become in this 
manner completely emptied of air and collapsed. 

Congenital atelectasis occurs in weak and sickly infants or may be 
due to prc-muture delivery, and it may result from accidents in birth, 
auch 1)8 llie inspiration of amniotic and other fluids. 

In children, more or less permanent collapse is apt to follow an at- 
tack of brnnnhilis, whooping-cough, measles, typhoid fever, severe diar- 
rha?a, or any other exhausting disease. Disease of the brain or spinal 
ooixi interfering witli tlie pneumogsistric nerve may c:iuse it. Colla]>se 
of the lung may be due (o the pressure of mediastinal or intra-pulmo- 
nary tumors, or to effusion into the pleural sac. 

SvMcroMATor.oaY, — The essential symptoms are: great prostration; 
pallor or duskiness of the skin, which hangs in loose folds on the ema- 
ciated limbs; rapid, feeble pulse and coldness of the extremities: u feeble, 
insuftfcient cough; great dyepncea, without the lividity which usually 
attends this symptom, and rapid respiration, rising in young children 
from sixty to eighty per minute, with an altered rhythm iu the respira- 
tory acts. In this alteration of rhythm the pause follows inspiration 
and precedes expiration, instead of occurring between exjtiration and 
ii.spiration. as in health. 

The chief ai/fm are : retraction of the intercostal spaces and lower 
rib« during inspiration, dulncss over the collapsed lung when the apneu- 
matosis la considerable, and feeble or absent vesicular murmur, usually 
with harsh or bronchial respiration over the affected parts. 

Jnsjieetion reveals the rapidity of respiration and its changed rhythm 
and retraction of the intercostal spaces and lower ribs during iuspira- 



tiou. The Utter is ft very important sigu, but it also occurs in othor 
discAses. . 

Iti children the signi of percusaion are uot so rcliublc us in ndulta, 
but when the dise»M^ id well initrkcd, more or less duliiifiui will be found 
over the aftected portions, usually firiit iiL the biiiie oi thu lunge, then at 
their anterior borders, and fiuully along tiie epinul column. If a whole 
lobe is involved, diilnesa like that of pnoumoniu will be presfnt. Not 
infrequently the collapsed cells are so scitttered through the luiigd, uiid 
the adjacent cells aro so distended, that the affection may be quite ox- 
tensive without giving any sigus ou pt^rcussion. 

By auscultation, harsh or bronchial rcapimtion may be heard over 
the colbipsed cells instea<I of tlie vesicular murmur. 

Usually portions of the lung immediately surrounding the afTected 
lobules remain pervious to air. so that tbu vesit-nlar murmur i« not en- 
tirely lost; the sounds from the air vesicles are then mingled with thoso 
from the bronchi, causing broncho-vesicular respiration. Ordinarily, 
numerous bronchial rales are present, which may completely mask tho 
vesicular murmur. 

Diagnosis. — Pulmonary collapse U most likely to be mistaken for 
pneumonia ur pleuritic clTusious. 

The diagnosis in many cases must depend mainly on the symptoms, 
«s the signs are by no moans distinctive. Whenever dnlness occurs, its 
rapid appearance, within twenty-four or thirty>siT hours succeeding tho 
<igi)S of bronchitis, is an clement of great value in diagnosis. 

In pulmonary collapse there are few if any crepitant niles, which are 
considered pathugnomuuio at pnenmunia. In the latter disease there is 
Uiit the retraction of the cheat noticed incullapse^and duluess is UBually 
greater and tho bronchial breathing more marked than in tho diseasB 
uuder consideration. The fever symptoms are more marked in pnea- 

The features that distinguish pleuriay from pulmonary collapse are 
the fl&tneaa instead of dulnesa on percussion, change in the level of flat- 
ness and absence of a'ocal fremitus, and feebleuess or absence of respira- 
tory sounds over pleuntl etTusious. 

PRorfNoeis.— Mild atelectasis in the new-bom, not dopondont apoa 
congenital defect, may bo corrected if restorative measures bo early ap- 
plied and long continued. If of long rlnrntion.orwheu in adults due to 
extreme compression, the affection is liable to be permanent and to cauM 
more or less emphysema and fiually to giro rise to lobular pneumonift 
or phthisis. 

Atelectasis following broncliitis and whooping-cough is especially 
fatal. According to Loomis (Practice of Medicine, p. 158), twen^- 
five per cent of the loul mortality in young infants results from atelec- 
tasis following bronchitis. 

TuEATMENT.— lluviug fairly established the respiratory fuDCtions at 


PULMONAUX JjJiiJi'difJi^. 

birth by the onliuur}* nictliuUs of ihu ubatetriciuti, it must not bo I 
gotleu iu the subsotfuciu tn'^itmiiit of this iruuditiuii tlmt Uebility is llie 
chief fuclgr in its pioUuctiuii. Tri-nlmc-nl iiiiisl ihtirt-furis bu ;-u]ni(irliiig 
from the first. We must also atturupt to remove the tjecretions from 
the broiiehi, so us lo prevent iinpliciition of olher air c^Ils. Willi 
iu view, a mindoprcafitiig omoti<i may Iw given when the debility i» ii( 
Tery ^reat, but it is genenilly unsafe to repeat ii. In mild cases eipee 
tonint dose» of ipucuc are useful. In severe eaiiieii umnionium uarboiiatc 
or ammuiiiuni iodidi; willt ah;ohoHn i^timuhintii iiro indicated. Countor- 
irritation of the surfiujc l)V nuMins of vigorous friction or sinapii^ms is 
naefal in most cases. The diet 8hoHl<i be nonri«hing. hnt not too con- 
centrated. Concentrated nourishment h apt to derange the digest!* 
organs^ and do mor^ liiirm timn good. 


Pulmonary oedema consists of an interstiHal extmvasntion of serniiK 
irith effuaiou into the vesicular portion of the Uings, which rcuders the 
cells and bronchioles correspondingly inijtervious to air. 


cedema may occur either ante mortem or post mortem; a given ease can 
only be settled by reference to the history, and llie syniploms and iign% 
present before death. It affeets most fretjuently the dependent parttsof 
the lungs, but it may involve the whole or any i>art of one or both. Iu 
•well-umrked tcdemu, the pleura is moist, and its cjivity may oontoi 
serum. Tlie luug docs not collapse on opening the chest, and is abno 
mallr light colored, unless the a'dema is due to hypcra^mia. It is heavie 
llian normal, aud pits on prca'sure. The scrum oozing from the cut sur 
face is frothy in proportion to its tidmixture with air; very slightly soi 
the alveoli and bronchioles ore idmost completely fille<l with serum. I 
has a reddish tinge if the affection, is due to h>']}era'nnu, is always albu- 
minous, and usually contains alveolar epithelium, but unless due to hy- 
pera-miit it holds but few iutra-vuscular cellular elements. 

Stidlouy. — Pulmonary a>dema is probably duo in everj' case to on 
of three causes, viz. : abnormal permeiibility of the vascular walls from 
changes incident to certain diseases : increase of intra-vasculiir pressure 
from active or passive hyper»mia, or change in the character of the 
blood; two or all of these factors may co-operate in its causation. 

It is not infrequently assuclated with general dropsy dependent upon 
cardiac or renal disease. It may occur from heart failure in tlie course 
of acnte general disease such as typhoid fever, or in purpura, scorbutus. 
»Dfl3miit, and otiicr olironic affections. 

It may occur in one lung or a part of a lung from the presence in 
the other parte of collapse or oouBolidation ; and hence it often compli- 
cates pneumonia, phthisis, or pressure from tumors or pleuritic effusion. 




Symptomatoloot, — The chiof symptoms are dyspuusa, increased 
rapidity of rt'spimtion, und oough with frothy expoctorution. 

Tht! prinoipnl .siyns are Tery moist subcrepitant riUes, wiih more or 
lc«8 (lulncss oTtr the bust of the lungs. 

Inspection, )iiilputiou. uiid mensuration yield uo ohanicteristic signs. 
ICetipimtiuu is iucreu«cd in friKjueiK-v. 

liy porcUf«tfiuti, dulue£6 is obtained on both sides over the most d»< 
]>eudent ponious of the lun^^s. 

On auseultittiuii, tliere is a ft-eble respirutory murmur, whicli nuiy bo 
elightly broDclio-veBiculiir. with iibundunt ni»i;jt and cnLc1<1ing subcrepi- 
tant nilt?a. These Bonii'timva resembl*? tlie <:repilaiit niles of pneumonia, 
but lliey are Tiiore moist, not so numerous, and are nsiuilly heard in ex- 
piration as well as in inspiration. The vocal resonance may be iti- 

DiAGKOsis. — Pulmonary ecdema is liable to be mistaken for the 
first and third stagesof pneumonia, forhydrothorax, and capillary brou- 
chitis. The distinctive signs between these diseases are as follows: 


Slight dulcet upon both sides. DtdiiOKs nioi'e or Icm marked, um- 

ally ronflaed to one ttiile. 

Mucous and subcrepttaot r&les on Crepitant and sulKrepitant r&leeoa 

both sides. one side. 


Vocal fremitus may or may not be V''4x:al fremitus absent, 


Moderate dulncss. the upper level of Flatoeiw, the upper lino of which 

vrblchdocM not varj- ■with clianges in x'aries wiUi the changes in Uie]>atient's 
the patieotV position. iw^ition. 


Subcrepitant rAles. Atweuce of the renpiratory murroor 

and r&Ies. 

Pulmonary oedema is distinguished from capilhrtf bronchitU by the 
history, the presence of considerable dulness on percussion, and by ab- 
sence of the aigus and symjitoms of general bronchitis. 

Prognosis. — The prognosis is always grave in puhnouary tedeuia ac- 
companying general dropsy. <Edenm in frequently the cause of death 
in pneumonia. Extreme dyspnwa vriib bubbliug nllet" and rapidly de- 
Telopiug cyanosis coming on in such affections indicates a fatal termina- 

Tkeatmekt. — The treatment of this condition will depend upon the 



^^a»e With which it is afisociated. If it re*nlu from Bright's diseaw, 

aoridcs and cathartica vill be iiwessury to stiiimlate tho other emnn<y 

wnee. Diuretics will »Uo be useful in some laaea, bat the crippled 

aueva cannot respond readily to our efforts to increase their functiooal 

If the condition is dependent u|«n diBeiiso of the heart, digitalis will 
fte apecmlly useful. If it results from debility, induced by low forms of 
<Ji8eii9e, general stimuhitiou is very essential, and diuretics wul sudorifics 
*re indicated. 

If it results from pulmonary cougBstion, active counter-irritation by 
Sinapisms or dry cups ahuuld be nuuie, and diuretics, sudorifics, and 
<»tnartic8 should be Bimultaneously employed, care being taken not to 
•exhaust the patient. 

Uigitalig, scdpurius, potassium acetate, and ammonium acetate are 
■the best diuretics, Jaboraudi :uid the hot-air or vapor bath are the 
^ost suitable means to cause sweating. 

aaliiie cathartics, and elateriumoreuonymns may be employed when 
it is desired to act on the bowels. 

When patienta are greatly depressed from protracted disease, care 
0l]ould be taken to prevent jmlmonary oxlema, by frequently changing 
tli&ir position from the l)ack to the sides, and vice veraa. 


Pulmonary gangrene is a putrefactive necrosis of lung tissue, result- 
ig from pneumonia, sepcictemiii, or local injuries. 

AxATOMiCAL \su PATHOLOGICAL CnAR.aTEHisTics. — Gangrene 
isually occurs at the lower part of the lung, and. according to Flint, on 
^tbt* posterior aspect of tho upper portion of the lower lobe. It ia 
Tisuully contiued to a few lobules, bat sometimes is diffused throughout 

it large part or even the whole of a lobe. 
A part of the lung which is entirely deprived of its blood supply 
inidergoes coaguLition necrosis. Being exposed to the action of inuumer- 
tble Imcteria, the devitalized tissues speedily exhibit the ehanicteristics 
of moist gangrene. They bei:ome a tlark brown, dirty mass, wliich lifpie- 
fies, and appears in the expectoration as a greenish-black, extremely fetid 
flnid, containing organic germs, shreds of tissue, pns corpuscles', oil 
globules, pigment granules, and various products of chemical decompo- 
sition. Circumscribed gangrene is surrounded by a line of hypenemio 
demarcation not present in the diffuse form. The discharge of the 
ichorous slongh leaves an irregular cavity, intersected by vessels more 
or less occluded by thrombi. Tlie walls, at first ragijed, may granulate, 
and by contraction finally obliterate the sjmce, or a chronic abscess 
mav result. The process, at first limited, may become diffuse; in this 
form perforation of the pleura not infrequently occurs. From the 



local llirombi in the pulmoQar; and brouuhiul veeiselif, metasUilic septio 
jmboli muy uHtjtblisli secondary ulucetwus, in dUtunt organs. 

ETioLO(iv. — G;iiigrtiH« iiijiy develop in the (bourse of bronchitie, pnen- 
monui, phtlusis, cancer, or otlitr imlmonury digeasM, and nmy follow 
severe penetntting wonitdti or the eiitmnce of foreign bodits iuto the 
larger bronchi. It may eoinpliciite pyieraia, septics&niiu, or certain of 
the prolonged debilitating fevers. 

SYUPTOMATOLooy. — The principal aymptoniH are great prostration^ 
pallor, ema<:ijttion, nipid pulse, nipid and op]tre^se<l reapinition, htcmop- 
tyeis.anJ foiigb, with abundant greenii^h.browniith, or blackish purulent 
ipntnm of a sickening gimgronous odor, and containing fr.igments of the 
decomposing lung. The odor is not pcroeired in the breath const^Dtly, 
but mainly after cunghiiig. 

The most prominent »iijHii are: dulucss on percussion, witli large 
Knd gniall mucouii nikis; brouchial breathing or atidence of tliu respira- 
tory murmur; and, wlien the slough has been thrown ofl', gurgles and 
retfiiiratoi*}' aonnds indicative of a cavity. The disease at flrtd presents 
the signs of eonsotidation, which are soon followetl by breaking down of 
the liiDg tissue, and the production of vomic«. 

DiAGXosis. — M.ost of the symptoms and physical signs are not distinc- 
tive, as the same may be found in phthisis, bronchitis, or dilatation of 
the bronchial tubes. The diagnosis must therefore rest Ujwu the char- 
acter and the odor of the expectoration, which may be considered 

Small, circumscribed patches of gangrene, which occasionally occur 
in hronehifU or around tubercular deposits, cause fetid breath und fetid 
expectoration. The odor in these cases is only teniponiry, whereas in 
di^nso gangrene the fetor is persistent, though most marked after each 
act of cough and ex|>ectoration. 

In bronchial dilat^iiion or bmnchisctasis the sputum is abnndant and 
fetid, but not brownish in color, and the breath has not thai peculiar, 
sickening odor of gangrene, which, once impressed on the olfactory 
sense, is not eaisily forgotten. 

Pbooxosis.— This dependa largely upon the cause of the guugreno, 
and upon the extent of lung involved. In the diffuse form, death .a 
inevitable, usually within a few days. In tho circumscribed form, re- 
covery may occur, but in either cjise there is great danger from pviemla 
And sepsis, rieath may result from acute hemorrhage or cxhauittinn. 

Treatment.— Quinine, tincture of iron, alcoholics, jmd nonrishiug 
diet are the chief remedies in this affection. Inhalations of thymol, 
carbolic acid, creasote, eucalyptol. or tuipentino may be useful in modi- 
fying the ofTuusive odor and in limiting the amount of discharge. 
Anodynes shnnld be used to rioothe pain. Cases of cure are reported 
from external incision and drainage, conjoined with internal medica- 




Pulmonary cancer is fortunately a rare disease. It is usually of the 
medullary variety, though sclrrhuSj epithelioma^ and other varieties also 

Anatohical and Pathological Characteristics. — Cancer may- 
occur in miliary bodies scattered throughout the entire lung, or in 
nodules ranging from two to ten or twelve pounds in weight; or the 
lung tissue may be almost supplanted by the malignant deposit. 

Whether primary or secondary^ single or multiple, the ultimate result 
of pulmonary cancer is destruction of the lung immediately involved,, 
by pressure, atrophy, or by infiltration with the cancer cells and the pro- 
ducts of their degeneration. Extension occurs chiefiy along the lym- 
phatic spaces. AVhile growth proceeds at the periphery of the cancer, dis- 
organization takes pliice at its centre, where a cavity is usually formed 
after a time. About the cancerous nodules not infrequently the lung 
becomes congested, inflamed, (edematous, collapsed, or emphysematous. 
There is always enlargement of the bronchial glands, and usually pleu- 
ritis, with extensive thickening and adhesions, and effusion of bloody 
serum into the pleural sac. 

Etiology. — Pulmonary cancer rarely develops before the twentieth 
year, and more frequently affects men than women. Heredity can usu- 
ally be traced. It may spring primarily from the epithelial or connective 
tissue of the lung, according to its type. 

More frequently it is secondary to cancer in other parts, which pen- 
etrates the lungs by direct growth or by embolic cells through the cir- 

Symptomatology. — The most marked symptoms are pain and ema- 
ciation, with some dyspnoea and cough, and often bloody expectoration 
which resembles currant jelly. 

Tiie .signs vary with the conditions. If only the bronchial mucous 
membrane is affected by the cancerous deposit, we obtain simply the 
signs of bronchitis. If the air vesicles are filled, we obtain the signs of 
pulmonary consolidiition, as in pneumonia. When softening and ulceni- 
tion have occurred, cavernous signs are sometimes obtained. If part of 
the air vesicles are filled, and others remain open, we obtain broncho- 
vesicular respiration and other signs similar to those of phtliiais. 

The occurrence of the nodular variety of cancer in the lung gives 
rise to signs which are often distinctive. We generally notice the fol- 

Inspection reveals more or less loss of motion and retraction or 
bnlging of the tlioracic walls on the affected side; the former when the 
lung has colhipBed, the latter wlien the growth is peculiarly large or 
when considerable pleuritic effusion is present. 



On |iil|iatioii, vocal fremitiu will Iw feeble or fiiippreiised, according 
to tlio proximity of the tutuor to the chet^t wnlla. 

Porcusftion, most frefjtieiitly near the middle or the upi>er jwrt of 
tbu ehejit, will Rhow dulness or flatness over the tumor, according to its 
jic;irncss to the chest walls. In many instjinces, over one or more jduces 
luaonance remttius normal, surronnde^l hy nreiis of flnlTiese, owing to the 
prti8en<:« of a small portion of healthy lung surrounded by a c:ineerou8 

On auaciiltation, the respiratory aonnda may be feeble or entirely 9np- 
preaseti over the tumor. Occasioniilty the cancer rests upou n large 
bronchial tube, in such a position that the sounds from the latter are 
tnnsniitted to the surface, gtviug rise to broucbiul breathing and bron- 

if the plour.-i [a involved, tliere will be an exudation of serum into 
Hs cavity, yielding the signs of chronic or of snbnonte pleurisy. Upon 
exploratory aspiration, the fluid is often found more or lei's »ingninoIent. 

DlAUXOSi^. — When the disease is primary, it is very difliriilt to de- 
tect. When gccoudury to canter in other portions of the l)ody, the 
occurrence and persistence of bronchial or other pulmonary signs shonid 
lead us to suspect its true nature. 

I'ulmonary cancer is most likely to be mistaken for chronic or sub- 
ncnte pleurisy with effusion. It bears some resembbmee to phthisis, and 
iilso to aortic aneurism. 

If the cancer is attended with effusions into the ]deural sac, an accu- 
rate diagnosis cannot be made by the ordinary methods, but the chamo- 
ter of the fluid obtained by aspiration will usually enable as to make a 
correct dingnotiis. 

The differential points betveeu the uodulur variety of pulmonary 
.ODDcer and chronic pieuriny will be seen in the following table: 



Kpatlyconslaiitimiii; ami often cur- Uttl^", if any. j-ain : the cjcp'^ctoro. 

nint-jcliy expecloraliou. ' lion, if any, only puruleiii. 


Diilne*M does not begnu at the b*.*o Flatness beginning al llie ba»* of 

of the Inns: : iistmlly one or more ino- U»e lun^. uuiforni to lis iii>|>er hmit. 
lotrf) '*pot8 of ii'wiinnce within the 
area of tliilncsA or flatness 


V*uaWy some respiratory siffns, due Absence or the respirator}' murmur, 

to inolftUJ portions of normal lung, or and usually of the bconcliiu) sounds ; 

to only partial oontwdidation of the the latter when heard are UifTuspd and 

pulmonary parenchyma. Jintaitt. 


SonetinMS asanj^tif nolent fluid. The Serous or puniteot fluid is obtained, 
fluid, when serous, coa^lates mucti 
mora slowly than in pleurisy. 



Oancer of the lung ia not likely to be mutuken tor phihist'g, though 
such »n error might be niaik-. The caficcrous growth does not often 
begin iu the apex of the lung, and it may become very exlcu«tve without 
causing bronchial riiles. The reverse is tme in phthisic 

The history of norti^ nmuri»m is different, as iutnt-thoracic cancer ie 
nearly always secondary to external manifestations. The symptoms duo 
to pressure, viz., jwiin, dyspnu*a, dysphagiti, and venous congestion atul 
pulsation, are \cm persistent iu aneurism than in cancer. ^ 

AnenrisniH nsually have u distinct expansile pnleation, and whffl 
they cause a murninr, it in likely to be double, that is, eystolic and dia- 
Btolic. Cancers have no pulsation excepting that communicattHl from 
the aorta, and this is feeble and simply lifting. If a cancerous growth 
by pre«sure on the artery, causes a murmnr, it is always systolic, no 
second sound being produced. 

Prognosis. — The prognosis is always hopeless. Death usually 
BultB within a year. 

Treatment. — Auod)'nes to relievo pain are the only remedies thaT 
can be recommended. None of the remedies which have, from time to 
time, been recommended for the cure of cancer hare borne the ti^t of 


Tumors or morbid growths in the Inngs may result from hydatid 
syphilis, enlargement of glands, absce&ses, and maliguant disease. 


Hydatid cysts iu the lungs constitute a rare uffeclioh, which preseal 
symptoms Hnd f<igns similar to those of phthisis. The cyst n)oi<t U 
queiitly occnpies the lower lobe of the right lung, and is generally sei 
ondary to hydatids of (he liver. 

Anatomical asp Patholooicvl Ciiar.icteristics. — The wall 
a hydatid cyst is composed of an outer aud'an inner layer, and the cvst 
contains a clear fluid uou-coagn table by heat or acid. From the inncf 
membrane develop young echinocacci with chanicteristic hooktots; tbe^ 
cysts may in turn develop within themselves others of similar form. 

The growth after attaining a variable size may by fatty degeneratit 
of its contents undergo evolution and largely disappear, or it may 
main permanently as thewwt of calcification. Suppuration ma}* ocei 
within the cyst, and its sub8e(|uent course may l)e tlwt of an absceseT 
Agiiin, by gradual increase in size, it may produce great disturbance bj 
its pressure, by exciting inflammation, or by rupture into the surroni 
inglung or pleural cavity. 

KTioLi.Kjy. — Tlie ova of the ttenia echinococcus, which commonly i] 
habits the intestinal tract of dogs and other animals, upon entering tl 



hnmiin etomach are freed from their cupaules by the digestive fluida. 
Thence the pjmiailes huiTow to the Tisceru, chiefly the liver^ and bocomo 
hydatid cyst«. Tiio dii^eaeo ia rare in this country, and is seldom found 
excepting among jwopk- who mingle freely with the lower niiiinals. 

Symptomatologv.— Xlie symptoms are like those of plithiaia, viz., 
cma<.'tatiuu, night-swetitti, cough, dyHjiiiu^a, nnd cxpt'ctonttion of bloody 
and puralent s]»ut». Filially, hydiitid c\»iA, nr portions of them, and 
the booklets of tlie echinocooci may be thrown off through the brouohi. 

Symptoms of pyrexia are due to the ftecondar}' inllAmmution^ not to 
any specific notion. 

The principn) sifjm, if the tumor bo large, ore: bulging and loss of 
motion of the side, nodulnr prominences in the intercofital spnces: and, 
when the cysts approach the surftioc of the lung, duhioss or llatueiis ou 
percussion, with su]tprt'ssed respirutiou or tubular breathing. A positive 
diagnosis can selduni be made until tbe booklets of the echinoco<-'cua 
are di^'uvered in the sputum. This dues not occur until hite in the 
disease, when, after death of the e;(/u£0OH, it begins to be ejected from 
the body. 

According to Bird, the diagnosis may be made with a fair degree of 
certainty ejirly in the disciuic if the eyst is of any considombh' size and 
impinges against the chest wall, lu such cases the following signs have 
been noticed : 

Inspection reveals det-nbilus always on the sound side. The respim- 
tory movements of the affet-tcd side are dt-Qcient, and tliere may he 
slight bulging in one or more phices along the hitercostul spaces, over 
the cysts. 

Vocal fremitus may be absent, and fluntnation can sonteiinios be de- 
tected over the cyst by palpation. 

On percussion, flatness is found over a limited area corresponding to 
the cyst. In order to be of value in diagnosis, this area of flatness should 
not be less, than three or four inches in diameter. It should have a 
ronnded outline, and it must be clearly sepiirated by a line of demnrca* 
tioD from the surrounding resominee. It does not change with the posi- 
tiou of the patient. 

Ill auscultation there is absence of the respiratory murmur over the 
area of flatness, and normal respiration around it, immediiitcly l>eyoud 
the line of demarcation. The compressed lung close about the cyst may 
cause a more or leM tubular sound. 

PtAGNOSiti.^The affection is liable to be mistaken for phthisis or 
circumscriU-d pleurisy. Attention to the differential oharacters noted 
in the following table will aid iu making the diagnosis: 

Btdatid cvsts ov tbk Lu:«a6. PnTaisia. 

Promioeace of UieiDtei-costul spaces. No proniineoc** of tlie ioteroostat 



Hydatid cysts of the lungs. PHxmsis. 

Absence of fremitus, and perhaps Exaggerated vocal fremitus ; no 

fluctuation over the cyst. fluctuation over the consolidated lung, 

PercuMvon. ' 

Flatness over the cyst sharply de- Diilness over consolidated lung, 

fliied by alineof demarcation from the gradually fading off into normal res- 
resonance of the surrounding healthy onance. 


No tubercle bacilli in simple cases. Tubercle bacilli commonly present 

in the sputum. 
Absenceof respiratory murmur over Broncho-vesicular respiration, or 

cyst t^flat area). cavernous signs over dull area. 

The distinctive features between hydatid cysts of the lungs and 
circumscribed pleurisy are as follows: 

Hydatid cysts of the lunqs. Cibcuiiscbibed pleurisy. 


Usually located in the infra-clavicu- Usually located at the base of the 

lar or axillary regions. chest. 

Symptom* and Signa. 

Gradual accession of the local and Usually ushered in with acute febril? 

constitutional symptoms. symptoms. 

Nodular prominence of intercostal Uniform prominence of intercostal 

spaces. spaces. 

Percussion and Auscultation. 

Signs usually in the upper part of the Signs generally in the lower part of 

chest. the chest. 

Treatment.— As tlie disease can seldom be distinguislied from 
phthisis, the treatment must generally be the same as for the latter. 
In those cases where tlie disease can be positively diagnosticated, aspira- 
tion of the cyst and injection with iodine (Form. 11) is the most rational 


The people in some parts of China, Corea, and Japan, by the use of 
surface or ditch water in the preparation of uncooked food, and for 
drinking purposes, are liable to a peculiar form of pulmonary ilise*\Be 
due to entrance into tlie lung of the distoma pulmonale, which infests 
these waters. It is an animal parasite somewhat resembling an ordinary 
leech in miniature, being eight or ten millimetres long, with oval and 
ventral suckers by which it effects locomotion. 



By burrowing in the walls o^ the bronchi it canses atculiir broncbi- 
«ctatic navit!P«, surrouniletl by irregnlar zones of congostiou inid iiitlum- 
tion and containing debris, mucus, and the parasttBS with their ova. 

S\"MPTOMATOMM{Y. — The sijmpiou)/i and niijnx are those of chronio 
bronchitis of increasing severity associated with frequent, and often 
severe hemorrhages. 

The presence of the characteristic organism in the expectoration ^ 
the history of the ease^ and the geographical locality of its occnrrence 
establish Ihe. dinynoHis, 

Some patients recover with or without treatment, bnt the afTeoiion 
is of long durntion and no specific medication avails. Prophylaxis is 
the most important part of treatment (Annual of Universal Medical iSci- 
ences, 1888). 


It is ft well-recognized fact that syphilis canses a morbid condition 
of the lungs, the Bigns of which in no way differ from those of ordinary 
phthisis. Cases are occasionally ol>scrved in which a specific form of 
bronchitis or gtimmata occurs as u result of the venereal taint. 

The signs of syphilitic brunehitis are the siuue as tho^e of the non- 
«peciGc uffecliou. A distinction between the two can only Xye made by 
attention to the histon,' and the attendant symptoms. 

DlAONOjiiK. — The differential diagnosis between ayphilitio disease of 
the pulmonary parenchyma and phthisis is extremely difficult, and 
often inipossilde. But when uueomplic:ited, pulmonary syphilis usually 
differs from phthisii, us shown in tlie following tabic: 



Hintorg atid Symptoms. 

The hislory ttt sypbili«; ihioktiiirig 
oftli*> peno^teun) anil jtoricliuiidriuin 
<i\'fr the inner «>ni| nf tJit> ilaviolf^-s am) 
one or morp iif tliw nn-tilagefl of tlii* 
upjK>r i-ibft, with t(iih-sti.*i-nii) leiidernewi 
on in-essui-e over the upper |>ttrt «f ibc 
•lernuni. Csiinlly ppJIIk*!- fever norde- 
«idetl >.>nia(.-iuiioii, am) no haMnnpty^is. 

I'lt^ysical Signs. 

Xo history of sypliilis; no thidieniuff 
uT the |>eriustetini ur pericliunilrjum 
owrtii»> t'Livick-s ur curtilages uf the 
uppei" pib». [Mid no !ttih-Kt*>i'nal tciider- 
nes-i. Hpctio fpwr ami ii)ar)rL'(l pma- 
ciution always present, with usually 

Dninew) over Uie noilulcH, iisiiully 
oonlltKMl t<» on*; Uwt;. uiiil Tuunil »t its 
inw or «l Ihv lower part of the npiwr 
lobe. T)m; tUilne>» ■•■iiiiuiiiri^' cii-ctiiu- 
■M-ritied for 11 long; time. Viscid sub- 
civpitant rAles, or s^vc-ntl miK-uus 
«l)c){a, dilTusMl over a oonKidcmble por- 
tion of tJie ItinfT. i>re l>«)ipved to he one 
of the enrliPHt indimlionn of th*- srph- 
ihttc itft*^ iioii : f:ilpr tlie uiiKi'iiltiitory 
xigott arc tlie sartiu tu thwie of phtliisis- 

DiilnoM usu&lly at the apex, and 
^Tidiiiilly I'XtvDding' over the «ur> 
roiiDtliDt; lung. 



Pnoososis.— The prognosis is favorable iuuncompliaited cases when 
diecuvered eiirly. 

Treatment. — Anti-STphilitic constitutioual remedies as iodine, potus^ 
BiDm iadide,and tbti compounds of mercury are iudiciated. If thette were 
oftener tried in casea of so-called phthinia, probably more vould be 
cured. We should nlao employ tonic and supporting measures, similar 
to those recommended in pulmouury phthisis. 


Aa an independent affection, this is of rare occurrence. It deserves 
attention here from its close resemblance in some particulars to phthisis. 

Ak.\tomical and P.\ti!ological t'HAKAcrEiusTns.— The chief 
bronchial glands lie at the bifurcation of the trachea and about the two 
main bronchi, where they are uumerous and in relation in front with 
the aorta, pulmonary artery, and |H.'ricardiuui; behind with the aorta^ 
oesophagus, vena azygoa, and sympathetic: plexus. Those about the 
bronchi are also adjacent to the large venous and arterial brnuchee and 
pneumogastric and recurrent laryngeal nerves. 

Knlargcmeut of these glands occurs from engorgement and increase 
of iuterstilLul connective tissue with thiukeniug uf the capsule. When 
acutt), Kuppuration may occur. 

EriouaoY. — Some enlargement of the bronchial glands usually ao- 
oompanies inflammation of the Inng or bronchitis; it is marked in 
phthisis, syphilis, and malignant disease of these orgiins. It also occurs 
to some extent in typhoid fever, measles, whooping-cough, and other in- 
fectious diseases. 

Symi'TOMATolocy. — The prominent symptoms are: a dry, ringing,, 
and paroxysmal cough like that of jiertussis hut without the whoop; 
with dyspnoea, and more or less pain and tenderness on pressure near 
the fourth or the fifth vertebra, associated with emaciation, hectic flueh^ 
and night-sweats. 

The symptoms vary greatly according to the size and position of th© 
enlargement. Compression of the bronchi and lungs gives rise to cougb, 
expectoration, and dyapn(pa. 

I'resBure upon the recurrent laryngeal nerve prwluces' dyspnoea, occa- 
sionally of a spasmodic ty|>e, and may also cause hoarseness or aphonia. 

Crowding of the tanior upon the cpsophagns produces dysj>hagia; 
pain and tenderness result from implication of the sjTiijmthetin pletus. 
Compression of the pneumogastric accounts for the palpitation, ntpid 
pulse, and the nauseik and vomiting that sometimes occur. 

On inspection, we find aa si(j»i* frequently, distention of the cervical 
veins and sometimes cyanosis, rarely deficiency or absence of respinitorj 
movements of one side due to ocelusion of the main bronchus. 

By palpation and percussion, tenderness muy usuoUy bo detected over 



the bronchial glands in the interacapnhir region neur the fourth and 
fifth dorsal rertebne. Circumscribed dnlnesa over the enlarged gUnda 
is sometimes found. Compression of a bronchus maV cause collapse of 
the lung, with consequent uniform dulness. 

By uuBcultation, we usually heur numerous n'lles and feeble or 
harsh respiration, or in other words tlie signs of consumption. Some- 
times arterial innrmiir^ may be detected. Agiiin, pressure on a bronchus 
may cause Iftcalized riiles and feeble respiration; or it mayjireYcnt respi- 
ratory sonnds in the portion of lung fiU]>plied by that bronchus. In 
these cases n deep breath will fref|nently bring out the respinitory sound, 
where it could not be heard in ordinary respirntion. 

DlAcyosis.— Enlargement of tht- bronchial glands cunnut usually 
be distinguished frum phthisis, but in some instances a reasonably cer- 
tain difTereutiutiun can be made by reuienibering that the disease under 
consideration usually occurs at an earlier ago than phthisis, and that 
the pain, lendeniesB,and dnlness which it induces are first found in the 
region of the bronchial glands, ininte-ad of over the apex of one hing. 

Piio(;sosis. — The prognosis must be based upon the evidences uf the 
structures inrolved, the size of the enlargement, and its rate of growth. 
A sitiiplu inllammutory enlargement may be arrested, but if tiTUiinaiing 
in Bup]>uration it is frequently fatal. >Syp}ii!itie adenitis rajiidly yiehls 
to appropriate remedies. Malignant disease in thia locality is always 

Tuberculosis of these glands is likewise nnfavorable. 

Tbeatuent.— Treatment is nsuatly of little avail in this disease, but 
the remedies which are most beneficial in scrofulous enlargement of the 
fiuperlicial glands should Ifc tried. Iodine, potitssiam iodide, calcium 
chloride and cod-liver oil may be used, with quinine to relieve fever, or 
iron when fever is not present. 

The diet should be plain but nutritious, and all the surroundings of 
the patient should be made as healthful as possible. 


Pertussis is an infectious, contagious disease, often epidemic, and char- 
acterized by paroxysmal, spasmodic cough terminating in a prolonged 
inspiratory crowing or whooping pouml. It is most common in children 
under ten years of age; it is rare before the third month: it seldom ofTects 
idulta but is occasionally observed even in advanced life. One attack 
usually gives immunity from later ones. 

AyATOMiCAL AsnPATHOLOoiCALCiiARACTEKiSTics. — The ouly mor- 
bid condition, found in fatal caae^ of pertussis, which is due to the dis* 
Mae specifically, is a more or less mai'ked catarrhal inflammntion of th» 
upper air passftges, luryni, trachea, and large bronchi. Other patholu;:- 
icul conditions present are secondary and due largely to the severity uf 


the cough. Pulmonary resicular emphysema is commonly present, and 
sometimes bronchiectasis, chiefly in the upper lobes. Pneumonia and 
atelectasis are not infrequent complications. There may be congestion 
of the meninges and apoplectic extraTasation into the brain, associated 
with effusion of serum into the cerebral cavities. Prolapsus ani and 
hernia are occasionally observed as results of the cough, and more 
rarely, rupture of the memhrana tympani. 

Etiology. — It is highly contagious and is said to affect even the 
lower animals. Infection is usually conveyed directly from one person 
to another, though a third person may be the medium of communication. 
Recent evidence favors the germ theory of its production, but as yet no 
one micro-organism has been discovered as the sole cause. 

A stage of incubation of from two to fourteen days precedes the ap- 
pearance of catarrhal symptoms. 

Symptomatology. — The disease is conveniently divided into a catar- 
rhal, a paroxysmal, and a declining stage. Sneezing, coryza, epiphora, 
and some cough characterize the first period, which commonly lasts from 
one to two weeks, and iu no way differs from an ordinary cold. 

The more severe the affection, the shorter the first stage. In the 
second period, the cough becomes a series of short expiratory efforts 
ending in a prolonged inspiration with a stridulous whooping sound 
caused by spasmodic contraction of the glottis. 

Generally several of these series occur in succession, terminating with 
the expectoration of a small amount of viscid secretion, and with some 
of a &othy nature, and often vomiting of a large amount of thick, 
glairy mucus. These paroxysms last from half a minute to a minute or 
longer, and recur during the height of the attack, every two or three 
hours, or sometimes three or four times an hour. The longer the inter- 
vals, the more severe the paroxysms. They are more frequent at night. 

Conjunctival hemorrhage, oedema of the eyelids, and epistaxis are 
frequently caused by the venous congestion which occurs during the 
cough. In some cases there is marked cyanosis, followed by great ex- 
haustion. Three or four weeks is the average duration of the second 
stage. In mild cases the characteristic cough may be entirely absent. 
In some cases it may persist as a habit for many months even after con- 
valescence. The symptoms of the third stage are those of a declining 
<»tarrhal inflammation of the air pasBuges, which usually lasts about two 

DiAGN'Osis. — The diagnosis rests upon the history, the peculiar char- 
acter of the cough, and tlie expectontion or vomiting of large quantities 
of viscid mucus. Affections of the bronchial mucous membrane, or of 
the pulmonary parencliyma, which are frequently develojied during the 
course of pertussis, yield the sjinie signs as when they occur independ- 

pKOGXOsiri. — Whooping-cough is a serious disease among infants. The 


prognosis improTos with increasing age, and larger children seldom suc- 
cumb to the affection, excepting when it is complicated by other disease. 
The indications are good if the patient is fairly well between the par- 
oxysms, but evidence of illness is significant of some complication. In- 
tercurrent attacks of measles or other diseases are unfavorable. Bron- 
chitis and broncho-pneumonia, especially the latter, frequently cause a 
fatal termination. Cerebral congestion, apoplexy and convulsions, or 
more rarely, hemorrhage from a mucous surface may be the cause of 

The patient may die from emaciation and exhaustion due to fre- 
quent vomiting. The affection is frequently preceded or followed by 

Treatment. — Many "specifics" have been recommended for this 
disease, but none have proved effectual. 

Morphine and chloral may be given in doses suited to the age of the 
patient, especially to adults (Form. 2). For children I like better potas- 
sium and ammonium bromide or hydrobromic acid with syrup of luctn- 
carium, with or without syrup of hydriodic acid. 

Sulphate of quinine in large doses, given in solution so as to make 
the strongest possible impression on the sense of tiiste, has been highly 
recommended, and, according to reports in the current medical litera- 
ture, it will cure the majority of cases in a few days; but my own expe- 
rience with it has been unsatisfactory. 

My experience with the preparations of anemone pratensis, thymus 
vulgaris and Oenothera biennis has been very limited, but never satisfac- 
tory. Antipyrine in doses of gr. ij. every three to five hours for a child 
twelve years of age, to be discontinued as soon as any cyanosis ap- 
pears, is highly recommended by many; and bromoform in doses of 
Til sB.-i. for a child of the same age, has been extolled by others. 


TTxDER pulaiouary phthisiB may be grouped several affections, differ^ 
ing somewhat in their nnntomicnl charncteristicfi, but closely resembling 
each other in their physical signs. From tliis Ititter fnct, it is especially 
appropriate, in the matter of diagnosis, to t-ousider them together. The 
term phthisis will then include all those wasting pulmonary afTectiuDS 
which are ulteuded with e^tudiition or inlillrutiun iiHo the pulmonary 
parenchyma, ranping consolidation, and are attended or followed by more 
or less induration uud coutraciion and snbeeqiient breaking down of hmg 
tissue, whether these diseases be the result of a simple inflammatory 
affection, or the cause or the refiult of tuhertuhir infiltration. 'I he term 
pulmonary phthisis will therefore include fibroid phtliiiiiB and the ordi- 
nary sou t« and chronic forms of pulmonary tubert-uloais. Any special 
symptoms or signs whicli are of value in differentiating between these 
rarious conditions will be separuti'Iy considered. 

Fibroid phthi^iis is aUo known as cirrhosis, induration, or fibroid de- 
generation of the lung; sometimes as chronic catarrhal pneumonia, and 
occasionally as bronchieotasia. 

The ordinary forms of phthisie have varioos names, as, chronic 
cronpous pneumonia, caseous pneumonia, cheesy or tuljerculons iutiltra^ 
tioD of the lung, chrouic tuberculosis, and pueumonic phthisis. 


Pulmonary tuberculosis may be more or less acute or chronic; run- 
ning its course within u period of six mouths or a year, or beiag pro- 
longed in eiceptiouul cases for many years. The term acute tubercular 
j>hthi8is is properly applied to miliary tuljerculosis of the lung as a part 

^H of tt generally disscmiuutod diseasu. 

^P Anatomical AND Pathological Char-^cteriotics. — Upon j>ost-mor- 
tem examination usually both lungs are found to be affcL'tcd. A lung 
which is the seat of ordinary tuberculosis may appear superficially normal 
or niuttltid, with grayish -yellow areas over which minute tulwrcles may be 
aeon in the pleura. This membrane may also l>e covered with an inflam- 

Ijuatory exudate. The organ it* heavier, more solid, and le«a crepitant 
than normal. Section usually reveals at the npei one or more ragged 
cavities, and yellow, cheesy niusaes, some of which may be semi- 



fluid. About these are miliary foci of caseation, a lino in diameter^ 
sharply defined to the naked eye, ronndeil, firm, transluceut, and gruy 
or yellowiah in color. Thronghont the rest of the affected lobe or the 
«ntire organ may be Bcattered miljftry tubercles, and larger ihc ^izo 
of a pea, more yellow iu color. There is aceompuxiyihg brouchitie, and 
from the severed tubes, some of which are dilate<l, pus may bo pressed. 
The non-tuberciilar parts of thtf lung may be the seat of oraphysoma or con- 
gestion and opdema, and the bronchial glands are infiltrated and enlarged. 
In acute tuberculosis, tubercle bacilli commonly fiud tudgment 
on the mucous membrane of the bronchioles or alvuoli, having entered 
the bronchi with the inspired air, or occadionally by rupture into the 


ne.S8.— ToBcaouL ii,uuiitcvll; A. pi>itl>rlii-Ml««Ua: crouodlriiiplLoKtoelto: <t,flbfou 


pAssages of a tubercular gland. They may, however, reach the lung 
through the circulation by one or more emboli from a distant tuber- 
cular involvement of a vein or the thoracic duct Whether ihcy pri- 
marily gain footing on the epithelium of the air passages or on tho 
eudotheliuni withiu the vessels, under favoring conditions they effect 
the formation of a tubercle. 

The tuherrle has no constant form, bnt consists of one or more mnlti- 
uuclear giant cdU, surrouuded by au aggregation of smaller epiiheliuid 
cells, about which is a xone of round lymphoid cells the size of leucocytes 
and smaller than epithelioid celln. Between these, and wntinunim wirh 
the irrpgtilar processes of the giaut cells, is a fibrous reticulum more 
or leis promiQenU 

Tubercle bacilli are present in and about these elements. 

Epithelioid and giant cells, though not [>eculiar to the tubercle, are 
more frequently found iu it than elsewhere. 

The many oval nuclei of the giaut cells are arranged at its circnm> 
fercnuc or at opposite poles. The epithelioid cells may have one or 
two nuclei; the lymphoid celU, which are smaller than the epithelioid, 
have eafdi a siugle relatively large nucleus. A proiniueut feature «>f ihe 



tubercle is its non-vnscularity, with u tendency to undergo early coag-ti- 
lation necrosis, with coalescence of its cells into a homogeneous, firm, 
gray nias^, which Inter becomes softer, clieesr, nml yellow. 

This ciweaiion invariubly hegins nt the centre of tlie nodule, itnd is 
probiibly tho result uf the IuqVl ot nourishment nnil the specific action of 
the bucilli. This tubercle foriniition is the siime when occurring in the 
lungs as elsewhere; its 8ubgiefjut.'iit courso is, however, very difftieiit and 
vttricB in theso organs ftcoording to the mode of infection, the resistjince 
of the tissues, the number of bitcilli and possibly their vinilenoe. Frnm 
tho primary focus, the niigrating leucocytes and round celbearryihe 
tubercle bacilli into tho surrounding intercellular and perivascular 
lyuiph spaces and into neighboring alrcoU. Xew tubercle develops wiier- 
ever the germs gain footing, and, either as a process of iiiHamnii.tory 
exudation ur uf cell prolifenitiun starting from their walls, the adjacent 
air cells be(:onie filled with Qbrin and celluhtr elements beiiriiig tlie nox- 
ious princij>le. The walls of the alveoli and neaociiite<l bronchi become 
infiltrated with round cells and thickened. The capillary plexus is de- 
stroyed as the process extends and the tuberclea ooalcsce, forming larger 
fooL While extension proceeds at the uircnmfcrcnce, the centre under- 
goes caseation and softening, and eventually nmybc partially disirhargcd 
through the bruncliij leaving an irregular, rapidly sloughing t-avily behind. 
By iu<piration into other alveoli this discharge becomes the means of fur- 
ther lobular extension. In some instances, in addition to these evidences 
of acute infliimmation, breaking down of the lung, and wide dissenii- 
Dfttion of caseous foci, and more or less extensive fibroid thickening or 
cirrhosis of the [K-ri bronchial and interlobular tissues will be observed. 
Such are cases either of ehronic intlaniinatiou of the lung ujHin which 
' tuljerculosis has supervened, or of primary pulmonary tuberculosis in 
which the partially successful efforts of nature to limit the disease have 
resulted in connective-tissue hyperplasia. 

Etiolooy. — The predisposing causes of the disease are those inflii- 
enoes whicli depreciate the genenil heiilth of the individual or which, by 
diminishing locid tissue resistance, afford fitting soil for growth of the 
bacilli. Though the essential cause, the tubercle bacillus, is probably 
rarely trausuiitteil from mother to child, it is reasonable to snppoee that 
the weakness of constitution which tul>ercuhjsis engenders in the parent 
may be inherit^-d by the olTspring. In so far, the latter is a more suita- 
ble tield for infection. As reported by James T. Whittaker, of Cincin- 
nati, ubservatious by Caokor {Veuhchg Mediziual'Zeitunyj Berlin, Jan., 
18lv^) and F. V. Birch-Hirschfeld {IfeHinrhp mffiirhiixrhr WorheHxchnf'ty 
I*ipzig, March, 189"^) seem to prove that the banilli may Iw transmitted 
directly from the mother to the fcptns. Children of those who are 
debtl)tat<Hl by other diseases, by vicious habita, or by age receive a 
simihtr heritage. The predispo-sition tn tuberculosis may also beacquired 
by those who are habitually subjected to improper hygienic intlnences. 



Poor or inmifHoient food, scanty clothing, want of clesnlineos, impure 
or damp and chilly air, and lack of annshine, rariouBly combined, may 
redace the most robust nonBtitntion to a ronditiim aa fHvnrnble to 
phthiBie tuf. is the inherited, so-t'iilU'd armfulDUg diiitlieaii?. Prolonged 
lactation, frequent rhihl-bearing, ntrohuliiini, and clironie malaria, by 
enfeebling tho constitntion, also prepare l\w way for InUerciihtr infec- 
tion. Rronehitis, pnounionin, and other pii)monary iiffeftinns frequently 
prejtart' the soil locally for the growth of the 8|KJcitlc germ. 

It is now generally conceded that the ultimate cauBe of tuberculosis 
is the tubercle bacillus, as fir*t determineil by K'x'h in 18-S*..*. This is a 
slender rod varying in length from one-quarter to one*huIf the diauicter 
of a rod blood corpuMile; it ia tstr.oglit or curred, occurring singly, in 
chains, or in grou)>s,and is incapable of voluntary motion. When prop- 
erly stained, it has a peculiar bi*aide<l appearance, and if highly niagiiiQed. 
Btnull bright spots may be seen within the rod. having the tippeantnce of 
Biiores. The bacilli are I'clativcly enduring, but grow outside the body 
only under the most cart-ful regnlution of tempfnitnre, nutrient media, 
and other conditions. Tubercle UicilH enter the lung chiefly through 
the uir pjiesages, conveyed by particles of dried phthisictil E{jutuui or 

£ntranco may take place through the circulation from a primary 
focus elsewhere. Such a focus may in rare instances be estiiblished by 
the ingestion of luberculoui^ meat or of milk from a diitoiiscd linimal, 
Chickc-ns that are allowed to eat the pputum from tul>ercuIous pmients 
often contract the disease and may become a gource of infectioD. There 
can be no doubt that in a small percentage of cases the disease is con- 
tracted by direct contagion, as in case of those who have nursed con- 
sumptives long and closely. However, norH'ithstanding the vart multi- 
tudes who yearly die of consumption, very few well-ant henticated ca5es 
of direct contagion^ or infection from ingestion of tuberculoussitbgtanccs, 
can be adduced. The investigations of Henry P. Loomia, of Xow York 
(Hesesirches of the Lr>onii& Laboratory, Xo. 1, p. 75), show that forty 
per cent of the bodies of persons dying suddenly iu general good heidth, 
apparently iM?rfectly free from tuberculosis, have tho bacilli in the 
bronchial glands. Therefore, while it may be admitted that KochV 
bacillus is the ultimate cause of the disease, it appears impot«nt except- 
ing in the presence of a favorable soil as furnished by thoee of depraved 

Stjiptomatoixjov. — The chief symptoms of ordinary pulmoti.'iry 
tuberculosis are only too well known, even by the laity. Few there are 
who have not noticed among their immediate friends the bright and 
suffused eye, backing cough, progressive emaciation, hemoptysis or pur- 
ulent sputum, the hectic flush, and the night-sweats of tbi» dread dise;ise. 

The affection often comes on insidiously, with ii slight hacking cough. 
which does not attract attention till the |wtient tiikes a severe cold, or is 



tAken down with some acnie disease from which he doee not coiivulwce 
at the proper time; he is theu discovered to have s3-mptoins of con- 
sumption. Sometimes, howevt-r, there may have been no hacking cough 
in the begiaiiing; wo uro often told that the disease started with a severe 
cold, whoopitig-congh, meaales, influonxa, typhoid fever, intermittent 
fever, pariuriiion, or chronic affection of the throat or bronchial Tubes. 
la quite a large percentage of cases the patient bus been apparently in ■ 
perfect health nntil ha*nioptysig has occurred; from this he may have 
perfectly recovered, but noi infrequently the gyniptoma of a grave dis- 
ease huve steadily progressed. Often there is a history of prolonged 
overwork and exhaustion culminating in fever, supposed to he roalari- 
ouB or typhoid, during whii-h the evidences of pulmonary disease ar« 
diic'uvered. In most instiiiices lotis of vcight occurs early in the affeo- 
tiou, depending generally upon loss of appetite or imperfect digestion. 
Daily fever of two or three degrees is common, and a nearly uniform 
symptom is rapidity of the pulse; even while other symi)tom« may not 
be pronounced, the pulse frequently runs from one hundred to one hnn- 
dred and thirty per minute. The cough is at first hacking, with little 
or no expectoration; subsequently the sputum may become mucous and 
later mnco- purulent. Hwmoptysia occurs in a considerable number of 
cuses, but not in all; in many, early in theatUiek; in others, not until the 
close of the disease. A simplo streaking uf the sputum with blood 
should not be considered as evidence of tuberculosis. In mauj coses 
these symptoms gradually increase for six or eight weeks, and then 
slowly Bubdidc until the disease is arrested> and it may not again become 
active; but in the majority who are less fortunate^ as the disease pro* 
presses there are only periods of comparative health between tlie attacks 
of great depression, and each of these latter is likely to leave the patient 
weaker than when it begnn, bo that he grows worse, although at times, 
not only the patient, but his friends are encouraged to believe that he is 

Disorders of the digestive tract are prominent accompaniments of 
the pulmonary trouble. Aimrexia, cominouly an early itymptom, may 
be aE80ciat«4! with nausea and vomiting; the latter may Ik ilue to tlie 
severity of thu cough. Gastric pains, which are often present, may be 
reriex or may be dependent upon au inflamed condition of the mueons 
membrane of the stomach. Diarrhcea is frequently very troublesome in 
advanced cases, and is not uncommon at any period of the disease* 
Kapid emaciation, proportioned to the acuteness of the atTectiou, is a 
natural conse<)Ufnt of continued fever and anorexia, and attendant mal< 
nutntiou nmy l>e aggravated by litemoptysis or a chronic colliquative 
diarrhu-a. In many instances tulurcular patients are }io]>eful to the 
«nd, though this is less common than is generally supposed. In tbe 
later stages of the ilisease, cerebral aniemia or possibly tubercular changes 
in the brain itself, or the sympathetic effects of imperfect digestion 
nffcct the mental condition, causing irritability, fretfulness, 'cerebral 



fAtigue upou nieotnl exertiun, and finally, iu sonte eiiai-a, Iiullticiimtions 
or fixed delirium; tliouj^h commonly the mind remuiun clear to the l:ist. 

The *i'^(w differ in Trtrioua stajjea <if the uffectjun, the most im|inp. 
taut being; diminished movement and sinking in of the cbeet walls in 
the infraKjIftvicnlar region, with dulnesa on parcusaion; and nt an early 
stage, feeble re(<j)iratiou. ur HubiTepitant n'lleit rontined to one apex. 
foUuwed by broncho- vesicular respiration, exaggerated vocal resonance, 
juetiilliL" rules, and the signs of cavities. 

riitliiBis is generally described x\i having tfiree 3tagi?e, but these run 
impen'fijitihly into eacli other, iu that the eigne of two or of nil of them 
are likely to be combined at one time in the sanif individuMl. Tha 
fitage^, therefore, f*jinnot be sharply delineated, and I think an attempt 
to describe the signs of each separately wotild only Isad to confusion. 

The BtJi^os of phthisis consist of: tiret, the incipifnt stage: seeund» 
the stage of more complete deposition, occasioning coniiiolidntion iiinl re- 
tracliun; and third, the stjigo of softening with breaking down of lung 
tisiiue and the formation of oaTities. The pulmonary lesions occur with 
alKint efjual fre(|ueney on the right and on the lefl sidi- uf tlie chei«t,jind 
almoat always they are to be fuund at the a|H>x uf the lung. 

Inspection nntl mensuration yield no sign^ in the early stage of this 
disease, except incre:iKe4l nipidity of the respimtory m»tvementp. After 
a few weeks, in the second stnge, in addition to the rapid respirations, 
we observe more or less lo«s of motion, with sinking in of the rhe^t 
wall over the affected org:in, especially diiring deep inspinition. lu 
the la^t stage of the disease, there is marked emaciation, with promi- 
nence of the clavicles due to the sinking in uf the tissues above and 
I>elow them; loss of motion becomes more distinct, and there 10 depreis- 
sion of the chest wa)ls, usually in the infra-clavicular region. 

BxoefitUmal.—Xn iixcAi\i\\on\i\ cu-ws, cavities may oxist in the apices of tb« 
lungs wiltiout uny L-'.>iutilerublu (]«[>reHsion of \.\w chest walls or diuiiuutiuo ia 
their niuvciui-nt«, 

Early, palpation furnishes no signs. As soon as any considerablo 
amount of cousolidatiuu has taken place, the vocal fremitus is apt to ha 
increased, but this sign 'ms vurtable, and therefore unreliable. S^imetimea 
gurgling fremitus is detected over superficial cavities. 

Ernrptionnl. — Shrinking' of Th« aifecteii lunj^ may di-ag the heart a nhort dlo* 
TAOce from il.t nomial positiun, ait inillcat«d by the site of its tip«x beuL The 
f^mnutipn of a lar|;e cavity ixvii^iunolly causes biils'iag of the portion of Iba 
cheat which was formerly dcpresw-d. 

On iH-Tcnesion in the tir^t fi/itge of this diseiue. there is alight dulness 
if the superficial portions of the hing be affected; but if only Uie deeper 
fttructures are involved, this sign may be absent. 

Dulnes:'. when slight, U best obtained with the patient's mouth opeUf 
and the djfferetice in the resonance of the two sides can be most easily 
recognized at the end uf a full inspiration. 



The late H. A. Johnson, of Cliicu)^, told me that he &otneUin«a ohiAioed ex- 
cellent results, in obscom rtisi's, by listeitin^ wiili tlie oitiiimry hinaunil :ttrtti(^ 
aco|>e, the cbe^t [>iec<< of wbii-b wus h«lil by ibe patient nbmil twu inuhoa id front 
of his opea mouth while pcrcus&ioa was being made on U\e client. 

Id this connection, it must be constuntly borue in mind that mod- 
erate dolness i& frequently a nornutl sign over the right apox» nnd that 
QX\wv diseases than phthisis, as, for example, bronchitis and cireuiu- 
scrihed ]>neumDnia. not infrequently cause temporary duluess iu thu 
infra- CI lav ipular regiun. 

I)ulnes8 orer the left apes, even though slight, is always abnormal, 
and, when persistent, is nearly always a sign of phthisis. Marki'd dul- 
ness, if persistent, has the same eigniflcant^o when found over the right 
apex. This sign is sometimes found behind when it cannot be deteotetJ 
iu front. It is frequently present in the en pra-cl avion lar or clavioular 
region when it cuuuot be obtained below the clavicle. 

Exct'ptiviifii. — In Ibt: llrst Htu^e vt [ibthisis Ibe ti-KHinncc in sotuatimv^ 
TesioulQ-lynipunitK-, on wtxiunt uf secondary cirruniM,-nbi->l t-inphysunia. 

Cunftoltdatiou ot the ileepor jKirtionH of the lutig iiiiiy ciiuse no ihiInvK> upon 
ordinary percussion i( healthy hing tissue intervene beiwi^n it unJ tlie sitrfiwc. 
In fon.'ibli* percii&£ion a snmll amount of consolidntion at llm aiu'fu-e of the hin;; 
may be tiverlooked in consequence of the intense iwtonanco from the deeper 

It iihould be remembered, in estimating the amount of phthisical con- 
Bolidation. tlmt the degree of Juliiei^s and its area maybe due to the 
temponiry luinsoliilatiou of circumscribed pncuaiouiii. The extent uf 
phthisical coneulidatiou in such cAses can only be aacertjiined after the 
inflammatory product has been abs<jrbo4l. 

Iu the uvi-ond iitufje ot phthisis, dulness becomes very marked, and 
gnidunlly extends over a wider area, owing to progressive pulmouary 
consolidatioii; up to this time, dulnesE is almost universally t:un6ned 
to one side. \i the same lime, tubular — or, according to Flint, tym- 
panitic — resriiiance may be caused by the bronchial tubes or the 
trachea, especially when percussion is maile nc:ir the borders of the tipper 
part of the stonium. 

Exceptional.— Iu this, as in llie first stage, veBiculo-tympantUc resonutu^e 
may be obtained in mre instances. 

In the third Ktayt; dulness is obtained over the affected lung, unless 
cavities of considornblo size exist nejir the surface. In this case, reso- 
nance over a limited portion, surrounded by dnlnese and corresponding 
to the cjivity. may be tympanitic, amphoric, or cnicked-pot iu char- 
acter. Sometimes early iu the morning, duhicfis or flatness may hi oh- 
'Hfted over a cavity, owing lu its being filled with secretions, which will 
^place, after free expectoration, to the signs of a vomici. In this 
{e, or in the latter part of the second stage, dulness nearly always 



apl»edir)! at the apex of the opposite lung, where it can bo detected bv 
oauipariug the resonance ovor the diseaaod etruottire with tlmt below th» 
ecoud or third rih. 

Amoug tiib early Bigns of thu diseaae to be detected by utitictiUation 
are feeble or cog-wheel respinitlon, with ftubcrepitanl Mies, limited 
to n Bmull portion of the iipfx of ouf lung. Oi .;u-ioniilIy tlie iriucous 
click or a few crepitant or sibilant r.lles,or eriiinpiiiig ur friction sounds, 
may be heard in the same locality. Broncho* vesicular respimtion is 
obtained a little later. The henrt-sotind^ are heard with nbuormtil iu- 
tensily over the affected lung: if the cotit-olidntion be upon the right 
lide, the first sound of the heart wilt be nioEt distinct; if upon the left, 
^tfae second sound is more intense than the first. 

In the first stage, the exaggerated bronchia] whisper is a sign of 
considerable value, and exaggerate*! vocal resonance can usually be ob- 

At a hitcr period^ in the second stage, bronchoTesicnlar reiipiration 
becomes distinct, the respiratory sounds are harsh and tubular m qual- 
ity, and the expiratory murmur is prolonged and high-pitched. There 
are also large and small, moist, cmekling, ur metallic rdles, which are 
often sticky in characler, and not affected by coiij.'hing. Friction truuiids 
are often present, due to circumst-ribed jdeiiritis, caused by the tubercu- 
lar deposit in the pleura. In a few atses, subrrepitani or sibilant, and 
occasionally sonorous, rdles may still be heard in the second stage, lim- 
ited to a small s|)flce over the affected tissue. Krtles are generally most 
abundant in the morning, before free expectoration has taken phice. 
Vocal rewnaucf, with the whispered or the loud voice, ib now tjidgifcr- 
ated or bronchophonie. In uonie cases, wheTi tlie consolidated lung im- 
mediately surrounds a large bronchial tube, pcctorihtquy may be ob- 
tained. |)uring the latter part of this stage, the eigne of incipient 
phthisis usually appear at the apcv of the opposite lung. 

In the third stage, when cavities have formed in the lungs, if they 
are empty and are connected with a bronchial lube, aivernous or 
broncho-cavcruous resi>iration will be detected. True cavenmus rpspi- 
ration, of a soft blowing or pufhng chanictt-r. and of low jiitch, is one of 
the very rare sign^ of jihthisis. Broncho-cavernous respiration, hnving 
much of the bronchial element, still with a 'hollow quality strongly 
snggesiire of a oaviiy. is heard in nearly every case, .\mphoric respira- 
tion is found in exceptional instances only. Associated with these signs 
we usually hear numerous rAles and gurgles with bronchophony, pec* 
toriloqiiy. or nivernoiis voice, and occasionally niclnlHr linklinj; and 
amphoric voice. The nigns of the second stage also aregenenilly present. 

If cavities are filled with fluid, none of the ordinary signs of the 
third stiffe may be obljiined. Small cavities located in the deeper por- 
tions of the lungs are not easily detected. 

lu adraiiced phthisis, we vnay rerisonably conclude that a cavity ex- 


'M* whenever the respiratory and vocal sounds over a small space, and 
iimitef] tO'it, are peculiarly intense and bronchial in character, and asso- 
^riated with metallic rales. 

l»iA(Jsosi8. — Pulmonary tuberculosis is to be distinguished from 
Mronic laryngitis, chronic bronchitis, pleurisy, chronic pneumonia, syph* 
Uu of the lung, cancer of the lung, and other intrapthoracic tumors. Its 
differential diagnosis from these affections will be found under their 
respective titles. The diagnosis will depend upon the history, ^mp- 
toms, and physical signs just mentioned, and upon the discoTery of 
tubercle bacilli in the sputum. The presence of these bacilli in any 
numlKii- is always indicative of tuberculosis, and in mtjst cases their 
ubunduuce is in proportion to the severity of the disease (Clinical Diag- 
TI0H18, Jaksch) ; their absence from the sputum is not in every case posi- 
tive evidence that the disease does not exist. 

Elastic 0bre8 in the sputum, though not peculiar to tuberculosis, are indicia 
tlve of pulmonary ulceration. 

To Stain Tubercle Bacilli is Sputum. — Many modifications of 
the Koch-Ehrlich method for staining tubercle bacilli have been sug- 

Ziehl's solution, which remains good for many months, is now com- 
monly employed instead of the aniline preparations. It consists of dis- 
tilled water one hundred parts, alcohol ten, carbolic acid five, fuchsin 
one part. The procedure which I have found most convenient is as 

(1) Examine the sputum on a plate of glass against a black back- 

(^) Pick out a very small quantity of nummulated purulent sputum. 

A platinum needle fixed in a glass rod is most suitable for this purpose; it 
should be sterilised in ttie flame of an alcohol lamp or Buosen burner before 


(3) Spread the selected sputum, in a thin layer, evenly between two 
glass slides, by drawing them successively one upon the other. 

(4) Dry in the air or high above the flame of an alcohol Iwnp or 
Bunsen burner. 

(5) Fix tlie albumin by passing the slide several times through the 
flame with the film iii)wurd. 

{i\) Pour about twenty minims of Ziehl's solution upon the slide 
thus propiired, nnd lieut over the flume till it steams. 

(t) Iji't it stimtl for thirty seconds, or longer; then wash in clean 

(S) Di'colurize to a fuint pink color with a two or three per cent 
sohiti"»n of uulplmrii- or any of the mineral acids. 

This cun lu' done best by dipping the slide for a few seconds in *ba 



w*id sttluliou, wushing directlv in water, aud liuldiug it up to the light 
for iusjMictiou, re|K.*ating the operation until the faint pink color is ob- 

(f*) Count«rstaiu with a two or three per cent wat«ry aolation of 
xnethvleno blue, wtiich is merely iKiured upou the slide and left from 
thirty to sUty sooondfl with or without heating. Methylene hlne, if a 
gooil article, is readily Holiihle in water. Two or three grains of chloral 
may be added to the ounce of methylene solution to prevent decompu- 

(10) "Wash in clean water. 

(11) Dry, and mount with cover-glaM in glycerine or permanently in 
balsam, and examine; or dry and examine directly without a cover- 
glass, with a one-twelfth oil immersion lens. This lens with a No. 4 
eyepiece (Zeiss) magni6es about a thousjind diameters and shows the 
Uicilli as represented in 'Fig. 59, which was drawn for me by Uene- 
age Gibbee, of the University of Michigan. 

The bacilli may be seen distinctly with lower powers, but their detec- 
tion ia much more easily and sjHfedily accomplished by this lens. 

Thus prepared, the small beaded twicilli appear red. while all other 
micro* organ isms, cells, albumin, nnd fibres are fitained bine. The only 
other micro-organism yet discovere*! which closely resembles the tuber- 
cle bacillus in form, size, and manner of staining is the bacillus of lep- 
rosy, which difr<.*r8 from the tubercle bacillus in taking the watery 
nuilin sljiius ir(|uully as well as other buutcria (Linsley's trunslaLiuu 
of Fraenkers Bacteriologj', page 231). 

Discovery of the bacilli may sometimes be faeititatetl by ihuroughly 
stirring, and boiling iu a large test-tube, about 3 i. of the apulum with 
3 vi. of a solution of caustic soda, :i parts to 1,000, until it forms a 
thin muss. This should Im uUuwfd to settle twenty-four hours, when 
the sediment, which carries down the bacilli, should be examined. 


Miliary taberonlosis of the longs is a part of a general disease; 
though all the riscera, and especially the peritoneum, pli-ura, and men- 
inges, may be involved, the lungs are the chief seat of deposit. 


the aize of a pin-head are observed seattert>d over the pleura and dissem- 
inated throughout the aiTected lungs, whirh arc usually congested and 
obdemutous. To the unaided eye these tubercles appear sharply defined. 
Microscopically the outer zone of lymphoid cells ia seen to merge gr^- 
ually iiiUj the surrounding lung. The air cells contain to some degree 
the elementa of exudation. 

KnoixinY. — The immediate foeus of general infection may be in any 


VTguu, \ouea, joiul^, or in the oriniirj tract, but usaally it is in the 
JaDgs or IvinpliAtic glmoda. 

Ulctiration iuto a lymphatic tmuk Is foUowed by entnuico of bacilli 
iuto Che circulation and more or le^ extensive infection of other purUi. 

SvuiTOiiATonxiV. — The general s}-n)ptonis are very like those of 
typhoid fuver, tlough the temperature is frequently highest in the 
morning, ranging between 103" and lofl" F., and occasionally going np 
to 107" F. Prostration is very early ami marked. Involvement nf tlio 
meninges gives intfinric iieadache, vomiting, opisthotonos, delirimn, and 
ocular disturbance. The pnlmonury symptoms are not choracteristici 
but cough is usually present and esi>eclorutioti, if present, is frothy in- 
stead of muco-puruleut. Xo tubt-rcle buc-iUi are present iu the sputum, 
unless H localized tu)H.>rculotjis uf the luug has existed before occurrence 
of the miliary form ol the difieow. 

Acute miliary tuberculosis is attended by no physical signa anleea 
the mucous membrane lining the air passages is involved, and then 
there are no signs except those o^ bronchitis. The diagnosis in such 
coses niUBt rest ufton the history and symptoms, and the exclusion of 
other ])ulmoniiry iiffections. 

DiAOXOsis.— Discrimination between the various forms of phthisis 
is often attended with more or less nnceriA^uty. The principal features 
of value in distinguishing between them muy be seen iu the following 


The constitutional nynip- 
toros come on slowly, and 
are less »rvere ihun would 
natumlly be expected from 
thecnndition otttie lunj^.tts 
iodicateJ by |>liyiiic)il sij^iu^. 


The coDstilutional The disease is ushered in 

gymptonis come on more with cliilU and fever njih- 

rapidly, and are pntver out complete rctui-udons, 

than would be ex|M;ctt*d und Uinre is rapid acve«< 

from till) ]jhy*ical signs. sioDOfgravecoastitulfonol 

Rymptonw. wlnpti cannot 

bo .icfouritcfl for by the 

broocLilis, si^ns of which 

are Uie ouly ones to be ob- 


The fever Is Intermit- Thofevermoreoonlin* Fever remittent, tem- 

tcnt. wfUi an afternoon or uous, with nearly con- pertiture oJteu hiKrhest in 

evening (jlcvatioQ in tero- slant elevation of tem> tlieniurning, varymgfi'om 

pvrature of from one to perature. but less 103' to 105' orevea wr F. 

two de^refv. markf^l exacerbutiooa. 

I>lurrha-a not common. Diarrhoea usual. 




mcsiirsiMPi-K isFLAy- ok the orwnart lobis. 


Bn|iiil respiration, and 
signs of ciHiitoliilaliuu upua 
[>{iI(>utloti, iHjrcufaMon. nnd 

tending over a large jmrl 
of till.' lung. 

No tubercle bacilli in 


Rapid res pi ration, 
pliyfiical iigvs ul cuiitfjl- 
idittion l(;»s marked uod 
Itiiiilcd to a Amnllerarpii 
than in Ibe preceding 

Tiil>ercleli>acilli inftpu. 

Rapid respimtion. wilh 
usiiftllytlte jtigus ui l>ron- 
clillJs, Olid ordiaorily nt> 
iiign5 of L-oiiftulidatiuQ, Init 
orcasionolly Blight dul- 

Usually no tubercle bOf 
cUli in sputum. 


5y;(on;/wij*.— Fibroid degeneration of the lungs; fibrosis; chronic 
pneninoniM; interstitial )met)moniii; cirrhosis, or scirrhua of the lungs; 
induration ut Iho lungs. 

Filirnid phthisis ia a cbrouic iiifluniumiury :itlectiuii characterized 
by com pa ni lively slow progress, thougli in the majority of cases it fiuoUj 
teriitinates in lubcrculudia. As compu-red with the ordinary form of 
cunsuixipiion, the b-yniptoms art* shght iu proportion to thi* uuiuuuC of 
lung tissue involved. 

Anatomical and I*.vth«ix)OICal Charactrkistics. — The chief ana- 
tomical changes consist of hyperplasia of the interalTeohir, interlobular, 
and peribronchial struoturcs, which encroach npou the uir passages and 
blood-vessels, correspondingly diminishing their capacity; this encroacb- 
moul is &ubse<|UtiUily iitcrcu«ed by the contraction of the newly formed 
Blements. There is little or no exudation into the air cells. The dis- 
[^«aBe may involve a imrt or the whole of one lung, or both Inngs may be 
affected, though commonly it is confined to one side of the chest 
throughout the greater portion of its course. 

]usi»ection of the alTcOted organ reveals In most fatsos more or less 
exteuiiivf adhesions uf the overlying pleura, and often extensive thick* 
«ning of the latter wenibrauu, especiully when the disease has resulted 
from pleurisy. 

Occasionally fluid ia found in circumscribed pockets of the purtiully 
obliterated pleural cavity. The thickened pleura may present very 
naoh the appearance and density of tibro-cartilage. When the process 
is general, an entire lung may be found shrunken to one-tenth uf its 
normal size. The color varies from a dark red to a blaish-gruy, marbled 
with black and streaked with lighter lines. 

When localized, the shrunken, cirrhosed area contrasts strongly 
rith the adjacent normal or emphysematous lung tissue. This part is 
abnormally heavy, and sinks readily in water, and when pressed yields 
bnt little fluid from its cut surface. In advanccil cascs^ the tissue is 



BO firm that upon section the kuifo ^ratca as in cutting curliluge. The 
cut surface is of a dark griiy or blackish color, interw<iteii hy vt*nowtgh- 
whito biiiiils, mid mottled with lighter circles marking the positioa of 
ohliterutcd veg84.'l>« and tubes. 

Ar thp procuss advsinees, and c-oiUr:iction of the new liattuo occurs, 
many of th*' air cells become destroyed, idthoiigh here and there islets of 
normal or emphysematous vesicles may still remain. Dnring the pro- 
cess, many of the hroiidiial arteries, toother wilh numerous brnuehes of 
the pulraunar}' urtery are obliterated: and us a result of the pr»R>os8 of 
contraction, liere and there dilatation occurs in the bronchial tubes; and 
bronchiectatio cavities are found, lined by dark rod, thickened nincoua 
membrane, and cfintaining purulent fluid, or cheesy dehris. These cavi- 
tica may also bo the «eat of ulcenition or ganprone and vai-y from half 
au incli to tvo inches in diameter. The bronchial glands are frenueutiv 
enlarged, and ultimately these and the cirrhotic lung tissue, in many 
cases, become the seiit of tuberculosis. 

When the afTectiori is confined to one lung, the opposite organ niHT 
be functionally enlarged or may become emphysematous, and not infi^ 
quently at the autopsy tliis luug will be found the seat of bronehilis or 
acute croupous piieunioniu»-hieli lia.s bettu the immediate cause of death. 
In markeiJ cases the heart is disjilaced toward the allected organ bv 
traction of the contnicting tiasuen, an<l its right cavitiets are usually 
dihitcd, wliilo their walls iire hyj)ertrophied as the result of obstruction 
to the pas&'ige of venous blood through the lung. 

K'noumv.— The disease occurs must commonly in males betweon 
fifteen and forty years of age, and is generally the rct'ult of local causes 
having little or no dependence upon diathesis. Catarrhal pneumonitk 
and pleurisy are among the most frequent (causes of the disease, but it 
mv.y result from ehrouic broncliitis or acute croupous pneumonia; cir- 
cumscribed indumtion is also a common result of arrested iiiilmonurv 

SyMiTOMATOLOOY. — Tbo progress of fihroid phthisis is not so rapid 
B8 that of the common form of consumption; but its symptoms and 
signs are usunlly much the same excepting that the symptoms do not 
a]i{>ear commensurate with the pulmonary lesions, as indicated by tho 
physical signs. 

As a rule, the disease is chronic from its inception, although its d( 
Tolnpment may date from an attack of pleurisy, pneamonia, or broa-| 
cbitis. The origin is often oltscure, and the history is similar to that of 
chronic bronchitis, ftith frequent cxacerbjitions. Dyspnoea, though oftea 
iilMent or moderate, increases with the advance of the disease, and ie 
subject to exacerbations, during which the ditticulty of breathing may 
be experiencod for seveml days. Daring the hitter portion of the dis- 
ease dyspnoctt is constant upon any exertion, and eventually becomes very 
groat, even though the patient is quiet. Cough u a common symptom^ 

F!BR<Ht) PHTItlHltL 

though it varies mnoh iu differeut cases, and different periods of the 
Bame case. It is increased bj recurrent iittaeks of hroochitie, and is 
genemlly worsft during tho winter monthft. When hronchieptaBis exists, 
the cough is likely to be jwroxysmul, esiiecially severe in the morning, 
uid accompanied b}- a profuse, fetid exjfectoratioii, after which relief 
may bo experienced for seveml hours, Vuniiting often follows lhe«» 
piiroxysnis of coughing. The sputa nmy be scanty, and viscid, but when 
dilatation of the bronchial tubes has taken place, it in generally copiouB,. 
sometimes amounting to two or three piuts in the twenty-four hours. 
It may coneist of mucus ur mucu*pus, and is usually uf a yellowish or 
greenish-yellow color. 

Ila^nioptysis is not nncomraon. even in the absence of tnbercnlosis. 
During tlie grenter portion of the divotme the Hi>petite usually renuiina 
pwtd. and conspqueiitfv the strength may he fair »ntl emaciation gradual 
unless tuberculosis superfencji. Jn well-mnrked cases the signs arc tol- 
erably distinctive. 

Inspection sIjowi^ flattening of the chest wall over the affected part, 
uid dopressiun of the shoulder may bo observed. 

Ou palpation, vocal fremitus is exaggerated. The heart is dislocated 
more or le«8 toward the affected side, as shown by the positiou of the 

Percussion gives dulnees over the affected side and exaggerated res- 
onance on the sound iiide, whi<'h sometimes extends, in consequence of 
the distention of the himiihy lung, from two to four inches beyond the 
mudbiu line toward the affected side. 

Auscultiition gives bronchiiil breathing and bronchophony, with or 
without bronchial n'lles. .Subcrepituut niles iirc, however, couimonly 
present- The vesicular murmur is feeble or absent. 

The dingnosis^ prognosis, an<! treatment of flbrnid phthisis will be 
considered with pulmonary tuberculosis, though we may here stale that, 
during the earlier part of the disease, the treatment indicated is essen- 
tially the same as that for chronic bronchitis. 


Acute miliar>- tuberculosis freipiently runs its course within three to six 
weeks, and seldom extends over three months. Chronic tuberculosis- 
may terminate fatally within five or six months, but it of ton lasts for 
two or three years, lilt' avenige duration being about eighteen months. 
The records of autopnies show lliat about twenty-five per cent of the 
patients dying m ho8)utaIs ns a rc^lt of accidents and acute disictse. 
liave ciciitriccs in the apices of the lungs resulting from old iuAamnia- 
tions, probably of tubercular origin; and experience has shown llutqnile 
a large percentage of pnticnia suffering from well>marked though not 
extensive tuberculosis recover. While I am not able to fortify my im- 
pression by statisticjj. I believe tlmt. all told, about thirty-three per cent 



recoTer undtT ortlinnry cuitililioiiti, tuii] I think tlml putieiitg sent cnrly 
to high iillituiles unil n dry ntiiiaspliert! have their chances of recovery 
lucreiiux] fully fifty ]M.'r trent. Whera the digeiiee is so extensive nt the 
apex of one Imig tltjit the signs may hti n^copnized below the sccoiid rib, 
perfect refxtvery, so that no ■gigns wlmtevor van be detected, sddom 
oocnrs, hot the disease not infrequently becomes arrested, the cough »nd 
:ill other symptoms dissippuaring, tlie evidence given by » scar in tlio 
Inng Iveiiig all that can he detectetl on careful physicnl examinotion. 
When tlio disease has extended as low as the fonrlli rib, therL- uro » 
few cases in whom it may be arrested, provided they hnrc the best 
hygienic surroundings; but after the whole of the upper lobe of one 
lung and possibly u small part of the lowur lobe, togctlier with the apex 
(if the opposite lung, have becomo involved, it is very raru timt much 
imitrovenieut tnkea place, though even when these conditions exi«it 
;ind lifter cavities of considerable size have been formed, we otxiision* 
ally find the disease arrested, so that the patient may live for many 

L'suAlly fibroid phthisis continues four or five ye^rs, sometimes 
louger, but finally it eveatuates in tuberculosis, termiutiting iu much 
the same \*'ay as the ordinary form of this disease. ■ Usually death rcstilts 
from asthenia, occasionally from heart failure, iind in a small percent^iga 
of cases from hemorrhage. Out of over six hundred private cases of 
which I have records, but five are known to have died from hemorrhage. 
Generally tho approach of death ia indicated by rapid extension of tlie 
disease and speedy failure of the vital powers. 

After decided swelling of the feet occurs, patients seldom live more 
than five or six weeks; they naually succumb in from three to eight 
weeks, when the strength has so far failed tliat they are unable to leave 
tho bed, though sometimes life is more prolonged. Two or three diiya 
before the fatal issue, many consumptives become so feeble that the 
sputum is raised with great difficulty; cough becomes less and less fro- 
quciit, and may finally ceaso a few hours before death. 

Trkatmbst op the VxRiors Forms of Put.monary Prthisi**. — 
Having considered some of the special forms which jmlmonury phthisis 
assumes, we may discuss moru f\illy the general treatment. 

As a nuitter of prophylaxis, healthy persons should not occupy the 
siuie apartment with consumptives, and great care should be exercised 
to prevent the drying of tuliorcutar sputum, and to thoroughly disinfect 
or ilestroy it. The treatment of acute tuberculosis ran stddom if ever 
be more than palliative, though it is proper to use the same remedies 
that are recommended -for more protracted forms of the disease, 

For chronic tuberoulosis the most important remedies are alcohol, 
malt preparations, cod-liver oil, nalcium chloride, quinine, iron, iodine, 
fifiiniacol, and oil of cloves, with proper climate. 



Alcohol should be use*! in hirge quantities iib muuli i\» ciin be borne 
viihont affecting the hciul, provi(lin{^ it does not derange digestion or 
cause elevfition of temperature. 

Cod-liTer oil should ha given to those patients vho can take it wttb> 
out disturbing their digestion, in doses of a teospoonfnl to a tablesiH^ion- 
in] three times u day» always commencing with small doses. AVlicuever 
cod-liver oil cannot be borne, it may be substitntod by cream or prejMmi- 
tione of malt. The latter are nsually prefenible to oil during ivitnn 

Calciam chloride is a remedy of undoubted value in many coses. I 
have found it more aerviceablc than the calcium or sodinm liypopho?- 
pbites. The dose is from ten to twenty or oveu thirty grai)is llireo 
times a day. It may be dissolved in a smiitl (juautity of valur, and com- 
bined with the cml-liver oil. By shaking the bottle before the medirino 
IS poured out, the two can be sniliciently mixed. It may be added to an 
emulsion of cod-liver oil prepared as directed (Form. 3). 

Quinine is the best remedy for relieving hwtic fever. It will nsn- 
ally prove efficient when given in the some muimer as for intermittent 
fever. It acts most promptly when given in one or two large doses a 
coupiC of hours before the fever is expected. It should be i>oiitinued in 
this m:inner until the temperature falls or einchoiii^m appears; even 
though it fails torlieck the fever the patient is generally benefited by it. 

Iron is a vahmble remedy in this disease, but it must not be given 
when there is much fever, for it aggravates this symptom. 

Belladonna is the beat remedy for checking the night-swenl«. Si.t 
minims of the tincture of belludonna. ur the oiie-huudrwl-and-twcntieth 
of A grain of atropine, at bi<d-tinie, is riuffieient in umny casfcs. but the 
dose may bo increased to twice this amount, aud repeated two or three 
iimee daily if necessary. For the siime purpose, aromatic sulphuric acid, 
iflx. to x.T. properly diluted; minute doses of aconite; of agaricin, gr, \\ 
of line oxide, gr. iij. ; of ergotin, gr. ij.; or of black oxide of manguncso, 
gr. ij.; may bs given three times daily with success in eome cuses, but 
nny or all may fail. 1 have known obstinate night-sweats checked 
occiuionally by nibbing into the (»kin ii powder of four per cent of 
salicylic acid triturated with magnesium salicylate; by placing a largo 
pan of cold water under the bed at night, by sleeping iu light blankets, 
or by drinking a preparation made by steeping for two or three hours 
two heaping tables pooufuls of sago iu one imd onc-holf pints of water, 
reduced by evaporation to about one-half pint. 

Touic doses of mercur)' bichloride gr. ]^ to j^^, or gold and sodium 
chloride gr. ^^^ to ,V will 1^ found beneficial in some cases, especially 
those of a chronic catarrhal or fibroid character. The same may be 6uid 
of arsenious acid, but this must not l*o given when there is much fever. 

When there is a suspicion of syphilitic origin of the diseaao, potas- 
Biam iodide shonld be tried. 


As a rc:»iilt of numerous ex|>eriuieiitH on Guiiiea*[tigB and monkey's, 
E. U Shurly* "f Detroit, ami Heiieage U ilibt-s, of Auii Arlwr. Mioh. , have 
denioiiitruteil tliut :iniiiiais may be reuik-red iiuiiiunc to tiilten-ular vinia 
by hypuilermu- injections <jf ii<|iier>iiii lioluliong of vlicmically pure iudine^ 
prepared by J. E. Clark, of Detroit, or of gold and uodiuin chloride; 
and tliey liave ivfoinmeiKlcd. for tlie cure of consumption, liyi^Klvrmic 
injectioiui of these remedies with inhalations of chlorine gan. The in- 
jections should be made with an absoUitely clean syringe> which should 
Always he wiiinbed with pure abmhol liefore and after using. The treat- 
ment should be coninK'tire<I with email doses, which may be gradually 
increased until some constitutional effects are observed or until (be 
largeet dose recommended is rcache<I. It is usually best, excepting iu 
advanced cases, to begin with the iodine (thongh it is apt to cause con- 
Giderable smarting), and it slionUl be continued ten to fourteen days. 
nnd thou may bu given alternately with the gold and sodium chloride 
solution, and later, after four or five weeks, the gold solution may be 
used alone if everything is going well. In some patients tlie gold and 
Bodium chloride answers best, but 1 think most beiiefit will be derived 
from the iodine. The dose of iodine is from one-twentieth to 0De*6ixtli 
of a grain, and of the gold and sodium chloride from one-tweuty-fourth 
to one-eighth of a gmiii. 

When symptoms of iodism api>ear or there is loss of ap)>otite. di8> 
tar1>ance of the bowels, or L>omp1aint of unusual fatigue, gold prepara- 
tion may bo snlMitituted for a day or two, when the iodine may Ik' given 
ugain iu diminished doses, which may snbsequently ho gradually in- 
creased. Sometimes, white i>ntients are receiving the gold and sodium 
chloride in large doses, pains are experienced in tlie bowels, and in some 
iiutuucej there arc uncomfortable sensations in the head; occasloiiallyr 
also, profuse sweating has been noticed. If any of these symptoms de- 
velop, the dojte slionld l>e at onre diminiBbed, or the rt'n}edy sulistituted 
by the itnline. The most favorablu place for llic iujec-tion is bencjith tlie 
loos<^> skin in rbe gluteal region. As it is dittimilt to get at this point 
on account of the clothing, the injections arc given to women just 
below the inferior angle of thescapuhi or between this and the spinal 
column. Injections are advised daily for about two weeks, every second 
day for the two following weeks, and subsequently once in three^ four, 
five. six. or seven days, gradually diminishing the frequency according 
to the result. When these remedies are acting well, the appetite aud 
strength gradually improve, the weight increases, and the cough and ex- 
pectoration gradually diminish. The chlorine inhalations may be given 
either by means of some of the common or specially devised inhalers, or 
iu a room filled with chlorine gas. The latter is applicable to hospitals 
where small rooms can Iw arranged, or even to small bedrooms, where 
it is readily carried out in the following manner: £rst,a steam-atomizer 
ifl made to throw iuto the atmosphere of the room a solution of sodium 


chloride, about tiftcen grainft to the nance; this is continued until tlie 
atmosphere is so permeatt*d hy the spray that a person on the opi>o6it« 
side of the room nan taste the salt. One or two tea«{K>onfals of chlo- 
rinated lime are then placed upon a saucer and wet with a mixture of 
hydrochloric acid one part and wat*>r two parts, whirh cnusea the rapid 
liberation of chlorine gas. This ig then held directly under the fipray of 
salt solution, and tlie gas is carried by it into the atmosphere nf (he room, 
where the patient s\U for ten or fifteen minutes — as long as he oan woll 
tolerate the inhalation. 

I have employed this treatment in over a hnndre<l cases of phthisis 
during the last few months, and found it very beneficial in the first sljige, 
helpful in some cases during the second stage but of only little vsdiie in 
the third stage, though occasionally even then some appear heneHted by it. 

Among other remedies iu phthisis, creaaote has been very highly 
recommende^l, in doses of one to five Tninimtii. or even as much Jis half a 
drachm, several times a day. It has ap|>eared to roe moet benefiuial in 
moderate or small doses (Form. 7). Morsen's croftsote is seemingly leas 
irrituting4han other preparations. Guaiaeol, one of the chief constitn- 
ents of creasote, has been r|uitc extensively tried in the trentment of 
pulmonary tuberculosis. Althcngh I have had but little experience 
with it. general report, and eapwially the apparently gowi resulta oli- 
tained from its use in surgicd tnhiTruhjsis by Xicholas Senn and W. 
'J'. Itelfielil, of t'hicdgo, induce me to recommend its thorough trial in 
pulmonar>' phthisis. It may be administered in essentially the same 
doaes aud manner as creasote, but I prefer the carbonate of gnaiacol, 
which has but little taste or odor, causc^i little irritation, and is appar- 
ently qnita as oflUcient when given in corresponding doses. 

Oil of cloves given five times a day, in doses of two to twelve min- 
ims, or oil of cassia, in doses of oue to live minims, in conjunction with 
other remedies, has Ixwn of great benefit iu some coses. The medicine 
thonid be drop{>ed in c«{>sules Just before it \i taken and administered 
with each meat and in the middle uf the foreuuuu and afteruDon, the 
patient taking, wlien possible, a glass of milk with t^ach d(«e— uerer 
takiug it on an empty stomach lest it cause irritation. The duse should 
be small at first and increased, one-half to ono minim each day until 
the maximum dose is attained unless it disturbs the digestive organs. 

The therap4*iitic value of tubercnliu ia still uncertaiu, but the 
majority of those who have tried it believe that it is more potent for 
harm than for good. 

Sedative troches (Forms. 35, 36, 30, 33, and 35) and sedative in- 
halations of benzoin, opium, or chloroform are nsoful in allaying the 
cough (Forms. 53 to OO). Stimnlant inhalations are frequently ser- 
viceable in the early stages of the disease. They are moat conveniently 
administered with the Globe nebulizer shown in Fig. 30. For this 
purpose, iodine, carbolic acid, creasote, or oil of white pine arc most 



fiequentiv umhI (Forms. G'i^ 68, 60, and 72 to 74). Congh mixtures ar« 
nrcpfcgarj, €«p«cmll r late in the <Iiiu*afie, but they should bo gireu ii.<i spar- 
ingly as possible. Sc«Iative trocben and uihalatione are prefembly when 
tLcT vitl answer the pur[H)i^. The neuralgic painii which ofteu trouble 
phthisical patients are best prevented by regular and vigorouit frictions 
of the surface with u course towel; when severe, they art! usuiillr 
promptly relieved by hot applications to the surface. These applii.-a- 
tions should bens hot as can be borne, and should be frequently repeated 
until p'lin aubsideit. 

ConntorirritfltioD is useful, especially in cases of an inflammatory 
dinraeter, as those growing on t of pneumonia, bronchicisy or pleuritis, 
b-fore tubercles have been depositc*!. 

I sometimes employ for this purpose an ointment composed of tartar 

ma. v.— Olou Kebi'Uzkii. ^Sdlr. np«t>u>nl wUh vn MiriimnurvoT t«B Of Ari««li pounda 
only. It nioy also be um^ by xht IkauJ ball. 

emetic, crotou oil, cautharides, stramonium, and camphor (Form. ](>). 
It is an effectual aud almost ptiiuless oounterirritaut. Burguudy pitch 
plasters crotou uil, iodine, or blihters may he used for the siuie ])Urpuse. 

The digestive functions must receive careful attention. Nutritious 
and easily digestible diet of varied elmmeter should be ordered. 

Climitlie Treat me nL—^lfmy consumptives will be greatly benefited 
by suitable climatic iullueuees. tu the Grst stage of [ditLisis, I believo 
that the patient's chances of recovery are improved from fifty to seventy- 
five per cent by residence in a suitable climate; in the second stage, from 
fifteen to thirty per cent; in the third etage, a small percentage will be 
permaneutly beuetited; aud iu a large proportion of others life may be 
oonsidenibly ))rolonged. 

There is no climate to which consumptives may bo scut indiscrim- 
inately, but suitable places should be seleet|.-d for each putienL Some 


patients foel better in cold weather, but the majority are better in sum; 
raer. It will be found that those who feel best in winter are likely to be 
benefited by a comparatively cool climate, the others in a warm climate. 
Ab a rule, a warm, dry climate and high altitude are most salutary. It 
is always desirable, when there are no contra-indicutious, that the ; atient 
iu the early stages of the disease should be sent to an altitude of from 
six to seven thousand feet; but this is not suitable for those who ^^'e 
nervous to a marked degree, or who have a high temperature, pro- 
nounced cardiac diseitse, emphysema, or laryngeal complications. Ha;mop- 
tyeis is not, as is often supposed, a contra -indication to a sojourn in a 
high altitude; on the contrary, bleeding is often promptly checked by 
this change, and those who seldom or never have hemorrhages in a high 
altitude frequently experience them quickly upon a return to a lower 
level. In the second stage of the disease, a high altitude is often bene- 
ficial, but we cannot feel so certain of its results; therefore it is best to 
send the patients to an altitude of not more than two or three thou* 
sand feet, and, if they do well, subsequently advise a higher altitude. 

In the earlier stages, warmth is not so important, providing an abun- 
dance of sunshine and dry atmosphere can be obtained, though it is 
usually best to recommend for such patients a soiitliern latitude in winter. 

In this counlty in summer the high altitude of Colorado, AVyoming, 
Montana, and Utah affords a typical climate for these cases, whereas iu 
winter they generally do better in New Mexico, western Texas, or 

Those for whom an altitude of two or three thousand feet is prefers 
ble often do well in summer in some portions of Dakota, Nebraska, and 
Minnesota; in the Adirondacks, or the mountains of Virginia, North 
Carolina, or Tennessee. In winter, more suitable climates are found in 
warmer latitudes; many cases will do well in eastern Tennessee or west- 
em North Carolina or in Georgia at from fifteen to eighteen hundred 
feet above the sea. The typical climate for these cases in the winter 
months is found in Arizona or southern California, in the latter among 
the foot-hills as far as possible removed from the ocean. Southern New 
Mexico and the western portion of Texas are favored by a similar cli- 
mate. In many parts of Mexico, patients in tlie first and second stages 
of consumption do remarkably well during the winter months. 

In the Old World, the mountainous regions of southern Germany, 
of Switzerland, Austria, Spain, France, Algiers, and Egypt, according to 
their temperature, offer advantageous resorts for summer or winter. 

In the advanced stage of the disease, patients, if sent anywhere, 
should be recommended to a warm climate and usually to a compara- 
tively low altitude, of not more than one or two thousand feet above tlie 
sea. For these, a typical climate is found in Arizona or southern Cali- 
fornia, and many of them do well in Florida, South Carolina, Georgia^ 
and Texas. 


In the Old World, these patients aleo find a snitable climate in southern 
Spain or France and in Algiers or Egypt, but usually persona who have 
passed to this stage of the disease are much better off at home, where 
they are surrounded by friends and the comforts that cannot be ob- 
tained elsewhere. No patients should be advised to go from home ex- 
cept those whose financial condition will enable them to secure easily 
the comforts as well as the necessaries of life, and usually to surround 
themselves with agreeable companions and friends. 




A EKowLEDRE of tbo anfttomy nnd physiologjr of Ike heart ia so esscn- 
tiiU to a correct diagnosis, that ve shuU givi; ihem brief coiigide ration 
before proceeding to the means for detecting cardiac diseases. 

The heart is a hollow, muscuhir org-an of i;uni<'al form, which as the 
centre of circulation distributes blood throughout the entire botly. 
IxK'jited near the centnil portion of the chest, it is held in plane above 
by the large blood-vessels springing from its base, and below by the at- 
tachment to the diaphnigm of the tibru-serons sac which envelops it. In 
front it is aheUcred by the sternum; posteriorly by the thick chest 
valk, and spinal column; and laterally it is cushioned by the Inngs. 

U« long axis is oblique to the jierpendiuular axis of the tOiesl: its bai«B 
is directed upward, outward^ and backward toward the right shoulder; 
its apex downward and fonrard. 

Tlie pericardium, the libro-serons sac which envelops this organ, is 
voni]to8ed of an external, fibrous layer and an iuternul, serous layer. The 
external layer incloses the arteries for about two inches from the base of 
the heart, and i^ continuous with their external covering; below, it is 
attached to the dia|thr!igm. The internal, serous layer completely en- 
velops the heart, and covers the blood-vessels springing from its baaa 
fur about two inches. It is then reflected upon the inner surface of tho 
tihroas layer, and passing downward covers the iipjwr surfnre of the 
diaphragm, Iwnoath the heart, thus forming a closed kic siniihir to the 
pIcnrM. The two serous aurfacos of the pericardium, ronstiintly in ap- 
position during heullli, are moistene<l hyseruui.and glide npon each 
other without friction during the action of the heart. The pericardium 
extends from the level of the second to that of the seventli left coiital 
cartibge. It is farther from the chest walls superiorly than inferiorly. 

The heart, with its pericardium, ia in relation: anteriorly, with the 
anterior borders of the lungs and a small portion of the thoraric walls, 
Irom which it is separated by a small amount of areolar tissue; lateraUy, 
with the Inngs covered by the pleurte; posteriorly, upon each side, with 
the lungs and pleurfe. In the middle line posteriorly, it lies near the 
spinal column, from which it is separated by cellular tissue and the 
morta and oesophagus. 



The heart is iiboat the size of its owner's fist, its weight rangiug 
women from uight to ten (•iiiices, iu iiieu from ten to twelve. T 
anterior surface is eouvci,; the posteriur surface fluttciiwl; ilie right bo: 
der is long, thin, uiiil ehitrp; the left burder is aliurt, tliick, and roun<leiI. 
Runuiii^ kingituiiin'.iily ubuut thu heart is a well-defiiu'd fissure, found 
upon the anterior surface within hulf or tlireo-qniirters uf iin itidi of the^ 
left burder, and on tlie foslerior surface a similar dislancc from the 
right border. This (insure lodges the ooronary arteries, which supply 
the hturt with blood; and it indicutes the position of the sepLum, wUieh 
divides the right side of the heart from the left. Ncnr the base of the 
heart is li tranRverse fissure, interrupted in front by the origin of the 
pnlniouury artery. This fissure indicates the pogition of the septnia 
between the cavities at the base of the hmrt and those at the »pt!X. 

By these septa, the heart is divided into four cavities : two above at the 
base, known as the right and left aurirles; two below at the apex, known 
as the right and left itntnchs. Ench of these cavities is capable of con- 
taining about two fluid ount'ea. The walls of the cavities npon the right 
side are thinner tlmn those upon the left, and the walls of the auricles 
are much thinner than those of the vcntridos. 

Tho right auricle receives the blood from the venous system, through 
the ascending and descending veuie cuva;, and transmits it tlirougli tho 
nuric-ulo-ventriculnr opening, into the right ventricle, which, contracting, 
forces the bloml onward through the pulinonnry artery into the lungs. 
The loft auricle,, receiving the blood from the lungs through the pul- 
monarj' veins, transmits it to the left ventricle, whence it is distributed, 
bv the aorta and its branches, throughout the body. 

The internal surface of the heart is lined by a glistening membron 
known fts tlie euiioranUum, folds of Mhich at the various orifices con- 
stitute tile valves. At the orifice between the right auricle and the right 
Tontricle, we find three of these folds, which nre named tho tricnEi>id 
valves. At the orifice of the pnlmonnry artery are three simihtr folds, 
knouu as the pulmonary semi-luuar valves. At the aortic orifice are a 
similar number, called theaortic semi-lunar valves. At the orifice between 
the left auricle and ventricle are two folds, known as the niitml valves. 

The greater portion of the heart lies heneiith the lower part of the 
sternum, but the right auricle, atid h small part of tho right ventricle, 
e:iteud from one-half to three-fourths of an inch to the right of the 
sternum; the ventricles extend about two inches to the left (Fig. 1). 

The auricles are on u line with the third ribs, the right auricle ex- 
tending considerably beyond the stenmni into the third interspace upon 
the right side, tho left being located beneath thi' third left costal carti- 
lage and intercostal 8|»ace upon the left. The left ventricle lies mninly 
behind the right; tni;t jMirt of it which is superficial is found entirely 
to the left of tho sternum. Most of the right ventricle lies behind the 
lower part of the sternum; but u small part of it, at the base, extends to- 


the right (»f llie stenuim^ and its \\\wx in ruunil to tlto Ipft of tins bone 
h) the triangular spuce between tho stfriinm and the margin of the left 
lung. The base of tho hfart extends to the upper inargin of the third 
rib, corresponding beliind to the sixth and seventli dorsul vertebrrc; its 
upex lies at the flftli costal interspace from an inch uud it half to two 
inches below the nippU*. about half uti inch to the right of the tnntnniil- 
Ltry line, and two or two ;tnd a liidf iiiclieii to the left of the sternnm. 
The position of the npex changes slightly with the respirator}' mov^- 
ments, the position of the patient, or with the distention of the slomuch. 

It is KuA t)mt lltc npex miiy move n» iDiioli asan inch and a hitir from left to 
riKl>t. or rice tvrsn. wli^ii the pnlifiii lii-s on the rijjiil or tli« loft sitlo; a few 
ClweAliavR b«en reporttnl in whii^li pi-olnn^ini decubitus on one side «eeni8 to 
liave caused periuuneDl tUalucatioii of ttje lienK. 

From the base to the apex of the lieart, in u vertical line, the di»> 
t»nce is nliont tive inohL'n. Mearfuriiig from the mesoi^ternal line U) the 
loft over the thinl rib, the heart extends from two and oiieOtfllf to three 
inches, uver the fuurlli rib three and cue-half to four inches, and iu 
tlte fifth interspace front thivc to three and une-luilf inches. 

Pimlinn tif the rcz/rc*.— The relation of the valves to the surface of 
Uie che«t may be ascertained by jiaiiifing needles through the cliest walla 
of the ciidav<«r before the thorax is npeneil. In this niunner it hns be^u 
kfifcrtiinetl thai the pulmonary valves lie beneath the junction of the 
tliird costiil cartilage of the left side with the eternuni. The niitnil 
Ynlves lie close to (ho left border of tho steiiium in the third intercostal 
space. The tricui'pid tulve^ lie in front of the mitiiil. near the middle 
of tho sternum, un a line with the fourth ribs. The aortic %'alvee li« 
beneath the steninni, jusl below the level of the third ribs, and a litllo 
iu the loft of the median line (Fiir. 1). As indicated in Ireiiting of the 
chest regions, a very gmall circle, wiih its centre at the left edg« uf the 
steruuui iu the third intercostal simcc, will include the greater part of 
mil of these valvce. 

Till? dtsrreponcy notiresiMe in the iIoBcriptioiis, by djfTi^ivnt niithors, of Ih* 
po^ttinii of the v»lve<i is pruimbly chic, iu tlie main, lo their Itomj; locatetj ofler 
tlif thoi-iuc hiis been opeaeil, when the collapse of the lunges has more or kat 
.phuxl the hwirt. 


The aorfn springs from the base of the left ventricle, and passes 
upward, forward, ami to the right, to the second intercostal space, where 
it is more superficial than in any other part of its conrse. In this situ- 
ation, it is within tho pericardial sac; thence it passes backward, upward, 
and to the left, and finally jiasse* downward, bending completely upon 
itself, so a« to rest along the left side of the fifth and »ixtli dorsal ver- 
tebne. Tho highest portion of the arch is on a Uuo with the first custo- 
■tomnl itrtienlatioD, 



The Tentriculur diastole follows ittuucdintely uftcr their systole. 
The eluatic tissue of the urtcrios oontracts, forcing u portion of the blood 
bftckwurd towiirU the henrt, which it is })i'cveiitcd fruiu entering by the 
•bruiit ch>suri.' of the »omi-lunar valvo8 thut guurU the uortic aud pul- 
monary orifices. 

With i/iasloh of the rentrxchif the he!irta«auin«8 its fonner shape and 
position, the aurioulo-rentricular valves open, and blood flows passively 
into the ventricles. This occupies about one-fourth of the period of a 
complete airdiac pulsation. 

Closure of the »i>nii-lun»r Tulves, which is cftused by the contraction 
4t( the arteries, produce-s the second sound of the heart. 

The diai^tule of the ventricles is followeil by a period of rest, which 
<H!cnpie8 about one-fourth of the time for a complete pulsation. 

During this period, the blood continnes to flow from the auricles 
mto the ventricles, so that, at the instunt just prccodiug another pulso- 



■< z 

Tio. SI,— PBvnoi.ooicj,L actk^x or ras hurt (altMwl sllichtly from tlalnliKi'). 

In ll)r> tlla^Tvm. the Uuwr drela reprsKoU tbe phj-Hiokjgtcal acUaD of th« bMut, apart rron 
4iir mitnlfffst filrm. 

Tlic i)UUTt.-in!lerepr«fleiitBtbeexUrrualiiiaiil(eHUiiJdiuiot Uie biurt'* atftlan: tlw rl»K iMtwom 
"^ circle* iUiuitnttt>a the Bouads utd perlouls ^r itll«n<«: outBii)<^i>t the uut«r rlrde reftrewiibi tbo 
miiiliii al Ota apcuc afaioat Uis cbeat walL Udm radlaUiv traat Uit) eeotrs reprawol tbe puks 
to Cba mck, wrtoc and ankli-. 

iion, all of the cavities of the heart are full, but not distended. With 
the contraction of the auricles, the ventricle* are di«tendefl by an addi- 
tional amount of blood, but probably the auricles are not completely 
emptied. The distention of the ventricles, caused by tbe systole of the 
auricles, excites their contraction, and the blood is forced onward into 
ttie arteries. If the cycle of time taken up by a cunliae pulsation were 
divided into five equal parts, about one-fifth would be occupied hy the 
kjfltole of the anncles, two-fifths by the systole of the ventriclos, and 
two-fifrhff by the dijistole of the ventrirles and the period of repose. 
The physio logical action of the heart in graphically represented b; a 
motiification of Oairdner's diagram (Fig. 31). 

183 TH£ MBART. 

As Bocn by tbo iliiigram, iho sjstole of the nnrtchK gives rise to do 
exterual iimnlffstutioiiB, but with the beginniDg of the ttniricular *ya- 
toir KG jiiiiiiveiiite the first sound of tho heart uuil, at the same time, 
we may feet the beat of tlic apex agaiust llic chest wall, uiitj tht* carotid 

The lon;,^, first sound, a^ indicated in the diu^tnim. is followed by a 
shurt period of silence, known as the first eileniT, during which the 
radial pulse may usually bo felt. 

tmiiiediaiely fuUuwiug tho first silence tho ventricular diastole 
begins, :ind with it occurs the second souud of the hearty which, as in- 
dicUed in the iliugram, is lihurler thau tho first, uud is fuUowed by the 
second or long silence, extending through the period of rest and the 
time occupied by the auricular systola 

lu some cases only one souud of the heart can be heard, either at the 
iipox or at the base. In such instances, in onler to determine which is 
the fiiijt and which tho second, it is absolutely uecessani' to associate the 
auond with the imerial pnlsntion. This can only be done, in the major- 
ity ol cuiiff, by feeling fur the carotid pulse, which occurs with tho first 
sound of the heart. If the heart were beating slowly, it might be easy 
to recognize the position of the radiid jiulse between lh« first and second 
sounds; luit as the length of the first silence, during which this may be 
felt, does not usually exceed tho tenth of a second, it is difficult to be 
certain wlicther it accompanies the latter part of the first or the first 
part of the second sound. Knowledge of the iustunt whcu the carotid 
pulsation or the apex beat takes place is iudispcnsablo in ascertaining 
whether an abnormal sound precedes or accompanies the systole of the 

The regular contraction, dilatation, and rest of tho heart consti- 
tute what is kuowu as its rhythm. In licalth, eiich pulsation is 
similar in every respect to those which precede and follow it. In 
disease of the heart, alterations in the riiVtUm arc among the most 
constaut sigua; and iu all tlic allcctiuus giving ri^ to abnormal sounds 
produced at the valvular orifices, tho signs occur with either contraotion 
or dilatation of the organ. It therefore becomes necessary in the physical 
diagnosis of cardiac disease to ascertain the rhythm of the heart. When 
the pulsations are of normal fre<{Uency this is an easy matter, if we 
recollect that the first souud is dull, heavy, ntid prolonged, while the 
second sound is comparatively short and clacking, and that the period 
of restf or long silence, follows the second and precedes tlu> first, and 
also the first sound is coincident witli the carotid pulse and the impulse 
of the apex beat. If the heart is beating more than a hundred times 
per minute, it is always difficnlt, nnd frequently imposgible, by ausculta- 
tion alone, to distinguish between the two sonnds. 

If we divide the eotiru |wnod of the cardiac pidKations into two portA, one of 
iDotioD and the other of rcbt, it al once becomes evident tltat the more rapid tho 



puJsations the ehorter miul be Uie perioti of rvpofie, and coosequeottv Iheshorter 
will be Uie silence between the iwo nmuiiiIs of the heart. This is well illustrated 
by a series of circles of iacrefuJng size (Fig*. S2). 

In th^ flrst or smallest circle, wliich indicates the most rapid pulsatioD of the 
heart, the intervals between the Qrat and second, and the second and first, 

no. St— Rbtteh or TSB HBUtT (Loons). 

fiouods are eqool ; whereas in tiie largest circle, Jn which the interval between 
the Qrst oad second sounds is represented by the saino distance upon the circum- 
fersace as in the siuull circle, tlie time between the second and the (Irst sound is 
greatly iDcreused, aa indicated by the greater disiunce on Uie circumference. 
la Ihesmull circle the tiinu between llic first anil the second souud in equal to that 
between the second and the llj-st, while iii tlie large circle the ttnie between Uia 
firat and the second iiouiid. which correspondit to the period of motioo, is only 
alwut ono-foni-th as great as that which includes the period of rest between the 
second and the (int. 


The methcMls employed in examination of the heart are thoee already 
dewribed, except Eticcnssion. 

Upon inspection of a patient snttering from cardiac advanced dis- 
ease» we often observe a ]>eou)iar sodden expression, with ptifilness of 
the lower eyelids. In many instances there is marked pulsation of the 
veins and arteries at the base of the neck. Slight pulsation of the 
jngnlar vein is not a sign of cardiac disease, for it may be caused normally 
by the auricular contraction. Distinct systolic jngnlar pulsation in this 
position is always associated with more or less dilatation of the right 
aide of tlic heart, which iiiuy result from protracted eniphy»t!mii, mitral 
disease, or ubbtrucliou of the pulmonary artery by embolism or throm- 
bosis. When very marked, eajieeially on tlic light side, it is always as- 
sociateil with dihitJttiDn of tho right ventricle .-ttul regurgitation of blood 
through the tricuspid valven, hy which the im]tul^ is transmitted di- 
rectly to the jugular veins, as there aVe no valves guarding the opening; 
of tho descending vena cava into the right anrick*. Pulsation in the 
TeioB is always most distinct when the patient i^ Iviug down, and may 
be rendered still more noticeable by pressing the blood upward in the 
vein with the fingt'r, and idluwing the vessel to refill from below. 

VisibU' pultfiitiaii in iliB superficial arteries is not uncommon in con- 
ditions of health; but M'hen this is exc-essive and symmetrical in the 
carotid, subclavian, and brachial arteries, it is alwaii-s due to hypertrophy 
and dilatation of the left ventricle^ with regurgitation through the aortic 
Talres. Marked pulsation confined to one subclavian or carotid artery 




nsnallr inHinates dilatation of tlie vessel, aud the uommencement of an 

By inspecting the chest, we obtain information regarding the/or*?* 
of Uie cardiac region and the position and character of the apex beat. 

Enhirijcimnt or bultjing of the jfrtf>c(rr(ltal ret/r'on may be normal, but 
it is frir([ucntly duo to enlargement of the heart or effusion into the 
pericuriiial &ac. lu this latter instance, the intercostal spaces are more 
prominent than in the former. 

The unuHiially dmtiiiirt pulxatlonn ottcn seen in children and eroaoiated per- 
Bonn h&vtf been mistaken for bul^'iti;^'; but siicii errors may be avoided by careiul 
iasp«ctiou aad palpation. 

Rachitis may cause bulging of the preeoordial region, but in such in- 
stances a corresponding depression is usually found on the posterior 
aspect of the chest, immediately to the left of the spine, and the spine 
is generally curved. 

Prominence anteriorly caused by aneurism of the aorta is found only 
above the fourth rib. 

Depression iu Hit! priKcordial rpfjion, of a permanent chamoter, usa* 
ally indicates previous perlcarditifj wilh aillieslon of the two surfaces of 
the pericardium to each other, aud of the pericatrdium to the costal 

Care must be taken not to confound wiib this condilioa tlios« rliyihmical de- 
pressions which niuy o<.->:iir inileiwnUent of ailh«siutis, us the result ol atmo- 
spheric pr«9«ure. These tube pUu.*; utiL'n the hi-ui-t i^ L'lilut';^*^! and the left lung 
contracted, provided the i»er8oti bus thin and clastic chc»l wiills. 

Inspection reveals any alteration in the position, character, and force I 
of the itfH-x Ixut. The apei is crowded upward and outward by hyper> 
trojihy of the left lobe of the liver or by abdominal tumors. It may bd 
carried directly upward to a point above the fifth rib by pericardial 
effusions; it is raised by contraction of the left lung, as in fibroid 
phtkitiiti. It is crowded downward and to the right, when the left lung 
is enlarged by emphysema, or it may be drawn iu the same direction by 
contraction of the right luiLg. It is crowded to the right by collections 
of fluid or of air in tlio left pleural sac, or by large tumors occupying 
that side of the chest ; to the left, by corresponding conditions upon the 
right side. It is forced downw-ird by anearisms or by other medias- 
tinal tumors and is drawn downward and inward by hypertrophy of the 
right ventricle. It is carried downward and to tiie left by hypertrophy 
of both ventricles, but in uiiconiplicated liypertroi)by the ape.x seldoiu 
extends more than an inch to the left nf its nnrtnul position. It is also 
caj-ried downward, and often far to the left, by enlargemi^iit nf the hearty 
as the result of dilatation or of dilatation and hypertrophy fombined. 
The significance of alterations in the position of the apex beat is showu 
at a glance in the following table: 




J>i»pliiv(;mentii of the Ajfj?. 
Apex crowded t<J tbv right or loft. 

Apex MUfwtl. 

Apex more or less upward oad out- 
ward (to Uie left). 

Apex depressed. 

Apex more or less downnrard and to 
tlw ri^jbt, 

A|>ex more or less downward and to 
the left. 


Fluid, air, nr tunmni inoppoiijleajde 
of chest, or coDtruclion of tliu corre- 
fi|ionding Iudi*. 

Pericardial effusions. Cuntruclion 
of left lung. 

lIyij.?rtropliy of the ]«ft lobe of Uie 
Ifver. Al>doniiQal tumorn and peri- 
card in I t^tTllHtOtl. 

Aneurism or other mediastinal tu- 

Puliuuiiory emphysema. Contrac- 
tion of till! right Inng: or hypertro|>liy 
of the njfbt ventricle. 

Ilypepli-ophy of the left or 1k>Ui 
>'entricleA. Dilatation of the heart. 
Hyftertropby witti dilatation. 

The areii over which the cardiac inipnhe can be seeu is increased in 
all those diseases which cause enlurgeoiL-nt ul tbo heart. 

yc€blo pulsationd above the fourth rib arc usually duo to auricular 
contraction, but they may be cnused by an aneurism of the aorta. The«e 
two <;onditiuns ( be distinguished front each other by noting the time 
of their occurrence. Pulaatiou of the auriclen olwaya precedes the apex 
beat, while that of an aneurism must necessarily follow or accompany it. 
If the lieart is acting slowly, this distinction can be made easily by ordi- 
nary inflpectioD, but this is not the case if it is beating rapidly. Under 
Buch circurastauces the differentiation is fucllitatcd by attaching, by 
means of wax, two bristles, each carrying a paper flag, to the two pulsat- 
ing points, one ovor the apex and the other above tiie fourtli rib. By 
watching their BiOTemeuts, it will be easy to determine which is first and 
which second. 

When there is dilatation of the ventricles, or when agglutination of 
the two surfaces of the pericardium has taken place, the rhararffr of 
the impulse is wavy or undulating; it may sometimes be seen over the 
«ntire precordial region. 

Alterations in the force of the impulse may bo recognized ordinarily 
upon inspection, but can be better appreciated by palpation. 

Before examining the heart by palpation, it is always desirable to 
Mt»rtain the condition of the j/uUe, the tiigus furuiahed by which are 
aoiuetimes sufiicient to establish the diagnosis. 

If the radial pulse is of iinmtnal forc^ ujion the two sides, it is proli- 
ably caused by an aneurism, though it may depend upon an abnormal 
didtribntioD of the arteries. In the latter cMe pulsations iu the brachial 
urteriei' iire alike on the two sides; whereas, iu case of aortic auenriini, 
tbey Tary in force, 



U the pulse is siimll and weak when the arm is hanging in the oatn* 
nil posilioUf und if it ([isfippcars upon raising ihe arm, geucral anteniiu 
i»i prt'sciit, luid it may be itie only cunse for this sign. When the »nu is 
iu the uiitunil ]>ositiou, if the pulse is smikll aud weak, and if it main- 
t»in8 the Kaine chamctcristtcs when tlio arm u elevated, thero is likely 
to ho disease at the milm] valves; if the ptilite \a altw very irregular, it is 
probably caused by uiitral steuoiiit*. 

If the pulse is small aud irregular, but distinct, and upon elevation 
of the arm becomes still more distinct, two lesions are i>resent, one at 
the mitral valves, and the other at the aortic. 

If the pulse is full and distinct with the arm in its natural position, 
and becomes much more distinct and assumes the characteristics known 
JM hammer pulise when the arm is elevated, there is prof>ahIy regurgi- 
tation through ihe aortic valves, witli more or less hypertrophy and 
dilatation of the left ventricle. 

Upon examining the chest by palpation, we obtain cridence concern- 
iug the force, freijueney, and regulurity of the heart's action, aud we 
may dctoct-abnormul pulsations or thrills. 

By pressing firmly upon the sternum with one hand, while the other 
is pressed upon the back, wu arc sometimes able to detect pnliMtiona 
in a slightly dilated aorta which oould not be felt in tin ordiu&ry 

The position of the impulse la to be noted. Forcible pulsation above 
the fourth rib may be dne to an aneurism; but if observed to the left of 
the i^tennim, it is ordinarily caused by hypertrophy and dilatation of the 
left auricle. The two conditions may be differentiated by observing- 
whether the pulsation precedes or follows the apex beat. 

When the left lung is retnicted frum the base of the heart, palsation 
of the pulmonary artery may he frequently seen in the second inter- 
costal space. It can be distinguished from pulsations of the auricle by 
the time of its occurrence. 

Abnormal pulsations along the course of the aorta are nearly always 
anenrismal; but in Tcry rare instances they are caused by displacement 
of the artery, as in rachitis. If the pnlsations are feeble, titey can bo 
most distinctly felt during expiration. 

Pulsation benesith the lower portion of the sternum, and in the epi- 
gastric region, with disapptarauce of the apex beat, is a sign of enlarge- 
ment of the right ventricle. 

The/orf« of the heart mi»y be increased or diminished. 

The force is increa/tfd in simjile hypertrophy, and in hyi)ertrophy 
with dilatation, whenever the former more than compensjttes for the 
latter. It is slightly increased in the iiirly stages of endocarditis, and 
of pericarditiis: and it is increased by simple irritability of the heart, as 
in hysterical palpitation. 

OccasiouiiUy a donble shock is felt iu case o£ extensive bypcrirophj 
and dihitiition, due to the rebound of the hei:rt after its systole. 

The force is thvnuxxhed when the chest walls are very thick, iu con* 
Be<)Ucnco of a large amount of adipose tissue; when the heart is abnor- 
mally separated from the chest walls, as in pulmonary emphysenitt; and 
when there is effusion into the pericardial sac. It is also diminished 
when the hi-iirt is eufeebleil by atrophy, fatty degeueration and S4>fteh- 
ing. or genend muscular debility resulting from protracted or low forms 
of fever or other disease. 

The )iQsition of the apex beAt can often be detected by pnljMition 
when it is not perceptible upon inspection. It is altered by the diseases 
mentioued in speaking uf inspection. 

The/re^wtfHi-^ of the heart's action is increased iu such a great vari- 
ety uf diseases that it is not a sign of much importance in the diagnosis 
of cardiuc ulfectioiis. 

JrmijuUirity of the heart's action is often a sign of diseiiso in this 

When the pericardial surfaces are roughened by e.xndation,/riWro« 
fremituM may bo obt4;ined. This is usually most distinct in the fourth 
intercostal spuce, near the left margin of the sternum. 

Kt'gurgitation tiirough tlie valvular orilices gives rise to a pecnlicr 
vibration known us the pvrrttiif tremor or thrill, which may be felt by 
the fingers. This is s<tmetimps detei^ted by simjjly touching the sur- 
face, but in other iiistnnces tirm pressure must be maile. 

£xceptiomtK — TLe muua Kviisali'm in <Kx.-iuiioually coiumunicatetl from tba 
largvr arteries. 

yeeh\e epignstric puhftfion is fref^nently found in perfectly healthy 
individtials; but pulsation in this luoality, asm/eiated witli absonce of 
Uieapex beat from its normal position, is generally the result of dilatation 
of the right ventricle, with or without hyjiertrophy. This is u common 
sign of dilatation of thu right side uf the heai't caused by pulmonary 
emphysema. Epigastric pulsation nniy be due to the impulse uf the 
abdominal aorta, es])ecially in emaciated people who have formerly been 
of full habit. It ooi'urs also when a tumor rests upon the aorta in such 
a manner as to be lifted with each pulsation; and it is one of the signs 
of aneurism of tliis artery. 

Excepiioncd. — Sometimes epigastric pulsation is due to tbe actiou of Uie 
heart upon the left lobe of tJte hver. 

Uepatie pulsation in a few i-are iastuuces is cuuiwd by venous i-v^urjj'itulion 
from n dil.ited riRtit vontriole, through the tricuspi*! vaU-en and llic n^lit auricle, 
into the iiscending vena cava. It wimptinicn exlf-iuls over the entire liyiKH'lion- 
driJic region of the right hh1«, but in oTj>pr instances it is limiteil In » (tortiuti of 
the hver. Sunilar puliiationK nn* obnerveil in very rare cases, as the result of an 
ftueon»ni, tiie pulsalionn uf which are traasmitteU throui^i tlie liver. 

Suoielmies u peculrur pulMitiou is communicated to tlie epigastric region by 



th* iTitole of the Iteart, the apex of which draws the diaphragm upward in coo- 
trnction instead of urowdin^ ), in I'^mKOiiimm-e of uij:glutiniiti()ri uf Uie 
two ffurfuces of the pericardium. This puliation is the rovei-sc* of thut ordinarily 
observed, the expansion taking pUce with the dilatation instead of with th« con- 
traction of the h«ari. 

By peruuBsion, we learii the size of the heart, or delect collectiona of 
lluid or air in tho poricanlinm. It Is gtiienilly considered vcrj" diHieult 
to map out this orgun by jiercussion, but by attention to the following 
rules we iiud it companitivcly easy. The patient should bo iu tlie re- 
rumbent posture when the examination is made, and the force of the 
blow ehouhl he proportionate to the dejitli of the part to be examined. 
To lejini the extent of the cai'diac area wliich is not covered by lung, we 
must percuss lightly; to learn the deeper outlinca of tlie organ, a harder 
stroke must )» made. 

For clinical purposes, it is not necessary to find the exact limits of 
the heart in every direction, for our resolts will be equally good if w© 
Mcertnin simply the upper, lower, and latenil lines of dulness, orer its 
greaiter diameters. 

Tojind the b»se of the heart, percussion should be performed on a I 
lino parallel tu the steniuui and abuiil aii intdi to l}u> left, so as to nroid 
the dulness occasioned by the aorta and ihe pulitiuiiiiry artery, which in 
no way differs from that of the heart itself. On this line percussion I 
should be matle from alwve downward, until we rwich the upper limit of 
cardiuc duluess, ordinarily found at the third rib. 

Ti/ hcafe the lateral tfonndarkn, percussion should be made in the 
fourth intercostal spaces. Beginning in the right mammary region, 
where there is perfect resonance, the examination siiould be earritHl 
{Tadually toward the sternum, until the cardiuc dulness is reuched; 
which will Hsimlly be about half an inch to the right of this bone. 

Upi>n the left side, the examination shonld bo commenced left of the 
line of the nipple, and oarried grudunlly toward the sternum, until ciir- 
r'iac duhiess is obtained, usually about half an ioch to the right of the 
loammillary line. 

It is a difficult matter, by simple jtercussion, to find the huper border 
1^ the heart, sinew it lies immediately ubuve the left lobe of the liver, 
and tt distinction between the dull or Hat sounds produced by theee 
two orjrnns is hardly practicnbia If we find the apex of the heart either 
by palpation or by aneoultation, and then the upper surface of the liver, 
ill the right mammary region, by forcible percussion, and draw a straight 
line between these two points, it will correspond almost exactly with the 
inferior border of the heart. 

Cardiac DulnfotH. — Iu a small triangular space at the inner part of 
the left mammiiry region, and at the lower part of the sternum, the 
heart lies close to the chest wall, not being covered by the anterior border 
of the Inng (Fig. 1). This area, which is about two and one-half ioohea 



in width, and nearly the same in height, is known a« tbe arm of super- 
jicial jardiuf dubivnif. It might npjtropriutely be called the area of 
canlinr jhitiK'stf. Tbe apex of lliis trii»iij?le is ut the centre of the ster- 
num, neai'ly ou a Hue with I In; /ourth rib; tbe hise cnrrc^puuilti to the 
costal c^irtilage of the sixth rib. 

This space is iilttred in extent by various iliaeascs of the heart and 
the luugi^. lis area is usually incrciscd hy nil thotse iiffec-liuus wbicli 
cause onbirgenient of the heart, us hypertrophy and dihttatiou, or simple 

Id «oiiie ca»i.>8 of hypertrophy, an r*mphyftcmatoiift condition of the hing inura 
than couDterbalattces the enlargement at the heart, and thiu the ftpac«, in»teat| 
K«I beinf; iocreaseil, ih Uiininifihed. 

H This area Ih aleo increased by effusions of fluid into the pericardial 


■^ Nominlly, the area is increased by forced expiration, and diwinishsd 

^by deep inspiration. 

^p The area of superficial cardiac dnlness is diminUhtd by emphysema, 
which crowds the anterior border of the left lung over the heart. an<] by 
pneumothorax: it '\n ohiiteratvfl in the rare disease knoun a« pueumo- 
pericardiumr in which air or gas collects in the pericardial sac, and thtt 
normal dulness is supplanted by tympanitic resonatiee. 

The arfft of dftf/i-sftifed rardinc ihihiexn corresponds to the borders ol 

HjEhe heart. It extends normally from the third rib above to the resonance 

1 of iho stomach below; and luterally from about tbroe^fourlbs of an 
inch to the right of the sternum to within half an inch of the left nip- 
ple. This ai'ca of dulness is iucrcased in those affections which causa 
onlargemcnt of the heart, as hypertrophy and dilatation, and by peri- 
cardial effusions. 

When the diilness is first increased in the upper portion of the pr».. 
exordial space above the third ribs, we may be almost certain that there 

is pericardial effusion, for an increase in the vertical diameter of this 

^feea is seldom found iu disease of the heart itself. 

^^ The area of cardiac dulness is apparently increased by consolidatioa 

if <lje left lung. 

t7*lie outlines of the heart may be traced a little more easily by atwcoltntory 
CJ ffhion llian by Uie on1inar>- method of percussinK. In prataising- ihiR method. 
rrxiky ei»)'loy ritlier thf* solid stethoscope made for this parpose, or iho 
' *'-»*»ry hin.iuraJ Rt<»lhoseope with the small cliest-piece. In either caso Ih» 
B * — g>i«ce nhoiild lie phicfd over thf inoHt superflciid («irl at the heart, and [ler- 
r *:» *x should be made from the i-eswjnant portion oI the lunjrs luwurU the con- 
O-^^^i-tion of The heart, from above downward and laterally from wiUiout in- 
— By iliin method, as feoon aa Uie outer limits of the pericardium are 

1 * the change in the percuuioa note fa at once perceptible to the littteaer. 

"^Uacultation over the heart, accurate information cannot nsually 
'-f^^ed by the unaided ear; but by mediate ausenltatioUf especially 




it tlie small cbeet-pieco of the 8tethosoo|>e be used, most sitlisfuctorv 
results cun be secured. 

The puticnt should be in llu- refinnlx'Mt poiiitionduniigatleaHtapor- 
ti(}ii uf ihf exaiinnutiuii, wliicli !<li<jnli] be ooiiiuieneed wIiiIl- the itidivitUntl 
is breatliing iiiitunilly. Siibscfjiiontly, the putieut should bo directed to 
take three or four deep iiispiratioiii*, which will unable ns more clearly 
lo delect sounds that nrc produced by the liiugs. Theu be sliouhl hold 
bis breiUh for a few secouds, which will euitble tis to eliminatv pulmo- 
nary sounds, uud will reudtr the heurt-sigus uiure distinct. 

The exftmiiiatioTi must uot stop with the pra;curJiaI snace, but 
should be ciirried over the entire ehost. and tlie various points must b« 
loeuHzed at which the heart sounds, both nornnd and abnormal, may 
be he:ird nio»t dliitiuetly. It is uot the polut at which the sound may 
be heard which is of dIuguuHtic importance, but t\xQ point at whirh iV i> 


Considerable difference of opinion exists regarding the cause of the 
heart sounds. All concede tlial the sccund sound is iitiuully produced bj 
closure cf the scnti-liumr valves; and it is geneniUy admitted that several 
elements enter into the production ui the first sound, though the ini- 
portauee of each of these is variously estimated by different anthors. 

The mjiin factors in the proiUiction of the first sound are: Hrst, the 
cloaore of the mitral and the tricuspid vjilves: second, the contrHction 
of the muscular tlbres of the bciirt; tliird, the impulse of the ajiex 
against the chest walls. Besides these elenicTits, friction of the blood 
ag]iiiist the inner surface of the heart, and of the heart against the sur^ 
rounding tissues, evidently plays some part in forming this sound. ( 
believe that the contntotion of the muscular fibers is a much more im- 
portant factor in the production of tho first sound than is geuerully 

Tlip influence of tbo contraction of the muscular flbi-es may be sbo^vn by ihe 
following- Kinipio experiment. Pla^e the t'nd of tli€ stclhoscoiH.' ovt-r the body 
of a niusol<' tt-liirli «»n hf ronlract4?d or i-elaxed witliout nioviRc the inlegunicnts, 
BK, for I'x.iinple, iitmn the ball of the thiuiib : t]i.-x and extend (lif; leniiiual 
plialanx re^fiilarly almut seventy times a niinule uiul (nie will bear vvlmt tilniusl 
sevtns to be the heart beatiag immediately ben^iitli the iitsli'uiiit.-iit. Skudu Ktutes 
IIkiI Ihe tieart, sounds may be produced bv thi* ai-terii^s. and it opiwaif. u> lollow 
witli tolenible certainty Ibat both ventricles, the pulmonai->' arteiy, and llie aoita 
ai-e capable, eueb Mipamtely, of producing both tlie first and second sounds fietcep. 
tible in llie region of Ihe heart. 

In heiiUh. the /iVW sQuml of the heart is dull, soft, and prolonged, as 
compared witlt the second, and is synchronous with the systole of the 
heart. Ilie njiex lieat. and carotid pulse. Its point of maximam intensity 
corro8p<inds to the a[>ex beat. 

The aeiQttd aoutid of the heart, which is dependent upon closure of 


tbc semi<Iunar valves, cnused by resilieuce of tfao arierieSf is shorter, 
Bhar^jcr, uud more superfieiul tbnn the first, uiid poseeasea none oi tluit 
muscular element obacrrud iu the Intttr. it coiiu-ides vith the dtiuitulc 
of the heiirt and follows the arteriul puUc :tiid tipex beat. ltd jKiiit of 
gra:itcst iiiteuiuty is cl the artii;u1;itioii of the left third costal curtttago 
with tlie sternum. IniineiUaloly following the serond stmnil in ll;o 
period of silence, which varies in duration with the i-npidity of the 
heurt'a action. 

T/i€ exiriii of /he area oxer which Iho c:irdiiic sounds n\ay be heard 
will vary with the adaptjibility of tht* surrounding orgiiiis for trutisniit- 
tiiig sounds. If the lungs :ire fsolidified, the rounds may be heard much 
farthtir tlian in thi> normal etindition; but if tlie lungs are emphyscnta- 
tous, tho soands aro not Iteard ns far a& in health. 

Usually the sounds produced upon the right side are heard loudest 
over the corresponding portion of the heart, and toward tlic right side 
of the etcrnuui; whilo those produced upun tliL' left are hoard loudest 
over the left side of the heart, and nearer the k-ft nipple. 

As a nile, the lieart sonnds arc louder in c-hildren and in those with 
thin chest w.alls tJuin in adaltn or in those with the parietes very mus- 
cular or thickened by adijWBo tisane. Tho intensity v:;rit-s in different 
individuals with the clianging force of the impulse and tlie conforma- 
tion of the chest walls, and with peculiar idiosyncnisies, which we can- 
not well undorstund. 

Hence, we re<'ogni:^u the necessity of studying a large number of 
healthy hearta, for no ouv individual can be Uiken as u standard. 


The heart sounds are modified by disease, in their intensity, pitch, 
guaUty, mat, and rhythit. They may be preceded, ac<;ompanied, ur 
followed by abnormal sounds known as murmurs; or murmurs may 
entirely supplant tiieni. 

The iuteusity of tin? heart sounds is i ucn'o.tpfl by hypertrophy of the 
ventricles, nervous irrit^ibility, cardiac palpitation, consolidation of ad- 
jacent luDg tissue, and, exceptionally^ by dilatation of the heart. The 
intensity of these sonnds is dimiimhed by simple dilatation of the ven- 
tricles, by fatty degeneration of the muscular fibres of the heart, ur by 
deposition of fat between them or on the surface of the organ, by soft- 
ening or debility of the muscular fibres as the result of protracted dis- 
ease, for example, typhus or typhoid fever, and by pericardial effusions. 
It is also diminished by pulmonary emphysema. The heart sounds ore 
■oraotimes masked by bronchial niles. 

The -ywrt^iVy of the heart sounds is considerably altered in a great 
rariety of disrnsei^. The sounds, instead of iK-ing ck^tr and distinct, as 
in typical healthy ciises, may be slightly mutlled. or they may be associ- 
Ated with an indistinct and transient sound which closelv resemble!) 'l 



murmur. This impuritr of the heart sounde, unless Maociated with 
other Eigne of cardiuc dJaeaae, U at mi diagnostic importance, becMiiBt- ifc 
^Tery fre<inently ocfrnra as the result of pulmonary disease when the 
:eart 18 in no way inrolred, and it is often noticed in healthy indi- 

The first sound of the heart is rendered duller and lower in pitch 

than natural, by hypertrophy of the ventricles, with thiokening of tho 

tricuspid and niitml valves. The second sound is modified in the aamo 

Way by thickening of the semi-lunar valves without regurgitjition, and by 

>S8 of elasticity in the arterial wall^. 

The first Bourtd of the heart is sharper and higher pitched than nor- 
lal in dilatation of the ventricles without alteration of the auriculo- 
rentricular valves. 

The second soun'l of the heart may be higher pitched than natural, 
)r, in other words, acce».t:mted, at cither tho aortic or the pulmonary 

At the aortic orifice, this sound is somewliat intensified by hyper- 
rtrophy of the left ventricle, tlua to obstruction in the art«rj-. A ventri- 
[elo thus hypertrophied propels the blood with increased force into the 
Aorta, unduly distends this vessel, and thus causes sudden and more 
forcible contraction of the artery, with a sharper sound from the scmi> 
I;jnar valves. Wpll-markpd accentuation of the second sound in this 

•position results from scUiug back, on tho valves, of an incresised volume 
of blood, and it is always caused by dilatation of tho aorta. 

Accentuation of the second sound at tht pulmonary orifice occurs ia 
ft great variety of ditieases. It is tlic most pe.'sisteut of nil the signs of 
Cardiac disease, but it is also found in nearly every «isc of pulmonary 
congestion from whatever cauae. Whenever the/e is obstruction or re- 
gurgitatiua ut tlie mitral orifice, there must be increased tension of tlie 
blood in the left auricle and in the pulmonary veins, which will be 
transmitted through the short pulmonary circuit Uick to the pulmO' 
nary artery. This will cause a sudden and sharper elo.Jiire of tho valve* 
fhicU guard the outlet of the right ventricle. Obstruct-on in the pul- 
monary circuit fnmi disease of the lungs, by inducing hypertrophy and 
dilatation of the right ventricle, causes extreme distentiot. of the pul- 
monary arterv with each pulsation, and consequent accent a dt ion of the 
I second sound in the pulnionarj* area. 
The heart sounds become metallic or tinkling in quality in irritable 
conditions of the organ and when the stomach is distended with gaa. 
E.Tcejftional—T\v heart sounds are very inetajlic in chai-acter in the rare 
disease known as pneumo-pericanUum. They are ■oraetimes metalhc in left- 
Bided pneumoOiorax. Th« Home chnractt-r i» somotimes noticed with llie ^cond 
"oiintl, at the aortic oriOce, when there i* atheroma of thi« vessel limited to its 
initial portion. 

The seat of the heart sounds is a limited space in which they can be 


Iwttrd moat distinctly. It may be altered by several diseuees. The 
sonndfi obtuiuable over the apex are heard above their normal position* 
whenever the nUlominal org»us are so enlarged as to eneroui'li upuu the 
thoracic cavity, m in disteulion of the stomach, or calurgeniont of the 
hver. or ascites, or large ovarian tumors. They are also heard ttbova 
their normiil position when efTu«ioti is pre^ut iu the periciinliiil site. 

These sounds are heard belon- their tisuiil sent when the upi.'X u 
depressed by mediastinal tumors, or by hypertrophy with dilatation of 
the auricles. They are displaced laterally by pleuritic effusions, pnen- 
mothonis, and by deformities of the chest. They are displaced to tlia 
]eft whenever the heart is enlarged, wliuthor by hypertrophy or by dila- 
tation, or when it is dmwn from its position by contracting adheKiona. 

The rhythm of the heiirt soundii i^ ulteretl by many dise;i»e«. 

Fre^juently the heart arts regularly for some time, iind then drops 
one or more beats to go on »g:iin with its regular pulgations. This is 
known as an iNiermiftent rhtjihm. 

If the intermittent rhythm includes tho i>criod of one i)ulsTilion only, 
it is of no s{>ecial importance, us such phenomena mx;ur under a variety 
of circnmstiinceH, independent of curdiuc dlseuite; it is a cnrions fact 
that intermission in tlie heart's action often occurs in some people just 
preceding a thunder-titorm. But if this intermission occupies the time 
of two or three pulsations, and if the heart's action is irregular — that is, 
beating rapidly, then slowly, fintilly interniittlug, nnd thou sUirting up 
irith nipid pnlsjitions, us if to make up for lost time — it is a sign of car^ 
diac diseat-e. 

The first aonnd iif the lieart is jtrolouijeti by hypertrophy of tho ven- 
tricles, and by agglatinatiou of the surfaces of the pericardium. It is 
4horientd in dihitation of the ventricles, and both sounds are shorleued 
by fatty degeneration and softening of the heart walls. 

The pertwl of refmttc is souiettmea pmUimjpU by obstruction to tho 
onward How of the blood into the left ventricle, owing to stenosis of the 
Diitnd orifice. 

KEDiPLirATioN OP soiTXDS, another alteration of tho rhythm, con- 
insts of a repetition of ono or both of the heart sounds during u t>ingla 
pulsatiuu, so that three or fonr sounds may be heard witli each contrac- 
tion of the heart. Ordinarily, the right and left sides of the heart con- 
tract at exactly the same time, and consequently the soutkIk which aro 
protlnrcd in the two cannot be disting^uished; but oca-isionally there is & 
«light interval ht^tween the closure of the valves at the auriculo-vontrio- 
nlar or at the arterial orifices of the two sides, so that the sontids do not 
occur simultaneously, and thuH the first sountl ntuy be doublerl. tho 
second sound remaining natunil; or the second sound may be doubled, 
the first ri'inainitig single: or both may be doubled. 

This phenomenon occurs in disoiises of the hoart, bnt may often Iw 
discovered in health, if searched for with the differcDtial stethoscope 


(Fig. 15). When occurring in disease, reduplication is usually 
caused by stenosis of the mitral orifice or incompetence of its ralves. 
This gives rise to increased tension in the pulmoimry circuit and to 
abrupt closure of the pulmonary semilunar valves, which thus slightly 
anticipates the closure of the aortic valves, and causes reduplication of 
the second sound. 

Reduplication of the first sound is due to tardy closure of the mitral 
valves. Some care will be necessary to avoid mistaking reduplication 
for endocardial murmurs which precede or follow the normal sounds. 
Intermission is a characteristic of reduplication (Loomis' Physical 
Diagnosis). In some cases reduplication is infiuenced by the acts of 
respiration. In forced or laborious respiration, the first sound may bj 
reduplicated at the end of inspiration and at the beginning of expira- 
tion; the second sound may be reduplicated at the end of expiration and 
at the beginning of inspiration. 


THE UKART. —Continued. 


ThI! abnormiil fiouuds lieurd over the prEeconlial region are ilenom- 
innled murtuurH. homeliiiiuii these ure jtroUuucd ufKiii the surface of 
the heart, hetwei'ii the two layera of llie iierirjirdium, but iiiont of thorn 
originate witliiii iho heart. Thu hitter arc known aa ciidocardiiil iitid 
the former as exocardial murmurs. 

The exocakiuai. or ptKiCAKDiAi. FHirxios sofxns or mukmurs 
are pi'oduceil by the rubbiug togelhcr of the rouglieuod surfaces of the 
pericardium, iu the same mattQcr that frictiou sounds are produced 
Tithin the ptoura. These murmurs vury greatly iu their iiileiisity and 
qnality. Souietinies they are very indistinct, at others loud. In cjuality, 
they may be grazing, gi*atiug, rubbing, croakiug, or crackling, like 
pleuritic friction houihU 

The (jualily of an exocardial luurmnr yielils no information regard- 
ing the peculiar condition of the surface which produces it, though, iu 
the dry stage of pericarditis, tlie grazing sound is the one most likely to 
be beanl. 

Theee murninrti may be either single or double; that is, they nuty 
occur with the systole or with the diastole of the heart, or with both- 
They sometimes accompany the valvular sounds; ut other times they 
arc mdependeut of them. They arc always superficial in character asid 
they seem to be produced immediately beneath lliu chest walls. The area 
orer which they can be heard ib restricted to tlie pra;cordial space. They 
are genendly heard loudeist ut the junctioti of the fourth left costal car- 
tilage wiih the sternum. They generally last for only a few hours, sel- 
dom longer than one or two days, and then disappear in consequence of 
the exudation of serum into the pericardium. As the serous effuHiou 
becomes tibsorbed in the later stage of pericarditis, the friction murmur 
may reajipear. 

Pericardial friction sounds are distinguiehed from endocardini mur- 
murs - first, by their Buperficlal character: second, by l>oing limited to the 
precordial space, i.e., never being transmitted to the left of the apex, or 
above the base of the heart; third, by their being independent of valvular 
sounds; and fourth, by the variation in their intensity with changes iu 
the position of the patient. Whcu the patient is iu the erect or in the 



recuuibent posture, the heart does not approach so near to the surfuce 
of the cbeit us when he is leuniiigweU fornunl.&nd therefore (hcsouuda 
are uot hs distinct. In geiiend, tlio intensity is greater during expira- 
tion thun during inspiration. 

Periuiirdial friction soiindB are diBtinguiehed from pleuritic friction 
sounds by their confinement to the prsecordia, by their synchronism 
with the cardifl'! movemeuta instead of the respiration, tind by cuutiuu- 
auce during lempurury suspensiuu of the respiratory act. 

Ejccf:ittio»nl.—\z shoiili.1 be reiuemberLMi Unit, in some t-iuws uf plourisv, nib- 
bitig uf the filiiviM l-iyoruf ttic ]>cHc-Ar(liiim ai^ainst an inflaiiiecl pleura pvM ri»« 
to a fnctjon sound having the »<aine rbytlini as the heart, ntid cutiUnuing while 
respiration is suspended. Huch a. sig-n is called a eardio-jjictiritic fricHtm mur- 
ffiur. It is easily tuistakea Tor Uie pericanliul miirinur, hut its cuiisv should 
always bn suspected tvlieu otiier si^'ns of pleurisy exist, especially if the pieunsy 
be associated with pueunioniu. Thi» (lound dilTent (rum the penL-iinljut iniirinur 
in tlie UDifurmity in iriti^nbity uf the siivces^ive soumls, in its htiataliun to the 
border vt the lioui't, and. hi Kuiue wkM;s w tlie eml of iiispiratiun, ftiid in yen- 
ertUly btttng aJTectMl to a greater or tem degree by the movements of iiuspiriLtiua, 

EximcARDiAL 3JL'KUL'ii.s vary in tlieir intensity, pitcii, and quality; 
but tliese elements are of very little imjiortance from a diagnostic point 
of view, as the intensity and the pitch of the sounds yield ns no infor- 
mation whatever, and the quality is never characteristic, except in the 
presystolic murntur duo to stenosis of the mitnil oritlco. 

These Bounds are produced by changes in the physical condition of 
the heiirt, in whicli vase they are known us organic nmrniurs; or by 
changes in tlie condition of thu blood, when they are termed inorganic, 
ana-niiu, or liEemic murmurs. 

Organic murmurs arc usnnlly permanent, though not infrequently 
they cease for a considerable length of time, and in some cases they 
may entirely disappear. The inorganic murmurs are tntnsitury— present 
for a few huuK or days and then disappearing permanently, or to recur 
after a short interval. Sometimes they come and go while the exami- 
nation is being made. 

A murmur in t)te prteconlinl ^pnce indicates nothing except a di»* 
tnrbance of the normal relations of the begirt to the blood, and may bo 
due to a change in thu physical condition of the heart itself or in the 
normal composition of the blood, or it may result from irregular oon- 
tractions of the cardiac uiuscle. 

The important things to nolo regarding a murmur are: 6r8t, the 
seat; second, the rhythm: and third, the quality. The direction in 
wbich the sound is roost clearly transmitted is also an essential fentnre 
in diagnoitis. 

in noting the rhythm, we observe the relation of the murmur to the 
systole and the diastole of the ventricles, and we ascertain whether it 
precedes, accom])anies, or follows thti first or second sound of the heart. 




In a few instances, the peculiar quality of tho Bonnd itsolf is im- 
portant. Some murmnre are grating, othera blowing or rushing lo 
quality, and obhors arc harsh, or soft, or muaical. A mnrmiir may have 
many of these eharacteriatics at different times without any appreciable 
change in th« conditions which produce it 

Whenever we hear an abnormal sound in the pr»conliiil ^mce, we 
ahonld ascertain, by careful examination, its point of maximum intensity, 
whether it is ayncbronous with either the contraction or the dilatation 
of the cardiac cavities and depends upon the current of blood through 
the valvular orifices, or whether it \s produced outside the heurt. As 
the majority of abnormal cardiac sounds are produced within llie heart, 
Iho presumption is always that a murmur is endocardial: if we should 
liud it coin]taratirely deep seated, and synchronous with the Hyatole or 
the diastole of the ventricles, and transmitted to the left of the apex, 
or above the base of the heart, we may safely conclude that it belongs 
to tb^ class. 

When we remember that nearly all endocardial murmurs are pro- 
duced at one of the valvular oritices, and that thc«o approxiinutu to 
closely to each other that a circle half an inch in diameter may include 
a portion of each, it is at once appureni ihat it must be imiH)H8ihle to 
distinguish between difTurunt cuducardial sounds by liuteuiug for them 
directly over their point of origin. 

Sound loses its intensity by passing from one medium to another, as 
will occur in tbe passage of sound from one cavity of the heart to an- 
other, and any sound produced by fluid in motion is transmitted in the 
din'cti'.n of the current wliieti cjiuses it. A knowledge of thesir two facts 
will aid us greiitly in differentiating between endocardial ifounds. We 
shall find that, as a rule, sounds produced in any of the caviUe« of the 
heart, or transniitted into chem, are best heard over tho sjMice where 
that cjivity is moet supertieiiil. For example, the only point at which 
the left ventricle impinges directly on tbe chest wall is where the apex 
ibont is felt: murmurs produced nt its uuriculur orifice ni-e hi-H heanl at 
^ihis spot, while those at the tricuspid oriHcc am nin^t dj^iinct over that 
|)ortion of the right ventricle which is superficial. The murmurs at the 
nortic and pulmonary orifices are respectively heard with the greatest 
distinctness whore these arteries approach nearest the chest wall. 

Some of the endocardial murmurs, however, are produced by blood 

Cowing in an abnormal direction. Therefore, the areas in which mur- 

I mars pro<lunoil at tho various oriBces are most distinct will not always 

tzoctly correspond to the positions in which the normal soundc are 


Before examining the heart by auscultation, we should ascertain its 
superior and laleml limits by jicrcussion or by auscultatory percussion, 
■ud, either by these methods or by palpation, determine the position of 
the aper. 



Tha mitral nrea, as the spiice is named -where tho mitral sounds may 
be heard with maximum intensity, corresponds to a circle two inches iai 
diameter, which includes the apex of the heart (.-I, Fig. 3:J). If this 
orgiui is in its normal position, the circle, as shown iu the diagram, will 
have its centre near the normal position of the npcx beat; but if, from 
enlargement or other causes, the heart is displaced to the left, the posi- 
tion of this circle is correspondingly changed. 

Mitral mormurs, if caused by regurgitation, arc also heard diffused 
for ft distance varying from one to three inches to the left of thi- apex. 
Often they may be heard bciiind, aiuug the left side of the sixth and 
iereiilli dorsal vertebrse, with nearly the same intensity as in front; 



- —'a "n 



.—** ■■■" 



FMl SS.. NijLUor EaDooAHDUt. Mi-quDiu. A. Mitral Aiva-. Jf , .vortlo anA ; C. uictMpUum; 

H, |iutmaiuU7 area. 

sometimes they may be heard in this position wheti They are not distinct; 
in front. 

Care must be Takc-n not to coofounil mitnil murmurs i\ith aortic rc^iirgitatit 
murmurs, wliicii aro occasioiiully liuurd at the lower angle ot the left scapula, 
and in the left axillary rc^vn ; or with aneiu-isTiml niurroura, whicb n:a.v also be 
heard along- (he left liule of thn spinal column, m Uie same position as the mitral 
regurptaiit imimiur. 

A milnil regurgititnt mnrmnrdifferB from an aneurismnl murmur in 
being heard behind only between the fifth and the eighth dorsal vertebraf. 
The anonrismal murmur may be he:ird above the fifth vertebra, and, with^ 
diminished intensity, below the eighth as well us between the two. W 

An aortic direct murmur, heard behind, should not be mistaken for 
»* mitral regurgitant murmur, since It is heurd loudest abcvc the lower— 
border of the fifth dorsal vertebra, V 

Mitral ffKurgitaot mumiure may sometiroes disappear, even Uiough due to 
organic lesious. In such cases. o'"<"fnt"silion of the second sound at the pulmo- 
"^'■y oiniico may be tlio ouly abnuraial bik" remaining. 



If a mitral muniinr is obstructive, or direct^ i.a., due to stenosia nf 
the mitral orifice, it will bo henrd iit the :i|H!X, but will not be distinctly 
Iransniitted to the left, uud will luit Iw Iiwird behind. 

It is to be borne in niiiid that, in speiiking of the nroas of niitnnurs, 
we refer only to the ptjsitiona ;»t wliich they niny bo hc-nrd with tlie 
yreattst inUnsity. Sometimes a mitral mnrmur may be lieurd over the 
whole 2>rwcordial region, or even over the entire chest, hut its point of 
maximum intensity will correapoud to the area which ve have juet 

The tricuspid area of mnrmunt is limited to the triangnlnr B])Aoe {C, 
Fig. 33) where the right Tentncle is superficial. These murmurs ore 
ordinarily loudest over the xiphoid <.'«rtihige» or along the left bordtrr uf 
the sternum, at the junction of the sixth or seventh costal cartilage, 
and are scklom audible above the third rib. This latit-r feature distin- 
guishej them from aortic and pulmonic murmurs. WIilmi the heart is 
bvpertrophied or diluted, their inteu!<ily will suinetimcu be greatest at tha 
junction of the fourth costal cartilage with the sternum. These mur- 
murs are superficial in cbara'-ter aa o<jn]]>ared with tliost* occurring upon 
the left side of the heart. If tnin»niitted in any <Hr**rlirtn, they will bo 
heard more distinctly to the right than to the left of the parasternal line. 

The jitdviOniirtf fina of murmurs corresponds to a small circle about 
an inch in diameter, located just above the thir<l costal curtilage at the 
left border uf the sternum, and covering the pulmonary artery (D, 
Fig. iW). Pulmonic murmura are heanl mc*t distinctly directly over 
the pulmonary artery. These sounds are never heard in the carotid 
und subclavian arterieit. If due to regurgitidion tlirough the pulmo- 
nary valves into the right ventricle, they may be moirt intense, an Inch 
or an inch and a half below this area, near the left margin of Iho 
sternum. They are not heard at the apex, and this distinguishes them 
from some aortic murmurs. These, like the tricusjiid murmurs, are 
comparatively sujierficial. 

The 'lortiv arm of murmurs cannot bo so sharply defined as the areas 
of the murmurs we have jnst described. Aortic murmurs are usually 
loudest in the second intercostal space of the right side, where the artery 
up]>roaches most closely to the thoracic walls; or along the right margin 
of the stenmm from the second to the fourth rib; but they are often 
heanl over tho whole sternum {B, Fig. 33). 

Aortic murmurs are propagntetl to the carotid or subclavian artcricSj 
and are frequently heard be^t in these localities. Occasionally they nra 
louder in the pulinomiry area than at any other ]>oiiit. In eucIi in- 
stances they are dititinguished from palmonary murmurs by being heard 
uls<i in the arteries at the base uf the neck. Aortic murmurs are often 
board liebind. niong the left side of tho third and fonrth dorsjil verte- 
bne, and with diminishing intensity for a considerable distance down the 
spine. They are frequently very distinct at the apex at the bean. 


Aortic rognrgitont mnrmnrs aro often londeet over the lower piirt of 

he sternum, though we expect to fiud them most dtBtinct a shori <iiii- 

:inc(> bubw the uuriic vtilves. These murmurs arc frc-queutly uutlibk in 

the loft ttxillftvy region, and at Ihu lower angle of tho scii|)uUi. Tho 

patient may often hoar tlieni himself, eajHHiially when lying down. 

Exceptionat. — Aortic miimiiirs may sometimes be heard over the :irter)«s 
when tliey are nut diHtiact at the ba«e of the heart. At other tini«^& they are 
audibh; ut the biLse ot the heart ouly ; uad atiU a£:a)D. tliey may be distuict over 
the entire piiLiordiul i-L'^-iun. 

Itcgurgitiint aortic murmtini are frequently heard in all the arteries 
which are accessible tn ausrultatinn. It should be remembered thiit the 
aortic murmurs are tho only ones that may be heard above the clavicles. 

ik>th tho obstructive and the regurgitant aortic murmurs vary much, 
in intensity. Sometimes it is nef^essiry to listen intently in orih r to 
hear them ut all. In uther eased they arc so loud that they may be heurd 
at some distance from the patiput 

The rhylhm of a murmur refers to the relation which it bears to the 
cardiac pulsation^ and consequently to the first and second sounds of 
the hc:'.rt. In determining the rhythm of a murmur, we mu^t tirst as- 
certain which is the first and which lis© second sound of the heart. This 
vill not be u dillicutt task if the heiu-t is pulsiititig slowly and buth. 
suunds are distinct; for we know tbitt tho first sound is the louder and 
longer, and that it is u88<.iciated with tlic impulse of the apex against thu 
chest wall. In sume instances only une vt the valvular sounds can be 
heurd at tho apex or at the lui^o, and in such eases a nmrmur would 
very niitnmlly ha mistaken for the other sound. In every case of doubt 
we rau^t feel for the citrotid pulsci which is always synchronous with the 
first sound of the heitrt, and will therefore enable us to determine the 
rhythm of tho murmur. 

The quality of endocardial mnrmnrs gives lis no information regard- 
ing their place of origin or the conditions which produce ihein. except- 
ing in cases of presystolic niitnil mtirmnrs, which will be presently de- 
scribed> and ana?mtc murmur?, which are always soft in character. 

Cauxex of Emlwardiftl Munnurn. — Presystolic mitral and tricuspid 
niurraurs, preceding as they do the first smuikI uf the heart, must occur 
while tho blood is passing from the auricles into tho ventricles, and 
while the valves arc thrown out upon the current (Fig. 34). They aro 
always caused hy narrowing fsteiiosia) uf the auriculo-vcntricular urifice. 
which obstructs the onward flow of blood. Such a murmur, if produced 
upon the left side, will be loudest ut the apex, but will not be trans- 
milted to the left of the ai>ex, and cannot be heard behind. It is called 
« roitml presystolic or obiitrnetive nuirmur. This is perhaps the only 
murmur where the quality of the sound is of any 8pccl;il diagnostic 
Talue. According to Italfour, the qtndity of these murmurs is charao< 
tctietiu. though uot exactly the same in all cases. It may bo quite ao- 



corately repreeenU'd by vocalizing the eymbols Rrrb or Voot. If 
a murmur which precedes the first 60und of the heart is produoeii upon 
the righi aide— whicli is extremely luicommon — it is called a tricuspid 
obstructive murmur, and its ureu is limited to the triuugulur space i\ al 
the lower portion of the sternum (Fig. 33). 

Systolic murraura, or murmurs iit:i:oiu|Kinyiiig or foHowiiig the first 
Bound of the heart., must occur with the contraction of tbu ventricles, 
the closure of the anriculo-veutricular valves* and the propulsion of the 
blood from the ventricles into the arteries. They may be due to lesions 
at any of the valvular orifices. 

The mitral, syetolic or regurgitint. murmur is produt^ed at the mitral 
orifice, and itt due to thickening, corrugation, ur udtiei^joii of the valves, 
which prevents them from perfectly closing the ori&ce, and thus allows 



VkSt S4— AnucVLUt SmoiA A. C. CoBlnwttMl auricle; B, D. dIUbvt T«iUflck«. Mllr«l umI 
tricuspid Tidres open : Mtnlluau- valves dosed. 

the blood to repirgitate into the left anricle. It may also result from 
rnptnre or undue shortening or stretching of the cohimna? carncjc of 
their tendons, which normally keep the valves from jriving way bofor* 
the column of blood. This murmur is generally si^ft an«i blowing, and 
may be musical in quality: it will be londest in the mitral area. It will 
be transmitted to tho left of the afwx. and may be heard posteriorly 
along the left side of the spinal column from the fifth to the eighth 
dorsal vertebra. It is seldom beuni in this situation with the &ame in- 
tensity a^ at the apex, but occasionally it is distinct behind when it is 
not audible in front. If a mitral murninr is cauit-d simply by roughen* 
ing of the ventricular surface of the valves, it will not be heard beside 
the sixth or seventh dorsal vertebra, though it may be heard about th» 
inferior an^de of the scapula., and in tho left axillary region. 

Sometimea endocardial murmurs are produce<l by dilaUitiun of the 
veatriclee, which jirevents perfect closure of the mitral valvee. Such 



jnnnnnrs have been termed curahh miiral regurgitant intinnurnt u 
they disappear when the tonirity of the muactilar fibre haa beconif suffi- 
ciently restored to contract the cavitieB to their original «ize These 
murmurs iire probably caiusecl by dihitation of the ventricles without a 
f^orrespondiug clougntiou of the diubcuIi papilhires in coneeqneno^ of 
■which the chorda! teudinea) are too short to iillow tlie voltes to close. 
Tht.' tricuspid systolic, or regurgiUint. murmur will be hcjird in the tri- 
cusjjid area, and if transmitted iu either direction will be louder to the 
right than to tlie left. It will not bo beard at the apex distinctly, and 
never lo the left of ti^e upex or behind. This niurmur baa generally a 
blowing ipiality. 

If tho aortio systolic, obstructive or direct, cinirniur is of urganio 
origin, it will be caused by constriction of the aortic semiluuar valves, 







Flo. St.— SnrroLB or tk« Vkmtuclbii. A. C, AurirW tllUtInK-, B. P, v«nttidMCODtr«etl>tK S^inl- 

lunar va1v«> op«n ; mllnii uni UicuspM vkIvm dowd. 

or by roughening uf their ventricular surfaces, or possibly by ilisease of 
the artery. It will bo produced while tho blood is passing from the 
ventrlrles into the iirterieii (Fig. 3*)), and will be heard in the aortic area 
over the serond intercostal space of the right side, or over other por- 
tions of the sternum as shown by the space ft (Fig. 33). It will also 
be heard in the arteries of the neok. and frequently nt the left of the 
third and fourth dorsal vertebra; posteriorly and possibly with dimin- 
ished intensity farther down the spine. 

If this murmur is loudest over the pulmonary artery, as occasioually 
happens, it may l>e distinguished, from murmurs produce^] at the pul- 
monary uriticc, by the fact that it is transmitted to the carotid and sub- 
clavian nriches. 

A systolic murmur produced ut the pulmonary orifice is likely to be 
a hemic murmur; but if of organic origin, it is usually due to obstruc- 


iinuhr to that just described w oocnrring si the H>rttc v«1tm« 
These mannnn are fOBetimei e«a$e4 br preasnie on the mterj from 
ibi^ed fbuuU; or bj coasthction of the artery from pleuritic adh^ 
or fibroid phthi»is with cuniraction of the long. Soeh a munnur 
win be heard most distinctly in the polmonarr area (D, Fig. H), 
and wX UDt br audible in the uteriea at the base of the neck. 

DLi:<TOLlc Mt'UtCKS — A mDrmur accompanring or folloTtng tlie 
sound of the heart oociLrs with the iliastole of the rentriclea, 
id miut be due to regurgitation of blood from the arteries through the 
semilunar TalveSr on either the right or the left side. 

If a marmur, accompanying or foUoving the aecond sound of the 

^lieart, ckccurs at the aortic orifice, it vill be due to regurgiuitioii uf blood 

from the urtery iuto the left Tentricle, and may be called aortic diastulirt or 

irgitanL It vill genemlly Ih* soft and bloving in cbiira<-U'r, though 

may be harsh. It irill he heanl in the aortic area, but U8u:il1y most 

distinctly a short distance below the TtUred; it will be propiigiitcd down 

the sternum and it may sometimes be loadest at the ensiform appendix. 

EjTfjitiomat. — In s»m< inxtancvs sucli murmurs nrv ven* dJxtinct at ihr npcx. 
In ihe axillATT rvi^ioii ubuut tiie lower unele of Uie left scofiulu, or uver ail \argn 
sap<rQci:iJ arWri«8. 

If produced at the pnlrnonary onlire, a diastolic mnrmiir is i)iie 
to regurgitation through the pulmonary Talves, and is vallvd a 
pnlrnonary diastolic or r^nrgitant murmur. Sneh mnrmurs are ex- 
tremely rare. 

When such a murmur does occur, it will be hoartl in the pulmonary 
area, or an inch or an inch aud a half below this space, and it will not 
be transmitted to the large arteries or to the luwer part of the sternnm* 
By this Utter fiict it may easily be Jidtingui.shod from a similar nmrninr 
at the aortic orifice. 

Thus, we may have eight distinct Vftlmlnr murmurs, four of which 
are obstructive aud four rc>gurgituut. Two of thcDc, viz., the rpgurgi- 
taut pnlmouary und the obstructive tricuspid murmurs, are »o very rara 
thut thoir existence is doubted by many skilled diaguosticiana. Regurgi- 
tsul triirugpid murmurs nre rare except lis tho consi'quoiicc i>f illetroso of 
the left side of tlie heart, which gives rise to such dilnUition of iho right 
Tentrirle that the aurlcnlo-veulricnlur orifice becomes too largo to be 
closed by the tricuspid ralves. 

We may hare two or more of these sounds conibine<l in any ciise; 
thus, it is not uncommon to obtain a mitral regurgiUnt murmur iieso- 
cinted with an aortic obstrnotive, und perhaps also with iin aortic 
regurgitant murmur; or wo may hnVe both the mitral obstructive and 
regurgitant, with the aortic obstructive and regurgitant murmur. 

Murmurs are common in the left side of the heart, but rare io the 
right side. 



According to my obserration, Ihe various murmurs occur iu the fol- 
lowing order of frequency: mitral regurgitant, aortic regurgitant, aortic 
obstniotive, mitral obstructive or presystolic, and tricuspid regurgitant. 

Vestuicular MritMnis. — There are certain niurinurs occasion ally 
heard in the precordial region, wbidj are neither of valvular nor of 
tuemic origin. They are most frequent during tlio acute etage of en- 
docarditis, but tliey nlso occur in chronic endocarditis. They some- 
times prect'du und sometimes fulluw etulucurdltis, iiiul in suine iiistanccH 
they are apparently induced by simple irritiibility of the heart. They 
accompany the first sound of the heart, and are loudest at the apex. 
These murmurs seem to bo caused by roughening of the endocardium or 
of the chordiP tendines, or by irregular contraction of the musculiir fibres 
of the ventricles. They are of coniparatirely rare occurrence, and then 
are usually mistaken for v:ilviil;ir ninrninrs. They may be distinguished 
from the hitter by their rhythm and by their sout. These murmurs are 
most likely to be confounded with mitral regurgitant and aortic or 
pulmoniiry obstructive murmurs. 

A ventricular murmur, though beard at the apex witb the lirst sound 
of the heart, is ner-'er transmttted to the lefl; wliereby it is distinguished 
from the mitnil regurgitant murmur, vliich possesses the same rhythm. 
A ventricular murmur is uerer heard ahwe thr hnse- <tf thf heart, and thns 
is distinguished from aortic and pulmonary murmurs. 

Frequently in exaniination of the heart, impure sounds are ob- 
tained, which closely resemble faint valvular muramrs. They are gen- 
erally heard just at the cud of inspiration, und usually cease when respi- 
ration is suspended. These are not constant, but may come and go 
during the examination. 

Cottj/trittul j$titrriiurs arise from im|H'rfect L-losuro of the foramen 
ovale, which allows the blood to pass directly from the right into the left 
auricle. This occflsions a murmur which is audible over the base. of 
tho heart. It is heanl with tlie systole of the ventriclea, and is not 
transmitted into tiio arteries, or to the left of the apex. It may thus he> 
distinguished from aortic and mitral murmurs. This murmur always 
occurs in curly life, and is associated with a ryimotic appearance of ihe 
countenance. \Vhen tho child reaches the age of ten or twelve years, 
other endocardial murmurs usually eupervene. 

Ifivmit vtuntn/r/i form another variety of adventitious sounds dne to 
changes in the composition of the blood instead of to nnatomieal changes 
in the heart. They are also termed aniemic, or inorganic murmurs. 
They are always systolic, genemlly most distinct over the aorta, and are 
diffused through the vessels of the neck. Stmietimes they may be heard 
in the second intercostal space of the left side, about nn inch and a half 
to the left of the pulmonary .artery. 

The ha;niic murmurs which are produced in the aorta are dne simply 
to change in the composition' of the blond. Those heard to the left of 



the palmonary nrtery eepni to bu prodiu-Ofl by slight dilatutiou of the 
left ventricle, with coiide<|Dent imperreut closure of the valve» 
and mure or less regiirgitHtion of blood into the unricle. 

These murmurs are inconstant; they ofteu come and go during the 
fixaiaination.und fiuuUy they pennuneully disuppeoras proper treutuient 
removes ihe unaMiiic condition of the blood. 

The foDowing t-hanicteri sties distingniah them from organic mnr- 
mnra: they nlways accompany the 6i'ft eotind of the heart; they are soft 
and blowing in eharncter; ihoee which ure arterial mny be heard OTcr 
m:iny uf the aortic branches and ure often loudest over the carotids in- 
stead I'f ovt-r the aurtj, where the aortic obstructive muniiurs would be 
most distiuL-C. TbotiC whiuh art; mitral may be heard a vuriabli> diut'inco 
to the left of the pulmonary artery. They ure inconstant and likely to 
be present when the lieart's action is mpid, but absent wlien it is slow. 
They are incapable af supplanting the uornuil heart sounds, or even of 
making them less dititinct, and are usually associated with the venons 

The£e murmurs are also attended by the symptoms and signs of gen- 
eral ansmia. Except in complicated cases, they are not ai^sociated with 
the signs of other cardiac disease. 


In rare instances, sounds may be heard over the pr»cordtal spacw» 
which are not endocanlial or pericardial. These result from the action 
of the heart upon the lungs, and usually cease when the respirations oro 

With the systole of the ventricles, a loud blowing sound may he oc* 
casioned by a large pnlntomiry cavity situated near the heart. Hore or 
less distinct blowing sounds are frequently heard when the systole of the 
heart occurs just at the end of inspiration. These cease when the jm- 
tient holds his breath. 

Friction sounds may be produced by tlie action of the heart npuu 
the overlying pleura. Generally these may be easily distinguished irum 
peri(:ardial friction sounils by their seat, and by their disupivearanee with 
the cessation of respiration. The pericardial friction sounds are heard 
most distinctly along the left border of tlie sternum: hut t^oniids pro- 
duced within the pleura by the action of the heart are heard nutst clearly 
over the outer portion of the mammary region. They are aUo usually 
associated with friction sounds over other portions of the left lung. 
Ordinary pleuritic friction sonnds are sometimes obser^'ed in the pre- 
cordial region: but these disappear when the patient holds his breath. 

The sounds caused by the action of the heart* upon the luugs occa> 
aionally resemble bronehitil nilca: but as these are limited to the pne- 
oordial t<p:H-e, they are not lil^ely to be mistukeu fur sounds due lo pul- 
ZDonarv disease. 




Sabclavian murmurs are often heard just bcucatli the clavicle, at the 
outer portion of the infni-ciaviculHr region, more frequently upon the 
left timn upon the right side. Mu^itof these aeeui to nie to be produced 
b^ the prf8«ure of the stethoscope; but niunnun' frequently occnr in 
this locality, and over other purls of the subohiviau arlen*. which are 
not due to external ciiuseB. They are supposed to reeult Xruni pressure 
upon the artery, either by ronsolidated hmg tissue or by cicatririal 
bands resulting from ph>urisy: but their ex:irt cause is not knorn. 
They are most frequently usiiociuted with consolidation of the apei of 
the lung. 

TtrnoESCEXCE of the superficial veins of the neck and upper part of 
the trunk is a c^ign of curdiae or pulmonary disease, and of aortie unen- 
rism or otlier intni-thorauic Lumors. The condition is caused by direct 
pressure on th« veins, or by increase in the intra-thonieic pressure from 
pulmonary disease, and consequent interfi^renco with tho return of blood 
to the heart. It is always most noticeable when the jmtient is in che 
recumbent position. 

This turgescencj inuy be cither tcmponiry or perniunent. If the 
former, it is uiost marked in expiration or after iittacks of cougiilng, 
and it will entirely disnppeiir upon deep iuspinition. 

Ttmpornry { nrtjescenve ol these veins is generallv due lo congestion of 
the pulmonary circuit, resulting from disease of the lungs, which com- 
presses the capillaries, and consequently causes distention of the pul- 
monary arteries and of the right side of the heart, and, through it, of 
the descending vemi cuv:i and its branches. 

Permanent turf/escciue most commonly results from disease of the 
mitral valves, which either obstructs the onward current of blood into 
the left ventricle or allows free regurgitation into the auricle. Thia 
gives rise to engorgement of tlie pulmonary circuit, which cannot be 
relieved by doep inspiration. Permanent congestion may bo duo to 
obstruction of the desceudinar vena cava by a ihromhns, or more fre- 
quently by the pressure of an aneurism or other tumor. 

Lm-alizMl hift/imce/ue, confined to u single vein and its branches, 
is always the result of a thrombus, an embolus, or of pressure upon the 
blood •vessel. 

Venous pclsatioit with marked pulsation in the jugular veins is 
observed when there is' permauent engorgement of the descending ven:t 
C2iva, wliich generally results from extreme emphysemii or stenosis of 
the mitral valves with secondary tricuspid regurgitation. 

Pulsiition in the jugulur volus is nsuully observed just above tbft 

rsyocs sioirs. 


claTiclos. though sometimefl it extends over the whole course of the vsb- 
Be\. It U most marked in the dorsal decnbitiu, and is more dii>tinDt 
npau the riglit than upon the left side, hecauw thp current of blood 
from the right venirii-le. through the auricle^ finds its way more rcadilj 
into the reins of that aide. 

Venous pulsation mar precede the inijmlse of Iho apei and the fir«t 
■ound of the heurt, or may follow it In other words, it may be either 
iresyBloIic or sistulic. 

Prayftolie renons pulsation is dac to regurgitation of blood into the 
Teinfl doriiig the conlniction of the tturiclei. 

SyjftiiUc TYiious jmhn/iun is due to contraction of the right ventricle 
with regitrgitiition of blood through the tricuspid valves into the auricle 
and thence into ihe veins. When slight and tempomry, this is termed 
relative venous pulsation; when permanent, it is known as absolute 
Tenous pulsation. In order to be of value in the diagnoein of trioB«pid 

irgit4itiou, it mnst be risible during both inspiration and expiration. 

Pulsiitiou of The jugulur veins mcy be simplv (he transmitted impulw 
from tlie carotids. In such cases, there will bo simply » lifting impuUer 
instead of expiutsion of the blood-vessel, and the vein will not bo tortuous 
as ID true venons pulsation. 

Pulsation in the i-rinn o« the had' of the hnntls has been repeatedly 
noticed by Peter, of Paris, in advanced consumptioti, and occasionally 
in other affeotiuns. It is increased by compressing the wrist, and there- 
fore must be jiropagated through the ciipilbiriofi from the left side of the 
heart. It ma}' be mure readily seen tlmn felt. 

Peter thinks this phenomenon due to pttndysiaof the muscular fibres 
of the arterieit, through excess of carbonic Hcid in the blood. This r.ire 
phenomenon, when seen, indicates the ne;ir approach of detith. 

Collapse op the JcorLAH veins i^ said to occur with the systole 
of the ventricles, in some cases, whore there is a^lutiuation of the two 
sarfaceii of the jwricurdium. 

The VESuis JiiitMrit, venous hum or bruit d« diablf is a con- 
it humming sound frequently obtained over the jugular vein just 
above the clnricle. or in the inter-cliivicular notch. It is gonemlly awto- 
ciated with an arterial hcemic murmur. It occasionally occurs in healthy 
persons, bat is most often found in those who arc anttmic, esiHKsially in 
chlorotie women. 

Thist sign is most apt to be hoiii;d when the patient is sitting or 
standiug.and is usuiilly soft und humming in character, but occasionally 
mnsical. hissing, or even loud and roaring 

Interimtlent vt-nou* inm-mura syuchrununs with Ihe pulsations of the 
heart, are among the rarest sigus of carduic diseasti. Tliey may be pro- 
systolic, systolic, or diastolic. The presyjstolic murmurs arc beani only 
when the patient is lying down, and must result from regurgitation of 
blood from the right auricle into the open vein^t. The systolic murmur 


r/Zi' HEART. 

is usually heard moat distinctly just above the cUiTiclc on the right side. 
It is due tu regurgitution from the right ventricle through the uuricle 
and inUi the veins. Tlie diajitolic iiuiriiiur i6 i-xtreniely rare. It is said 
to require, for its production, hypertrophy and dilatation ot the heart, 
■with aneurism. These mnnnurs may be mistaken for arterial murniura. 
They may be distinguished from the latter by slightly pressing on the 
blood-Tessel, which will prevent the venous hum, but will not so affect 
the arterial murmur. 


By the use of the sphygmograph we are enabled to obtain a graphic 
statement of the condition of the circulatory system, written, as it were. 


Fid. 80,— Markt'i &>mt<]mooiui>s. 

by the heart itself, ^len all the ponditiona are favorable, thie stated 
nit^nt furnishes interesting information to physiologists; bnt so much 
depends upon the Adjustment of the instrument, its proper working. 

Ho. 37.- NiiNMAi. lUuuL Pcuu tTcimii). 

and the pressure made upon the artery that np to the present time th 
instrument has been of littlo clinical vahie. When all the conditions 
are perfect, the tracings of the pulse may indic-ate: the time occupied 

by the systole and the diastole of the heart; 
the force of the heart's contraction; the resist- 
ance to the onward eurrenl of blood, or its re- 
gurgitation thruiigh the valves, and the tenaioa 
of tiie arteries. 

The tnicing is <:oinpo8ed of n series of cii rves, 
each of which rej>reseTits a cArdinc pnl^uilion. 

In the tracing of the normal radiid pulse as 
shown ^Figfl. 37 and 38) each completed series 
contiistH of a line of uscont, a summit, and 
H line of descent. The line of ascent a 6 
iu the normal condition is perpendiciiliir to 
the plan*: of the base. It is produced an the blood is jin»pe1]ed into 
urLi.!-), ..ud iudiuutett the force ot the heart by its height, aad 

F»0. M.- StiiutAi. KJtiitAi. Vtuat, 
Sixauc Trace Fnl^iuiki). 



the rapidity of the current uf bloody by ita direction. When the blood 
is retarded in its passage from the left ventricle into the aorta, as in 

r». ».— Aownc UBtnuxnon (IUn>BX). 

constriction at the aortic oritioc, this liiic will run more or less obliquelj 
to the right, uccording t<* the anioiiiit of <»b!«trtu^tioii ^Kigs. .'{!• and 40). 


fill, ki.— Auimc OBBTRCcnnx (FoncKj- 

When the palsatioti is forcible, the altitude is much greater than when 
it is weak. The summit b (Fig. 3T) iu the normal condition a mero 

Flo. 41.— KmLU. RaoinuiiTATKiit. 

point. Ir reached at the InHtaut when the artery in most ftilly distended, 
immediately after tlie sv^tolo nf iho left vent rifle. Wlien the vessel ia 

lUOffT Aeui. 

■^^-i- J^ 

r^'V.rv-. p-^ f;^ 

LriT ABU. 
Fio. 4J.-Aircpsna or Amjuoiijco Aoku (LooWki. 

incomplcteiy tilled the sumiiiii is rounded, ur llie line of descent m«y 
run almost horizonuUy for a sliort distance. Examples of this ar6 

fonnd in mitml regiirgiiaiiuii (Fig. 41j. or m-Ik-u the iirtery is [»artiallj 
<iCCluiieti by an anenri^m (Fi^. \'l), and whon frep regnr^iiation ihrongll 

Via. 4L— AtMcna OanwcnoM .uto KaacioiTATiox iljuauty. 

the aortic vrtkts [irerenis full distention of the wrU-rv {Figs. 43 and 44). 
The line of descent b c (Fig. 37» corresponds to the period of nriprial 




■jBtolo and cardiac diastole. The length of the lino indicutes the nipid- 
itj of the heart's actiuii. When tli& liciirt \s, bcutiiig rapidly, the line i» 
short; when buiitiiig bluwly, the line i.4 itorres[ioiidiiigly luuficthcncd. The 
uiidulatiDu^ in this line (/ t'/(Fig. 3T) wtm known us the first, second, 
and third secondary wave*. The firi»t secoudary wave tl is jtroduced by 
the natural oontrnction of the artery. The second wave e corresponds 
to the impulsu occasionally felt, which is termed dicrotivm. The third 


Vlft. v.— iRoirimT HTmrncpar mox OBarHL'CTH)!! in tdb Artkrjdlss, dps to BaiOBT'a 

liuiOBii or Tee Kidneys, 

irarc / is not often jireitent. The depresaioii g murks the complete 
closure of the aortio valves. A t<mall notch, in the line of descent is 
often seen near the siiinniii. 

Instead of having the form sliown in this figure, the line of descent 
may rnn obliquely doM'uwaril in nearly a straight course. It may have 
a generally convex or contavL- form, and the position of the' secondary 
waves may vary in distance from the points b and e. 

Couvfxily of the line of descent or small secondary waves (Fig. 45) 

Ni^r^-vi "sjxKjvMx 

Pio, 4C.— ^KXiLE I'l'lhe (FoarsR). 

are due to increased arterial tension, as when there is incipient hyper- 
trophy of the heart in consequence of contraction of the arterioles in 
Bright's diaeuse. 

Concavity of the line of descent is due to diminished arterial tension. 

Sudden dropping of the line of descent indicutes aortic regurgitation 
(Fig. 43). 

In the normal tracing, the first secondary wave is found on a level 

no. 47.— llrnui. CditmrKKmoii <Ha*ouo. 

with the junction of the nnddle with the upper thinl of the line of 
ascent; but with loss of elasticity of the artery it occurs nearer the sum- 
mit, as in the senile pulse (Fig. 46). The same condition of the artery 
is indicated by ubsouee of dierotism. 

In mitral stenosis or constriction, the line of ascent is oblique, the 
summit rounded, the line of descent prolonged, and the secondary wavea 
are absent or indistinct. 

TU£: tiPUyuMOUHAPH. 211 

Froiti whit hfts Itcen aiid. we learii tlmt tbe sphygwographio tracing 
is no: liiagDOstio of any ilUt;:i;3c, :lh will be at utice apjtarent in looking 
ovor the tmciugs tiiken in dttTcrent am&i of tlie uinie disease (Figs. 39 
and 40, 43 and 44); but the general ui»pourauce of tbo curve mjiy indi- 
cate Hpeciul conditions. The spfniul points to notice In tbe tmciug ore: 

FtB. 48.^liTau. CoMtunriDN aao Titiuir«np RronuinrATioM 4llATt>lK>. 

the height and the obliquity of the line of aacent; the acutcness m 
rotundity of the summit; the length of the line of descent; tbi- con- 
Texity of the line of descent; and the nearness to the summit of the 
eccondary waves. 

Sanderson considered this instrument principally useful in detecting 

Via. «.— llnwuBiCffir t»v Oilaiahok ur tuk iIuht iIIavi'Kxj. Uij[h uoe ol iiMat; ffud^te 

MUuK of Uue of lieaoeut 

iucreaeed arterial tensiou consequent upon hypertrophy of the left ven- 
tricle (Fig. 45). 

Francis £. An^tie thought that when the instrument worked per- 
fectly, if .ncctimtely adjusted, it would tje of value in the diagnosis, not 
only of commencing hypertrophy of tbe heart, but also of aortic regurgi- 
tation (Fig. 43), and especially of aneurism of tbe aorta (Fig. 44), 



Pericarditis is an inflammation of the pericardium, acute, subacute, 
or chronic, usually associated with myocarditis or endocarditis or both. 

Anatomical and Pathological Characteristics. — Acute peri- 
carditis, like inflammation of the pleura, is characterized by dryness 
and reddening from hyperiemia of the subserous ve88el8,and by infiltration 
and swelling of the serous and Subserous tissues. This is followed by 
desquamation of the endothelium, loss of the normal glistening charac- 
ter, and the appearance of a highly albuminous exudate upon the surface 
of the membrane (pericarditis fibrinosa). This is usually localized at 
first, but becomes more widely spread by the cardiac motion, and later 
assumes a roughened, shaggy aspect (hairy heart). The inflammatory 
lymph may cover the entire surface of the pericardium, but is apt to be 
confined to the upper part. 

In the acute form of the disease, serum is usually effused in small 
amount. It sometimes becomes enclosed in. pockets formed by adhe- 
sions, but is sooner or later absorbed. The opposite walls may become 
permanently adherent by organization of the exudate into fibrous bands 
which connect the two surfaces, or the cavity may be obliterated by 
complete adhesion of the two surfaces. The pericardium itself is more 
or lees thickened. In subacute inflammation, the effusion of serum be- 
comes abundant (pericarditis serosa), its appearance and quality viiry. 
ing with the amount of serum, fibrin/ red and white corpuscles present. 
The pericardial sac, when greatly distended, assumes a pyramidal form, its 
base downward, its apex at the base of the heart, and in enlarging it en- 
croaches upon the lungs and diaphragm. 

Milk Spots. — Frequently opaque, yellowish or gray raised and sharply 
defined patches termed milk spots are found on the surface of the 
pericardium, otherwise normal. They are due to hyperplasia and in- 
creased density of its fibrous elements, and probably arise from friction 
of an enlarged heart against neighboring parts (Hamilton, Text-Book 
of Pathology, page 558). Extravasation of blood into the sac, with tlie 
fibrin and serum, characterizes the hemorrhagic variety of pericarditis, 
commonly associated with cancer scorbutus or purpura. 

In the purulent form, or pericarditis purosa, bacteria are found in 
the yellow or greenish fiuid which may have been purulent from the 
first or have become so secondarily. 



Ghrouic [lericanlitis la usually consecutive to the acute form, and 
often pre8eut8, iu addition to the adhesion and flbroiia baiidH, extensive 
thickening ami oalciireoua depusitii. Extenaion of the inflammation mny 
result in myocanliti* with weakening, atrophy or fatty degeneration of 
the heart muscle, followed by dilatation of the cavities. The walla 
may undergo compensatory hypertrophy; extreme dilatation of limited 
portions of the rentri<;nlar wall constituti'i^ what la turniiHl cardiac 

Etiology. — Acute rheumatism is the moat common cause of peri- 
carditis, as of endocarditis and myocarditis, hence their freijuent coei- 

Other not infrequent antecedent disorders arc Bright's disease, alco- 
holism, syphilis, tuberculosis, typhoid fever, and uoule infectious dis- 
ease; also cancer, jmrpui-a, pernicious auitniio, and scorbutus, which 
produce the hemorrhagic form. In early life the exanlltemata often 
cause this affection. It may also arise from ]>enetrating wounds, severe 
contusions, and by extension of inflammation from neighboring parts; 
occasionally no cause can be detected. 

iSYMrroMATOLOGY. — The affection may bo divided into three stag^] 
similar to those of plenrisy — a dry stage, a stage of effusion, and a staj 
of absorption. 

The most common symptoms are : pain in the prscordial and epigai 
trie regions, shooting to the shoulder, and augmented by movements 
or by pressure; more or less fever, the temperature rising from one to 
Four degrees; but in fatal cases sometimes fulling again shortly before 
death; a small, wiry, irregular i)uldt>, running from !)() to ]'.!0 tx^ats piT 
ruiniite; iwlema, dyBpntra, and ucfasjonally dysphagia. Any or all of 
sliest) symptoms may lx> ahaient; usually there is u history of coincideut 
or preceding rheumatism. 

The essential fiffu? iu the order of their occurrence are: irritablttj 
ttction of the heai-t; friction fremitus and murmur; increased cardiaa^ 
dulness, ultimately obtaiued over a triangular area extending consid- 
erably to the left of the apex; feebleness of the heart's impulse and 
vtunds, both of which are iuteusified wheu the patieut leans well for- 

In thsjirsl W/i,^, upon inspection and palpation, we discover nothing 
except an irritable action of the heart, with slightly increased force, and> 
in the latter part of the first stage, friction fremitus. 

Upon auscultation, agnizing friction sound may sometimes be heard 
very early in the disease along the left Imrder of the sternum, usually 
most distinct at the fourth costo-stemal junction. This sound nwy be 
distinguished from endocardial murmurs by its rhythm and seat, and by 
the fa(!t thnt its intensity is ineroasod by pressure itnd by a full inspira- 
tion. In the latter part of this stiigo. friction soimdn of a hamher qual- 
ity may be obtained. Those may be either feeble or very intense. 

In th$ sccont/ stage of the disease, the signs vary somewhat with the 
amount of effusion. 

On inspection in children uud vouug adults, with elastic chest valli, 
bulging of the pr*GordJal region, extending from the second to the sixth 
rib, may bo noticed. Tlie respiratory movements of the left lung are 
somcwliat impeded, and the apex beat is carried npwnrd and to the 
left into the fourtli intercostal space. 

Palpation coutirnis the signs obtained by inspection. The impulse 
of the heart is feeble, especially xvhen the patient is lying njwn his baolt; 
bat when ho is leaning forward, it ig mucli nioro fon-ibh- tlwn in either 
the erect or ihe recumbent position. This Is an important fact in the 
diagnosis. When the pericardium is greatly distendeil, the diaphragm 
may be forced downward, so as to cause bulging in the epigsistric region. 
Undnlntion of the whole priecordial region, due to the action of the 
heart upon tlie surrounding fluid, may fi-ef|ucutly bo felt, and occasion- 
ally fluctuation can be detected. 

Upon percussion, both the superficial and the deep-seated areas of 
duluesB lire increased. At first the latter is increased in its vertical 
diiimeier, und dulness is noticeable principally above the base of the 
heart in the second intercostal space, where the sernm first collects. 
Tins is esi>ecjany mar]ce<l when the person is in the recumbent posture. 

Von Stoffella. of Vicouu, hits noticed in tiK-ve caaos a duloe»s over the base of 
the heart, in tvciit«lK--iicy change to r«;»unaiicc when the jiatieiit &its up (Internti- 
Uotiale klinifiche Ftundgchau, FcIj., If-W). 

^^ hen the effusion becomes somewhat greater, aemm collects at the 
lower part of the pericardinl sac; dulness is then increased in the trans- 
verse diameter at Iht- level of the apex, and thy area of dulncas becomes 
triangukr with it« base ilownward, corresitondiug to the form of the 
pericardium. Thisi trianguhir sbape remains, however great the effu- 
sion may be. In extensive efTusion, the duluess nuiy extend from the 
first rib above to the resonance of the stomach belnw, and laterally from 
Uie right nipple to a point about two inches beyond the left nipple. 

E. Pins. ID n-ell-marict-d cases, lius fretnienlly olies47rv<xl, wht'o Ihe patient is 
recurabcDl or sitting, a small afoa on tlte left Ride |Hiatt'riorly. ovt>r whk'h th*?re 
is (]uIq,'.s« with broDrhial hi-c-^thing- and inoi'eaAed vocal resonance, but no rdles 
or friction sounds ( W'ienrr iMdizininche Pi'tim, Marvh. 1990). 

This IS mo«t marked in a circular space the size of a silver dollar, extcodinp 
*rom a p.ijnt at>oiit three flng«ra' breadth below tb« an^eofthc scapula to withia 
two of the lower marsrin of the lung*. If tlw patient Iwnds forward, and e>ip«Hially 
it Ite aB^nm"*. the kDf«>elbow pojilkire, diilncM largely diitappears. vesitrulor i-wo- 
&an^-« taking- the plai-* of abnormal sounds. These plienomena aiv prolwibly due 
to prvssurv upon the lung, which i» relieved by a furvranl displacement inotdenl 
to Chang* in p^wuure. 

The position of the apex beat having been determined by palpation 
ftttscuttationr the exisleuee ^^ dulne«s to the left of (bis point and 

pEuiLAHDiTia. ai5 

1>elow it becomes an important element in distinguishing pericardilia 
from euhirgfiiieiit of the lieiirt: in the hittor the apci beat corresponds 
very nearly to the limit of dulnesH on tlie left. 

Ill tin.' difffi-pinia] diii^iiosisof p»Trciii-(tial effusions. T. M. Rotcti, uf Boston, 
cdamderft an iirt>:i. or HntnesA in the fifth intorx--OKtih.l space of X\\& rii^tit side, about 
an ioch froin the border of the st«raum, a very importnnt si^n. 

The friction sounds nsuuUj lieard on »uacalt8tion in the first stage- 
generally disappear when plTnsion occurB, in consequence of the separa- 
tion of thi^ jiericardial surfaces; yet they may remain at the base of the 
heart throughout the disease. In the second stage, the heart sounda 
are feeble and distant, but may be rendered more distinct by cnusing 
the patient to lean well forward; sometimes friction sounds may be 
reproduced by this means. 

Pulmonary sounds are not heard over the area of flatness in the 
prsecordial region. 

//( the third gtntfr. the signs of tlie Re<H)nd stage disappear, the bulging 
gradually diminishes, the apex beat becomes more and more perceptible 
and returns to its normal position; tliero is a gradual diminution in the 
area of dulness: friction tioundH may return and remain until resfdutiuD 
has taken place, or until the two t-urfaces of the pericardium have be- 
come adherent: the respinitory sounds may again be heard in the prse- 

Exceptional. — Occ&KJonaUy f rictioa sounds cnnlinue lon(( after apparent re- 
covery . 

We have no means of determining when adhesions of the pericardial 
surface have taken |dace unless the extenial layer of the sac has also 
adhered to tlie chest walls. When this has occurred, the intercostal 
spaces are seen to be depressed with each systole of the ventricles, and 
ultimately pemianent depression of the pnecordial region may take 
place. In some cases, when the heart is considerably hypcrtrophicd and 
diluted, dragging in of the epigastric region is caused by each pulsation 
«f the heart. 

l>i.ioNosi8.— Pericarditis is liable to be mistaken for pleurisy or en- 
docarditis or for mediastinal tumors. 

The first stage ol jiUuriJty causes pain and friction sounds similar to> 
those of pericarditis, and. if it happen to involve only the anterior por- 
tion of the left pleura, considerable care will be necessary to avoid an 
error in diagnosis. The distinctive features between the two affectiona 
are presented in the following table: 


Commonly of rheumatic origin. Non-rheumatic. 





Pain UI1UEII7 iQ the pnecordial re- Paio usually in th« infiu-udlluT' 

(ion. region. 


Friction soundi confined to the re- 
poQ of the heart and syochroQCUK 
with its muvements. und not affected 
by th« respiratory uoveiueots. 

Friction sounds, thoug'h they may 
be confined to the prscordtal region, 
are >^n(.Tally heard farther to the left. 
They are not synchronous with the 
puUatioDs of the heart, but occur with 
the respiratory nioveineDt«, nod al- 
most invariably oease when respira- 
tion !■ suspended. 

Symptoms due to preamre by mediastinal tumor/t on vessels or norveft 
or bronchi are prominent; not so iu pericarditis. There is also accom- 
panying enlargement of the glands of the neck, and absence of some of 
the symptoms uud signs of inHammution whirh characterize pericarditis. 
Malignant growths also cause marked and peculiar cachexia and have no 
itory of rhenmati»m. 

For the distinctive features between endocarditia and inflammatioD 
of the pericardium, see endocarditis. 

Pboososis. — Acute rheumatic pericarditis usually ends in resolution 
vithin three weeks, very rarely iu doath. It niay^ however, become sub- 
acute or chronic 

Adhesive obliteration of the pericardial sac tends to weaken the 
heart muscles, and, if associated with a crippled condition of the valves^ 
18 unfavorable; usually such adhesions result in cardiac hypertrophy. 
Slight adhesions always remain but are of little significance. 

Fluid effusion is absorbed in most cases in ten to tifteen days, but 
largo pericardial eflnsion may cause sudden deaths or by long-continued 
embarrasjimcnt of the heart's activity give rise to atrophy or fatty de- 
generation and consequoDt danger of sudden death from pulmouury 
cedema or cardiac imnilysis on slight over>exertion. Purulent and hem- 
orrhage pericarditis are always dangerous. Pericarditis accompanying 
nephritis is serious. 

Tbeatment.— With the first symptoms of pericarditis, the patient 
should be put to bed, to remain absolutely quiet until convnlescenco 
has been established. Hot poultices should be kept constantly applied 
to the whole anterior surface of the Cliesl. Opiates should be given io 
just sufficient quantity to control pain. Depressing measures of uU 
kinds must be avoided. 

If the cause of the disease can be ascertained, it should be removed- 
Bbenmatism will call for alkalies, guaiacum, or small doses of colclii- 
cum. The latter must not be given in doses sufficient to derange diges- 
tion or cause depression. Salicylic acid should not be given on account 



21 : 

of its depressing cfiEecU on the iie:irt, but the salicylates arc loss objec- 
tiooKble. If this affectiun follow depressing fevers, the supporting 
mcttsuros which uro required for the latter should be more uiwiduuusly 
applied. If it result from Bright's disease, sulinc cathurtic;^ \ix mod- 
«nite doaos, diaphoretics, especially viipor or hot-air baths, dry cupping 
orer the loins, and small doses of digitulia will be indicated. In most 
cases, iron is a ueeessary remedy, and quinine vill nsually be bcuellciul in 
tuuiutuiuiug streugth. 

The diet should be eoueeutnited and nutritious, and, so far as possi- 
ble, fluids should be avoided. If effusion takes place, its removal will 
be favored more by the mean« caIculat<HJ to maintain the strength than 
by the various drastic cathartics so often prescribed. In many cju'tee, 
Kood effects will follow the judicious use of hot-air baths, to promote 
diaphoresis; or of potnssiam iodide, bitartrate, or acetate, or fluid extract 
&f scopariue, to cause diuresis; or of fluid extract of euonymus or small 
doses of elatcrium, to induce catharsis. 

If pressure on the heart from pericardial effusiou becomea excessive, 
the question of aspiration will suggeat itsiilf. I would recommend this 
operation in casea where heart failure seems imminent, but it should bft 
held as a last resort. 

During convalescence from this disease, the greatest care Is necessary 
for ten or twelve weeks to avoid expoeure or active exercise. The heart 
is always weakened by such an attack, and there is a tendency to dilata- 
tion, which should be guarded against by small doses of digitalis, strych- 
niue, and arsenious acid. To promote strength still further, we should 
make free use of iron and good diet. The patient should avoid every- 
thing which would cause the heart extra labor. 

If acnto inflammation of the pericardium doea not terminate in re- 
covery within three weeks, the disease is termed chronic perirardiliii. 
This condition may be characterized by a collection of fluid in the peri- 
cardiuni or by adtieaion of the two surfaces of this sac. If the fluid be- 
comea purulent it is termed pyo- pericardium. 

In the former case, conntcr-irritation. diuretics, and ottthartice are 
indicated: but in both caises, iron and cardiac tonics must bo constantly 
employed, and excessive action is to Iw avoided. If the effusion be piirii- 
leutfOr if a nou>purulent accumulation be sufficient to cause great irrogn- 
larity of the heart with muffling of its sounds, or to throaton collapse.' 
aspiration shonld be performed, prcfenibly in tht.- fifth intercostal space, 
two and a quarter inches to the left of the meso-sternal line, i>., near 
the junction of the sixth costal curtilage with the rib. Some recom- 
lueud a point between the left side of the eusiform cartilage and the 
luljaceut border of the costal cartilages. In pyo-pericardium. aspiration 
may be rei)e]ited aeveral times, but with small hoi>c of permanent relief. 
Incision, followed by antiseptic irrigation and temporar)' drainage, has 
been recommended. 




Pneumo-hydropericarJinm is one of ilie nirMt of cardiac ilisoaaes. 
As the name indirate^, it is a condition in which air or gas and fluid 
occupy the pericar*iial sac. 

Etiology, — Air or gne may enter the pericardial Rae througli a pen- 
etrating wonnd or llatulous tract couimunlattiug willi the irat-hea, 
bronchi, leKojihagiiin, stumoch. or possibly the inlestiiiui}; ur ga^ may in 
rare instjtncf.s rfsiilt from denonijiosition of fluid within the sjit; [Da 
CoBta, Metlical Diagnosis; ako Hainilion, Text-Book of Pathology). 

SVMPixiMATOLuciy. — The eswntial sigHs of the affection are tympanitic 
reeon&iu'e over the air, ami Hatneae over the Jhiid, diaiigiug as the patient 
shifts from recumbency to the sitting posture; and, on auscultation, a 
spladhiugKonnd synchronous with the pulsation of the heju-t and entirely 
iude[>eiidcnt of the respiratory moremeutfi. The heart sounds have a 
metallit? quality. The syniplofua are similar to those of ppricarditia. 

PiAWXosis. — Pneumo-hydrotlxjrax and wrtain conditions of the 
stomach might possibly bo mistaken forpnenmo-hydropericardinni; hrit 
there is no danger of an error in diagtiosis if wo rememher that the 
signs of pneumo-hydrothorax are foun^l on the side and posteriorly; and 
that the splashing sotutds sometimes ^iroduced within the stomach aro 
heiird below the prweordial region. 

I'koosiisis Axn Tkeatmknt. — The casfs are usually speedily fatal. 
"When they are nrolonged. tho treatment must be expecUint. 


nydro])erieardium is a tmnstuhiiion ur non-Inflammatory efTusion 
into the pericardial sac similar to that of hydrothorax. 

Anatomical and Patuological Chailvcteristics.— The liquid is 
of a pule yellow or greenish color, alkaline reaction, ealtish taste, is not 
spontaneously coagulable, ami lias a specific gravity of 1005 to 1024. 

The c|uantitr varies from a few ounces to several pounds; the peri- 
cardium in the latter case being markedly distended and presenting the 
appennince of an obliiso cone with base downward. 

Long-continued or excessive pressure of this effusion greatly impeiles 
cardiac action, and the heart mu.tcle weakens and degenerates. 

ErioLfuiy. — llydropericardium ugually accompanies dropsical effu- 
sion into the other closed cavities, dependent upon heart, renal, or pul- 
monary disease; rarely it is duo to an altered condition of the blood ac- 
companying the cancerous and other grave cachexia?. 

Stmptomatolohy. — The symptoms and signs are simihir to thoaa 
attending the efTnsion of pericanlitis, hut without friction sonnds or 
other svmptoms of inHnmmation. 

DlAUKmsltj. — The diagnosis depends on the history and the manifesto- 


tioos of the cuiaatirc discus^.', with iiicroascd disturbuico of the heart, 
enlarged area of cardiac duliiosd, and signs peculiar to the presence of 
fluid in the pericardium. Exploratory aspiration may be em]ik>yed if 

Pbuusosis. — If the efiFnsion ia large iu amount and accompnnics vtU- 
vuhir lesions, it may ranse sndden death from preaRnrt* npon an ulrcmly 
embarrassed heart. Treatment should be chiefly directed to the uuutoitive 
diBease, from which death usually occurs. 


Inflammation of the lining membrane of the heart may bo acnto or 
chronic The former ie nsnally n non-alcerative affection the result of 
rheumatism, but an ulcerative form also occurs us the product of septic 
infeiHion. It has been taHousIv termed ulcerative, iufectionsr septic, 
and by Virchuw, malignant endocarditis. Chronic endocarditis may be 
«uch from the beginning, but it usually follows the simple acute form 
of the disease. 

ASAToMicAi. AX» pATHoi.rtoirAi. Chakaoteristics. — Normally tho 
endowirdiuni from within outward eonsifits of a single layer of jtolygonal 
endothelial cells, a thin elastic basement membniue, and a layer of nucle- 
ated white flbroiKi tissue joinetl to the cardiac muscular structure by 
looae arevhir tissue. The vulvcs of the heart are reduidicjitiiins of the 
endocardium, thoae at the aoriculo-Tentrinular septum containing also 
a few striate^l mnscnliir fibres. Blood -vess^'ls ramify in the loose areolar 
tii^sue, but nowhere penetrate the three layers of the endocardium; these, 
like the cornea, receive nourishment from the lymphatic siiaoes. 

A few veflseU accompaay tbe muscular tJbre« of the mitral and tricuspid 

In the early stage of (trutf pndotfirfUih, the endocardium appears 
slightly opar|ue or distinctly cloudy; later it is roughened, but redness ia 
rarely viaiblo after death. Tho i>iib-eudonirdial mpilliiry plexus is in- 
jecte*!. The lymidi b|hiccb are crowded with inflammatory proiluels. The 
fibrous lityer, chiefly, but also the areolar tissue. benomcH inflltrated with 
round cells; as these proliferate, cloudy swelluig occurs in the nativu 
fibrous celts, which appear, as the disease advances (Hamilton, Text- 
Book of Pathology) to become homogeneous and to be in great part 
absorbed. The aUccted membrane becomes thickened; proliferation of 
cells and tlieir irregular accumulation gradually forces the endothelium 
and bfisement structure Twfore it, iiroducing minute papillnry i>rojec(ions. 
Swelling aud consequent distention Anally retiiilt in destruction of tfas 
bas«raeut layer, and endothelial desquamation at the summits of thn 
projections; upon these flbrin is deposited from the blood current. As 
the growth thus increjises by proliferation witjiin and fibrinnus accretioo 
vithout, it takes an irregnlar verrucous form, spreading at its summit 



snd constricted at its bnae. These vegetations diBvctIoj> most luxuriantly 
upon the valvular margins whore most friction occurs, especially along 
the ventricular margin of the aortic valve. They niuy attain the size of 
tt pea. Thi« j>roces$ is attended by no vu£cuIarizatiou until far advanced, 
when the veii&els ut the base extend for a short distance into the vege- 
tation (Plamilton, hn: cit.). 

Etiiiuxiy. — Acute endocarditis occnrs most frequently in those 
under thirty years of age, and is most often the result of acute rheuma- 
tism. It also occurs in those suffering from gout, ditibcteit, uleoliulieni, 
Brighfs diseast>, scarlet fevtr. typhoid fL-ver. diphtheria, pneumonia, 
syphilis, and tuberculosis; chorea appears to be an ucc-asional cause. 

SYMi*T(tMAT(ir-(»(iY. — The usual sjTiiptomH are: a sense of UTiea^iness 
about the heiirt, fever, a short cough, dyspnce-a, and an anxious counte- 

The tompenitnre rarely reaches 103^° F. In some cases vertigo and 
other cerebral symptoms may occur, or gastric disturbance, but none of 
these arc constant features. 

Among tlio ,iit/uji, inspection communly reveiila turgeacence and an 
anxious expression of the face. Thu cardiac impulse may \*e visible over 
an enlargwl area. 

In the iM'ginning, the pulsations are apt to be forcible and irregular, 
vith a corresponding pulse. An endocardial thrill is sometimes detected 
by pulpiition. 

Percussion gives no increase of dulness in uncomplicated cases. 

Auscultation usually reveals a soft, systolic 'murmur, due to endo- 
cardial or valvular thickening or roughening; these, however, may be 
present without u murmur. Often the 9e(tond sound at the base w 
doubled from inco-ordinated action of the two sides of the heart. Mur- 
jours may occur from lesiooA at any of the valves, but are most frequently 
heard at the apex. 

DiAo>*0!<i8. — When some of the above symptoms appear in the course 
of any of the cjiusative diseases, and these signs are obtained over n. 
heart the sounds of which were formerly normal, we may reasonably 
suspect inllammation of the endocardium. 

Acute endocarditis, when occurring independent of jiericardiiU., ia 
liable to be mistaken for the latter disease. Pericarditis may be dis- 
tinguished from uncomplicated inHumniation of the endocardinm by 
the quality, rhythm and seat of the murmur. 

Acute ZKDOf:ABi>rns. 


Uurinur blowing. 

^uoJffy of murmur. 

Di-stinctly riibbmfj^ or rrictioo itoiinc 
tv-utid-Iro KliuHliii;; ; iucreaaed in m- 
tetiKJly un tlie imtieol's bmidiDK tur- 
wunl ;uitl lukiu;; u deep iiuipiruUoUt 
also by pressure ot stethoscope. 



Acute bsdocaboitih. 


Hhs/thm of murmur. 

Murmur not exactlj* synchronotui 

witd th-i valvular boiiuos. ac;! ort4;n 
<M.'cup« dtinii^ both the systole nml the 
iJioAtolc o( the heart ; is not cua^ilant. 

IStinnur synchronous with the (h'»t 
Bound ot the heaii, :ii)(l ilcwa tiol <.h:cui- 
witb tbe diustote tmlesti r<?^'urt;ilation 
takes placf.' throuf^h the uurtic! orpiil- 
moQar>' semilunar voJi'cs. 

Stat of miirmur, 
Uurmurloudestatapcxof honri.and Murniiir heard loudciiL at bord(!r of 

djffiKed b«yond the prs&cordia. Rtcmiim nftir the Tonrth or Hfth Mt 

co«tal ctkrtilage. Limited to prse- 

PnooNosis. — Acute rheumatic endocarditia naunlly runs its course m 
two to four weeks, and is seldom fjitJiI unless coniplirated with other 
disonlere. l.*ne iittai'k, however, renders the part mora viihiemblu tt* 
sabecqueut disense. In fiivonible aises, endocardial innrmure deprewsw 
or entirely disHppoar during eouvnlesoeiico, but permanent v:ilvular 
leaionH remain in about twenty-Sve jwr L-ent of all eases of acute mitral 
eudoL-arditis (IjOomis' Practical Medicine). Theae, e^iwciully in chil- 
dren, are usually rapidly compensated for by cardiac liyi>ortrophy. 
These permanent lesions otvan cannot be detected until contraolion of 
tlie influnimatory products takes plac^, some veeka or months after 
subsidence of the acute iuMammation. 

The pro^osia is rendered correspondingly grave by marked antece- 
dent de]ireciation of peueral health: by the coexistence of disease of the 
-verioardium or heart muscle; by an inlercurrence of pulmonary an<l other 
dis<*a8es:by the development of typhoid symptoms; or the presence of signs 
and symptoms indicative of cerebral, splenic, hepatic, or renal embolism. 

Tkeatmf.nt.— Endocarditis is nearly always the result of rheuma- 
tism, chorea, pya-inia. or the acute esantheniatous fevers. The proper 
trentnipnt for tht-^e affnrtions is that which should in the wain he em 
ployed iu the secondnry heart disease. 

Perfect rjniet should he maintained, not only during the active stage, 
bat also during the convalescence. 

In the very inception of the attack^ a full dose of quinine will occa- 
sionally cut it phort. [juter, this remedy and iron are very useful. Dur- 
ing the treaimont, the patient should be keja iu a warm room ut TO*^ to 
75° F., and the chest should be specially guarded from exposure. 

Sihsi^tn re^-oTHmends a liniment of tincture of Iwlladonna and chloro- 
form sprinkled <in ootton-wool and kept applie<l to the prjpoordial region. 
Great depreesion caIIs for alcoholic stimulants and nux vomica or digi- 
talis The latter in modenttc doses, combined with quinine, arseniona 
acid, and iron, is needed during convalescence, but oaro should be taken 
not to overstiniulatc the heart. 

£irogjftV>na/— Nearly all cas«s of endocarditis ar« a«flociat«d with or follow 



otljt>r ili»!«, uikI ure uUendetl by syiiiptoiiiii which demnnd supporiiiig treat- 
ment : IhiI nuw utitl then one ucctirs without appnrent cause in » robust |>orson 
of full liahit In such wisp. hletnliDg wotiW uudoubledly prove henefl- 
oiiil hv i-elieviii}' lh« over-hurdened heart. 


Ulceraiive ciicIncartlitiB is a destructive hilliiiTitmitiou of llio cudocAr- 
ilium duo t<i iufei.'tinii, urtuully running a rapid ami fatJil couriw. Kither 
or both sidiis uf the heart miu he its seat, ttut most frequeutlv the left \& 
involved. On llie surface cf the otidncardiiuii, cliiefly on the rulrcs, 
may 1>b found gray fleahy vegetutioua springing from the i^ub-siToiis 
tissue, frequently u^risociatud with greenish-colored dots and coutaining 
perhaih) minute jiurtilcnt cavities. 

Micro-orgHiiiania are always jireKent, pyogenic bacteria, piieuniococci, 
or tulwrcle liacilli domiahhig with others of a hnrndess nature. Ulcers 
may c(Mixist with vegetJiti<uiB or they may mark the sit* of those whiith 
have disuppearetl; their edges are irregular autl thickened, aud their 
floors purulent; )>erfoi'ation of tho valves is a cummon result. Not in - 
freiiuenlly these uli:ers are the ftourtie of septic omhnlisni indistaiitorgans. 

Etioi.i>ov. — I'IcerativR fnilncaniitis may t>e paiiwil hy vurioiis putho- 
getiiu bacteria which gain entrauf^e to tlie circulation in the ditTereut 
speciiic affections mentioned when speaking of the etiology and treat- 
ment of acute endocarditis, but most ufteu during pywmia; occasionaUy 
it arises idiopathically. 

SYMl'ToMATtiLOdY. — The aftcctiou often lias symptoms and signs 
similar to tho.^e of myocarditis. 

'I'lic usual pyijipt-jins may he those of severe enteric fever, the attack 
being often usliered in by a chill, followed by prostration, dtdirium, or 
comii. The leinpcnituro usually ranges liigher than normal, from two 
ttt four degrees I*. The tongue is often dry and bro^ii; vomiting and 
di.-rrhuL'a are common. The pulse U nii>id and iiTcgular, and sometimes 
there arc pric<Hirdiut pains and palpitatiou uf the heart, with dyspiiom 
and occasionally articular pains. 

The evidences of embolism are often seen. 

Sometimes no idgns whatever are present, in other instances auscul- 
tation reveals the signs of valvular disease, and repeated oxamiuatiun 
may show rapidly progressing valvular changes. 

Diagnosis. — The absonco of cardiac Bymptouis in mauy cases is 
likely to mislead the physician into the diagnosis of iuteruittent or 
lyphoid fever, nr of pyajmiu; but if attention is directed to the heart, 
and it is kno«*n to have been previously healthy, the oocnirence of a 
systolic mitral or tricnspid murmur, with the symptoms jost mentioned, 
renders the diagnosis reasonably certain. 

Piioososis.— The prognosis is always grave, the disease usually ter- 
minating in death from the primary septic condition or from secondary 
pyfttmic itivolvcmcnt of the bruin, kidneys, spleen, liver, or other orgaud. 



evidenced by hemiplegia or alt)uminuriii or sudden enlargement oud 
teudcniess of the spleen or liver. 

TliEATMEST. — Ulcerative eiidooHrditia rMulta from ]>y»mi:i or sepli- 
Ctt^niia, and consequently requires the mcHt viguruua supporting mea- 
sures. Large doses of quinine and aUrolioUo stiinulantit are indleuted. 

Sanaoni recom iiends sodiani RuljihiM-urbolutf' in thirtr-gniin doses* 
with inunctions of curboliztd uil {Lomlxu Proiht inner, .Iiir:., J881t). 


In chronic endocarditis the non-nloerati\'e inflainnmliou, which ia 
lesBJioute from tlu* tttart tliiin in the acute disease, Wcomer- jirutracteil, 
cell intiltnitiou and hyperplasia Iniing followed by organisation und 
marked contraction, uspeeially lit the haa« of the vegetation. The 
thickened tissues cunimuuly become atheromatous in patches, these iti 
turn undergoing colcilioilion, us seen in the yellow areas aud nodules of 
concretion scattered over the surface. Fre«(Ueutly it is ccincident with 
a like condition in thb walls of the aorta. Indolent ulcere fometime» 
exist where calcareous scales have been itetached or where an atheroma- 
tous patch has softened. These changes may tjccur on any part of the 
eudociirdiutn, but the h>L-aI efTeets of chronic endocarditis are motiit dis- 
tinctly recorded in the valves. 

Following the slight thickening of the acnt* stage, there is grenl^^r'' 
hyjterplasia of the areolar and white Hhrous tisane, esitecially along tlie 
edges of the valves. Organization with inevitable retnictioii jirodnco* 
incOTUpptcnce of the valves. Xarrowing of the aortic orifice may \i\^n 
result from the occurrence of the same proc*;ss in tlie fibrous ring which 
normally exists at the ha^e of the vaKej* at the cardio-nortic junclion. 
Complete culciticatiou of this ring is an occasional result. 

Atheroma and ealcurcons depcisit* also occnr in the valves. 

Adhesions mav form between the valves! and the nortie wall. VegC' 
tutions often fringe their ventricular margin. Ulcen.tion prone to fn). 
low fibrosis und atheroma may perforate the vnlTeentirely. or from jniitial 
destruction give rise to valvular aneurism. The mitral valves are sub- 
ject to similar changes, and, as the free edges of the valves are continu- 
ous, general contraction narrows the orifice in marked cases In a mere 
alit like a buttonhole. 

The chordivtendinew are involved in the process of thickening and re- 
traction, and roar l>ecDme agglutinated into one or more short, fibrous 
bands which draw down the cuntructoil mitral margin, converting the 
valves into a funnel-shaped prnje«:tion into the ventricle. 

The tricuspid valve is seldom so affected. Aortic regurgitation or 
obatruction produces dilatation of the left ventricle followed in favora- 
ble cases by compensatory hypertrophy of its walls. Like conditions of 
the mitral orifice produce like efTects in the left auricle. 


Theoretically, similar affections at the tricuspid and pulmonary valves 
produce corresponding changes in the cavities and walls of the right 
heart; but practically tricuspid stenosis, and stenosis and regurgitation 
at the pulmonary valves, are exceedingly rare. Tricuspid regurgitation, 
with dilatation and hypertrophy of the right heart, is usually the result; 
of serious lesions of the left heart. 

■ Chronic valvular lesions, though sometimes occurring alone are apt 
to produce disease of other organs, by obstructing the circulation. 
In the lungs, we find congestion, oedema, bronchitis, apoplexy, brown 
induration, and lobar pneumonia. The kidneys may become congested 
and enliirged, and are not infrequently the seat of embolic infarcts or mul- 
tiple abscesses. The same is true of the spleen. Continuous engorgement 
may cause parenchymatous, fatty, or atrophic degeneration of the liver, 
or chronic catarrh of the gastro-intestinal mucous membrane; and 
occasionally embolism or apoplectic extravasation may take place in the 

Endocarditis may produce at the orifices of the heart either obstruc- 
tion or insufficiency of the valves. 

Stenosis or stricture may be the result of thickening of the valves 
from the presence of calcareous deposit, atheromatous or fibroid tissue, 
or extensive vegetations ; or of adhesions between the valves, or of indura- 
tion, hyperpJasia, and contraction of the margins of the openings. Rarely 
it is a congenital condition. 

Incompetency may be due to perforation, tearing, or inflammatory re- 
traction of the valves or to rigidity from calcareous deposit; to rupture 
or abnormal shortening or lengthening of the chordae tendinete, dilata- 
tion of the ventricle without compensatory lengthening of the chords and 
their muscles; and to spasm of the columnfe carueae. 

Etiology. — Chronic endocarditis is more frequent in men than in 
women. It usually follows the acute non-ulcerative form of the disease, 
but niiiy be chronic from tlie beginning, especially when associated with 
chronic alcoholism, rheumatism, gout, or old age. 

Symi'T0MAT0LO{4Y. — Chronic endocarditis sooner or later causes ir- 
regularity in the action of the heart, lividity of the lips, oedema, and 
dyspnu'a on exertion. Dizziness and vertigo with facial pallor and 
sometimes syncope arise from cerebral anemia; sudden loss of conscious- 
ness with subsequent paraplegia may arise from cerebral embolism or 
apoplexy. Headache, tinnitus aurium and muscae volitantes are com- 
monly due to cerebral congestion. 

Often cardiac pains occur, frequently shooting to the left shoulder 
and down the arm. Sometimes tliere is true angina pectoris. Cardiac 
dyspno'a and palpitation are common. The pulse may be rapid, weak, 
irregular, intermittent, small, wiry, or full and compressible. The so- 
called water-hammer, collapsing, jerking or piston pulse is charac- 
teristic of aortic regurgitation. The pulse in other valvular lesions is 



not diftgoostic, bnt indicatca the force of the he:'.rt, the tone of the ves- 
sels, and the condition of the circDiation. 

If the piihnoiiftiy eiroul.itioh bt* einbarrossed, ciug'i, dysjincwi, oppri'S- 
cioti.aiid proIustuexpeL'turutioii lire jirt>»eiit,('3pecinlty on exortioD. Blood- 
sUtiiifd iij)utuiu is cuiuiuuii, mid hiemoptysis not infre<|Uent. 

CiuueHil vuiiouu cugorgemeut its uiuiiifeated by cyanosis, tenderuesB 
and onlurgcment of the liver aud upleen, aiiorexiii, iiuusea and vomitirtg, 
and eouietirucs jaundice; also by nlhnminuriA with casts, scanty and oc- 
casionally bltxjdtitiiiued urinv, h. ricking cedema commencing in the 
lover liuibti, and elTusIuu intu the serous cavities. 

The sigus require careful discrimiuutiun. Aortic obgtruction, com- 
monly maiiifcHting the ftymptonia of cerebml aniemia, \i charucterized by 
ft luird. wiry, but regular pnlse; enlargenu'nt uf the left heart ; ii systolic 
murmur with the first sound usually hai'sh, londest at the right seeoiul 
intercostal space, occiu^iomilly at the left or over the upper part of Uie 
sternum. This murmur is conveyed into the vessels of the neck, islieard 
behind, and toward the apex but with diminichcd intensity, and is not 
tnmsmitted to the left of the aj>cx. The pulmonic second sound is feeble. 

Aortic retjurffitation exhibits no peculiar early symptoms. It istOiar- 
aet<eri£i>d by a full, strung, but collapsing pulse. Tin* h'ft lieart isetilargbd; 
the i.iirolidd beat forcibly, aud distinct capillary pulsatiuu may souictimt^a 
be seen beneaih the finger-nails aud the mucous membrane of the lips, aud 
at ihtr fundus uf the eye. It muses a diastolic munnur, soft and blun ing, 
occurring with or fnllowing the second sound, which is must distinct over 
the lower part of the sternum, bnt is sometimes beard behind aud in the 
arteried of the ntM^k. It is more widoly diffused than any other murmur. 

.l/iVrtr/r'^^/rHtyiOK causes marked pulmonary symptoms and signs, and 
is acconipiiuied by a soft, small pulse aud a purring thrill most distinct at 
the apex: by left auricular enlargement, sometimes but not usually elic- 
ited by percussion; and by the mitnil presyslolir murmur preceding the 
first sound already noted as representetl by vricaliztng the symbols, R rr b 
or V o t. It is apt to be of longer duration than other murmurs. Its 
maximum intensity is about half an inch above the apex beat, it is loader 
when the patii^nt is erect, is not transmitted to the loft of the apex boat, 
2B not ht<ard behind, nor in the arteries of the neck. 

Mitral rsgnrgitatioH commonly prodncefl the symptoms of pulmonary, 
hepatir, and renal congestion, and is accompanied by a eomprcssibla 
and irregular pulse and enlargement of the left heart. The murmur 
pro<iurf>d is soft and blowing: it is systolic, accompanying or replacing tha 
firstst^mnd; and is herird bmd^st at the ajiex. It is trmsmitted to the 
left, and is often beard behind beside the sixth and seventh dorsal verte- 
br» opposite the mitral area in fronL It ii not prcpagsieU into the 
arteriea of the neck. The pulmonic second sound is intensified. 

TrieuHjtiil ref/urt/itatiou.MBU&Uy secondary to Icfiiims of the left heart 
or to puImon(ir)'disea»e8,and when marked, producing symptoms of paa- 



aive congestiou of tlie brain, an<l of the liver and other uhdominni nr- 
gatiB, exhibits the following signs; piilftatian of the jugulars, enlnrgoineat 
of the right heart, a conii>amti\*ely feeble Kvstolic inurimir replacing the 
first suuud, and londest in ihe tricuspid area. It h transmitted U* the 
right if at all, is not heard at the apex, K^hind. or over the carotids, and is 
seldom audible above the third rib. The pulmonic second sound is feeble. 

Tncuspid oMntelion and puhuonic reijurffUation are so rare as 
hardly to merit mention. Tho former causes presystolic, the latter a 
diastolic murmar; the former harbh,the latter soft; the former heard moet 
distinctly over the lower pnrt of the sternum, the tatter over the left 
second intercostal space, but propag:ite<i downward. The second pul- 
monic sound would probably he heard iu tricuspid obstruction, but 
would bo absont in pulmonic regurgitation. 

Pulmonii- oMrurtiou causes enlargement of the right heart and i^ 
systolic murmur with the first sound, of maxiintim intensity at the loft 
second intercostal space, occasionally transmitted toward the left shoul- 
der, but never downward to tho apex nor over the norta and curutids. 
It is not beard over tho lower part of the sternum or behind. Thero 
may be an attendant bruH rle (liable of the jugulars. 

Diagnosis. — The dilTerentiat diagnosis between different valvular 
lesions must Iw made from the foregoing symptoms and signs. In case 
of single, or clearly defined double valvular sounds, little confusion need 
arise in detcrmiuing their diastolic or systolic character if their rhythm 
be referred to the carotid pulse. This iu most cases can be felt on deep, 
digit:il prtissurc beneutli the angle of the jaw. just in front of the ante- 
rior margin of the sturnu-oleidu-mustoid. Not iufrcijueiitlr an aceurute- 
diagnosis is impossible when the action of the heart is rapid, irregular. 
and tumultuous. In these cases better results may be obtained by aus- 
cultation after proper exhibition of digitalis. In tho diagnosis of 
chronic endocarditis, too much siguiGcauce must not be attached to the 
presence of viilTular murmurs, as serious disease nuiy (.'xist withtmL 
them. Such cases are indicated by the various symptoms already nien- 
tioued aud by feeble or intermittent action of the heart, with increased 
area of cardiac dulnoss doe to hypertrophy or dilatation. 

Chronic endocarditis or organic disease of the heart may be confused 
with functional disease of the heart, pericarditis, antemia, aneurism, 
fatty degcncitition, cardiac dilatation, aud with certain congenital de< 
formitics of the heart. The diHerentiul poiuts are as follows: 


Palpltatioa comes od ^aduoUy. 



Frt»jucutly hblory of rlieuuittlisiu, 
f;out, or syphilis. 

Pulpitalion paroxysmal, comes ot. 
sudik-oly. iiutcousluut. 

History oftcu imiiils to ludijp-stign, 
hynt^ria, the nervous dtalliesui ur ex- 
cessive use of tobacco or tioXt^t^. 




Anxiety not mariced till luLu in ditt- Aoxiety, worry and nan-oufiness 

«ase. Palpibiiion ur^iially brought on pi-ominenl. Pnlpitation usuiilly witli- 
by exertion. Uy^pnu:;!, cyariosi*. oi- uiit exerlion. No evidence of onfanic 
coo^i. dtaturbacicu ollKrr limn aoeentift. 

Ealai^ment or llie heart, change in No etilargemeot of litmri. Mtirmiira 

Kpex beut. Murmurs may b« diii^*- if present me iucoiistnut, alwayi* *vsio. 

tolic: they may r(.>plnc« heart sounds; 
tbey are usually constant. 

lio. Atv dui' t«> iuiioniiii ."ind disappear 
on troalment. Heart ttouDds pi-esent 
though feeble. 




Usually cardiac: enlargement. Mtir- 
mura constant and u-iilt^ly dilTii^d; 
rommonly tiynchnmuns with hcntrt 
sounds which tliey may ivplace. 


Pattf^nl may appear robust Pulse 
nruiy be full and •t1i'«in<^. Ilenit en- 
lur:g;ed. Murmurs coojiitanl, widely 
diffused. No venous hum. 

No eularKvinent till second Magv. 
Klui-mtini continpit to narniw limits; 
moHt ilisliiict al left fourth ooftto-ster- 
iial urticiilatiou ; uoiuetinies increased 
on presMiit wiih s1«IJio»*--oih;, on devp 
in^pii-atioii, imd on forward iin'linatioo 
of (KXtient. Miiriiiurs int.-ons(ant and 
not synchronuu!^ with valvular sounds. 
Heart sounds not supplanted. 


Pallor and lauiiude. Pulse weak, 
i'ompressitjie, Hoait normal wr*. 
Mui-nuir inix>n9tant and often loudest 
over v:u-otld)9. Venous huui. 


No marked symptoms at boginninf;. Marked symptoms siKniflcant of 

pressure, oa. l)onng |iain, d,\-spl)agia, 

Heart enlarged. Pulse alike on both Henri of nornml siaw. Pulse often 

«tdes. No dilating impuUe. Murmur dilT«>rpnt on two sides. Dilatini; im- 
frequently widely transmitted. pulse. Pei:ultar bruit localized. Never 

li-uusmitted luwartl ajwx. 

The iliagnosis ot fntty heart reeU oliiofly upon the histor}* of the cnsc, 
the Bbsence of distinct sig^s of organic lesiooa, and the oecurreuco of 
Cheynt'-Stokea rosjnratton. 

(^HQi'Hiittl ihfnrm\he» of ihe heart ixm\ he AUx\ug\x'i%\\et\ hy the his- 
tory, tho blut-nt'ss of tlie siirfjioe. iiml \\\v ownrreni-e of a systolic nnir- 
niur not traiisunitted lo the left of the apex or to the arteries and heard 
only over thi< base of thu lietirt. 


IP Proonosib. — Organic Talvnlar heart disease ie rarely if erer curable, 
out in duration and fatality it varies widely in different caeea according 
to the cause, extent, seat, and progressive or noii-iirogreesive tendency 
ol til© lesion; the degree and rupiUity of compensation; the presence of 
compliciitious; the age. sex. and condition of the patient and his will- 
ingncBs and eapaciiy to follow :i proper mode of life and treatment. 

infanta and old people endure valvular dipcase poorly. In older 
chddren nnd adults, the lieait tends to compensate more quickly. 
Women are oftener affected than men, but they hare a better chance of 
prolonged life because t)f It** exposurL- tu severe strain and alcoliulic and 
other excesses with the re^nltiug jirterio- sclerosis, and angina pectoris 
01 organic origin. Ardnous and exposing ocoiip«iion8 and a reckless or 
pasiionate disposition intluence the prognosis unfavorably. A progres- 
siMj trend of the disease evidenced in the |Mi«t and pn^ent liistory is 
uiipropUious, etipeidally when associated with or dependent upon renal 
disorder. Evidence of dilatation without compensation or of coexistent 
arterio-acleroeis is ominous. The gravity increases with the number of 
if'fiiona^ and is grenitJy aiifrmented by tlie occurrence of diseases which 
weaken the heart. Heart disease dependent upon uncomplicated chorea 
18 not usually serious. In any case prompt relief following the use of 
heart tonics is a good sign. 

In aortic xtenosis^ compensatory hypertrophy is nsually prompt and 
may \ie efficient for years. The danger lies in failure of compensation, 
or in cerebral embolism, which is more frequent from this than from 
any other valvular disease. Death may also result from sudden heart 
failure or from pulmonary o'doma after secondary mitral insutKciency 
and left Tentricular dilatation. 

Aortic regurtjiUttion, though frequently existing for years and with- 
out much discomfort, is the moet apt of all valvular diseases to cause 
audden death, mitral stenosis ranking close in this restiect. It is most 
severe when suddenly developed (Loomis' Practical Medicine), and 
grave when followed by signs of mitral insutticlency, dilatation, heart 
failure, renal, or other visceral disease. Peath may occur from these or 
from cerehnil aniemia and syncope, from cerebnil apoplexy or embolism, 
or from asphyxia due to pulmonary congestion and ledema. 

Mitral 8feno»i8 renders the patient liable to pulmonary congestion, 
oedema, or apoplexy, and not infrequently ends in sudden cardiac failure. 
In mitral reffttrf/itftfinn, the prognosis is fairly good as compensatory 
hypertrophy is usually equal to the necessity, at least for some timo. 
Danger results from its failure and consequent general venous engorge- 
ment, giving rise to dropsy of the lungs, serous cavities, and limbs. 
Death from heart failure or from asphyxia naturally follows, bat only 
about two per cent of patients with mitral disease die suddenly. 

Trxmsftiii stenonts and /wiomjt of the pulmonary orifice are seldom 
met with, but, when present, are necessarily graTe conditions. 

Tru-uepid rtgurgitation is exceedingly graTe, whether the result of 



chronic pulmonary disease or aecoodary to lesions of the left heart, tn 
this condition, sudden increase in the* puhnoDary eugor^ment and 
death from stifToeution is u conetant danger. 

The symptoms usually iudicutire of a fatal imne in valrular disease 
of the heart are: great anxiety, with sense of oppression, followed by 
pallor, vertigo, syncope, and muscular debility, and irregular, weak, 
intermittent, and rapid pnlse of I'JO beats or more per minute, epjte- 
cially when accompanied, on palpation of the prawordia, by a pnrring 
tremor. Great anasarca and fluid efl'uAinn into the serous cavities, 
dyspucua, ht^moptysis, and cyanosis are bud sign& 

Tkkatmext. — In the treatment of valvular lesions, three things are 
constiintly to be borne in mind. The lubur of the heart must be ren^ 
dered as light as ponsible, the blood must be kept in u healthy condition, 
and the strength of the heart must be maintained. 

With the first object in. view, we interdict rapid walking, mnning, 
or henry lifting, and enjoin the patient to avoid climbing stairs, and 
indeed every act or form of exercise, mental or physirnl, which causes 
dyspncBa and palpitation. Wo attempt also by proper treatment to n*' 
move all obstruction to the circulation; hence, pulmonary and other dia> 
eases must receive appropriate treatment. Even a simple broncbitlf 
may be guftioient greatly to olwtruct. the pulmonary circulation. Porta!' 
oongestion, or obstruction in the aystemia capillaries which may be con- 
tracted as the reeult of nervous irritation caused by the retnjne<l excreta 
in Uright's disease must be relieved. Remembering that alTectiona of the 
lungs. livor, alimentary canal, kidneys, or skin may have caused tho 
carduic disoaae. or may greatly aggravate it, we naturally look for 
these, and seek to combat them by appropriate treatment 

With the second object in view, we aim to maintain free elimiuaiion 
by the kidncy«:, bowels, and skin, and recommend vegetable tonics, iron, 
and nutritious diet, with regular habits. 

To accomplish the third object, besides the means already suggested 
for relieving the heart of work and for furnishing it with jiropcr nutri- 
tion, we prohibit the use of tobacco and of all other depressing agents 
and ndminister various hrurt tunics, chief among wbi<:h are digitjilis, 
arsenic, and cactus grandillnni; belladonna and squills have a tonio 
effect ob the heart similar to these, though less potent. Tn many cast 
nnx vomica is a most useful remenly. 

Other heart tonics of value, alone or combined with digitalis, are: 
itrophanthus, beat given in tincture, ti].?. to x. ; sparteine eulplmte, gr. ^i ; 
caffeine citrate, gr. ij.-iij.; tincture of convallnria, tri x.-xx- ; and nitro- 
glycerin. The latter, in doses of gr. y\yf repeated within twenty minutes 
if necessary, is of special valne when a prompt cardiac stimulant is needed. 
Amyl nitrite acts in a similar manner. Sparteine seems of roost ralne, 
when given in full doses, in regulating the rhythm of the heart. Though 
the remedies directed to the heart itself are of the greatest service in the 




treatment of valvular •lisease, tliey sliotild not be usetl indiscriminately, 
for the apparcut weakness may eometimea be much more effectually over- 
come by medicines wliieli act upon some other organ. Moderate exercise 
ia Bometimee of great value in maintaining the strength of the heart 

In aortic obstruction or reijurgitation, it \b especially important to 
ftvoid taxing the ]>on-ur of the heart, and to maintain it« strength by 
cardiac tonics and a good supply of rich blood. Nature always attempts 
to eomjicnwite for the obstruction or regurgitation by hypertrophy of 
left ventricle; but a time finally comes when the compensation fails, 
en digitalis should be given to strengthen the muscular walla. Ten 
minims of tho tincture thren times a day is the ordinary dose, but the 
amount may be gradually increased until the heart pulsates regularly 
and with normal force, ]»roviding the kidneys act freely and the Rtomacli 
18 not deranged. Twenty minims may be given as often as every two 
hours, without danger, if there Is a free secretion of urinej but if the 
w stops, the digitalis must be at once suspended. 

When conipen&ution ia complete, so that the heart beats regularly 
and with normal force and frequency, good hygienic surroundings, with 
regulation of diet and exercise, are all that is needed. Exaggerated liy- 
I'ertrophy with t(Mi powerful systole demands cardiac sedatives. 

hi mitral uhi<lnu:tuiH or rtgurgitatimt, digitalis is usually most beno- 
»i*L It should !« given as just recommended for aortic disease. When 
It loses its effect, arsenioutt iicid or nux vomicji should be tried, alone or 
With the digitalis. Other diuretics, vapor or hot-air butha, and cathartics 
will be re<^uircd from time to time, to relieve pulmonary congestion and 
(Edema or genend dropsy. 

From the experiments of Germain Sec {La Trihune Mriliaik, 1890) 
wctose, a well-known constituent of milk, appears to be diuretic. Cal- 
omel in small doses is also a stimulant of tho renal function and is 
specially indicated when the liver is tugorged. 

It is important to continue the use of cardiac tonics in mcdinm dosea 
two or three times a day, for many months after the distressing symptoms, 
for which tho physician was lir»t called, have passed away: but tte 
amount must always be carefully regulateil, so us not to over-stimulate 
the organ. 

Biscase of the pulvwuartf vaftvs requires simihir treatment to that 
recommended for mitral affections. 

Jh tricuspid r«fftirtntfttvm, the same general rules laid down for the 
treatment of other valvular lesions are to he followed; but unless mitral 
disease coexists^ digitalis will do more harm than good, hy iu'.rrdtirj 
the vonous congestion of tho brain and of the abdominal organs. 




Myociirditis or inflammatiou of the muscular fibres of the heart may 
be acute or chronic. 

Anatomical AND Pathological CHAttACTEttisTics.— TheuRtial scat 
of myociirditifl is the wall of tlif left vi-ntricle. Very acute iiiHunima- 
tion is marked by infiltration and swelling of the muBcnIar fibres to- 
j;ethcr with their sheaths^ aiidtonde to their rapid disorganization nud 
the formation of small abscesses circumscribed by connective-tissue 
proliferation. Exceptionally the process ends in diffuso purulent infil- 

Ahscestttis weaken the wall of the heart, give rise to dilatation, niptnre, 
or }inenrii<in of the or(,^in, and tiuiy theinaolree diHcliurgc into the peri- 
canlial sac, producing pyo-pericardinni, or into thu ventricle, causini 

Chronic myocarditis is essentially interstitial, and eventuates in cir- 
rhosis, making the organ larger and heitvier thiin normal, viirjing in color 
from gray or pink to a bluish hue. The muscle becomes Inngh and in- 
«kistic and either inereuaed in thicknesii or attenu:ilod. The proe^^s is 
gradual, and may begin in the purls adjacent to the endonirdium or the 
pericardium or may primarily involve the intermmnculjir wrptn. 

New colls, tending to organize, produce pressure — atrophy of the mug- 
cuhir fibres or fiitty degeneration from disturbed nutrition. The growth 
of fibroid tissue may be so extensive as largely to replace musciilur 
elements, or it may exist only as cicatrices, scattered at irregulir inter- 
vals, commonly most marked at the apex (Hamilton, Test-Book of 


.■\« ft result, the atTectod wall i;* luiigh ami k-jitliery. either distinctly 

nitenuatf-'d or much thickened and of » gray color. 'J'his fibroid tissue 

sometimes undergoes calcification. The entire vail of an auricle hi 

been found in such a condition. 

ETiOLrt*iY. — Acutft myocarditis is usually of septic origin, either oo- 
cnrringas a part of pyemia or developed in the course of typhoid or 
other infections fevers. The chronic form usually accompanies rheu- 
matic endocarditis and periourditis, but may occur alone, llnber. how- 
ever, holds that it rather follows arterio-sclerosis of the coronary artery. 
Syphilis may also pro<luce it (Hamilton. o/>. cit.). 

.Symptomatology. — .irw/r vitfiyantUin is a rare affection, and of it« 
symptomt and signs vc know little, ajMirt from its association with en- 
docarditis or pericarditis. If, during the progruKs of either of these 
diseases, the heart's action becomes intermittent or irregular, and ther« 
is a tendency to syncope, it is probable that the muscular tissue of the 
organ ha* Itccome involved. 

The symptoms and signs frequently observed are: extreme pallor of 
the countenance, with coldness of the sDrfM« and a tendency to syo- 



oope; also pain nud opprHsion at the pr^fwrdia, with drapuoes unoiint- 
iiig to nrthopiin-a, and sighing respiration. The action of the hetirl is 
feeWe, fluttering', and irregular. The area of cardiac duhiees remuiiia 
nomial uiiIbsh dilatation or pericardial effoaioii exists. Both sounds uf 
the heart are aharp and valvular, the first very closely lescmhling the 
second. They may goirietimes be reprtwent^id hy the /«, /// (-•haract4?ristio 
of the ftptal lieart. Wltli these symptoms and sigas, the patient may 
complain of severe pain in the head and limbs, and there may be de- 
lirium or hemiplegia. All or only a part of theso may be proscut or 

The 8ym\iioma ot chronic mtfocarditis or JJbroid diseajie of the hoart 
most frequently noticed are cardiac pain, cBdema, and dyapncea, but all 
of thMe may be alwent. 

The«rif»«are: a weak, irregular, and rapid pulse and feeble apex beat> 
with coincident enlargement of the cardiac area of dulness. Beiluplica- 
tion of the first sound is also sometimes present. 

DlAON'OSis. — If an acute affection of the heart is attended with pallor 
and coldness of the surface, syncope, pain in the cardiac region, and a 
feeble, fluttering, and irregular pulsation, we may fairly suspect acute 
inflammation of its muscular walla. 

Neither the symptoms nor the signs nor these combined are snfficient 
to distingiiish accurately B'Ar{H>/ '/iVfl^f 0/ Mp A««r(^ from dilatation or 
fatty degeneration. In both, marked feebleness of the heart is present ; 
in fatty degeneration, tho heart is not so commonly enlarged as in the 
diffuse fibroid disease; the former is usually associated with anaemia, Lhe 
latter with general sclerosis, L-hronic nephritis, or syphilis. 

Aoconliu); to Riegel. the patliOf;uouK>iiic Hign of cliroitio myocarditis ia 
irregulanly of a«.*lion of the liearl, a total lo-ts o( rhythm ii[»pBaring early in the 
disease and reiiminin^ irrespective of the intlut^nce of tli^ituliH and olher a^nts 
ill i-esloriag tlie ronctional tictivily of i\vi oi'iT'io aiii] ilispellini; di-o|isy am) other 
symploiiis ol dL-fieifiil Iieart iK>wer {ZeitHcUrift fiir klinigehe ^fedicin. \S>*9). 
Irreg^ularity, tliuugh tv feature of iiiuny otht^r cafdiac coniliUons. is in tlieni aU 
wayx a late «yniptoin, due to secondary weakn«!)s, and it diitappears when hefkrt 
tonics Itave I>een effective. 

PuooNOSis. — Theoretically, the prognosis in myocarditis is always 
grave, especially in the acute form. Practically, a satisfactory prognosis 
is r.iroly possible, because an accnnite diagnosis can seldom be made. 
When occtirring with endocarditis and pericarditis, it adds to the danger 
of death from heart failure, cardiac aneurism or rupture, or from pul- 
mbmiry cougestiou and a?dema, or embolism and pyemia. The chronic 
lorm may terminate in generul dropsy or in death from cerebral anfeinia.i 

Trb.\tiient. — The treatment for myocarditis is that for its associated 
td frequently c^usitive diseases. 

Patients suffering from endocarditis, pericarditis or any obscure heart 
trouble, from typhoid fever or other debilitating iliseabes, in wliom royo- 


carditis may be even remotely suspected reqaire: perfect rest in the re- 
cambent position; avoidance of all mental or bodily strain; nutritious 
and easily assimilated diet; the maintenance of elimination from skin, 
bowels, and kidneys and moderate stimulation of the failing heart 
vith alcoholics, strychnine, digitalis, the ammonium compounds, or 




i^ynon;/m.«. — Enlftrgemunt of the heart; hjpersarcoaiB cordis. 

Siniph' cunliiu'. hypertrophy consists of hy]tertrt]phy (if llie miiscnljtr 
walls of one or more of the cardiuc ciivtties without titilargenient of tho 
cavity itself. 

AsATOMicAL A3»D PATHOLOGICAL Characteribtics,— Simple caf- 
diac hypertrophy untittendcti by (iihitation is compamtively rare and is 
seldom >jeneral. It may bo localized in any part of the cardiuc muscle, 
but it affects the wall of tho ventricle more frequently than that of the 
auricle, being oftenest confined to the left aide. The iaterrenlrinnlttr 
septum is not mtually much implicated. In well-marked eases the orgaa 
U always large and heavy, and changed in shape according to the seat 
of hvi)ertrophy. The wall ia not uiuommoniy donbled in tliickuess. It 
is re<lder and more rigid than normal, the enclosed cavities remaining 
patulous after death. The affected wall of the left ventricle will be 
eitra-friable; that of the right, tongh and leathery (Loomifl' Practical 
3Iediciuo). The hypertrophy results from increase in the muscular 
structure of the heart, whether in number or size of tho indiridutil fibres 
or in both. The increase does not involve tho connective tisisue tu any 
extent in simple hypertrophy, but may extend to the column^e carnese, 
especially of the left ventricle. 

KtioLOGY. — Simple cardiac hypertrophy may arise from functional 
over-action of the heart, due to prolonged or severe muscukr etTurts, to 
nervous or mental cauBcs. or to the effects of alcohol, leu, and coffee. It 
may result from slight obstruction iit the valvular oriflccs or to embar- 
rassment of the heart's action from displacement or pericardial adhesions. 
It may be ]>rodured by obstructed circulation outside tho heart, as from 
constriction of great vesaelji or pressure upon them; from degenerative 
changes of the arterial system, such as eudarterilis oblitenms, atheroma, 
and loss of elasticity ; or it may be caused by the obstruction resulting 
from contraction of the arterioles associated with Bripht's disease, alco- 
holism, and syphilis. It may be due to local or to visceral diaease,a« em- 
physemai cirrhosis of the lung, or pleural effusions which interfere with 
the pulmonary circuit. FhyEiologieal cardiac hypertrophy occurs ia 

Stmptomatologt.— The symptoms are not marked, though there ia 

SlilPLJi CARDIAC Ul'l*J£iiniOPtiy. 


a tendency to corebrul hyperaimia, oud palpicatioD on exertion or excitd- 
meut; a dry cougb nmy be preseut ut times, frum flight pulmonary con- 

The signs in tbis iilTection Yury with Ibe extent of the hypertrophy, 
and with the porLiuu uf the orguu involved. The esaeutial signs ure: 
inoreueed area of dulness aud increased force of impulse while the heart's 
action remains re;{ular. 

InsjifCliou in ebildreu frefjuently reveals a prominence of the pr»- 
cordi:il region when the hypertrophy \& gti^uenU, but in adults this can- 
not be detected. The action of the heart is regular and forcible. If 
the loft ventricle alone be hypertrophiod, the apex beat will be farther 
than usual to the left, and tlie visible area of the impulse increiiHed, often 
exteniltng over the whole praecordia. If the right ventricle i« affected, 
there will l>ft strong epigastric pulsation, anil the npex beat, if pcrceptU 
ble^ will be below and to the right of the usual position. 

Palpation confirms the signs as to the position and force of the apex 

On percussion, the areas of superficial and deep<seated cArdiac dnlncsa 
are found Lo be increased. The latter in simple hypertrophy of the 
left venlricle seldom extends more than an inch to the left of the nor- 
mal position. A larger area is almost always associated with more or 
less dilatation. In hypertrophy of the right ventricle, the duluees ex- 
tends considerably to the right of the storuum. 

In hypertrophy of the ventricles, auscultation finds the first sound 
of the heart greatly increased in intensity, and the elements of muscular 
contraction and impulsion are especially nuirkeil. The second sotind is 
also increased in intensity and more w^idoly diffused than normal. The 
action of the heart remains regular as long as hypertrophy compensates 
for the obstruction. 

The reiipiratory murmur is diminished or absent over a portion of the 
precordial region corresponding to the displacement of the lung. 

Diagnosis. — Simple cardiac hypertrophy may be confused with scr- 
erai affections, which will bo coneidereil to better advantage nndfr diag- 
nosis of hypertrophy and dilatation of the heitrt, from which it is distin- 
guished by the larger size of the heart and greater irregularity of action, 
with more of a heaving impulse in the latter. Again, in hypertrophy and 
dilatation of the heart, valvnlar mnrmurs are more commonly present 
than in simple hypertrophy; otherwise the symptoms and signs of the 
two iiffcctioni are substantially alike. 

Pkor.N'Osi.s. — Simple ciirdiac hypertrophy as a compcuBatory process 
is usually favorable, providing the causative factors be not snch as to 
produce eventual cardiac or vascular degeneration by their persistence 
or progrtssiveuess. Cases dependent simply upon mental or muscular 
excitement are not serious under a properly reguIateKl mode of life. 
'When there is a marked tendency to cerebral congestion, especially ia 



alcoholic subjects or those in whom arterial degeneration Visa taken 
pluce, this affoption is Huble to eTBntuato in cerebral apoplexy. 

Tkkatment.— Usually, hypertrophy of the heart should be farored 
rather than retarded; but in Bonie instances, Hymptonis of cerebral con- 
gestion appear such as pain, fuhiees of the hitail iind vertigo, which re- 
quire prompt attention. Uleeding will temporarily relieve those, but it 
ia not lu be re i-oni mended. Tincture oS acunite root in doses of two or 
three drops every two lionrs until relief Is obtained is the most efficient 
remedy in su<.'li iTistuuoes. Veratrtim viride may be used for the sumo 

It must not be forgotten that similar symptoms are caused by pas- 
sive congestion depending upon cardiac failure, and that in such oaeed 
the nconite would be harmful. These latter cases I have found most 
quickly relieved by riux vomica. The causes of the hypertrophy should 
be sought and removed ae far as possible. 


Hypertrophy and dilatation of the heart, also called eccentric cardiac 
hypertrophy, affecting the muscular walls and dilating the cavities, is 
caused by yielding of The walls to excc-ssive pressure, which may result 
from the same causes which induced the hypertrophy, or from regurgita- 
tiou of blood through incompetent valves. 

Symptom ATOi-ooY. — Dyspnu-a on exertion, oedema OBjwcially of the 
ankles, and occasional vertigo, and pitlpitatiou of the heart are cominun 
symptoms. In this affection, the action of the heart remains regular if 
the hypertrophy is sufficient to compensate for the dilatation; but it 
becomes irregular if the dilatation predominates. 

The essential signs are: increased area of visible impulse, with dis- 
placement of the apex beat downward and to the left, and a peeuliiir 
heaving iuipulMo with increased area of duluess. Endocardial uiurrours 
»re nearly always present. 

Inspection and jmlpation show that the area over which the cardiac 
impulse may be seen nnd felt is greatly increased, sometimes extending 
over the entire left side. The impulse often has a peculiar heaving or 
lifting character, sufficient in some instances to shako the bed on which 
the pitiient is lying. The apex beat may sometimes bo two or three 
inches lo the left of the left nipple, and us low as the eighth rib. 

lI|Kin percussion, the area of dulncs» is increased to the left and 
downward, in proportion to the enlargement of the organ; if the right 
reutricle is affectwi, it is also inorejised to the right. 

In ansentiation, both sounds of the heart are prolonged, and may 
often bt* heard over the entire chest. If valvular murmurs are present, 
they will be loudest in the nonnal areas, described in a previous chapter 
(Fi^. 32), but they may also be heard in some instanees ovr the whole 


DLA.GN081S. — Eccentric cardiHC hypertrophy niny be mistuken for re- 
tmction or f^iisoliducion of the lung, curdiuc UiUtatiou, jjcricurdial 
effusion, cftrdiuc diepkcemeut, thoracic auourism, or for simple ciirdiac 

Uetraction of the luntf due to pleuritic udhesiuns or pulmonary cir- 
rboHiH, T>y exposing a larger surface of the heart, may increase the area 
itt 8ui»orfieiul cardiac duluesa and thus eimulate hypertrophy; but the 
history of former trouble, pulmonary Bymptoms and aigne of more or leas 
promineuce. and the nurmul condition uf the pulise, heart soundtt, and 
force of the apex beat distinguish, it from cardiac hyperlr(»phy. The 
dielinc-tive features between eccentric cardiac hypertrophy and cotutoli- 
dnti'iii uf the hintf are &» follows: 



Cough Dot promiDent. Cough prominent 

Impultto nt apex forcible, aoUon tu- Force of apex beat normal. 


PuUe ftiU and stfong. HuIm normal or weak and rapid. 

Outlini; of ilulaesa quadrilateral and Outline irregular and extending b^ 

tfonflned to prwconlia. yond tim limiU of the heart. 

Heart tioundK intensified. Heart sounds normal. Bronciiial 

breathing', bronchophony, and ri.\^&. 

Eo-centric cardiac hypertrophy diffem friim dilatation of the heart as 

Hyfertboput akd dilatation of Dilatation or tue heart. 



SyrapboniN of cerebral hyperwiuia. Pro{;ressivi> geaeiul weakness, nod 

cedema of feot. 
Face Unshed ; e-arotids proniiuent ; Fuoe jialo or livid, v^ins turgid, pvr- 

apex l>eal hea^nng and forcible, and hapH ptit<uLUng: jugiilai-x ; a]>ex l>eat 
distinct over lai-ffe area. feeble, not alway<( vJKible. tlinu^'h it 

may be seen ovt^r an area larger tlian 
usual, but lesatlianthutof bypeiltropltj 
and dilatation. 


Apex beat forcible; pulae full and .\pex beit diffused, we«k ; pulse 

strong. weak and iire^lar. 


Bounds intensified ; first sound pro- Sounds feeble, and flrat sound short, 



Eccentric cardiac hypertrophy and pericardial effusion and hydro- 
pericardium have the following distinctions : 



Slowly developed and not promiQent. Symptoms acute in pericarditis. 

Apex beat strong-, displaced to the Apex beat weak, carried slightly to 

left, and depressed. left and apparently raised. 


Outline of dulness quadrilateral, and Outline triangular, and extending to 

not extending to left of apex beat. left of apex beat 


Heart sounds distinct Sounds feeble. 

No friction sounds. Friction sounds have been present in 

pericarditis, and may be still, at base of 


Eccentric cardiac a3rpertrophy and cardiac displacement differ thus: 

Htfertropht and dilatation op Cardiac displaceicbht. 

the heart. 

Cerebral hyperaemia. None characteristic. 


Heaving apex beat over great area. Apex beat of normal force ; area 

not necessarily enlarged. 


Area of dulness increased. Area of dulness not necessarily in- 



Sounds intensified. Sounds normal. 

Eccentric cardiac hypertrophy differs irom thoracic aneurism aa 
shown below: 

Hypertrophy and dilatation op Thoracic aneurism, 

the heart. 


No aphonia, dysphagia, or boring Boring pain, dysphagia, aphonia^ 

pain. etc., due to pressure. 

Impulse heaving and below fourth Impulse dilating and above fourtk 

rib. rib. Aneui'ismal thrill. 





Dulueiiis increastnl to ihe lefl untl DulneHs iiu.ivusctl U|iwtinl, 


Beart sounds intensified. Bruit ; heart sounds normal. 

pEooifosis. — The prognosis dopends largely upon the remoTahilitj 
of the causti.. or, if thiD U pcrmauont, upon its jirogressive or uou-pro- 
gresfiive cliaructcr. Kxistiug hy{>crtrophy, though suflicient to meet the 
OTiliimry dcmuuds of the case for years, may bf rendered inefficient by 
undiH3 musculnr atmin, oxhuuiiting diseiises, great and continued enio- 
tion»l disturbances^ or in seine cases hy pregnancy; the latter condition, 
however, is not contni-indif'-tttwl in modenite cases. 

When great force mnut be bjibitnally exerted by the ventricle to 
overcome increased resistance duo to obstruction or regurgitation, the evil 
^ffoctA arc apt to be manifested in chronic cungcstion of the lungs, in 
degeneniliun uf the arteries geiiendly, or in rn{>ture of cerebml vessels 
which may alrejidy be ihe seat of atheroma. 

Tke.\thkn't. — The treatment of this condition is essontiallr that of 
chronic en<locarditifi with valvular disease of the heart, with wliich it u 
nearly ulwuys iiA«ociaied. 

As long !ta hyiK'rtrophy is perfectly compcusjitory, uo treatment is 
demanded excei>t in case of excessive congestion, witli danger of 
apoplexy, when cardiac sedatives are indicated. (_>t)ierwise the hygienic 
and medicinal treatment suggested for dbfease of the heart should be 
carried out. 


Stffionijmf. — Passive aneurism of the heart; cardiectasis; cardiac 
diktat ion. 

Ihe heiiri refers to an :dinormal increase iTUhe cavities of the heart, irre- 
ipective of ihe condition uf its walls, nliich may lie relatively n*trnuii or 
attenuated. The aurinlcg are most frequently affected, and the right 
ventricle oftener than the left. Tho8hftj>eof a dilated licart depends 
upon the amount of dilatation, and npon the cavity or cavities invoKt-d. 
The shape may be irregular from bulging ofa single auricle or ventricle; 
or more uniformly enhirged, from stretchinrr of nil the cavities. The walls, 
if not normal, may he atrophic or slightly hypertrophic and may be tho 
It of various degenerations or infiltrations according to the cause of 
le afTcction. 

EtroLoiiY.— Pilatalion of the heart is dependent npon a disparity 
between the power of the cardiac muscle and the intra-cardhio pressure- 

twwlinif t/, rH.rogr«riTe change; sex and occnpauion, » itt- 
[J^^Ufft; ana hweaity, are remote factors in iu prodnction. 
''«irig *»u«fc, include all the conditions which weaken the 
\. J ^'rominent among these is atonj of ite moscubir 
'r*« Trom »n«mia, chlorosis, exhausting febrile and infectioua 
'r»ri««rr»5niB of innerration incident to sexual, alcoholic, 
'««MM-(»; or r:«rtain nervous disorders, as Graves^ disease. The 
'"* ""*y ''« weakened by degeneration. This may result from 
"I *""" '•'"'''>nury artery by embolism, arterio-scleroBis or con- 
"I'l imrldiirdiul aclhesions; or it maybe secondary to rhea- 
y» '»'• "yiiliilitic pericarditis, endocarditis, or myocarditis; or 
y '"'fiur, (lilt) to old age or to pressure from amyloid or fatty 
' ''"* K''"wths, or chronic pericardial effusion. The exciting 
'itiit 01, |„ iri(!ron„Q of intracardiac pressure. This may occur 
II'* <l iMiMWd, riiid from the pressure of tumors upon the aorta, pul- 
' y* "•■ other grout vessels; from general increase of arterial 
"""luttMl with Hrig]it*s disouso; from obstruction of smaller ves- 

'""I'Umt to prolungod muscular efforts, or to fibroid phthisis 
(ioiii((4ti „f the lungs; or from local vaacular degeneration duo 
■111. "yplilUs, liiul gout, notably to endarteritis obliterans. 
•MAToUKtv, — Tlio most frequent symptoms are: rapid and 
Togulur, iutorniittoiit pulso; cardiac palpitation and sensations 
Itm iiuil uitwuitioss; sighingrespirationjdyspncea, and syncope; 
irgttK(>onoo of tho veins, and congestion of the various organs, 
w\\\\\ of tho lungs, jaundice, or albuminuria. 
losl tiu|mrtant sitiHS are: fecblo and irregular action of the 
t^nlnrgotl an^u of dulnoss, oval in form, and not extending far 
of \\w u|H«x lH*t ; and foebleness of the heart sounds. 
'pM'urn, tho impulse of the heart's apex may not be visible. 
*U. it i* Ukoly to extend over a wider area than iu health, and 
of utftximum intensity is not easily determined. It is ooca- 
r an utuhtUtory character. 

neut diUtMtion *nd varicosity of the jugular wns is a sign of 
right auricle. 

(VAtiiMv, the tk^MNC hMt is found below the normal position and 
of it, and th* hwrtV action is im^hir in rhythm. The im- 
WWe^ which eiwble« u* nwtlily to distinguish this aifeoiion 
pHTx^l^hy. »wr hyjvMfT\»phy with dilatation. A purrinir trvmor 
vwtU t* obtained* eejwciallv when thei* is mitial neipirii:^- 

»k^tt *hi*w* the »r«« of ouduc dahwes inv'W*si?d to the r^b.: 
r\^t K-wKttws aw inwlTifd. and to she left whea the Irf: u- .- 
•*J^L .tuV.t*tss due to dilated aarvie« may extend upwir:. t- z 
t ;?.Sifm»v**. 
*.-v* wiiiataaaj an ^wJ tf«Uia«^ wtoA eoabJw as to i 



thu Jiseasc from pericariJitii, in which the signs, upon inspection and 
palpation, are nearly identical. 

My misonltation both sonndaof the heart nre found short, abrnpt, und 
fcohle, und frequently of equal length. The second sound muy be in- 
uudiblo at the apex, and the tirst may be reduplicated. 

Jf valvular munnura have been present, these become lens intense, 
and sometimes of a swirling character. The respiratory sounils over the 
appor portion of the left lung are often feeble. 

l>iAOXosis. — There is usually little difficulty in distinguishing dila- 
tation of the heart from all other afTcctiouG, excepting pcricurditiL 
The distinctive features between these tvo are aa follows: 







Impulse fe*ble and irr^ular, felt ImpuUte feeble and [rregular, felt 

bf/otraofl tu Utel^ftof its normal pa&{> abotv iu normal po«J(ioo,aDdlncreaa^ 
tion, and uot materially affected by in force when the patient Icaaa for* 
leaning' Uie patient's body forward. wrard. 

Oval outline of dulneiWt which does Triangular outline of dulness, wliicli 

not extend far to tlie left of the apex. extends coouderably to the left of the 

upex beat. 


n>-art ftound^i feeble, sliuri, and vul- Heart Hounds feeble, iiml nut »o 

vular, and not ult«red by pusiUon. markediy valvular, but intensilled by 

leaning the tK>dy forward. 

fstoligiH is a term which has been applied to a condition in which 
hTentricle cannot completely empty itself. It is nearly always asso- 
ciated with dilatation of the right ventricle. 

In this condition, the ini]UilKe of the heart heeomea very feeble, and 
shortly before death the valvular sounds or ninrmurB whi<:h may have 
been present become almost inaudible, or they may be supplanted by a 
continuous humming eouml. Tricuspid regtirgitation, with pulsation 
in the jugular veins, is likely to be developed during the course of this 

pKOoxoF^ls. — The prognosis is unfavorable according as dilatation rel- 
atively exceeds compensatory hypertrophy, the gravity depending upon 
degenerations of the musctUar wall, and upon the degree of obstruction 
to circulation. ANTien compensation is good and no eomplicationa exist, 
the patient may live for yei^rs; but associated valvular lesions, pulmonary 
afft(.tiaiis, Blight's disease, general anfcmia, hereditary predisposition 



to beiirt disease, and weakueas from an; cause reuder tbo progcoais itn- 

DvBpnwa anci irrcgnlar and intermittent pulse, tendency to dropsy* 
and ejncope are gravu signtt, indieutiiig that death niiiy occur suddeiilj 
at any time, though tlic piitient may linger for twreral months. 

Tkkatmest.— The tresitnient of dihitation of thi? heart and of asys- 
tolism should be the same as that recommended for chronic cndocarditia 
with valvular disease of the heart. 

Though the dihited cavities cannot be reduced lo normal, compenaii- 
tory hypertrophy of the walla may be induced and sliould ho encouraged 
by avoiding; all unnecessary exertion; by improving general nutrition 
with an abundance of easily digested food, tonics, and regulation of ex- 
cretion; and hy careful stimulation of the heart by digitalis, strophan- 
thus. spnrteiue, conTaUaria, or caffeine, and in suitable cases by moderate 


f Synonym. — Phtliisis of the heart. 
Atrophy of the heart is an extremely rare affection. It consists of 
simple attenuation of the walls of the heart, the cavities nsually remain- 
ing of normal Kize, but in some casea both the thickness of the walla 
and the eize of the cavities are diminished. 
The affection is sometimes congenital. It may be caused by old age, 
chronic wasting disease, or by constriction of the coronary arteries. 
DiAOXOSIs. — A diiignoais can n»rely, if ever, be made during lifaj 
but in the congenital variety we may possibly detect decreased area of 
cardiac dulness independent of pulmonary emphysema. 


There are two recognized varieties of fatty hejtrt: one, iu which 
there is a deposit of fatty tissue upon the surface of the heart or he- 
twecn its miieculsr fibres (irifiltnition), and the other, in which the mus- 
cular fibres themselves undergo fatty degeneration. 

Etiology.— The first vuriety of fatty heart is attributed, by Kennedy, 
to a fatty diiitheaia, and is assori.'ited M'itli obesity ; tlie second vuriety 
results from atheromatous degenerittion of the aorta, old age> nlcoholism» 
gout, or some prolonged wasting di.sease. 

SvMPTOHATOLOOY. — The ctvmptoms of fatty disease of tbe heart are 
practically the siinie in both varieties, and they are of tbo greatest im- 
portance from a diagnostic point of Tiew. The most prominent of these 
are: melancholia or irrit:»bility of temper, partial loss of memory, or 
hesitating speech: palpitation of the heart, dysjjtiani, and angina pec- 
toris. Other symptoms which are frequently noticed are: pallor and a 



snllov njipearaiice of the surface, witli conge^tiun of the ears anfl lipa; 
weight and pain in the heiiU; a sense uf paiii in the e|MgiiEtnuni; Houtile 
vision or toita nf Tisioii; iiiul the an-us senilis. Pseudo-apnplexy, and 
Chojrue-Stokcs respiration, when present, are Bymptonis of the greatest 

Fscudo^poplexy consists of attacks iu which the individual suddenly 
loses conticiotisness and fulls. It differs from true apoplexy in the 
mpidity of recovery. When theae attacks first make their appeamnoe, 
they seldom continue more than a minute or two, the patient coming 
out of them feeling perfectly well; but, as the disease progresses, tliey 
become more and more frequent, prolonged, and severe, and are at- 
tended with paralysis; even then the patient usually recovers completely 
iu a few days i:t most. 

The Cheyne-Stokea respiration, which appears late in the- disease, 
consists In the occurrence of a series of inspirations increajting to a max- 
imum, nud then declining in force and length until a st-iite of np|>iiront 
apn(£a is established. In thii« condition a patient may remain for such 
a length of time as to make his aiteudauis believe liini dead, when vk 
low inspiration, followed by one more decided, marks theconiniencfnieiit 
of a new ascending and descending Beries of inspirations. Although this 
is an imjwrtant symptom of fatty heart, it must not be forgotttm that 
H occasionally occurs in dilatation uud iu valvular disease of the organ. 

Jn fatly infiltration of the heart, obesity is a symptom of impor- 
tance. In fatty degenemtiou, loss of weight, after a person has been 
fleshy, is u valuable symptom. 

Among the si ynnoi fatty ihflf ration of tJic heart. an: a pulse usually 
alow — forty or fifty per minute— full, and sometimes even bounding; 
increased area of cardiac dulness on very careful percussion. 

In ffiift/ ifefffiienttioH, the pulse is weak and irregular and usually 
rapid. Auscultatiou over the apex will occisiunally reveal slow pulsa- 
tion; and even when the pulsation equals seventy per minute, it often 
conveys to the ear a sense of slowness. 

The inipulso of the apox in weak, and the intensity of the sounds 
feeble iu either variety. If valvular disease ooexiets. a soft systolic souffii 
may sometimes be detected by careful auscultation over the aorta. 

On inspection aud palimtion, the inipuUc is either indistinct or ab- 
sent; the apex remains in its normal position. The pulse in fatty de- 
posit i« slow and full; in fatty degeneration tt may be alow or rapid, 
iHit it usually appears to be rapid at the wrist, even though the heart' 
is beating slowly. 

By percussion, the heart is found of normal size in uncomplicated 
fat^ degeneration, but slightly enlarged iu fatty deposit 

In anscultjitioTi, the lirst i^ound is frequently absent, but If present 
it will be fcoble, short, and valvular, having lost nearly all of ita muscular 
element. The second sound is usually short, clacking, aud distant. 



A soft, blowing imirmnr may frequently he heiird over the aorta with 
the first sound, especially if the pntienl ia in the recumbent position. 

Exf^ptional. — Sometimes the }ieuK souittW in tliit ditteusi! are like tho»« of 
Ute I'cetuH in utero. ttaiiit:timt;:» they ui*e luetiUlio or i'jii^in^% unt) il is Biiiii that 
Ihe HecoDt] sound is someUiiiiJft prolcingeil ami intensified. 

Stokcft conftideretl the occurrence of pseudo-apoplexy with a soft nou^e 
in the aortic iireii, with the first sound of the heart, and a bIow pube 
positive evidence of fatty degeneration of the heart; but these signs are 
seldom combined in the same individual. 

A combination of several of the im|Kirtant Kymptoms and signs which 
have been cnumeratod is often present, and may justify a positive diag- 

DlAGKosis. — The physical signs arc not always well marked, aud a 
positive diagnosis is often impossible. Fatty heart is most likely to be 
mistakpn for functional affections of the organ, from which it can orjly 
be distinguished by careful »cnitiny of the syniplomB anil signs 
already enumerated, and the exclusion of hysterical affections and other 
functional causes. A distinction may sometimes be made by cansing 
the patient to walk briskly, when if the trouble is functional the heart's 
action becomes more regnlar and stronger and the sounds more distinct, 
whereas if organic changes are present the pnUations become more 
irregular and feebler than before. 

Pbognosis. — The prognosis is unfavorable in fatty degeueration. 
Fatty infiltration, when excessive, will produce degeneration of the mus- 
cular fibres from pressure; much can be done in mild cases by a proper 
system of diet and exercise. In either case, but especially in fatty de- 
generation, death hy syncope is apt to occur suddenly and without warn- 
ing, from excitement, overexertion or diBteution of the stomach or 
bowels by a too hearty meal or flatulence. 

TttEATMEyT. — The general treatment consists of cardiac and general 
tonics and is the some as for valvular diseases. Patients should be 
cautioned to avoid Uuiiig anything which c^uisea dyspnoevi. 

Arsenioufi acid is one of our best remedies in caitliuc degeneration, as 
it not only increa«ea the power of the heart, but also relieves the neuralgio 
pains, which are among the most distressing itymptoms of this diseesc. 
When the affection consists of fatty deposit on the surface of the he^irt, 
or between its muscular fibres, much may be accomplishoil by regulat* 
ing the diet. The patient should live principally on lean meat, avoiding 
as far as poaaible all fat-producing food, ttuch as sugar, surch, and nico* 
holic stimulants. He should take as little fluid as possible, and should 
wear warm woollen clothing, even in summer, to favor free diaphoresis, 
and should take systematic gentle exercise. These measures will lesaeir 
obesity aud strengthen the weak musclea. 



Anenrism of the heart is » rare affection, consisting of bulging of 
thut portion of the cnrdirtc walls which has been softened by inflamma- 
tion. It usually occurs at the upex of the left ventricle, and ocoasion- 
ally iii?olvcB the interventricular septum, bulging into the right 
oarity. Rarely, it inelades nearly the entire rentricnlar wall, which in 
such cases is thin and (]ilate<l, ami chit^tly fibroirs Trom lo^ of muscuUr 
fibre. Occasionally it is (taccutat«d. sometimes rexiching the size of a 
cocoanntf and connected with the ventricle by a narrow neck. The 
walla vary up to a quarter of an inch in thickness. The endothelium, 
though atrophied, usually remains intact. Commonly old stratified clots 
line its interior. 

Etiology. — Cardiac aneurism may develop from :iny condition which 
weakens the wall of the heart, such XMa dtseaye f>f the curonar}* arlorieSf 
fatty, fibroid, amyloid, or atrophic degeneration, or abscess whether or 
not the sequels of myocarditis, endocarditis, or pericarditis. 

Diagnosis aso Prognosis. — vV diagnosis can seldom be made before 
death, which usually occurs from rupture or heart failure due to weak- 
eniug of the muscle or mechunicul interference with its action. 

Treatment.— The treatment must be entirely symptomatic: when 
there is much cardiaic pain, roBtjand polaiwium iodide in mwlerately large 
doses are most efficient. I'hcre are no symptoms or signs to distingulslL 
cardiac aneurism from myocarditis. 


Rupture of the heart may follow myocarditis or fatty degeneration cf 
the heart. In the latter case, it seldom occurs in persons less than sixty 
years of age. 

STMrroMATOLooT. — The symptoms are: sharp, sudden pain in the 
priecnrdia! region, faintnoss, collapse, and apeedy death; though soma 
patients have lived forty -eight hours after the accident. 

Death is nsnally so sudden that an examination cannot be made, but 
the signs must of necessity be those of distention of the pericardium by 
fluid, with extreme weakness of the heart. Treatment would be ud> 


A few leases have been obscrrcd where heart disease seemed to have 
resulted from constitutional syphilis. Syphilitic affections of this organ 
consist of fibrinous exudations into the connective tissue, which may 
either soften and suppurate, forming ulcers or small abscesses, or be 
converted into masses of hardened fibroid tissue; and it is not im- 
prububle that, us suggested by Corvisart, vegetationa on the valves may 
in some co^ra have a syphilitic origin. An accarate diagnosis is imjiod- 
aiblu. No treatment can be liuggested where a diagnosis cannot be mmle. 



The heart is very sehlom the seat of iieophisniB. Congenitul angio- 
mata may exist ill its walls; aurcomata and L-jircin'miHta iniiy [ifnetnite 
it Xroiu adjacent organs. Hydatids are niruly Jouud. Of ihc*o uo diag- 
nosis vnu ha nuide. The. prutiitosin U nece^oartly tiiifavonible in tliu eiise 
of progressive tumors. Tbo frmimsiii uu»t bu symptoumtic. 


Sptio»i/itiif. — Cyanoftis, the bhie diitease. 

Horbns Ctprnleiis i^ ilio rQeiiltof cungeiiitnl malformation of the heart. 
Cyanosis, usually nuirked in the t';isi*«. it* jwcj-ihed. to gt-m-ral vpnouB con- 
gestion due to obstrnction in the riglit hi*jirt, but it bait also betfU Rnp*j 
posed to cc6ult from admixture of venous wirh arterial blood, 'i'hol 
morbid conditions, found post mortem, may bo pnteney of the ductus 
arteriosus or foramen ovale, dcticiciit inicrvcntricular septum or luir- 
rowing or complete closure of the puhiioiiic ohtico. Two or more of 
theiie abnormities are not infrequently combined, the first mentioned, 
being the defect mast often present. 

iSyjiPTOMATiiLOoy. — The unfortunate subjects are usually small and] 
feeble young children. Cyanosis may bo slight or it may amount to a deep 
purple or blue color. It occurs early, but may vary at different times. 
The saiMjrficial temperature is low, giving rise to chilliness. Cough^j 
dyspncBa, and frequent attacks of palpitation are common, appearing] 
after or inLTe!iiie<l by exurtion or excitement. 

As siffitx, inspection, in addition to the bluenesa of the surface, often 
reveals priecordial bulging and abnormal pulsation diffused to the epi-| 
gastriuni. I5y palpation, especially at the base of the heart, a thrill may 
be obtained. Percussion allows enlargement of the right heart; dulnesa, 
according to Gerlmrdt, nmy often be elicited along the left side of the 
sternum, as high as the second rib, owing to the enlargement of the 
conus arteriosus and distention of tbo puhnonary artery. AuBcultation 
may discover a systolic murmur over the region of the pulmonary artery, 
and rarely a diastolic murmur. A systolic murmur during the first 
three years of life is said to be invariably of congenital origin, 

DiAfiNORis. — In the r>ondon Lancet, May, 1ST9, Sansom formulates 
the following propositions relating to the diagnosis of congenital diseoso 
of the heart in children. 

First, in cases of congenital cyanosis, in which no cardiac raurmnr ia 
manifest, there is probably })atency of the foramen ovale. fl 

Second, in cases of cyanosis with murmur varying at inter\*als, and 
heard over the sternal ends of the third and fourth costal cartilages and 
intercostal spaces, there is probably patency of the foramen ovale. M 

Thinl, in cases of cyanosis with loud, unvarying systolic murmur," 
with maximum intensity internal to the posttiou of the apex beat, but 


heard also at the buck bctvuen the scapolie, there ia |irob:1>Iy itni>errec- 
tion of the rentriciihir septttin. 

Fourth, in cases of oyjitiosifi and of marked nnf^mia. in cliildren who 
maiiifL'St a ]>roi)oiiiiced Buperficinl tivstolir. nnirniur nt the biise I'f the 
heart, there is probably constriction of the pulmonary artery ut jt« ori- 
fice. Snch murmurB may be associated with aneemic mnrmnrs which are 
hoard nbuvi- ttie oliivicles. 

Fifth, ill ca«c8 of cungonitul iifTection of the heart in which there is 
evidence of considerable dilatation of the left chambers, it is probable 
that enUoL>;irditit) ulTecting tlie vulvus has coiiiitituted a oumplicatiun. 

pRotiN'Osls. — Mu(it Bubjectri iii congenital niiilf{»rmation of the heart 
lire but a few houra or days after birth, and vt-ry rarely reach advances) 
age. The prognoaia is be^tt in cases of eongemtal stenosis of the pnl- 
monary artery. 

Tre\tmext. — No specific treatment can bo recommended, but the 
«ame general rules should be observed as iu coses of mlvalar disease of 
the heart. 


Fanctional disorders of the heart are characterized by peculiar sensa- 
tions and by eliange in the f requeuey, force, or riiythm of tho pulse anil 
Apex beat, mid in the dmraetcr of the heart souuds, sevcml of these 
being eomnioniy iisitociati-d. 

The affection ordinarily manifests itself by frequent paroxysnuil at- 
tacks of palpitation and irregularity of the heart's action. It is aptly 
ctated by Balfour, that if a patirnt come complaining of disease of the 
heart who has not nlitaiuetl the opinion of a physician, we may, in the 
majority of cast's, ut(i(un> him that It is only a functional alTection, and 
that no organic <lisease exists; for the latter generally escapes notice 
until detected by the physician. 

Etioloot. — Tlie variations from the normal conditions may be tran- 
sient and paroxysmal, or more or loss constant.' They may aHfln from 
emotional causes, as, joy, fear, or shock, and from hyfteria, or hypochon- 
driasis. They ai-e often aHROi-Iated with cliorea, exoplithalmic goitre, and 
'Other functional nervous derangements. They may re-snlt from ovor-ex- 
crtion, from the exhausting influence of acute diseases, or from reflex 
irritation, especially of gtistric, hepatic, or intestinal oriffin, or from 
excessive venery. They may be due to antemia or to poisonous agencies 
acting through the t-irculation. whethirr referable to lithsmia. gout, 
rheumatism, lead poisoning, or inordinate Urte uf nleohol, tobitcco, tea, 
and coffee. Heredity and the nervous diathesis are also potent factors 
in their causation. 

SVHPTOHATOLOOY. — Ctrdialgia and palpitation or a snhjectire sens^ 
tion of the cardiac impulse, are the most constant ^rmptoms of func- 







tional disonso. and uiiually give rise to much anxiety. Abnnrmitlly rapid 
pulse (tachycardia) or abnomiaUy slow pulse (bradycardia), or irregU'^ 
]arity. intermittency, weakness, or fulness of its beat, and morbid pn©^ 
cordial ijoundd and aeiiiuitiuii» frti(|uently occur. Vertigo, tinnitus au- 
riuiu, uiid j)hoi:oj>hobia are not uuuummuu, and markod ]>seudo-angii 
peulorie may occur. 

Tliough tlie physical signs of the neurotic affection are in no waj 
cbaracterislic, physical diagnosis is of importance in excluding organic 
disease. _ 

By inspection and palpation we find the apex iu its Donnal poaicioin 
bat U8u:illy the impulse is comparatively feeble, thuugh the stroke may 
seem sharp and cjnirk. 'V\w. artion of the heart is usually irregular. 

Percussion shows the heart to he of normal size. 

In ausoultjttion, hoth sounds of the heart are abrupt, and may be ii 
tensitied. Occasionally the first sound has a metallic character. Fr< 
quentlyancemic murmurs are found in the aortic area, and also in a space 
vhich luis been improperly termed the pulmonary area, viz.. a limited 
area, an inch or an inch and a lialf to the left of the stenium, in the 
secuud intercostal sjiace. The murmur In the latter position is appar- 
ently due to slight niitral regurgfitatiou dependent upon a Meakeued 
condition of the left ventricle whif^h allows dilatation to such an extent 
that the mitml valves are unable completely to close the auriculo- 
ventricular orifice. In such cases the dilatation disappears, and the^ 
murmur ceases aa the muscles regain their tonicity. f 

DlAOXOSis. — It is of great importance to make au accurate differen- 
tial diagnosis between iunctional and organic heart discajjc. The chief 
points of distinction have been already noted in the differential diagnosis 
of chrouic endocarditis. 

The symptoms of functional disease of the heart may be associate 
with the signs of organic lesions merely as a coincidence. In such ii 
stances an exact diagnosis would be exlremely ditScuIt. It could only" 
be made by repeated careful examiuations and by the evidence afforded by 
treatment, under which many of the functional symptoms may disappear J 

PiiOON09ls.^Functional disorders of the heart usually continue for 
months or even years unless the cause can be ascertained and removed 
by proper treatment, but they are seldom if ever dangerous to Iife» ill 
true angina pectoris be excepted. ™ 

Tkeatmkst. — The first thing in these case^ is to impress upon the 
patient the fact that his heart symptoms are not due to organic diseaBOi 
aud that he is likely to recover entirely. This must be done after ^ 
careful and painstaking exauiiuation. Since neurotic affections of thA 
heart are usually due to antemiaf hysteria, uterine irritation, sexual 
abuses^ or the excessive use of alcoholic stimulants, or of toliacco, or of, 
tea und coffee, we should ascertaiu which of these operates in tlie 
before us, and advise accordingly. 





General tonics are usually Indicated. In a fen* cases digitalis will bo 
found »errioeable in controlling the action of the heart, but sjmrtL'ine 
sulphate gr. \ to i., tinct. of KtrophanthuR niv. to x., tinct, of couvul- 
luria TUX. to xv., or fl. ext. of ra^tiis gmndiflora irii. tn iv., tliree times 
a day are, as a rule^ more pfficient. In many cases strychnine and in 
others bromides are specially heneficiat, and occaaioniUly nitmglycerin, 
amyl nitrite, aconite, or veratrum viride may bo beneficially employed 
in small doses. 


Tachycardia is a term which may be broadly applied to an abnormal 
rapidity of the heart, occurring either aa a paroxysmal or as a more 
permanent affection, whether or not accompanied by weakness, irregular- 
ity, or lutormitteney ol the pulse. The )>ul8ationti may run trom une 
bnndred and twenty to even three hundred per minute. If the uctiun 
is rapid and the impulse forcible, it is L-unimonly termed ]mlpitution. 

Tachycardia may be a symptom of organic or of functional disease; 
it also occurs as an idiopathic ntTertion and is occasionally hereditary. 

In some instances of paroxysmal tnohycarclia as described by L. 
Bouveret {hiteruational Metllral Annuai, H, p. 252) in a report of 
eleven collected coaes, the heart, normal in the intervals, is seized with 
paroxysms of rapidity, which, if the attack bo of short duration, may 
fXeach two and even three hundre*! beats a minute. If tliese attacks 
'are prolonged for several days, symptoms of cerebral hyperiemia with 
embarrassment of the pulmonary and systemic circulation commonly 
ippear. In such cases, change to the normal action may occur snd- 
'denly, and may bo followed by decided prostration. Four ont of the 
eleven caaes died of asystole or sj'ncope. Instances of hereditary tachy- 
cardia have been known in which the heart heat with infantile rapidity 
through life seemingly without detriment to the individual. 

The so-called irritable heart of soldiers so well described by Da 
Coeta (Medical Diagnosis, page 405) is characterized by habitual rapidity 
complicated by paroxysms of palpitation and pri«<^ordial pain brought 
on by exercise, with frequent attacks of headache, dizziness, and cuta- 
neous hypenes thesis. 

"With the paroxysmal form of tachycardia in addition to the palpable 
tod risible rapidity of the cardiiic impulse, ])hysicul exploration may 
elicit signs of iKilmonary congestion. lu irritable heart, Da Custa says 
the action is rapid, often irregular and rather abrnpi and jerky, the fi»t 
sound short and sharp like the second, but sometimes very faint. 

pROQXOiitis. — In severe paroxysmal caseii, the prognosis is uncertain, 
Tsrying with the persistence, frergueney and severity of the attacks. 

Tbeatment is that suited to functional disease. 




Bniilvcunlia ur abuuniml Hluwueiw uf th« pulse though often seen 
in slight (Jt'greo, \% much rarer us a wcn-miirked cbamcteriBtic than 
rai)nl pulse. The freqtitjiiej' iiiny full as low as sovcuteen heats per 
minute (Balfour, EUiubiifijh Mett'iatl JonnutK 18D0). !n one variety both 
heart and pulse betit alike, in another the pnlsations of the heart wiiilo 
normal in frequency at the apex are so weak that all are not felt at the 
wrist. Prentiss' classification of the causes of slow pulse is as follows: 
distjjiiie or injury uf the nerve CfUtre causing paralysis of the eynipa- 
tfaetic nerve or irritation of the pneumogastric nerve; disease or Injury 
to thf trunk of the vagus, increasiug its irntability; disease or injury 
punilyzing the sympathetic; diiwase of the ciirdiac ganglia; disease of 
the heart muscles; action of poison? upon the uerve centre or endings 
{/iiti-^nKftiounf. MMicol .I/uift^f/, 1S!^I] ). I have seen a few cjises that 
seemed the direct result of prolonged aeverc paiu. When well marked, 
it is usually iin unfavonible sign, owing to the tendency to pseudo-epi- 
leptic and pseudo-apoplectic attacks. Death may occur during these 
seizures or from aetheniJL It may be a symptom of fatty heart. 

Treatment must aim at gencml nervous and cardiac stimulation. 



Angina pectoris is a term applied to attacks of severe paroxysm 
cardiiic p>tin, associated with a sense of impending death and minor 
plieuornena commonly symptoaiatic of serious organic leiiious. A dis- 
tinction is to bo drawn clinicully and etiologicuUy between true angina 
pectoris of organic origin and pseudo-angina or hysterical angina de- 
pendent upon diathetic or toxio influences. True angina most fre- 
quently atticks men of advanced yeurs. but the faleo variety is coiumon 
tound in comparatively youug neurotic women. 

Ktiologv.— True angina pectoris seems in most cases to depen 
upon arterio-seleroais and other diseases of the coronary arteries tending 
to their contraction or obliteration, and consequent deficient nutrition 
of the heart. According to Liegeoia (£H//cr/i'/ mcdtcah ties {'(jsprff, 1888) 
three-fourths of all cattes may be ossigneil to Bcleroais or atheroma of the 
coronary arteries or aorta. Not infrequently the affection appears to d^ 
pcnd upon cardiac dilatation, valvular disease, fatty and other degenerative 
changes, aneurism, or pertcuriliiis,any of which may disturb the circula- 
tion through the coronary aitvriuii. Douglas Powell believes vaauuiotor 
disturljance an essential factor in the iiinjovity of casijs uf angina pectoris 
{British .\hdiml Jounuil, 1801). Sometimes no cause for the disease 
can be diiK-overed. Among possible causes may be muntionvd organic 
affections, such as cancer involving the pneumo-gastric or cardiac au 



thoruoic picius of the sympathetic {Lyon MeiUcale^ 1888), chrooic DctintiB 
aud pigroeutary »ud.grantilur degeueratiun of nerve celU {Ln Semaiiu 
Atetlirafe^ March, 1600). Ilie iiiimt'tliate oaiiiie of thi* iMiroxysm iimy 
be emluli^jin uf the euroiuiry artery, but it is ii:iu:illy huiiiu mental or 
physical exertiou, sexuul deraitgement, error of diet, or exee&i, iiifluctic- 
itig the vtutumotur ineohauisin. OeeasiuuaUy the gouty aud rheiiitiatic 
diatheses, by vitiating the bloofi supply, are undoubted etiohigiciil fac- 
tors both in producing the primary diiieaBe and in favoring the j)arox- 
ysra. Pseudo-angina may be dne to reflex oauises or to direct central 
irritation. The former are eonimonly of gastric or hepatic origin, such 
as indigestion, gastric catarrh, tiatnlence, or the presence of gall stones; 
the latter include cerebral an<l spinal ncnrasthenia and locomotor ataxia. 

Symptomatology. — The most characteristic symptoms of true angina 
pectoris are agonizing sternid or prspconUal pain probably oansed in moet 
cases by over -distent ion of the heart, with a peculiar fear of impending 
death. This pain usnally radiates to the left shoulder and down the 
arm, often stopping at the elbow, but frequently extending to the ring 
and little finger. It is often severe up the side of the neck and Itehind 
the ear. It sometimes extends to the right side and may ocraslonally 
be felt in the thighs. The pain has been variously likenc<l to a stab, a 
thnist with a red-hot iron, a sensation of suffocation, or grip of nn icy 
hand. Pallor and fear are depicle^l on the countenanee, and respira- 
tion is frequently interrupted as though the sufferer had forgotten to 
breathe. Tlie pulse is usually, though not always, feeble and irregular 
or intermittent. The duration of acute attacks is usually from half an 
hour to two or even three hours, ami they not infrequently terminal© in 
ayncope or death. If the patient sunivea the first attark others are 
liable to occur at irregular intervals, at first far apart, but ere long 
nearer together until one finally proves fatal. Attacks of pseudo-angiua 
are generally of longer duration but of lees severity. 

No characteristic siijns accompany either variety of the affection, bnt 
Talvular dit^eiise, fatty degeneration, or dilatation of the heart is com- 
monly present in true angina. 

DiAososTs. — Angina pectoris pro^wr may be confused with the 
hysterical form, or, if mild, may possibly be mistaken for intercostal 
neuralgia, acute pleurisy, or myalgia. It may be distinguished from 
pseudo-angina pectoris by the following pointa: 

Tbuv akou<a PECTOmS. 

Hysterical or psKmo-AKOiKA 



Usually in men over forty; cordino 
lesions, eflpecialiy arterio-sclerosiA of 
the coronnry arl«rie« aad Tatty <le- 
gene ration. Atlackn caused by exer- 
tiun any time of day. 

Ofteneat in women t any age ; neu* 
ralf^c diathesis, but no cardiac )eslon«. 
AttacksspontaneouB ; usually al night. 



TBCB angina PECTOMfi. 

Htstehical or pmiotdo- angina 



Pain very severe and of short dura- 

CompantivesilaQce aofl miniobility; 
often speedily fata.]. Not tt:lievetl by 
aotl-neuralgic remedies. 

Murmurs and enlaiyeiueDt frequent. Xo organic diseasflL 

Pain less severe and of longer dura- 

Comparative agritatlon and activity; 
seldom if ever fatul. Believed by > 
neuralgic medication. 

It may be differentiated from intercoxtal neuralgia by tho history 
presence of tho characterietic painful points in the latter diseapo. In 
tnya/gi'/i, the character and seat of tho pain, the tendornoas of tlio mus- 
cles, and other symptoms are sufficiently dic.g:no8tit!. The pain of tfciUe 
pleurisy is attended by cough, pyrexia, aud distinct pliysieal signs uot 
present in angitm. 

Phoos'osis.— The first attacit of angina pectoris ia often fatal within 
two or three hours, and sometimes a suddeti sharp pain is the only warn- 
ing of instant death. More frequently thd patient survivus the first 
paroxysm, but after a few mouths dies in the second or third attack. 
Sometimes [tiitients live for many years subject to occasional attacks 
which gnidiially be<*i)nn' more and more frequent until finally resulting 
in dtMith. A cousidcrabla number, however, recover under appropriate 
treatment or at least live nanny years with but few and light attacks of 
the cardiac |>ain. In ]>aeudo-uugina, the proguoeis is favorable provid- 
ing its cause can be removed. 

Treatment. — For the paroxysms, alcoholic stimulauts, opiates, or 
inhalations of aniyl nitratu Tll.v. to vi., or of chlontfonn are most eRicient, 
Chloroform, though appareutly a duugeroua remedy, has proved harm* 
less, proni]>t, and etiicieut when administered us reconmiended by Ci. W. 
Balfour, of Edinburgh (C'linicul l^eetures on Disease of the Heart, 
187(>). Half a dnu-hm i.t poured upou a sponge at the bottom of a wide- 
niouthed bottle, from which the patient may brtathe ad Ubitum until 
relieved. The patient drops the bottle as B«)on as he becomes partially 
unconscious, and it rolls away. NitrogIy<!eriu has been recommended 
foi the cure of angina pectoris, and from the published reports it ap- 
pears that numerons cases have been benefited by it. 1 have found it 
of mnch value in stimnlating the heart and relieving the painful parox- 
ysm, but I have uot witnessed curative reenlts. It is administered 
either in pill, tablet triturate, or solution. The dose adminialered to 
relieve the paroxysm is ordinarily gr. -^^ which may be repeated onco 
in twenty minutes until three or four doses have been taken or relief is 
obtainedi unleaa itfi physiological effects are too strongly developed. 



When the eusceptibilitj of the patient to the remedy has been nacer- 
tained, doses two or three times larger may somotimcs be given. To 
prevent recnrrenoe of the attack, it may be giren three times daily, at 
first in doaes of gr. y^g, but these may be increased to five, t<^n, or even 
fifteen times a& mnch^ providing that it does noi canse severe headache, 
giddiness, or overpowering somnolence. Dnring the intervals between 
the attacks of angina, the same hygienic ruleii should be observed as ia 
valvnlur disease. Arseniona acid should be given in moderate do9e«, 
with or without iron, strychnine, and digitalis, acccrding to special 

Huchard claims that large doses of potassium iodide (grs. xl. to 1. 
daily) continne<l several years with intervals of eight or ten days each 
month during which it is suspended, will cure angina pectoris and arterio> 
sclerosis of the heart iOasf/te de.* lUpitauXy 1890). The remedy ig cer- 
tainly very efficient in relieving the pains of aneurism and sometimes in 
relieving cardiac pain. In pseudcKangina, the cau^ must be aecertaiued 
ard removed if possible. Remedies usnally should be directed to the 
relief nf rheumatism, aniemia, or debility, or, most important, to the 
correction of indigestion. 




The symptoms ascribed to iicute exud»tivo inflammation of the aarU 
have been described by Fmnk, Uizot, and others; but as stated by R. 
Douglufis I'owell, the disease as ii primary uffection is of very doubtful, 
if uot impossible, occurrcuco. We need not attempt to describe any of 
the signs or symptoms it might jwssibly occasion. 



Stfttonyms. — Aortic endarteritis ; aihcromatous degeneration of the 

Atheroma of the aorta may be defined as a degeuerution of tlic coats 
of the aorta, eoiisisliug of an irregular thickening and sotioniug of its 
wallti, especially of its inner couL 

II seldom occnrs liefore the forty-fifth year of age. H 

AxAToMH AL ANii P.\THOi.onn_AL Charactkiustk s.—Thc disefls© 
consists uf thic-keniug and fatty degeneration, usually followed by cal- 
careous iuGUnition and occasionally by ulceration. It is primarily con- 
fined to the iiitimu, but uot infrequently involves the muscular coat. It 
begins with inflammation, occurring in sirattered jmtches, winch have 
the milky opacity characteristic of the first stage of acute endocarditis ; 
later these become yellow from fatty change. These areas may coalesce 
to some extent, and deposits of lime suits commonly tiikc place, giving 
the surface a scaly or nodular upjMjarance and chalky hardness. Clcci-a- 
tioii occaaionally results from rapid central softening of the patch and 
distthurge of the debris. Microscopically, tlie thickened iutima early 
shows round and spindle cell infiltration and more or less increase of 
fibrous elements, but no hlood- vessels. Later the s]iotii of softening are 
found to contain oil globules, crystals of cholesterin, and a gmuular 
debris. These processes rofiult ut first in thickening of the arterial wall, 
finally weakening, loss of elasticity, dilatation, and in some coses anej^ 
rism. V 

The affection is uaually limited to the initial portion of the blooo^ 
vessel ; indeed clinical evidence of its existence beyond the transvei 
portion of the arch is very rare. 

KTioJ.ouy, — The chief causes are: gout, rheumatism, syphilis, cbroi 



nephritic, high living vitb inHufticient exercise, aud the excesfiivo nse of 
alcohohcfl. It fiomptimes rettults from uudue strain of the artery, as in 
excessive mnscutar efforts. 

SYMPTOXAToLOoy.— The symptoms of atheroma of the aorta are 
always obscure, and its phy.iical signs, in many cases, are far from posi- 
tive. Among the most prominent symptoms and sitjnt, we observe at- 
tacks of pjilpitation or anginal p;iin atiil dyspiiu'a, whirb art? usually 
brought on by exercise, but msiy ot'our independent of exertion. Dur- 
ing these attacks the pnl?e is commonly very weak. Signs of gen- 
eral atheroma may often be detected in the abnormal rigidity of the 
temporal, nidial, and brachial arteries. 

By iuspcL-tion and palpation, when dilatation has taken place, feeble 
pulsation may be seen or felt iu the second intercostal space close to 
the sternum, on the right side. 

Ui>on |>ercu3S)on, there is found a somewhat increased area of dulness 
OTer the ascending or transverse portion of the aorta. 

On ausoultAtion early in tlie disease, there may be some evidence of 
hypertroiihy of the left ventricle, as indicated by an increased impulse 
and muffling of the first sound of the heart. These signs, however, are 
not characteriHtic, as they might arise from emphysema or other cause 
of obstructed circulation. 

With the advent of dilatation, the Hrst sound of the heart becomes 
more indistinct, while there is accentuation of the serond sound over the 
uoi-tic valves, thought by some to be diagnostic of dilatation of the uorta, 
A short murmur is usually heard over the aorta, immediately after the 
systole of the ventricles, especially when the action of the heart is rapid. 
As dilatation pragresscs, tlic bruit becomes more distinct. It is some- 
times rough in elianicter. and may be associated with a purring tremor, 

The second sound may be partially supplanted by a faint diastolic 
murmur, due to dilatation at the origin of the artery, which renders 
the semilunar valvos incompetent to close the orifice, and allows regurgi- 
talion into the ventricles. 

When the heart is beating slowly and regularly, both the first and 
eeoond sounds may he accentuated over the upper part of the sternum, 
and the systole of the heart may be attended by a slight impulse in the 
aortic area; but this latter sign, to be of value, must be obtained when 
the patient is perfectly quiet. 

Ijater in the disease, dyspnoea becomes marked, the attacks of angina 
are more frequent and persistent, and the symptoms of embolism, such 
as hemiplegia, rigors, hsmuturia. auperficial hemorrhage-s, or gungrene, 
may make their uppearance: or tlie formation of n sacculate*! iineunsra 
from the aQectcd portion of the artery may be indicated by the sudden 
occurrence of jtain, dyspnma, and faintness. Finally, sudden death may 
result fiom heart failure or from rupture of the aorta. 

DlAOMoai».— The principal symptoms and signs of atheroma of the 



aorta are : p:iIpitation, pain, and djEpnoaa, with rigidity of the superiicia] 
arteries, muffling of the first sonnd of the heartland ac^entnation of the 
second, over tho aortic valrea. The* first heart sound is uenallr followed 
by a more or leas distinct systolic mnnnur. Somctimea there is a diaa- 
tolic murmnr in the region of the ascending or transren^* purtion of the 
urch of the aorbt, with slight increase in the area of dulness daring thu 
later stagce. The affection might be mistaken for simple diaeaw of the 
aortic valres, or inorganic disease of the heart, with ani^emic murmnrs. 

Though it may cause many of the symptoms and signs of atheroma, 
fiUeast of the aortic vttives is not attended by a rigid condition of the 
eaporficial arteries, or the peculiar neuralgic pains which usually attend, 
atheroma, and it does not cause accentuation of the secoud souud at the 
aortic ralves or an increased area of dulness at the base. 

When anipmic murmurs are associated with functional disease of the 
heart, they are not attended by rigidity of the superficial arteries^ bj 
the peculiarly distinct accentuation of the second sound, by the systolie 
shock, by the diastolic bruits or by increased area of dulness. 

Treatmest.— Morphine, nitroglycerin, or other anti-spasmodic rem- 
edies are indicated during the attacks of dyspnoea. Potassium iodide 
continued for months, with short intermissions, is sometimes useful. 
Excessive exertion most be avoided. 


An aneurism is a sao the cavity of which commnnicates with the 
lumen of the artery. 

Anatumical and Pathulooical Characteristics. — Aneurism m&y 
exist as a fusiform dilatation of the artery, but usually, when well 
marked, it is saccular, formiug a pouch-like projection from the vessel. 
Tlie wall of the aneurism may be composed of all the coats of the veaael^ 
tliough (Tommonly the muscular tunic is wanting. Karcly, the walls aro 
formed by a conden&atiou uf the surrounding tissues into which the 
artery has rupturetl, called diffuse aneurism. It the blood effects sepa- 
ration of the arterial cuats, a directing atioirigm is formed. The cavity 
is generally lined with coueeutrically stratified blood clots of varying 
agCf thickness, and consistence, which arc occasionally calcified. As 
the aneurism enlarges, pressure upon adjacent respiratory, circula- 
tory, nervous, or bony structures produces characteristic symptoms 
and may eventually effect their destruction. The walls of the sac gen- 
erally undergo atheromatous degeneration, and may rupture into the 
pleural cavity, lungs, bronchi, trachea, pericardium, u'sophiigns, or 
through the chest wall. 

Ktiology.— Aneurism occurs generally in adults, oftenest between 
the ages of forty and fifty. Occupations which subject the individual 
to exposure and severe bodily strain favor its development. Atheroma 


of the walls oi the artery is the chief predisposing cause, vkelher duo to 
syphilis, chronic aepliritis. gout, rhLniniatism, chronic iilcohoUsm, lead 
or mttrcuriiil poisoning, or lo Si'vtinil of these comhineil. The immpdi.ite 
cause maj he Atulden struiu. u blow, full or wound, or continued excesses. 


Anenrism of the sinases of Valsalva is usually so small as to give 
rise to no peculiar symptoms or signs, hut the indicutious of athe- 
romatous degeneration, with a pulmonary systolic or diastolic mnr- 
mur due to pressure of the aneurism on the origin of the pulmonViry 
artery^ might lewl us to suspect the true nature of the leeion. The diiig- 
nosis can rarely, if ever, be marie with certainty, as the tumor lies en- 
veloped in the pericardium, so close to the heart that it is almost impos- 
sible to distinguish between the murmurs which it producer and those 
of valvular origin. 


Aneurism of the arch of the aorta consists of preternatural dilatation 
of the artery, which may be general involving the whole circumference 
in a fusiform, cylindrical or globular swelling; or saccuhitedr forming a 
pimch-like projection from one side of the artery. 

Sacculated aueurisms are usually globular at first, but may subse- 
quently acquire different forms, especially the conicaL 

Aneurisms may occur in the ascending, transverse, or desnending 
portion of the urch of the aorta. About one-half have their origin in 
the ascending portion; a few involve both the ascending and the truus* 
verse, or simply the transverse portion of the urch. Nearly one-fourth 
nrise from the descending arch, and about the same number from that 
portion of the aorta between the arch and the diaphragm. 


Anenrism of the desceuding aorta ultimately causes & pulsating tumor 
behind, at the left of the spinal column, between the thirtl dorsal verte- 
bra and the poiut at which the uortu perforates the diaphnigni. Ero^ioa 
of the vertebrie, with cousequeut curvature of the spine, is usually pro- 
4laced by pressure. Subsequent compression of the spinal cord may 
<!»nsc paraplegia. The tumor, if large, usually displaces the heart for- 
ward and to the right. In exceptional instances, aneurisms of this por- 
tion of the aorta may be detected upon the right side of the Hptnal 
column, The brnit. in an aneurism of the desoending aortu, may bo 
distinguished from a mitral rcgurgituut murmur, frequently heard in a 
similar pf>sition, by the fact that the aneurismal murmur is heard nob 
only between the fifth and the eighth don'al vertebra, but also above 
«nd below this position. The mitral regurgitant murmur is not heard 



distinctly Above ttit- lower border of the fifth or below the upper border 
of ifae eighth vertcbni. 

Stupto^atolouv. — Tutiiors of thiii clumcter may somotimeii 
diiLguosticaleU from the H^aiptoinH, wheu they cannot be located by 
physical signs. The more prominent symptonis, though not indi- 
riilu.tlly charocterietic, maybe suSicient for the purpose of diagnoA^^ 
when grouped together, and are of great value when taken in connectio^H 
with the physii-al signs. Enumerated nearly in the order of thuir im-^ 
portance, they are: p;iin, dyspnom, palpitation, dysphagia, headache, aui^^ 
disordered vieion. ^H 

The pain in aortic aneurism is persistent, of a peculiar wearing, nch^^ 
itig, or burning churacter, and is referred to the region of the tumor. 
Frequently there are neuralgic exacerbations, with pain radiating in t 
course of contiguous nerves. 

byxpnofii of varying degree is geaerally present, and is usaally 
gravatcd by much slighter causes thau those whi<;h would occui 
the same symptom in other varieties of intrathoracic tumors. It t 
qnently occurs in severe jmroxysms, which may be due to one or mo: 
causes. Ordinarily, such attacks are ascribed to fipasm of the glotti 
resulting from irritation of one or both of the recurrent larvngeul nerves.' 
More probably they are due to paralysis of the abductor muscles of the 
glottis which arc supplied by these nerves, with consequent falling to- 
gether of the vocal cords, and obstmction of the glottis during iuspinu 

The exacerbations of this symptom are due in some instances to a> 
collection of mucus at the glottis; in otliers to the varying preesnre of 
the aneurism upon the nerve which, at one time, completely msj>end6 
iti function, at another interferes with it but slightly. The voice i& 
|3bo modified more or less by the same cause, and mav be entirely lost. 

Dyspntea is sometimes dependent upon narrowing of the tniobc*^ 
or of the bronchi from pressure of the aneurism. In such innil.'incce^ 
the paroxysms are probably ilne to a collection of mucui* which the 
patient may be unable to expectorate at the point of stricture. 

Paljntafion of the heart is generally produced by slight exertion: it 
may he due lo irritation of the sympathetic nerve ur piinilysis of the 
Trtgus from pressure. 

Dtf»phfigia, due to pressure npon the cesophagus. is often present, 
though it is a less frequent symptom nith imeurisnial than with other 

HMdache, due to interference with the return of blood to ihe heart. 
if! not uncommon. 

Dimrdered vinion is due to pressure upon the sympathetic nerve, 
and <-onsequent interference with the action of the iris. Ordinarily the 
pupil upon the afTe<'ted side is strungly contmcted, but in mre iDatanoM* 
from complete juinilysis of its sympathetic nerve, it may be dilated. 


ifmaopiyitis, to a eliglit ilegree, lit sin occatiional fivoiptom due to con- 
gestion of the niucoua niembmne. Copiouii liiemoptms frequently oc> 
cars at the close of the disease, when the Aneuriem nipturen Into the air 

The essential signs are: n pulsating tumor in the region of the norta. 
with systolic and diastolic shock and sometimes bruits. 

L'pon inspection, we often obaerre marked lividity of the face, neck, 
and upper extremities; with turgesceuce and a varicoso condition of the 
reins, and perliaps a-dema, due to obstruction in the return of Moud to 
the heart from pressure of the aneuriitni upon one of the renie innum- 
iiiattf or the descending vena cava. Occasionally a thick fleshy collar is 
fmud about the base of the neck, due to capillary turgcscencc. 

(Edeuia and turgesccnce are ordinarily limited to one side, and are 
ciiuat'd by pressure on one of the veuns innominatte. If the pressure is 
upon llie descending vena c:ivu, which la must likely to occur with an 
niiourism of the ascending arch, these signs will be found upon botii 

The snrfacd of the chest is seen to have a murble<l appearance, canscd 
hv* the prominence and blueness of the veins. 

A tumor may u«nally be olnierved in the course of the aorta, the 
position of which will indicate the part of the blood-vesael affected. 

When an aneurism originates in the sinuses of N'alsalva it caases no 
e eternal tumor. AVlien in the a»ceiiding [wrtion of the aorta, if bulging 
occurs, it will be seen in the second intercostal siwce at the right side of 
tbe sternum; but if large, it may ext«nd far into the infraclavicular 
>dgion, and even to the nmmmary. 

Aneurism of the transvcrac jiortion of the arch causes a tumor at the 
tipper part of the stcnium. 

When the ilcMjcnding arch is involved the tumor generally preeenta 
posteriorly at the left of the spinal column. 

Brwittional, — In exceptional case*, aa ftneurism of the descentlinK arch of 
the aorbi may bu fleen in front, and tn very rare iastaiicefi it may be found at 
the right nf th>; ft|>in:il cohiiun. 

Aneurisms of the descending aorta present {wsterlorly below the 
fourth dorsal vertebra at the left of the spiue. V«ry rarely they are 
aeen at the ri|.'lit of th*? a])inal column. 

These tumors vary iu size from a slight prominence to one as largo 
as a child^s bead. The alisence of a tumor does not necessarily prove 
that no aneurism exists; for, while the aneurism is sniall, it may not 
press upitn the chpi«t walls, and even when of considerable size the posi- 
tion may l»e such that no bulging ia occasioned. The larger of these 
tumors are ironenillv cnincal in form, and prei^ent very much the appear- 
ance of an immense Iwil, covered by thin glazed integument. 



If pulsation of the tumor be observed, it will occur rhythmically with 
the upox beat of the heart, rulaation, which cauuot otherwise be scoQj 
juay sometimes be detected by briugiiig the eye to the level of the sur- 
face of tliQ chest, us in stuiiditig behind the puticnt and looking down 
over hiK shoulders. No pulMitiun will be visible if the uneurismal sac la 
ocL-upied by fibrin or cougulattd blood. 

If the tumor press on une of the main bronchi the respiratory move- 
ments ou the corresponding side will be dluiiiiished or absent. 

By palpation we may frequently detect a tumor, the impulse of which 
cannot be seen; we can iiscertaiu the condition of the chest walla, 
whether there bo perfomlJou of the costal eartiluges, sternum, or ribs;, 
and may usually determine whether the contents of the tumor are fluid 
or Bolid. The character of the pulsation is expansile, that is, alike in 
every direction, and not simply lifting us is the case when a solid tumor 
rests upon an artery. 

Thf moBt valuable sign obtained by tliis method is the detection of 
two pulsating points, us though there were two licaits, one beating in 
the normal position iu the 6fth interspace, and the other above the third 

ir the aneurism is BO ■mull OR lopKcap« observation by onlinuiT pulpalion it 
may saiiii!liiaes be detected by piVMin^ firmly with oiiu hand ovtrr \\w aorta id 
frout, and with tin; otber imslvriorly. 

The impulse obtained over an aneurism may bo systolic, occurring 
with the contniction of the ventricles; or it may be both systolic and 
diastolic. The hitter, produced by contnit'tion of the artery, is usually 
slight, but occasioniilly quite forcible. When found, it is a valuublesign. 

Frequently these tumors give rise to a peculiar thrill, similar to the 
purring tremor; sometimes very early in the course of an aneurism of 
the transverse arch, an impulse or a thrill may be felt by pressing the 
finger downward behind the suprastenfal notch. 

Valuable information may be obtained in some cases from the pulse, 
or from sphygmo^raphic tracings (Fig. 42). If the aneurism press 
upon the arteria innominatn, or upon either of the subclavian 
arteries, or if either of these vessels is obstructed by a congnlnm. tho 
radial pulse M*ill be feebler u]mn the corresponding side. The carotids 
are sometimes similarly uflected. If atheromatous degeneration of the 
arteries be general, the superficial arteries, cspeciidly the radial and tem- 
poral, will be found rigid and non-elastic. 

Alterations in the movements of the chest walls and in the voca] 
fremitus are also to bo sought by jwlpation. Pressure on the air pas- 
sages will diminish the respiratory movements, and i^ause local or gen- 
eral diminution or absence of the vocal fremitus, according as a bronchus 
or the trachea is obstrncted or the lung itself compressed. 

Percu8«iou must be performed gently, especially over large aneurisms, 
as a forcible stroke might poeaibly rupture the weakene<} blood-vessoL 



TTpon gentle percuHsIoii, the extent of diilneHs will not correepond tu tlie 
size of the tumor, beuiuse af tbe overliipping borders of the lungs; but 
by a more fnrnihlo stroke^ or bj nuscultatory percuaaion, vo may deter- 
mine the limits ncc^nmtety. 

The area of abnormnl duliiess is usually much smaller than in other 
tumors, cuuKiiig syniptoms of equal gravity. 

The Beiine of rftRi(<tJince felt upon percnsslon i« a valuable sign in dis- 
tingitishing between aneurisms and other inlrathonicic tumors. Over 
n tumor fillfnl with fluid, the resistance '\<i much lees than over a solid 
growth or overnn aneurism filled with fibrinous deposits. 

If tho aneurism present posteriorly, dulnoss will be obtained in Ibo 
interscapniar region. If it press upon a main bronchus, or upon one 
luug, causing I'uUupfie or congestion of this organ, dulness will be found, 
over the corresponding side. 

In auBCulUittuu, upon listening over an aneurism, we first notice an 
impulse or shock with each contraction of the heart. This is frequently 
followed immediately by a second or diastolic shock, due to contRiction 
of the arteries. The impulse is usually attended by one or two sounds 
which consist mninly of the transmitted heart sounds, bnt are in part 
proiluced by dilatation and eontmction of the artery. 

These sounds may bo associated with or supplanted by murmurs 
somowhiU similar in character to endocardial oiurniurB, However, they 
are ordinarily less intense, though they may be ecen louder than the 
loudest heart murmurs. They are usually harsh in quiility, and are not 
tninsmitted into the same regions as endocardial murmurs. Sometimes 
neither soun<U nor murmurs can be detectetl over tho uneurisni. 

If the tumor press upon a main hronehus, the respinitorj' murmur 
will be diminished or absent upon the corresponding side, while on the 
other it will be exaggerated. In these instances a forced inspiration 
will sometimes distend tho lung, and bring out the respiratory raunnur 
where it could not be heanl during ordinary breathing. Vocal resonance 
will be diminished or absent over tho obstructed lung, and absent over 
tbe aneurism. If the lung be condensed by pressure, broncho- vesicular 
respiration may be hcai*d. 

If the tumor press upon tho recurrent laryngeal nerve, so as to cause 
jNiralyais or spasm of tiie vocal cords, there will be stridulous respiration, 
with dysphonia or aphonia, and inspection of the larynx will usually reveal 
the existence of paralysis of the curd on the corre»]>onding side, with 
possible ]vareei8 of the other. Occasionally the pre^^ure is upon both 
nerves, with consequent paralysis of both vocal cords. 

Ferdinand Schuell {Munchentr mediciniscke Wocfietisclmjt, April, 
1890) claims a new means for diagnosis of doep-scated thoracic aueu- 
risms in tho aneurismatoscope. Tliia consists of a soft rubber tube 
doaod at tho lower end and filled with colored fluid, a piece of glaaa 
tabing boing inserted into the upper end. WlioQ this apparatus is 


lUirtl.V liniorto<I into the a«ophtgii», it » mJ At the pi l w ri a ot of .a 
uhoiinmii "f tliu dMCouiIing »fch «re aoasniiicalal to the tube cm] am 
iii*lii'HtiMl ill till) rUe anil fall of the Sud. 

DiAHNiiNin.— Aneariflui of ib« thcnoe aorta m* be ooafeuaded 
Willi wild tumaw; with aortic pokitMa, dae lo ngargitation tfarongh 
tlioM'iniliiimr vuIvm; with paUning emprema; with dilauttoa of the 
mirirlo; mi'l with ronwii'Jation of the anterior border of tbe long, with 
iii)Puri«ii) of the pulmunary art«TT, and with anenriaBi of the arteria in- 

inniiliiiiU». ,. , ^ , .. I 

V,.noiu lurgoMonce. duptacenieiit of the heart, dolnen on fwrcns- 

ilou, wnil DKMllfiufltioiw of the resptratorr soands, doe to pr e -u re, are 

iltflii common to tbt*e and to other rarieties of intrathoracic tnmora. 

Variniio" in tho force and Tolume of the pulae on the two sides, expan- 

illi> imlnBti'm of the tomor, with a sbock and bniit, are uulljr charac- 

tj.riali'' "f unonriumB, but occaeionally even theae ogna may be caused by 

lolid xrowthi. A diaatolic bmit and shock orer an intrathoracic totuor^ 

(ioioni|ii"iio<l by a clear second soond at the base of the heart, ifidiaguoa- 

tic '»r wiif'ljriiirn, e^jHrcially if following a disiinct systolic brait and shock. 

A nmmiur at th« ba*e of the heart, taking the place of the second 

iound, when imociated with the signs of a tamor in the courK of the 

aorta, i« raluablo evidence of probable atfaeromatons degeneration of 

thtt aorta, iind the formation of an anenrism. 

Tlifl dilfcreutial fearnrtrs between aortic and pnloioDary aneurisnu 
U>d other diseaaes are pointed oat below. 

Aneurisms may be distingnished from other intmtborftcic tumors b|L 
ftttvntion to the hiiitory and symptoms as well as to the physical signs. 

The distinctire features between aneurism of the aorta and aoli 
tumors are aa follows; 

AaroBUU cr thx aobta. 

Solid tumobs. 


Seldom or n^vi^r occurring' before the 
iw*nty>nftli year of age. aad usually 
not UDtil after the forty>flfth year. 
Slight, If any, constltutioiuil disturb- 

Ufuially maJignant. They may ot^ 
cur in early tUe, and not iafrequeoUr 
before the twenty-fifth year. Om>« 
constitational disturbance. 


Piilnixin«taot.and of a burning, wear* 
fng, or iii.'tii(ig character and usually 
agKruvaiRil hycxercDw; frwiuently »ub- 
jfvl Ui nviinili^c exBccrtmtiuns. The 
wvmpiomB and Bigns of prewiure vary 
irorii itriie lo tjnuj, owiuKtuchaugesin 
J^ djrectioQ of tJie prcMure. 

Pain not so deep-seated as fo anei- 
mm; may t>e sharp and laocinaiing' 
iactiaructer; not alTccted by ejcerciae- 
DOtsulij«^-t 14> neuralgic exacerbations. 
The symptomti and sigus of pressure 
are conHtaiit, and su.*sdily iacreaae 
from day to day. 



ENBtntisM or Tas aorta. 

Solid TtmoBS. 


Ex|wnBiIf puli^utioQ, Often diitpar- 
iXy bt-lwuvu Uiu iitdiulputsuM o[ lli« two 
sides. Tlie urea uf diilaesi «mall in 
proftoition to thessizeof thetunioraDil 
Hie lenKtli or its history. Sensti of re- 
sulunce sli^bt. 

Nu piiUulion. cr if any, simply a 
aligttt lifting impiil)^, i.-au»Hf(l by the 
tumor resting' upon u large jirtery. 
Usually DodiftpELrity in the pul!u> of Iha 
two lilies. 

Arva of dulness large, and nH>idly 
increases. Sense of resitttaDce well 

lowing symptoms and eigna: 


upon the No symptoms of pre«&u re. 

Symptoms of pressure 
traclieu, oe-supliag'UH, or recurreat la- 
ryngeal nerve. 

Pulsation In a limited spacA over the 
ftrch of the aorta. 

Radial pulse not exaggerated oo 
eith^^rsidebyelevationof arm; usually 
feelilt; uii one Bide. 

Ini-reafced area of aortic dulness. 

Artt^rial bruits, syKtoIic or diastolic, 
generally distinct from endocardial 

Pulsation not only over the aoria, 
but Jn the carotids, subolavinns. and 

Piilfto sharp and apparently forcible; 
hammer pulse exa^'g<*nii<Ml Ity elev»- 
tion of Uiu arm. and alike uii both sides. 

No increase in the ui'v-u fif <liilntffts. 

Aortic regurgiLuot luui'mur, but no 
special bruit over the pultating vessel. 

Aneurism maj be simulated by jruhating empyema^ but ordinaril/ 
it can be easily distinguished by its position. If, however, perforatioi 
of the chest walls should take place in the course of the aorta, as in i 
<!aso recorded by Flint, the diagnosis would be much more difficult. 



Sffmptoms and Sign». 

,^vnptoms and signs of pressure up- 
«tt adjacent organs. 

THilnesB condned to tlie region of the 

Arterial bruits. No pulmonary 

nigtiR. uoleia there he pressure upon 
the tiuchva, broDcbus, or luog itseif. 
£:(panRi]e pitlKalion of tlie tumor. 

Usually no symptomH uf pressU'O 
upon the tracheu, ti-sopliugtiH, and 
other adjacent organs. 

Dulnefls or fiatnew* over llie pul»t- 
Ing tumor, and also over the lower part 
of one siae. 

No bi-uit. Signs due to compression 
of tlie lung by uuid in the pleural saa 
Pulsation Komewnat similar to that of 
aneurisms, Init usually lei^s expnnKile* 

of ibm aortm it dntingBidicd fnm m 4Qmiai rnmridU 

AvnTBaH or TmC JtOVTA. 


fl||Ba ■■# ■fi|i<oiiii dne to |ii imiiii F*w, if aar, tifgm^ aad 

^OH mi ^ KO^ wA ccgiBk PolMtkia fol< o( pncaune, P^lMtinn preceding 
iMV^tbMiTMaleaf tfaftvcmridMaiMt apex beat. 
Ik ^n bat. 

OhIobh ia Uac i«swm of Um aonm. DuImcm wtfcfibatf ^r beyoad 

A r l mr ml brats v omt mm , bat propa- trgion of Ibe aoHa. aod wwlly at a. 
fBtad aMMtl; oirer tlM aAenea, lower feircl ; osnallj eadooanlial inur- 

muri [MTprgi'H ia direcciDaadiffi^raiL 
from tboae of the aacatisiiial bnuL 

Anetirum of tbe aorta u (1iffereotut«d from commliiiHtinn of the 
lung by tbe pocition of tbe dnloew and br tbe aigiu npon »iiacnlu- 
tion. If cbe ooiuolidation U doe to an anecriam, care mast be tftken 
not to oTerlook tbe sigziB of the latter. 

AxKraxaH or the aosta. 

OovsouDAnox or taa ldirl 


Dulaeai limited lo the ooaxaa of the 


A Bonnal rMpiratory murmur maj 
often be beard ovcrtlie greater portion 
o< Um aoeurlsm. Arterial bniit». 

Dniaem act Umitad lo tbe 
rqgioD. but extending cxtemallj, and 
nsuall J invol vio^ tbe whole apex of tba 

KAlee and other sigm of cofuolida. 
liDU. No bruits exDr|>t(atf poeaibly a 
NV^totic&ubrlavian murmur. 

Anenrism of the Pulmonary Arhry. — .Aneurism of tbe palmoi 
artery 10 unc of the ntrest affectionti of the circulatory system. Froi 
the few oaaca which bare been deKfibed, we are nnable to oblaiu an] 
chartcteristic symptoms or signs. The principal indications which biive 
bcL'u noticed are: extreme cyanosis, with dropsy and great dyspnu^ 
associated with a strongly pnlsating tumor, located in the second inter- 
roiftal Kpace of the left side, and limited to this region. This tumor is 
likely to yield a thrill npon palpation. Upon auscultation, systolic or 
diastolic murmurs, or both, may be iletected, but they are not propafittted 
altuve the clavicles. It is hardly possible to distinguish aneurism of the 
pulmonary urtery from one of the aorta, which happens to prt-seut to the 
left of thu Bteruum. 

Tbe position of a pulmonary aneurism ia different from that of most 
aneurisms of the aorta. An aneurism of the ascending portion of tbe 
aorta might possibly present to the left of the sternum, though in this 
locality we are more likely to observe aneurism of the descending aorta. 
Th« distinctire features between aortic aneurisms and those of the put- 



monury artery may be stated, from the symptoms and eigua which hare 
been observed up to the preseut time, ati follows: 


An4*urtsni or tlie usceudini; atrh pre- 
aeiiU to tlie right ot tlio Kt*-Tiiiiii). and 
tfaoM of the deaceuditig arch usually 
present behind at the left ot the third 
dursul vert^bi-u, uuil v«pj' rarely in 

8ig:ns and symptoms due to pressiira 
upon the truchea, bronchial tubes, 
osaophaguB, bluod-veMeU. or recurrent 
lurj-n^real nervt*, coninioii. 

Bnuta, which may be propagated m- 
to the carotids and suUclavians. 

ANEraiSM OF Tm ptuiokart artert. 

The tumor ik confined to the second 
intercoettU space of the left side. 

The Blgaa of pressure are company 
lively slight, but usually tJien* i« rt>o. 
gestioQ or thefuoe.anniuirca, and great 

Bruits, Dot propapited above the 

Aneurism of ihe ArUria InnominiUa. — Aueurisma of the arteria 
innoDiinata eauac pnlaatiug tumora similar to those of the aorta. 

An aneurism of tlie arteria iuuomiData may be distinguisheil from 
an aoeuriam of the arch of the uorta — first, by its position; second, by 
the comparative absence of signs duo to pressure; aud third, by the 
effect ou the pulsation of couipressiou of the subclavian and carotid arte- 
ries. Such an aneurism is located entirely upon the right side of the 
flteninm, and causes a prominence in the region of the inner end of the 
clavicle. It is not likely to cause much pressure upon the recurrent 
laryngeal nerve with consequent obstruction of the larynx; or on the 
cesopbagu^, so as to interfere with deglutition; or upon the trachea so as 
to cause dvBpnora. Compression of the carotid or subclavian artery on 
the affected side greatly diminishes the pulsation in an aneurism of 
tlie innominate artery, but doei^ not affect the pulsation of an aneurism 
iuTolving the arch of the aorta alone. 

PitooNOsis. — The average duration of thoracic aneurism U two years 
aud a half (Loomia, Tracticul Medicine). Kecovery rarely occurs In 
some cases the aftortton seems to remain stationary for many months. 
Death may occur suddenly at any time; the prognosis as to diinition 
is tlierefore extremely uncertain. It depends somewhat upon the posi- 
tion of the aneurism^ the strucinres pressed upon, and the occupation, 
temperament, habits, and general health of the individual. Death 
nauolly occurs from niptnre of the sac, but may be due to asphyxia, 
pDeumonia, gangrene, or cerebral embolism. 

Tbeatmest. — A mixture composed of equal parts of tincture of 
belladonna and chloroform liniment has been recommended for relief 
of pain, hut when this is acute opiates will generally be required for 
temporary relief. The persistent boring pjiin will ui^nally be grcjitly or 
oompleteiy relieved after a day or two by potassium iodide given ia 
doses of gr. x. to xx., three or four times a day. These methods of 


treatment hare been sucee8£fallj employed in a fev cases for the relief 
or the cure of aneurisms. 

TufncU's method, which in sereral cases has succeeded in at least 
greatly relieving the patient, is a modification of Yalsalra's starvation 
plan. It consists of perfect rest in the recumbent position with mod- 
erate diet. 

Ciuiselli's methml of galrano puncture first proposed in 1846 has 
been successfully employed in a few coses and may be tried if the fore- 
going methods fail. It is especially applicable in sacculated aneurisms 
near to the surface. Before making the puncture the patient may be 
given a full dose of morphine, or a small amount of cocaine may be in- 
jected at the points when the needles are to be inserted. From fifteen 
to thirty small cells should be used, and insulated needles connected 
with both poles should be thrust vertically into the aneurism an inch or 
two iipftrt. Electrolysis should be continued fifteen or twenty minutes 
and may be -repeated after a week if necessary. Great care should be 
used in withdrawing the needles to avoid loosening the clot. 

During and after the operation, the patient should be kept qniet in 
the recumbent position. 

Another method consists of the use of large doses of potassinm 
iodide. This treatment usually soon relieves the severe neuralgic pains, 
and possesses the advantage of allowing the patient to move abont, though 
it is more effective if the patient can be kept continaoualy in a recnm- 
bent iKwition. The remedy should be given in doses of ten to thirty 
grains three times a day. The larger dose is much the best. Cory:a 
may be relieved by moderate doses of nnx vomica. If the stomach be- 
comes irritable, the medicine should be suspended for a few days. 
Sometimes patients will bear large doses who cannot tolerate small ones 

When an aneurism causes dyspntpa through spasm or paralysis of tie 
vocal cords, tracheotomy may be necessary; but this operation can co 
no good when the difficulty of breathing results from pressure on tbe 


Syiwnynu — Stenosis of the aorta. 

Coarctation of the aorta is one of the very rare affections of the ci"- 
culatory system. The constriction may be ring-like, as though a coid 
had been tied about the artery; it may consist of a cicatricial band, par- 
tially obstructing the calibre of the blood-vessel: or it maybedue toirrejr- 
nlar contraction of the artery, the result of inflammation. The nar- 
rowing of the vessel may be slight, or the aorta may have dwindled to 
an impervious cord. In a few instances the constriction has been found 
to be general, involving both the arch and the descending aorta. In 
«nch cases usually no symptoms have been observed until about the age 



of puberty, when deficient development of the lover extremities, and es- 
pecially of the sexual organs, has been the first indication of the condi- 

Inspection reveals ingns of hypertrophy and more or less dilatation 
of the heart; usually, dilatation of thenrt'li of the aurta,«f thesnbelatinn 
arteries, and of tlio carotids; a dilated and tortuous condition of the 
superficial arteries, which in the normal state are not visible. This con- 
dition of the superficial arteries is attended by marked pulsntiuii, and 
somt^times by small nnenrismal enlargements of the intercostal arteries 
Trhich may be sufficient to canse ercfsJon of the rilis. 

A thrill can generally be detected by palpation over the large «rteriea. 
The obstruction of the vessel renders the pulsation feeble in the branchee 
of the abdominal aorta, and causes feebleness or absence of the pulse in 
the tibial and popliteal arteries. Percussion gives no signs. On aueonl- 
tation, u harsh, high-pitched, and usually intense systolic or postsystiiHc 
murmur will bu heard over the aorta and larger blood-vesseh. This is 
usually most intense close to the edge of the sternum in the second in- 
tercostal space npon the right side. This murmur is propagated throngh 
the carotids and subclavians toward the shoulder, and may also be heard 
posteriorly over the course of the aorta. 

The occurrence of such a murmur will lead us to suspect the exist- 
ence of an aneurism; but the latter may be excluded by absence of the 
symptoms and signs due to pressure, and by the want of an increased 
area of dulness on percussion. 

DiA(iNosi8. — The diagnosis of coarctation of the aorta rests mainly 
upon the cnhirged and tortuous condition of the superficial arteries 'a 
the upper portion of the body, and the feeble pulsation in the lower C'l- 
tremitiefi, associated with an aortic systolic mnrmur. 

TreaTHEKT. — No treatment can be reeonuueuded. 


Excluding aneurisms, tumors within the cheet are nearly always m-** 
lignant in character, and are therefore attended with grave constitutionO 
aymptouiB; some arc of syphilitic and others of tubercular origin. 

Stjiitohatologt. — A growth usually cttuscs pain of a persistent 
character, sometimes lancinating, but not subject to the neuralgic par- 
oxysms which attend an aneuriitni. 

The principal «tgns are : turgescence of the Teins, cedema, dyspncea, 
dysphagia, and other evidences of pressure on surronnding organs, with 
dalnefls and loss of respiratory murmurs over the growth. 

By inspection we commonly find persistent turgescence of the veins, 
and cfidema of the neck and upper extremities in a more marked de- 
gree than from an anenrism. A tumor is nearly always i:ccon'pj:nied 
by- enlargement of the lymphatic glands in the neck rnd axillary ro- 



gions. The contlition of these glands is an important point in the 
differential diagtiiMis; for, if it ia due to malignant disease, they will 
be adherent to tbe surrounding tissaes, but, if the conditione ure not 
of malignant origin, tliey may nauully be moved freely beneath the in- 
tegument. The symptoms and signs caused by pressure on the sur- 
rounding organs are persistent, and they gradually inurcasc in severitv. 
A malignuul tumor is not usually coutiued to the course of the aorta, 
but is apt to extend u considerable distance beyond the borders of the 
stornum. A solid tumor docs not ordinarily pulsiite, and, when it dues, 
the pulsation is not ex|Hmsi1e, but is simpTy lifting. This impuliie is 
caused by the pulsation of a large artery upon wbitdi the tumor rests. 

On percussion, the sense of resistance is marked, and the area of duU. 
ness is usually much larger than over an aneurism, because the malig« 
nant disease gradually involves the adjacent lungs, instead of crowding 
thorn before it. 

By auscultation, no bruit can ho heard over a tumor, unless it pi 
Dpon au artery, and then the murmur is distant and comparatively' 

Exeeptional.^Xn those unique casea where a tumor coexists witli a uuiea- 
cent uneiirisni, Eonic iieriiliur )>henomeiia have been observed. The sense of rft> 
SMtance to tliA pt'ru-iisAioii stroke over an aneurism may be great ; whertjas over 
asolid tumor there may be only ftliffht reiiistance, and in the same posilioa w« 
may detect an expansile pulsatiou, which »Uuu]d mituruUy be found over an 

DiAoxosis. — The essential features which enable us to distinguish 
between a solid tumor within the chest and an aneurism were referred 
to in the consideration of aneurisms. 

Prognosis. — Sarcomata and carciuomata of the mediastinum ar© 
commonly fatal within a twelvemonth. Syphilistic growths will often 
Bnbside under jjroper remedies. Eiihirgement of the bronchial glands 
is not infrequently followed by suppuration, and often eventually termi- 
nates fatally. 

Treatment. — No special treatment can be recommended excepting 
that indicated by the constitutional dyscrasia. 

Diseases of the Throat. 



A cossiDERATioN of th© dtseasos of the chest is very properly asBoci- 
•..ed with a study of the upper air pn^sagea, since diseases of the nose, 
t iQcos, pharynx, or hirynx often cause symptoms which simulate tbo«e of 
l>(t)inoiiary affections, lu some instances so slight a difliculty as elougu- 
t'on uf the uvula will cituse the symptonit* nf hiryngitis, or even the pi^r- 
Aitent cough, emaciation, and other syuiptonis of the later stages uf 

For the extimiuatiou of the fauces it is generally necessary to depress 
the tongue. For this purpose n groat variety of tongue depressors hare 

Tto M,— TVrcii** Tosion 

Fin, S0. —BoswuKTS^ Toxaoa 
[lEPBSMoa <?-3 site}. 

been devised which will be found useful, but, if not at baud, a spoon- 
hundle, lead-pencil or the forefinger will answer the purpose. 

For ordinary use, ft spoon -liundlo is perhaps the best, as many pa- 
tients object to an iusirumenC which is usetl promiscuously. Of the 
difforont varieties of tongue depressors, for carrying iu the pocket those 
which are jninti'd ure most convenient (Fig. 51). In office practice, 
■oiue of the Inrger, stronger varieties are preferable (Figs. 50 nnd 53). 
Some patients can so control the base of the tongue us to allow a view of 
the throut without the uid of a depressor, but this is not the rule. A fair 
Tiew may often be obtained in children while they axe crying or cough- 
ing. If the child resists, a spoon-handle or other depressor may bo 



passed well back upon the base of the tongue, so aa to induce retching, 
vkicli vill afford ii good view of the pharynx. 

We should embrace every opportunity for inspecting the healthy 
throat, in order to become familiar with its normal conditions, other- 
vise we are unable to recognize quickly the siguB of diseuse. Upon 
inspectiou of the healthy fauces, we lirst notice the soft palate with 
the pendent uvula, whirh forms the back part of the roof of the 
month. Kunning downward from either side of the soft palate will be 
seen two folds of mucous memtrane, known as the anterior and poste- 
rior pillars of the fauces, between which may be seen a glandular mass, 
tenned the tonsil. Posteriorly we observe the posterior pharyngetil wall, 
Tphich closely covers the bodies of the cervical verlcbrffi. Superiorly, our 
field of Tisiou is obstructed by the palate; iuferiorly, by the base of the 


In order to look beyond the lines of direct vision, we must use mir- 
rors. Inspectioi* of the larynx with ihest; is called laryngoscopy, and _ 
the same method applied to the nasal pansages and nasopharynx is I 
called rhinosnopy. The et^sentialt; for laryngosropy are, a throat mirror 
and a gooil light. The cambination of a throat mirror and a reflector 
for dii'ecting the light is rnllod a laryngoscope. A reflector and smaller 
mirror used in exantiuing the nasopharynx is called a rhinoscope. 

UuTORY. — The cretiit of ha\ing diBcovor^l (lie art of larynKOBoopy is iiNunlty 
givea to Czeriimk, of festli, but many before liisiitiie li;ttJ ••X|wi-inieiit»'<l more or 
levR Bui-oL'ssfiilly in illutiiiiialiiijf llie ]iii-ynx, Buzziiii in thn be^inniiif; of the 
pn-scnlcvntiiiy, Beaiimlti in 1832. and Avery, of London, ta 1844 attempt«d to 
illummate tlie lni-\'nx by-nifans v( iirtiRoiul light conducted Ihruiigh tubes ; but, 
as »howo by Trou-ssetiu and bcili>c-<|, tlieso laittrunients crowded Uie tongue and 
epiglottis bcture them, boos nearly »r quite to c]os« the oriflce of the larynx. 
At most, tlioy ouuld ex|>0!u> only a small ptirtion of its pofiterior wall. 

About a hundi-cd years previous to these efforts, Levret, of Parifi, probabtj 
the first experimpnter in Oils direction, attempted to uee t)ie lurj-nx by meau of 
a email throat nunror, (.imilar to that now in uee. St-nn, of Geneva, in 18S7; 
Babbin;rlon. of Ltmdon, in 1829; Baumpft, of Lyons, in 1838; atul Linton, of Lon- 
don, in 1840, employed similar inRtrumentn with equally nnsatisfocfory result*. 
Wurden, in 1444, made exf)erimentM with a couple of prisms. Allot those in- 
veslitrators failed iiioi-e or less completely, for tiie rcuw>a that they could not se- 
cure suitable ilhuiniiatiun. 

The first to demonstrate the larynx in the living' subject was Si^oor Uanuel 
Oarcia. a teacher of vocal mu»ic >a London. Ho became quite expert in auto- 
laryngoscopy. and also succeeiled in demonstrating the larynx in others. 

Oarcia's uhservation^ \rere communicated to the Royal Society of London ia 
1H&5. They attracted little attention at An^t, for the art was Ihou^ht to Ik* o( oo 
practical value in the dia^no<u<( of di.Hease, because a thni-oiigh inspectioa waa 
Bupposed 1o depend upon a peculiar education of the mufit^lett which would enabla 
the patient to control the poi«ition and niovementa of hiM throat However, 
Oarcia'a writiugs iaduced TQrck, of Vieooa, to experimeot witli similar mlrrotft 



in the htHpitnl dunnf>'theftiimnier^r ld>^7 Altlioiigh TQroku-aK tjiirlyAuccessru] 
in r)iefu> PXpei-imf'ntA, he llnally (lir>'w lusitle his mirrors as tho autumn oatne on, 
bwuii-^ of Uie (htliciiUy in obtainitiK- sunlight. His experiments were not lost, 
for Czeniiuk, o\ Feslh. wlio iiud l>e(>n visiting in Viennu during theKumiiipr. bor- 
rowed tltfniirrursanttcontinuL'illheint'estigatiuns. Ht> uveix^iiiu lliv ililllciillies 
wliidi liiid previiJimty preveoled a. clear view of ihe lurynx, Ijy ciupluyiDK ihe 
reflector anil causing tlie ptitient to protnulo Hie tongue, ititlPitd uf iVprcssiiig 
iU and by substituting arti(K-ial light Tor the ilirr^'t ruys of th(_< s.\in. Soon a 
rivalry sprang up |)€twe«n Czermak and Ttirt-k as to the priority of their claims. 
Their letters, which were publiRhed in the various iiiiHlicut journals, hpieod a 
koowledfre i<f the new art throughout the mediml woiid. 

Thkoat mikkors have been made in various fornix. Some are round, 
others oval or lozenge-sbapc-d, and »tiil otliers <|UJidrilateral. For gen- 

/ / 


i ^. e 

no, en -TnitoAT UiR»>iur<tKt^B*KuoM-oFT. 1. a. Rand)*; 6, BtMn: c. cUrror. S. DUTemt 
lof routiil nilrn'rv. S. n.h,e, Difrnrent T'lrait of throat mlrrort. 

eiml use the round mirrors, varying in diameter from threo-eightha of an 
inch to .an inch and a rjuartcr are preferable. Mirrors should be made 
^-of clear and perfectly white glass. The qnality of the glass may be 
ted by placing a white card liefore the mirror. If the glass is per- 
fectly white, tho reflection will also bo white; if the glass is tinged with 
color, it will give a corresponding shade to the reflected image of the 
card, and would necefi^arlly similarly affect tho laryngeal image. 

The glass and its setting should be thin, in order to economize space 
in the throat. 

Ihe glass should be set firmly in a metallic frame, which mast en- 
as little ntt possible upon the anterior surface of the glass, so that 
19 hirgest ponaible reflecting surface maybe secured. Some of these 
mirrors are backed with amalgam, and others with silver-leaf. Silver- 


THE r/fnoAT. 

leaf renders a mirror more durable, ns it is less affeotefl by heat nnd 
moisture. 1 have used mirrors bncked vith amalgam many times duily 
for several months without xnjurJTig them, thoug)i one mar be ruined in 
u week if healed loo much or kU in the water. The mirror should be* 
firmly attached to a wire stem about four inches in length, at an angle 
of not loss than one hundred and twenty degi-ocs. This stem may bo 
fixed in a t>mall hsindle about three ini'hes h^ng, or the handle may be 
removable, the stem when imscrted btdng held by a set-screw. .Some 
laryngologists recommend a flexible stem, so that the angle of the mirror 
can be easily altered; but it is likely to become bent by contraction of 
the pahttine muscles, when the mirror is in position, in such a mannef 
that the hirynx cannot be seen. • 

An inflexible stem is always preferable, for the obliquity of the mif^ 
Tor can be euaily altered by elevating ur lowering the handle. If the 
beginner attempla to alter the (ibliijuity of the mirror by bt-nding the 
stem, he is likely to break the instrument iu his frequent attempts to 
aecnre an angle which will give a diflFertMit view nf the larynx; iind it is 
better for him to attribute want of success to lack of skill rather I ban to 
a defoct in the mirror. 

Illcmin'ation.— To obtain a perfect illumination of the hirynx. three 
tilings are necessary; first, the eye should bu brought as nearly as pos- 
sible into the centre of the beam of light used in theillumiuution; second, 
the light shouli] be bright, especially if a small throat mirror is used, 
for the smaller the mirror the fewer the mya viiich can be reflected 
from it, ai]d we must make up in intensity what is lost in volume; 
third, the focal point, when convergent rays are used, should fall upon 
the part to be inspected. * 

All forms of illumination which cost convergent rays into the larynx 
cause nbove and below the focid point wliat are known as rircles of dis- 
persion, in which the illumination for a short distance is nearly us bright 
as at the focal ])oint. In examining the larynx, an effort should be 
made to concentrate the rays of light on the vocal cords: the circles of 
dispersion will then give a good illumination for half an inch above or 
below the plane of the glottis. In men, the glottis is about three inches 
below the mirror when it is held in the posterior pari of tlie mouth, and 
in this position the mirror is about three inches from the lips; therefore 
in men the glottis is about six inrhes within the lips, Imt in wonien about 
five inches. As theeyeeannoi Ix* Ijrought nejirer to the mouth than five 
inches, without interfering with the manipulation of the instrument, the 
radiant or focal point must fall eleven inches from the reflector, which 
it wuni on the forehead. 

Being myself hypermetropic, I find it moat convenient to have the 
eye at legist eight inches from the [>:ttient's mouth: and therefore must 
use a, rofleclor which will concentrate the rays of light ut a point four- 
teen inches from itself. 




Persons with presbyopic eyea may obtain a good riew in the same 
manner, deficient accommodation in the eye may be corrected by glasses. 

Myopic eyes of less than oue-teuth will necessitate the ase of concave 
glut-scs; but for eyes, myopic from one-tcntli to one*scvoDtccutb, glosses 
will not bo needed, excepting to view tlic bifurcation of the trachea. 

To exnmino the bifurcation of the tradiea. which is five or six inches 
below the plane of the vocal cords, we must remember that the focal 
point should be at iMSt sixteen or seventeen inches distant from the 

The larynx may be illaminatcd by a simple flame, or a jdune or con- 
cave reflector with or without condensing lenses may be employed to 
reflect the rays of light into the thrmil. lu iUurainutiug the larynx by 
the direct rays of the sun, lenses are not used, and reflectors are not 
absolntely neop^sjirv. When diffiised davlight is employed, reflectors ;ire 
requircil to cum-entrate the rays. Though direct sunlight, or sometimes 
diftuscd daylight, gives a beautiful illumination, artificial light will he 
found in*disi)en8ftble for general use. Xutnral light cnnnot usually be 
secured in the proper position ut the time we wish to use it. 

JIluminatioH with Direct Artijicial Light. — When usingn simple flame 
without a reflector, the lanij) must be placed directly in front of the 
p.itieut's mouth, and shaded toward tlie eye of tlie ubi-erver. This will 
give a good illumination tf the light u very bright, but with tlie ordi- 
iniry lamp or gas-jet it is not satisfactory. This method may be im- 
proved by using n condensing lens with a focal distance of six or seven 
inches. The lens should Iw held between the light and the patient's 
mouth, and about five inches from the latter. The flame should 
be placed at a point which will cause its rays to be brought to a focus 
eleven inches beyond tlic lens at the plane of the glottis. The obser- 
ver's eye must then be brought nejir the edge of the lens, 

JHuminatwn with f}fj\rt'tfd Artifiiia) Lii/fit.—Thc nbore-nnmed ap- 
paratus nmy be supplementcil by« plane perforated reflector, which.placed 
iu front of the observer's eye, reflects into the mouth the rays from the 
condensing lens; or this reflector may be used with the simple flame 
with<mt a roiideiiser. 

In order to fulfil the three essential conditions — that is, to have the 
eye in the centre of the cone of light, to obtain a bright illnminntion. 
and to have the fooni point fall upon the port to be examined — lnr}-ngol- 
ogists generally reeort to a perforated rftnram rtflfi-inr. Such a mirror, 
by collecting many rays otherwise lost, and concentrating them on the 
point to Iw exiimiiiMl, intensifies the illumination, and the perforation 
in its centre brings* the observer's eye into lino with the centre uf the 
cone of light. Slany hiryngtdogists prefer to place the reflector alwve 
the eye, but unless a very bright light ia employed this position will not 
give a good illumination of the larjnx, and if a brilliant light is used It 
is very trying to the eyes. 



The reflectors rary in siz«, in focal diixance. ouid in the material of 
which they are constmcted. Thow nsod in tarrngcwcopy are nsually 
from three to four inches in diunecer, vith « focal diiitjuica ranging 
from fire or £ix to foorteen or sixteen inches. They are made of either 
glan or metal; the former are beet, ai thej do not<:ome dim br tnr- 
niahing. For ordinary u»e, a reflector with u focal dt^tAnce of seven or 
eight inehei will give better satisfaotion than one with a longer focuCf 
ext^ept when panillel r»T8 of light, as those of the san or of diffii.-ei) da^:. 
light are Xm be refletted. The rays coming from any urli6dal light are 
necesBartly dirergent* and consequently cannot be brought to a focui in 
the larynx by a reflector vith a focal distance of eleren inches, which 
would concentrale only parallel rays at the proper poinL 

With the ordinary position of the flame, aiid of the observer's eve, a 
reflector of seTen inches focal distance will throw the radiant point upon 
the glottis. The nidianl point may readily be moved toward and from 
the eye by increasing or lessening the disUince of the flame from the 
reflector, so that reflectors of varying focal distances may be emploved, 
providing the light is siiflicieutly intense. 

On acconnt of its simplicity, the formula TT ~ X "f" jT ^"** *•«» 
genenilly adopted in determining the focal dij^tance of the reflector, or 
the proper position of a flame, which, with a reflector of known focal 
distance, will cause the image of the flame to fall npon the glottis. 
The image of the flame and the radiant point are in this connection 
used as synonymous terms. The focal point is the same as the radiant 
point when parallel rays of light are employed. 

In this formula, F represents the focal distance of the reflector; 
A, the disliuioe of the reflector from the flame; A' the distance of 
the reflected image of the flame (focal or radiant point) from the 
reflector. Knowing the focal distance of the reflector, seven iuchca, 
and the proper distance of the imago of the flame, which, as already 
explained, should fall upon the glottis, and will therefore be eleven 
inobee from the reflector — Bve inches from the observer's eye to the 
patient's mouth, and six inches from the pjitient's lips to his vocal corda 
~-ire can readily ascertain the proper position of the flame by substitute 
ing the known quautities in the fumiula thus: 4 =: — - -^ ■^■^, This, re- 
duced, will give a fraction over nineteen inches as the value of A, which 
will represent the proper distance of the flame from the reflector. 

To And the fo&il distance of the reflector by tirtilicial light, we pro- 
ceed in iL similar manner with the same formula. Placing the light ;it 
a fixed point and the reflector iu front of it, we find the distances from 
the flume to the reflector, and from the reflector to the imago of the 
flame, by direct measurement with an ordinary taptr. These two known 
quantities being then inserted in the formula in the phice of A and A', 
the value of F can readily be obtained. The focal distance of a reflector 



nmy be eaeilv usrertHined with solar light by plneing it in the snnlight, 
tbrowiiig tbe railiaiit point on some object, and meu^uring its distance 
fi-om the C4?ntre of the reflector. The fociil distunco nntv b^ iiiaisurod 
n itli dittiised light h_v reflecting the iniiige of some distant ubjtitt, as a 
window^ ou Bonie jdune surface, and nieaaurlug the dietauce from tUie 
imngo to the refleotor. 

In usiug r^flectorji, it iu essential that the li^ht be so managed that 
the radiant point will fall on the juirl to be ilUiminale I. 

Stndpntt) of Uryngoscopy usually have great tlitllcnlty in obtaining 
a uniform illumination. Sonietimt'a the parts will be brilliantly illumi- 
nated; at other times with the same light and tin* ^:tnie laryngoiicope thft 
larynx ie only seen in a deep shadow. This is gent'mlly due to the im- 
proper position of the light. We must not forget that the larj-nx is 
necessarily fromolcvcn to fourteen inches frt>m the eye, and that, with » 
reflector of sex'ou or eight inches focal distance, if the Hnmc be placed 
too neur the eye, the radiant point will fall a considerable distance be- 
yond the glottis; or if too far from tlie eye. the radiant point will not 
reach the glottis. We should always know the focal distaiK-e of our ro- 
flector,and ascertain by the formula jnst explained the]>roperdigtanceut^ 
which to plac*^ the flanip, n*mi-mhoring that tho distanre of the radiant 
point from the it-Hector will vary inversely its the latter is carried towai-d 
or from the flame. 

Practically, if we have a proper reflector of sctpti to eight inches 
focal distance, it will not be necessary to measure accurately the di-i- 
tancc of the flame. Placing tho light beside the patient, wo may sit in 
front with tlie reflector, ten or eleven inches from the |witient'« mouth; 
carry the liglit forward or Intckwurd until its perfect inverted image 
falls on the piitient's Hps, this will be the projwr position for the light. 
By bringing the reflector about four inches nearer the mouth, the radi- 
ant point falls upon the glottis. 

Various contrivances are employed for holding the reflector. Cxermak 
at first had it fastened to a mouthpiece of orris root, which he held be> 
tween his teeth. Semeleder and others are in favor of a spectacle frame, 
to which the reflector is so fastened that it may rotate in any direction. 
If the pltysician happen to be myopic or hypermetropic, lenses may bo 
fitted in this frame to correct the error in accommodation. Jointed arms 
for holding tho reflector accompany many forms of illuminating nppa- 
ratns. Those are inconvenient for, if the (>atient moves after the arm 
has been adjusted, each movement may require a change in the position 
of the reflector. Kramer's head band, or some modificjition of it, is the 
most common, and, I think, the best dovice for holding the reflector. 
It consists of a head band with a metallic or vulcanite plate in front to 
frhich the reflector is attached by a ball-and-socket joint, which enables 
one to flx it in any position. Most of the head bands are open to two 
objections: first, they cannot be made tight enough to hold the reflector 



firmly without causing Iicudiiche; and second, tbe ball-nntl-socket joint 
is so cuQstructuU ttiut, ufter it becomes a little woni, it is imposaiblo io 
fix ihv reflector lirmlv. Schrotter's licaU Ixiud made of firm non-elastic 
webbing, witli uusal rc^t, obviutcs these ditliculties. 

Pu. M.— ticniunTBH'a Huo Baxd wira N^ut. Ucm. 

Whatever ihe menus employed for holding tho reflector, it must be 
borne in mind that the flnme mnet hare a certain definite relntion to the 
relleclor, depending on llie focal ilistunec of tho latter iind its diciUnt-p 
from the glottis, so that the image cjf the i1:inie will full upon the vocal 



Tta. Si.— KRusxan's Iu.cicoi«Toa. 
a, Lma ; b, rpfletrtor. 

Fio. OA.— XnMrtsa HAomrnK** RACR-JinvEiierr DrLL'*-vn 
CoXDEKm. For g»» or UKaiKlrnwut divtrtc %bL 

In phice of throwing the radiant point on the glottis, some physi. 
cianfl prefer to illuminate the parts to be examined with the bright diao 
of light which may be obtained in the circle of dispersion above or 
below the radiant point. 

SeTcnil instrnments hare been devieed for the purpose of rendering 
the light in thia disc more intense. 



One of the simplest of these is Krishubor's illnmiimtor (Fig. 55). It 
«onsifiU of a reflector and a contex lens, which may bo fustened by tho 
clamp to an ordiuary lamp. 

This rtpfmnitus will often giTC very satiafnctory results. 

Miicki-nzie'ii buUVeyo coiidenflcr ia used for the same pnrjiose. It 

con^JHts of :i ruck-iiioveiueiil gas fixtaro ivith u metallic chimney, which 

^tSKti bo jidiusted to the ordinary gns-hnrner (Fig. 5t!). The chimney h;is 

an orifice on one side for the condensing lens, and the liittcr is p)nr*'d 

At a fixed point in front of tho flame, 30 that the rays of light on leaving 



<--i /^ 

it will be nearly parallol. This illuminator may be brought directly in 
front of the patient's mouth for direct iUuniiniition, but it is geuerally 
used with a reflector of from eleven to fourteen inches focal distance. 

Fraenkers illuminator is somewhat similar in construction as regards 
the condensing lens, but ig so arranged that the rays of light on leaving 
the leoB may be made either divergent, parallel, or convergent, according 
to tho size and focal distance of the reflector which is employed. 

In accordance with my flU|c:ge«tion!t a »imi)ur condenser has been con- 
•trttctefl, which limy bt; used with Iln? orxiinary Around ^niA-buroer or Ohi*. 
man fittHl<!nt*3 latii|i {Fig. T)'). In (his I'OndonM'r the l^ita, whirh hiu a TikmI 
diAtunce of tliree mkI one-lmlf inchi^N. \% set about itvo iuchos Trom thi> (Iiiiiir, 
«o llittt the raj's of light are dtrer^at on leaving it, and are thus adapted 


for » reflector with a focul distance of 9eveQ or eight inciies. If it is desired to 
obtain 4 hrijfht cin-le of di-spersioa for illumination, or to use a reflector with a 
longer fix-aJ di«tanc(>, the cap in which the letu i« Ael can tie dmwn out so thai 
the ray5 will bt> Ir-as diTcrgent. 

Tbt&t.'ondeuser 18 comparatively iaexpensive, and |>ooe8Maall the advantages 
of the last two de»cribed, us wirll a» thuse of Tobold's lUuiuiuator. without lbs 
imperfeclioas of the latter. With tlii^ condenser and Frueukel'a, eitlier the 
radiant (>oint or Ilia vxkW of dt^iperMoa may he u»h1 (or illummatiug the glottis. 

ToboU's iUuminator. a coaibiuaiiou of leuses dei'ised by ToboM, is 
in common use. Weil bus showu tUut the apparatua is improred lir n*- 
znoving one or two of its leitseis. These lenses merely cause a large 
circle of dispersioiif which, though brilliant vben thrown on an external 
object, is, in point of fact, lese intense than the image of the flame, 

Tobold's apparatus has a combination of three lenses, two of whii-h, each 
baving a focal distance of about three mches, are placed closely together, and m> 
near the llame thul they cotltrct divergent rays as Ihey leave the lamp, and con- 
centrate ibem to a focus about six inches iu front of the second leo». The thinl 
len», fartliest from the dame, haa a focal distance of about five incboit. It is 
placed four inches in front of the second lens, about two inches within the point 
at which the rays of lij^ht are concentrated by the latter, so that the rayti of ht^ht 
falling on it are converjjent. The convcrKenl rays, by passing' throug^h the third 
lens, are rendered still more convergent, and are brought to a focus about Uiree 
inchcH in front of tlie apparatu-i, where the in3u^e of the dame is perfect. The 
refit^lor is Uxed about four mchen in front of tlie apparatus, or one inch beyond 
the radiant |H>int of Uie last leas. Here the rayjt, havmg crossed, are so widely 
diverKent. that a reflector of one and a Imlf inches focal distance would be re- 
quired to concenti-ate them upon tl»e glottis. The reflector used has a focal dis- 
tance varying, in difTerenl instrument examined, from live to nine iin.-hes. There- 
fore the ravH mu^t al»o leave tho reflector widely diver^nt, ho lliat most of 
them Will Im> loHt. Hence, we see that the larg« bundle of ra>> collected by the 
first letiH. which mig'ht theu have been entirely utilized, is first subjecied to tha 
XtxfA incident to refraction, and then !ai':ge]y thrown nn'ay. We must admit 
that a (tufficinnt number of rays are still retained to give a good illumination, 
though less intense than when only one lens is employed. 

No advantage can bo derived from such a combination, except where 
cheap lenses of a moderate couvexit; are placed together to secure & 
short focal distance. A single lens of sufficiently high power to ac- 
complish the some result would bo comparatively eipenairc. Tobold 
has also devised a smaller iuslruiuent known us the pocket illuminator, 
tbe construction of which is stmiliir to that of the one just described. 

The imuge of tbe flume may be eu mitgnlficd by n single- lens, »5 found 
in the condensers already mentioned, that it is as large as can possibly 
be reflected from any throat mirror. 

lu using comlensing lenses, any one of three methods may be adopted: 
tlie flame may he placed at the focal point of tbe lens; it iiiuv be placed 
beyond the focal point; it may be placed nearer to tbe lens than its foont 

With tbe flume at the focal point, tbe raye which atwnys leave the 




light in a divergent direction arc refniciod, bo as to loavc the Ions in a 
pamlle) direction, and they must thcu bo managed in tUt' suute manner 
as the parallel niya of sunlight or diffused daylight, lu this instance. 
a reflector of a diameter the «ame la that of tlic lens should he em- 
ployed, baring a focul distance of from eleven to fourteen inches. 
Thia will bring the image uf the flame upon the glottis, providing tho 
eye is from" five to eight inches from the month. 

When the flame is pUced beyond the focal distance of the lens, its 
divergent rays, after paesing through the lens, become convergent. Here 
the reflector may be smaller tliau the lens, but It must have a focal dis- 
tance of more than eleven inches; otherwise the rays will bo brought to 
B focus too soon. 

When the flame is placed nearer the lens than iUt focal distance, the 
rays, after pa^^ing tltroiigh, are still divergent, and. in order that none 
be lost, they must be received on a refle<'tor larger ihitn the lene, which 
niDst have a focal distance of not more than eight inches, the same focal 
{tistanco as that required when a flame is u^ed without a condensing 
lens. This is by far the best methutl for practical purposes, us it gives 
an illumination equally as good as the other methods, and does not ne- 
cessitate the possession of a numher of reflectors. 

Some form of condenser is desirable for office use, but I hare always 
found a simple concave reflector of large size and short focal distance 
snfiicient for ptirposes of diagnosis, and ordinitrily for operatioua within 
the larynx. Such a reflector may be nsed with an ordinary gas-jet or 
with any Ump, and may be sufficient, even if one is obliged to rely on 
caudles. For general use it will certainly bo found more satisfactory 
than a cumbersome illuminating apparatus. 

When performing operatious in tlie larynx, it is desirable to have as 
large a field illurainatcd as (wssible. This may be attained by means of 
the bnll's-eye condenser with the ordinary flame, or with a brighter light 
aud a rvfloctor M'ith a long fucul distance, so that the circle of dispersiuu 
can be utilized in place uf the radiant jioint. 

Several laryngoscopes, illuminated by electric light, have been in- 
Tented, hut they are not usuidlr fo satisfat-tory as the simple reflector 
and Argand burner or fierman student 'k lamp. 

A bright electric light, if properly arranged, would perhaps be the 
beat for Uiryngoscopy. and, next to ii, the oxyhydrogen light. The 
former, however, cannot always be obtained, and the latter, besides 
being difficult to manage, requires a grout deal of apparatus, and is 
consequently expensive. A good Arg:ind gas-burner or a German stu- 
dent's lamp with a bull's-eye condenser is all that is necessary for 
illumination, even during oponitions. I bavci sometimes obtained brill- 
iant illnminntioii even with a common kerosene lamp, having a cir('nl:ir 
wick like that shown in Fig. 55. For purposes of dingnosis, any ordi- 
nary lamp, freshly trimmed, and with a clean chiwuey, wiU generally bo 

•oflLdaiL Aa mggmud far J. Sofia CaiMB;, Kv» «r Ant imiTIh lied 
togvcbcor, >ad plutd m tnai of tW Wvl af s HpuB wed w * tttAcc 
tar, nmf be mtmdt to uuwtr tbe pofp oo if % knp enwot te obCAised. 

t>iJXa*eti ilmTltght, vbcn pnipertr ma^tgei^, pret « baiotifal illami- 
tmtiao of Ijw brjax. Arttfcid U^ Mae or knt diacufari tha im^e, 
mwDg tint DomsJ hrjnx to qtpear xeDsviik or icd, vbenu diffiued 
dftjlight ihovB ihe parts in tbeir nmnl ealan. Unfurti^iucelT the 
hltcr » KMon sofficieiitlT br^lit- Oa b fangbt dar, il li^fat cm b« 
admitted throogfa a aaaU opeotag inta a darkraed rmmd, en &£ to fmU 
opon the reOertor, it vill give a good iUsainatioa. If it is impcMnfale 
to sdmit the light throagfa a saall apertare, a good Tie* but saiDetisiea 
be obutue^t Nj pl^in^ the patient at the fortfaer side of tb« roaair op- 
posite a tingle window left DDCorered, with his back to the Eight. This 
podUofi will giro a moch better view than when the patioit u placed 
near the vindow. 

Direct sunlight may be emj^ored, viih the patient facing the vin- 
dow, in sttch a ixuition that the rar^ foil npon the thruat mirror held 
the phiirrnx. A wrioni hindninre to fhia method is that the light 
not often be obtained in a »aitable position. BeAeeted eunlight 
more fretjoenllj be emplojeU with the avl of a plane reSeetor, or of otti 
with a long focal distance, bat it is onlf in coroparatiTelj rare instmces 
that we have n proper exjKKure auJ finil the $un at the desirvi altitude. 

HeliofTtAts have been construttt-d for reflecting the eunlight in a 
given direction. They may be arranged by a eystem of clockwork to 
mninuiin the beam of hght at a giren point throngbont the day. This 
■pptiratua if very eipeiieive, and not to be recommended. 

An ordinary toilet mirror may be so placed pa to receive a beam of 
lunlighl. nnd dire«-t it horizontally in any desired direction; bat this i 
not often patisfiu-tory for cynscctitivc work. For the reasons natnedr 
are iisnally com]>ellc<l to ose artificial light, 

Loryngnscopy iihnnld bo practise*! with both natural and artificial 
light, to give fumiliarity with the appeomnce of the parts under both 
forma of ilhiniination. The mme Iar>'ux will have different shade* 
when vi<fwe4l by different lights; wliat api>earfi cougeeted when viewed 
by nrtiflcinl light, may seem of normal color by daylight. 

For 11m pur[>u»e of magoifyiog the ima^e of tlio lan'nx, Wertheim recom- 
msnded concave llirunt mirrors, and TQrck Bopge-sted a small tcl(f<icup«. soma 
lnipravemi*nu id whidi were made i\v VuUulini ; but these have all bwn found 
praHK-ally uw'lesH. 

The laryngoscope which I prefer consists of a perforated reflector 
f*)ur inches in diameter (Fig. hS), willi it focal distance of eight inches, 
allachi'd to Schnitter's hetui Ijand. with nasfll rest, by means of a bail- 
nnd-Aooket joint; with three round throat mirrors, three-eighths, seven* 
<^ghth8, and nine-eighths of an inch in diameter re*!pectively, the small- 



est for children, and one ovnl mirror three-fonrtha of an inch in diamo- 
ter, for use in oAseB of onLirgcd lAnsils. As before stated, thoso throat 
mirrors should tio btieke<:3 v.'\i\\ $i)Ter*lcaf und firmly fastened to an in- 
flexibk' stem, which nmy be i»eriMiiueulIy fasteued to the handhr or not, 
ns 18 most conTenient. The reflector need not he mure ihiin ttireo and 
one-half inches in diameter, but tho l.-irger instrument will reflect a 
greiiter nnmber of rnys, and thnH give a somewhat brigliter illumination. 
The fonr-inch reflector possesses the additional advantage, when worn 
before one eye. of shading the other from the light. The only objeetion 
] have found to it iii that the uttnc-hnieuL fur the ba]l*aiid-Bocket joint 
is in some instruments placed too far from the perforation, cuu^iug dilfi- 


Fki. SK— LuvMOtOOFlC lUn.BirToN. kiui AtlAt'ltiiK-fil for holilfu^ Imh tnoorrvct d^^rcan* mc- 
comniudntloii. Tb* ball for tMiU-RiMt'«>H'krt Joint lOioulil >>; (lUivl Aix'unUir 1^ iv^Xtn friini 
ctiaint of rt-flcotor. 

culty in bringing tho perforation grinarely before the eye. This objeo- 
tion eiiould alwnys be remedied by the nianufactarer. 

For an ilUiminating appai-atue, we may use an Argand gas-burner aU 
tached to a rack-moTenient fixture, similar to the one shown (Fig. 5ii), 
or a Germun student's lamp, which may be eiipplcmented by a condenser 
<Fig. 57). 

^f^lni/^uffl/^'ul of tfif Lanfuffim-ofMi. — After familiarizing onrselves 
■with the laryngoscope and the rules for its use, before attempting laryn- 
goscopy on a living subject, it is veil to practise for some limo on % 
dummy, or on a larynx which has been removed from the body and 
attached to a standard. If one of these ctinnot be obtained, wu may 
easily make a model by boring a couple of holea in a block of wooil — 
one about two inches in diameter to represent the month, and tho 
other about an inch iu diameter, intersecting the first at an angle of 
eighty degrees, to represent the larvTJX. By praeiising on it we may 

fumilurizc oarselves with the management of the light, reflector, and 
throat mirror, and may educate our hands to steadiness. 

llaring' learned to control the hands so that the mirror will not 
tremble, and to reflect the niys of light accunitely to the objective |>oint, 
ve may begin to practise u[K>n the living subject. A noric-e at first 
will find it uf great advantage to practise upon a jmtient who has baen 
trained and can undergo the manipulations of an anskilled hnnd with- 
OQt retching; subsequently he should practise upon healthy indirid* 
uals fur some time, in order to become so familiar with the normal 
appearance of the larynx that any deviations from it will l>e at once 

For the most favorable laryngoscopic examination the patient 
ibonid be seated in an erect position with the head thrown slightly 

r»t. BB.— I'MVTtm or Hkao oivmo thk Bbvt Vikw or LAXTur. as aaoms n 


back. The physician shonid be seated in front on the same or on a 
slightly higher level, and as close as pcysaible, with one knee on either 
side of the patient's knees, which are brought together. 

It is often neoessarr to make the exaniination with the patient slig-htly 
propped up in bod. unit tlic ph^'Bucian sittiiiff as best be may beside him ; or with 
the patient fitaiiditigr, as when a library drop-light is used, which cannot btt 
brought low enoiigli to illuminate the throat when the patient is itiltlog. 

The most suitable scat for the patient is a narrow chair, with a 
straight back, sufficiently high to support the head, and a seat not more 
than a foot in depth, wliieh will compel the jMitieiit to sit erect. For 
the physician a small stool, which can be raised or lowered to any de- 
aired level, is most convenient. 



The patient should be seated beside or just in front of the luble 
ffliicli holda the iiistrumeuU, with a cuspidor beside him, and n gltus of 
water close at band. If direct sunlight ta employed, the [Miiieut should 
be placfd near the window, facing the light, which, coming in over the 
physicuiu's shoulders, falls directly upuu the jiharyngeai mirror. With 
reOected suulight, the positions of patient and examiner as regards the 
window are reversed. When artiHoial tight is employed, the examining- 
room should be shaded. Tbo light should be placed on a levid witti the 
eyes of tho patient, and slightly behind him, so that it will not shine 
on his fuce^ and about six inches distant at one side, so that the rays 
may fall without obstruction on the reflector. If the flame is much 
above or below the level of the eyes of the [latient, ur far from his head, 
at one side, the angle at wluch the rays fall upon the reflector will bo 
so grcAt that a good illumination will be inipoeaible. The patient's 





no. <P.— IV wi Tion or Hbad mvnto a Pt>oR Vot or LAiintz, ut mtowv ix rmc BUtx CVF IT 

Tnt LOT fBiiowirE>. 

head should be inclined backward (Fig. 50), so that the edge of the 
npper incisor teeth will be nearly on a horizontal plane with the poste- 
rior margin of the soft palate. 

The reflector may be worn on the forehead, or preferably before one 
eye. If the himp is on the patient's right, the reflector should be placed 
in front of the examiners left eye, or I'lce versa. The throat mirror 
may be held in either hand, the patient's tongue being held by the other 
or by the patient himself. Right-handed persons should educate the 
left hand to tho tusk lis soon as possible; for when other instrnmenta 
are to be used, the right hand will be required for them. £ven in 
diagnostic manipulations ambidextcnty is very desirable, fur by hold- 
ing the mirror flrr>l with one hand and then with the other, uuy false 
impressions of as)'mmetry may be corrected. 



lu making a laryngOBCOpic cxarainntion, everything being in rea^li- 
ne88, the physiciim tukes his i>06ition in front of thu patieuCj and iixcs 
the reflector in its plucc; his eye is now brought within about ten inches 
of the ]mtient'8 lipn, upon which the light is directed. If tht? himp has 
been placed at th© proper dit^tiince, a perfect inverted image of the 
flnmc will be geen nn tlie patieiifa lips; otherwise the light shouh^ be 
moved backward or lorwurd iiutit this result u ubtoiucd. Tlio puLieut 








Via, U.— TBI I^itvmimcorK- HiRflon ix PostnoK 9nat to Oi«« 8io« iCt/mai'ii 

is then directed to protrude his lungut-, which the physioinn grasps mid 
holds between his tluunb and fore-finger, which huve Ihwu previously 
enveloped in a soft napkin. The eye of the examiner is then brougltt 
about four inches nearer, and the light from the reflector is so directotl 
tluit the brightest point falls on the base of the uvula, where it must be 
retainetj. The throat mirror, having been wfirmed for a moment over 
the lamp and its teinf»eraturc tested on the cheek or tuick of the hand, ia 
carried into position in the throat, and, by a slight, ^tendy movement ot 
the mirror, the image of the hirynx is brought into view (Fig. Gl). 



The first (liffionlty which the beginner experiences is to direct the 
light into the month, and th« second U to keep it there. Thtae diflicui- 
ties mny be readily ovt'icomt* by practice, aud sboiilil always be mastered 
ou 11 dummy or some other object before nu attempt is muUe to vMunine 
a patient. 

The pntient should protrude tl)e tongue oa far a^ po^irible by the 
muscles of the tongue itself, and i( niii^t be held gently by the ph^vsioian 
without un attempt to draw it farther out, for such an attempt would 
cause pnin and contraetinn of its muscles. 

A soft cloth is necessary in holding the tongne, not only for neatness, 
but because if it be gnisped simply witli the tingers it will elip uwar. 
In holding the tongue, the 6ngcr which is beneath it shonM be held 
slightly higher than the edge of the lower teetii, or the teeth may be 
oovert'd bv H napkin to avoid injury to the fr^viium. 

Whenever bolli uf iht' phyeirian'H hands art- lu b« occupied with in- 
fftrumcnts. the tongu« may be held liy thp patient; sometimes this is a 
nscful aid in overcoming the iiKliridnal's nervousness. 

Tlie throat mirror employed must correspond to the size of the 
fauces. The one most genemlly useful for adults is Beven-eighths of un 
inch in diameter: but mirrors one and ouc-futirth inches in diameter, 
or even somewhat larger, may often bo employed. The larger the 
mirror, the better the illumination. 

The mirror should be warmed so that the moiBtnro of the breath 
may not condense upon it. When first placed over the flame, a thJn lilm 
will be seen to spread orer Its surface, which disappears as soon as the 
ebss becomes warm. It is then of a proper ton)]>erature for use, bnt 
should always be tested on the cheek or back of the baud. 

Insleiul of warming tiie niirrur, its nu-fure may be covered witli a M>lutian of 
j^lyetTJiie and water l<> |>iw<>nt comleatiatlon of moisture ; this floes not leave 
Ro liaoii a reUectiii}.' surfuce. and. as a ri'itult. the image will be less dniliuct. 
Otiier devices have been &ii(:g't?3teil (or preventing comleosailOD of the breath oQ' 
the niirror. but they are of uo practical viilue. 

The mirror is less irritating to the fancea when warm, and it will re- 
tain the heat as long as it ought to be kept in the throat. It i>boutd he 
held like a penholder between the thumb and tingers, with the baud 
bent slightly backward u])on the wrist. It should be {Missed bonzoutally 
iut^i the moutli, with the reHocting surface downward, and Mirried 
promptly midway between the tongue and the roof of the mouth. Uick 
to the uvuln, which is caught upon it and curried upward and backward, 
until the rim of the mirror almost touches the posterior wall of tha 
pharynx. If the uvula hauga too low to be easily caught on the back 
of the mirror, it may be elevated by causing the patient to take a deep 
inspinition or to phonalc the syltuble a/i ur efi. If the throat will 
tolerate it, the mirror may be rested aguiust the posterior wall of the 


&i Cj- i -a» 

mt.fut ^ fumc ^rrr^-ff^ jj^t^li i i*- /■■■^ ^ Zi 

■;f ^•■j^ri'**- ; ^;_ •► !Uip?- r- _ 

-*>-r *^ .^c j"rr*r-r, tut- arrrr*- xn- »- <£ics!r tmm 
Jr.*— K V aov'Sif h*#- -joati^c TEC" 

V " f .^w a -,^«»«rUit ■•'ni*- Tat- ictt * _ 

vh^?r A h^ iirroE '•• -cesiF ^uoi^E' Tea; :c » -iRtf 

TrH 'bir trrmr x:rrnr Ji yrna«. hk «dL i^ihil kshb it ^es 

■^^j^i" -i^^r */ -ft^ ^^ •€ "tli^ IIKeifc BBC IE "IK i^^XE. ^ W^ ^V 
'-■,^rf»- !■,*■ «;:.-r*i.r «r jil"'^Z!l«»t -grrsa-^ •£ TBS K^TESnm^ 'TW 

-e,'^r-'.^ -T.'x '' il** iiili-.'**. »"r".I rji "'il:. Ill ■•-.w>-^%~\ _, jji. -,, iTTTm'-nii.-:» 

» r^i -,-»--■.;<—*..'.- '■■">. T\^ ".ir"-Tr ill- aj^Jai?- 1 :: ''iiirL vxa. A si.i- 
■f>^ _/-^/ '..^ ::-'<':nf'.f.c I.—- .mi.i:7 >*•: t-jt^ ?• ii.: i ;r m. miua^ jm^ 



The mirror should not be kept in the thro:it more lhnn twenty or 
thirty secoiulii, but Iho exiiDiiimtion umy be coutiiiiied by reinlroduf iiig 
it fiifvcrtLl timet!. 

Whenever the sligliteat nulieiition of retching oacnrs, the mirror 
liimt be instantly witliJmwn, but. after \\ few moments, linother tridi 
Uuiy bo m.ide. which the pjitient will iignnlty tolenito a« well as the first. 

When inserting tlie mirror, its reflecting surface should not touch 
the tonn:tte, nor its back rub against the palate. The former accident 
-clouds the reflecting surface, ^and either is likely to eauae retching or 
An attempt to swallow, which will prerent the examination. 


The obstacles fretpioDtly encountered in laryngoscopy can nsnaHy bo 
overcome by a little Ijiot and patience, at lenst at a second sitting. \Vo 
abould not expect a thorough view of the larynx without introducing 
the mirror two or three times; though, if the patient's throat is not 
sensitive, by rotating the mirror slightly the entire larynx may some- 
times be iuepectcrl with a single introduction ot the mirror. 

The jiriiu'ipal obstacles to be overcome are: an elongated uvula, en- 
Jnrged tonsils, irritjible fauces, a short frwniim. iirebing upward of the 
back of the tongue, and a pendent epiglottis. In two r<ases. one an 
actor, and the other an elocutionist, T have fonnil difficulty in inspecting 
the larynx apparently on account of hypertrophy of the lingual muscles, 
vhich greatly restricted the space between the tongue and the posterior 
vail of the pliarynx. 

Ax ELONGATED UVULA, hanging bolow tho mirror, appears ns though 
curled over the lower edge jind resting upon the reflecting surface. Thla 
is rery confusing and prevents a view of the parts below. 

To obviate this diflU-ulty in ordinary I'ases, it is only neceesary to nse 
a large mirror and to be cjireful in plaring it against the nvnla. Mir* 
rors have been devised with a little pocket in the back for catohing the 
arnla, bnt they are now rarely if ever used. If the uvula is so long that 
it cannot be managed with a large mirror, it may be contracted by as- 
tringents; if theiio are inadequate, tt should be amputated and the ex- 
amination made at a subsequent sitting. 

On account of irritable FArCE-' some patients cannot hear simple 
Inspection of the mouth without gagging or retching; others are so af- 
fected when the tongue is protruded; still others as soon as the throAt 
mirror touches the fauces. 

To overcome these difficulties, the patient should be fnlly impressed 
with the necessity of the examination, and urged to restrain himself 
from retching; the mirror ehnuld then be introduced during a deep 
inspiration or as the patient aays cA or aA, which elevates the uvula, 
and, by thus preventing the necessity for pressure against the palate^ 
secure* Tnuch greater tolerance of the instrument. 


With uervuus patients it is often best^ for the Kake of firat guining 
their coufideiice, to introduce the mirror once or twice so iti jutt to 
touch the palftte, and then wiclidruw it at once without nttcnipting to 
sec thu larvux. Ice may be mucked for tift«en or tveiity uii»uie8. to 
produce some degree of temporary local oufesthesia. If the^e devices 
fail, tlie most feiiaible method for overcoming the disposition lu retching 
is tin application a few times of a small amount of u ten-|M.M'-cent solu- 
tion of cocaine, by spray. 

Many persons, in whom the pharynx is scnsitiro, will tolerate an 
exauiimition at a second or third sitting, in whom bitrdly a glimjiae coulii 
be obtained at the tiret. lu »uch cages it is a good plun to have tlm 
patient educate the throat to bear instruments, by introducing a ^pooii- 
liandle against the uvula before a mirror eevenil limes daily during thiv 

Id cases of n-ntahnity of tbe fauces, some lar>'nirolo?t!ttM ivrommend titilU- 
tJOD of the palnte with a prube or a penholder Uefore atluiupting to introdutv 
til* mirror, m order thut Ihe parts inuy bc-come ucTustoiued to iiiaiiipulAtum. 
, Various other devtceH hitve been reconimeDded fur uvenroitun;; Uit* tteusilivcaiiaa 
u painting llie fuuees with diloroforni uoil luoiphiiii*, laluiliition of a f«w 
rhiffsof cbloroform. and the internal iifte of larg^ dowrs of pulusKiiini bramidif ; 
but none of these meusiims are very salisfactory. Ordinurlly we will sucoeeil 
best simply by |»ativii(:«* and care in introducing and luddiiiLr the luitror. supple- 
mented, when necessary, by the use of ice or (x>cainp. Tbe faii<-eft arv more 
Irritiibin when tbi; btoiiiacb is disordered and dunii>c dii^vHtiun tlnta ut other 
times: then^fore it i^ be«t, whenever tbe throat is )t<*iisilive, to make the oxanii- 
naUou l>eforu eating or not until thre« or four hours-afterward. 

A ttHOKT yRiUKim is one of tbe minor obstacles. If it proves verr 
troublesome, it may be cut with a jmir of bUinl-poiiite<l scissors. OP THE TOSGI'E Gccurs in some patients just us the mir- 
ror is being carried between the t**eth, the posterior part of the tongtip 
arching upward, so as to touch the soft paUite, iiiid tbua preventing tlie 
passage of the mirror into the fauces; or ruuiainiug here to intercept 
the rays of light after the mirror is in position. This ditticulty is best 
overcome by cautioning the patient not to strain and by care nut tn 
draw the tongue far out of the mouth or downward toward the chin. 

Sometimes a good view of the larynx can be obtained in these in- 
stances by holding the throat mirrorncarly horizontally against ihc p;tlalr. 
and rctlecting the light upon it from below upward. In some caseii. trie 
patient, by watching the movements of his tongue in a hand mirror, 
may be able to keep its base depressed. Other patients will need li 
jiructise before a mirror at home for several days before control of tlie 
organ can bo obtained. Tongue depressors seem indicated in ihcsecaso». 
but are of little value. 

Greatly enlarged tonsils may prevent the introduction of anj 
mirror into the throat; in such cs^es the only remedy is excision. Wliea 




thev are only moderately enlarged, it will gnmetimes be impossiMe to 
introduce the ordinary mirror without touching them l>oth, ttnd perhupit 
ciiu«iiijr rptrhinjr; but in many caries, if the mirror is carried promptly 
between iin<l iH-hinil tlie toneiU, the throat will rumaiu quiet, even 
though both sides have l>een touched. In other canes it is l>e«l to use an 
otbI mirror, ,.hioh may be pn*«scfl into tlie fancea without touching the 

A LAROB OR FF.KI>EN'T RPinLOTTlA \s Sometimes an insurnionnlable 
^b«tftcle to laryngoscopy. When the glosso-epiglotlidean li>:anjenl> are 
rekuced, or when the epiglottis is swollen, it falls downward, so that its 

Tree edge mnv roet against the pharyngeal wall, leaving little if any 
«pace for the passage of light. In some of these ai^-ea we can obtain a 
view of the larynx by causing the pjitient to sound the letter in a 
high key or to utter a high falsetto note. A vocal sound, as alt ur 
sh made during inHpiritiun, will liave ti !<iiiiilar effet:^t. Hy a laugh 
or a cough the epigluMis may be thrown upward with :i sudden- jerk. In 
other instances it is only necessary for the patient to drawn a deep 
breath in order to raise the epiglottis siitticiently to give a view beneath 
it Frequently by passing the mirror lower into ilie pharynic. and more 
perpendicuhiriy than usual, the inferior surface of the epiglottis and 
other portions of the larynx may be seen. 

Various instruments have been devisetl 
for lifting the epi;;lottis. The lH*st nf these 
is known as \'uUuliiii's staff, a ^tont whale- 
bone or metallic rod. bent neiirly to » right 
.ingle about an inch from the end. with its 
terminal extremity turned slightly backward. 
It may be passed behind the lip uf the epi- 
glottiij, so as to lift and draw it fcrwui-d. 

Occasionally when operations are to be 
performed, or for simple inspection, s<»nie 
special instnimeiit may be necessary to hold 
the lip of the epiglottis forward. For this 
purpose Brnns' pincette has been recom- 
mended. Instruments of this kind, how- 
«Ter, usually cause too much irritation to be 
tolerated, and asimpte bent staff or strong probe will be found prefernblc. 

It occasionally happens that only the posterior part of the larnix can 
be M«D, and the vocal cords canuot be brought into Tiew. Id such in- 

\ 7J 

Flo M — IxTRA-OLornc Lumr> 

ooacupr Kuiall niH«aK' tulrmr 
In pci>ak>D lu Utr. fromtrft <>f Um 
tnu.-lHwl cantiln 


■tanceB the moTements of the arytenoid cartilages maybe seen snffi* 
oiently to enable us to judge of the mobility of the cords; bat the ap- 
pearance of the tissue covering them is not an accurate indication of the 
condition of the mucous membrane in other portions of the larynx. 


It is sometimes desirable to inspect the larynx from below, which 
may be done, after tracheotomy, through a fenestra in the cannla, by 
the aid of a small metallic mirror (Fig. 63). 

Fia. M.— Rklativx IVjnint>jii» or Lartkx ^m m Iiuot iv trs L^mrKatmoopto MouMm 


Flo. tt.— NouuL Linrxx in Rnrnunon. kvuuhisd. Pan* nacg«nit«)] lo Ptmder them mnre 
eooiliicuoua. 1,1. UnRUftlMirtAoeof eplglotUa:2.9,lUT»sulMn1kc*Qf cp(ftloUi«: SJiMteiilRdcrrM 
flf c|4gloui» ; 4. 4. |iliarTafo«pigloUlc fofals: t>. &. •rr-eplKlBtttc fulda; 0^ outhiun of rplclurnH : 7, 
gli»ii>eplgln«tic UguHMtt ; ft, 8. mloptilK' : 9, V, pytiffrnti mduw^ : 10. V), foKtrrtar ptiaryvf^al wait 
•0«lfDimK«lntocBBO|)tu^s: 1 1. InlM'-U'rieooii] lovtsurv ; 12. 1i£,canilagc«cirSttntnnni : I3,iitt«r- 
knrt«on44l loM : 14. 14. cartllwi^ of Vi'tiftb«n-K : IB. )&■ rentrkulAr baa^bi : 10. 10. tocbI corda : 17. IT, 
nntriclM: if*. 18. postertor vocal proc«MM : lf>,thjrroM eartflo^t: a)Lcri«o-tfarn>tdfiiembnu)« i SI, 
crimlil cM-tilnffs ; a, SS, Xf, rlufc* of tnchek ; Za, Sl^ S3, S8. Intcrqwow b«t<reeii rtags ot tnu4m 

below close to the lower edge of the mirror. The sides of Uib larynx 
are not reverscil in the image. 

An ininge of the whole larynx can seldom be obtained at a single 
glance; but by i^light rotation of the mirror, with elevation and depre^- 
sion of the handle, so ag to alter the plane uf ihe reflecting surfnee, the 
different parts may be brought into view. The vocal L-ords, because ot 



their white appearance and frequent respiratoTV movements, natnrally 
attract the most attention, and when onco seen can hardly be forgotten; 
but the epiglottis comes first into view. 

The norual larvnx is «hown in a somewhat exaggerated form 
(Fig. 65) in order that the parts may be more clearly identified. 

TiiE EPIGLOTTIS IS tt leaf-Iikc valve, which covers the upper opening 
of the hiryux and closes it during deghiiition. 

The base of the epiglottis — in reality the apex of the cartilage — 
la connected with the thyroid cartilage at its receding angle by a long 
narrow band, known as the thyro-cpiglottic ligament; a small band, tho 
hyo-epiglotlic ligament, connects it with the posterior surface of iho 
hyoid bouu. The free extremity is broad and rounded. Tlie liuguul or 
upper surface of this cartilage usually curves forward, its concavity 
toward the base uf the tongue. Its covering of mucous nieinbrune fornin 
a median and two hiterul folds, known as the glosso-eplgloltic folds. 
The central one of these is also called the frsnum of the epiglottis, of 
the glosso-epiglottic ligament as it contains a ligamentous band. The 
lateral folds contain no tlbrons tissue tiud are frequently iibsent. The 
laryngeal or inferior surface curves in a reverse direction. It is convex 
from above downward, and concave from side to side. To its sides are 
attached the pharyngo-epiglottic and the iiry-epiglottic folds. 

It varies greatly in size and furtn in different iudividnuls (Figs. ^6 to 
71). It may be long and thin, ur short and thick; it may tie broad, or 
narrow and pointed; its free edge may be curved like a bow, it may be 
folded in upon itself like a scroll in what is known as tlio jews-hurp 
form (Fig. 70), or it may be asymmotrieal. It may cover the whola 
larynx, or it may be nearly invisible. Sometimes only the upper or ou- 
lerior surface of the epiglottis can be seen, at other times its lower por- 
tion or laryngeal surface is most visible; again, only its tip is brought 
into view; and still agiiin considerable [lortions of both the anterior and 
llie posterion surfaces nuty be seen at tlie same time. 

With respiration, the lip of the epiglottis rises and falls slightly. 
With phonation it is generally thrown upward, and in deglutition it ia 
carried downward to the posterior border of the larynx. 

The whole epigiottis is seldoii* vi«iblu even to a skilful laryngologist. 
Usually a portion of its upper surface is visible on each side. In the 
middle, its laryngeal surface is turned upward like a lip. and below this 
a small prominence may frequently bo seen near the base of the epiglot- 
tis, known as its eushioi}, j)ad. or protuberance (Fig. fiK), 

The color of this organ varies in different piirts. The upper surface 
is of a pinkish hue, and frequently blood-vessels may be seen crossing 
it. The lip looks like a yellow cariiluj^e. as it really is, covered with 
mucous membrane. The cushion generally uppeurs of a much brighter 
red color than other portions of the epiglottis. When the whole of the 
laryngeal surface can be seen, it often has a uniform bright-red color. 


Ttam. U to T).— KuRMAL I.XKV}fX, 
WHD Vkmrnjuaw*- 


Flo. f7.--L^rpt>-o or Arvtbnoid Cahtu-aocm tx PaoNATios, wmi OArtra or Tocai. Omuw. 
Fio flM.-4:aiiHio)t iir »ioix>rrt« VmBUC : xo Qapixi) up Vocal Coumi in PaoKATum 

Fm. (KL— Poivtkd F.rtt.iAmt»; Ventkiolks DuTtXtrr; IXunxATKiw. 
no- iQ.— ' .Tirir»iiARp" on OnKriA-tJEB Kpiaumra- 


Tlie fettialv burox mny h«ri; ttie form tii-jvn la anr at th« prveodl&K llffur««, 

some plastic eultsUnce (Fig. 65). They vary greatly in depth and in width 
in difTorent indiviihmls, iind in rarious positions of tUv fpiglottia in the 
wme individual. Tlieso siniises eliould tilways be exnmincd up they 
frequently give Indgeniont to portiona of food which aro u sourct! of irri- 
CfliioDi and Ihey iiri' sometimes the seat of ulcers. 



Thk akytksoid (.'ARTiL.\nE.s — ao imini'd on account of their ajtftar- 
t>i)t rewniblaiice iluriiig jitioiuition to Uie iios« uf u {liicher— ujipeur Lhh 
roath the free edge fif Ihe epigloltis. Thev are tuu in niitulttr, unt 
opon each side. They are located at the back of tho Liryui, re^tinK 
upon the \ip{>er border of the cricoid nirtilagc. EiicOi of these i^artilAge? 
is somevhiit pyniinidal. The apex, which is slightly pointed and rnrred 
uj)wiird and inward, io surmounted by a smuH conioid nodule, which has 
been nanied the comiculuni laryngti! or cartilage of Sautorini. 

Trr I'Airrii.AitK.^ \*v Santuhim. which urc Ui<uully about the siza 
of n millet seeii. are most prominent when the glottis is cl-jsed, aii in 
phoujtion. The niiicotis membrane iniinediately covering their .ipii'e& 
IB of n lighter hue than ttiat in other parts of the larynx, but the light 
color is usually surroundeu by a zone of deeper re<l. 

The CAttTiLAtiKs OF WnisuEur, are just external to the cartiluges of 
Santuriiii, in the fold of mucous membrane which extends on either side 
to the cNlge uf the epiglottis, prominences known also as the cuneiform 

These cartilages rury considerably tn form in different individuals. 
They are usually round, but are occasionnlly triangular, the iipioes being 
direi ted downward. Sometimes tliey are hardly vis^ible, bnt they are gen- 
erally quite distinct and fully as largo aa the cartilages of SantorinL 
These, like the coruieula, are of a lighter color than the folds which 
contain thcni, but they are usually surrounded by a zone of munous 
membrane redder tlum the general surface. 

lu a few instances a small nodule, due to a third cartilage, i^ ^e^u 
between the rartiluges <tf Wrislierg and ihe cartilages of Santorini on 
each side. The cartilages of Wriiilwrg and those of Saalorini are some- 
times termed the supra-arytonoid cartihiges. 


constitute the lateral and jtart of the posterior bonier uf the snperior 
opening of the larynx. They cunaist of folds of mucous membrane, one 
on each Kide, which extend like bows from the arytenoid cartdages up- 
ward and forwanl to tho sides of the epiglottis. They are usually from 
one-twelfth to one-eighth of an inch in thickness, but are occasionally thin 
nnd shar]). In color they closely resemble tho gums, and are somewhat 
Jigliler than the zones about the bases of the snjint-arytenoid cartilages. 


found extemid to the folds jnst named, and between them and tho wings 
of the thyroid cartilage. The broad end of each sinus is directed for- 
wanl, and Itti apex iKickward. It Is bounded internally by the cjnad- 
rangular membrane, the upper border of which is formed bythoary- 
epiglottic fold, anteriorly by tho wing of the thyroid cartilnge, and 
laterally by the wall of the phar}-n\. Like the valemta?, these sinuses 
often give lodgement to foreign bodies, and are frequently the seat o£ 



Tns rBKTRICULAS BAXDS, kiionrn nUn iia the sniierior or fiilac vooal 
cmrds, the regulators of the gluttiis, or the sit|H>rior ligaments of the 
larynx, are thick folds of hiucduh nieinbmne which ittretch soroga tht^ 
larynx in an antero-poeterior direction, about half an inch bMnw its 
superior opening^ and a isbort ilistince above the true vocil t'ord?. 'I'iipy 
arc frequently very prominent, standing out in thick welt« from the 
sides of the larynx. In other instances, they can hardly be distin- 
gnisfaed from the surrounding tissues. They are of a deeper red color 
tli:in the tissnes above them, but their inferior or inner honler« gen- 
erally appear pale in the laryngoseopic image, on acconnt of being illn- 
niin.ited nioro perfectly than the siirronnding parts. Just beneath the 
anterior ends of the false vocal cords and above the true cords may fre- 
qnently be seen a fossa, about the size of u pin's head which has been 


V ni—Vinr or Lkpt Sidc or LiRryi rrPitcx>. a. Left vocal cord : t>. povtcrlor ponioa ot 
v«F«itriclc* ; e. Ml vnntrk-iiliir ttanil ; it, |HMlrrior K'.irfACi- of «|alelMete: e, border of ar}r-«|j|gluUlc 
foM ; /. Wt cortila^ trf WrtBUrru ; y, nglil v^irtilBtfa <if Wri»l<rg ; A. li^ht voc«l foixl. 

named by Mackenzie the fossa innominatn. This oommuniuates with 
the laryngeal sinuses upon either side. 

The vestriclks of the uarym are fousd immediately beneath 
the ventricular bands. These consist on either side uf an obloug fossa, 
which is the opening to a nij He mr of mucous membrane, known as the 
a:iL'irnUis laryngis. They are bounded above by the false vocal conls; 
below, by the true vocal cords; and externally, by the thyro-arytenoid 

Tho ventricles are seldom seen, and, when visible, usnally appear 
merely as dark lines; but occasionally they are patulous, with a width of 
nearly ono-eigbth of an inch. 

TuK SACCCLUS LARYXOis exteuds upward and outward in a conical 
form beneath tlie ventricular band. The mucous membmue lining it is 
studded with the openings of sixty or seventy follicular glands, the secre- 
tion from which is apparently intended for lubricating the vocal cords. 
This pouch is covered by a fibrous mcntbrane, and this membrane by 
muscular tissue, which, according to Hilton, compresses the sacculusand 
discharges its secretion upon the vocal cords. 

The vocal cords, known also as the inferior or true vocal cords, are 
the moBt important objects to be seen ou iuapectiou of the larynx. 

Thpy (ippeiir tis two pearly white bands 8trotche<1, one along eacli side of 
tho iaryiix from ha nritorior to its posterior purl. 

In tiie iiclult they vury from fivo-t-ighlJis of an inch to one inch in 
length, anil are usually about ono-cightit of au inch in breiidth; thev on 
somt>timea perfectly white In women, but in men thoy are usually ut % 
yellowish white hue. They consist of tibrous tmndB covered bv a thin 
layer of closely adherent mncous membnirie, being attached anteriorly 
to a depression between the ol* of the thyroid eiu-tilngc, posteriorly to' anterior angles at the bnae of the arytenoid cartilages. 

During- rej^pimtion the corda alternately upproaol) each other and 
recede, lejiviiig b*-tween them a triangular opening for the paFsagp of air. 
Tho cords and the space between them form what is known as tho t/ht^ 
tiK. The free edges conatitn'o the lips of the glottis^ and the chink or 

Kie. Tl.— NoBiut. LfcftTMX or Womam is FuKMAnux or Rkao Toxu tOosBiO. 

Assure between them is called the rima glottidis. The front of thft" 
rima is formed by the anterior commissure of the vocal cords, its sides bj 
the cords themselves, and lu batie by the arytenoid cartilages and th« 
inierarytenoid fold. In the adult, this fisKiirc varies in length from 
seven to ten lines in women, and from ten to thirteen in men. At ita 
widest part it ordinarily meatiiire^ from three to six lines, but on deep 
inspiration it may measure us much as eight or ten lines. In children 
it is of course much smaller. 

On inspiration, the cords separate widely at their posterior extremi- 
ties; but their anterior extrentities remain close together, thus forminir 
a triiingnlar opening. On expiration they approach more nearly together, 
and in phonntion their two borders are more or less closely approximuled 
but there ia usually a narrow tissure between them throughout their en- 
tire length. In women, and oocasionally iu men, during the production 
of hejid tones, the vocal proeesscB are pressed firmly together, so that the 
fissure is left only betw(>eik the anterior parts of the cords. 

From a careful photographic study of the larynx daring the prodno 
tion of the singing voine, Thomas R. French (Tnui suctions of Anicricm 
Idryngnlugical Association, 1>*8S) concludes that the female voice has 
three and the male voice two registers; the transition from one to the 
Dftxt higher being usnally marked by backward movement of the epi- 





glottis, change iii the shape uf the glottis, iliortetnng of the uordSj and 
uu apparent iucretue in their tension. Protrusion of tho ton^e doea 
not mat«riaUy affect the Uir^iigoBcopic uppearunoe. 

The oonis are Bonieliiiie« lent^h«aed in men on chan>;inK to a higher register. 

The i-HocEftsus vocales or vo«il processes sire Hotuutinies seen aa 
four 3-cllowLsh spot«, two anteriorly and two posteriorly, whcro the vocal 
cords iiruuttaclicd to thu cartilages, but the anterior processes arc not 
often vitiiblc. Usually, wheu we speak of the viK-al processes, simply the 
anterior angles of t]ie arytenoid cartilages are referred to. Curl Seller 
has tlf^criU'd narrow fusiform cartilages", fouiul along the edge of tht, 
vocal c(trd» in women. Thpse are un\y rudimunlary in men. 

The iNTER-ARYTEKoin KOU> or posterior ^ommissuro is a hand of 
mucous membrane whicli extends between the arytenoid lyirtiliigcs. Th» 
prominence of this fold depends upon the position of the c-jirtilages. 
When the glottis is open, it may measure six or eight millimetres iii 
length; but when the coi-ds are approximated, it is folded upon itself str 
that it can hardly be socu. 

The cricoid cartilaor may ui<ually bo seen a short distance belov 
Uie vocjil conis, separated from their anterior extremities by the lower 
]iortion of the thyruid rurtilage and by the crico-thyroid membrane. 
This cartilnge is of a lighter hue than the nembraiiuus tissue above or 
below it, and is similar in color to the rings of the traeheji. 

The tracheal cartilages or rings of the trachea are usually visible^ 
arching across this tube from side to side with their concavities directed 
inward and downward. The upper of these rings are very distinct and 
of a yellowish or a light pinkish hue. They arc separated from each 
other by the intervening mcmbnuious tissue, which is of a darkur color. 

As we carry the inspection farther down the tnichea, the cartilages 
Appear narrower and narrower until their outlines are Hnally losL 

The nuieous membrane lining the trachea is generally paler than that 
covering tliu surface of the lurynx. 

Considerable variety In the shape and movements of different parttt 
of the larynx may occur within the limits of health. This is cepecially 
the case with the epiglottis; and variations in the appearance of the ary> 
tenoid cartilnges and of the commissures, and slight alterations in other 
parte of the hirj'nx may occasionally be found, as illustrated in Fig?. 66 
to 71. The epiglottis muy possess any of the various forms already 
spoken of. The sup ra-ary tenoid cartilages vary considerably In their 
size and form, as already mentioned. The position of the arytenoids 
varies; constantly with respiration and phonation, and may he quite dif- 
ferent in healthy individuals (Figs. fiC to Tl). 

In disease of the larynx, changes in its form and movements consti- 
tut* the principal signs. There may be hypertrophy or swelling of its 
various parts, with more or less loss of movement, or ulceration may 




Khinoscopy or exnmination of the nasal cftvitips is termod anterior or 
posterior acconiing to the position of the parts inspected. 


Anterior rhinoscopy or the initpection of tlie snterifr nares is per- 
formed vith the aid of die laryngoscopic reflector and itna^al specnhim. 
Various instrumental have hcen made for the purpose. A simple hivalve 

cnlura, snch as shown in Fig. 7C> is most satisfactory for pnrposoe of 
diagnosis; but when operations arc to be performed, instruments that 
will retain their positiuu when placed in the nostrils are preferred by 
some laryngolugislei (Figs. 7? and 78). No special Uirectionsare needed for 
anterior rhinoscopy, excepting tliai, in order to view the back jwrt 
j of the niiaal c'lvities from the front, a (condenser, and ii reflector an de- 
^scribed with the laryngoscope, are very desimble, and it is absolutely 


Pia. 77.— Jaittu* Bmua. VtMtu Smnrbcii <H vlxp't. 

necessary that the light be properly focnssed according to the principles 
laid down in speaking of condensing lenses. No obstacles will be found 
to the examiniUionr excepting in unrnly children, unless there be some 
deformity or swelling of flie turbinated bodiee. The Intier is eummou, 
bat may usunllv be quickly reduced by a (fmull amount of a spray of 
<N>caine. The nares are usually about one-eighih of an inch in width and 
from an inch to two inches in height. The inferior turbinated body is 
«een occupying about two-thirds ul the outer wall; and the middle tur- 
binated, much smaller, is seen at the upper part of the cavity occupying 
ubout one-t{uarl(T of the outer wall, and usually approiiching to within 
iruiu oue-iwelfth tu one-Hixtceutli of iin inch of the geptum. 

Thtt superior turbinated body cuunut be seen. The whole cavity ig 


Ti^^ ^'ffiOAT. 

coTered with gmootb macoafi '"^"■^''•w, awTnallrof about the nme 
color aa thm corerine the gti«i»*» *>"! often, ander I«as perfect illu. 
mination, iipi)earing ilijehtly coOgm^ The normal relatioiu of the 
pitrU. iibout an innh hncit of the ntatriU, are shown In the acoonipdnr- 
ing cut from the photograph of a frozen section prepurtd for me br C. 
fl. Stowell.of Wafehiugton. D. C. The »oft tuques are somevhat sbmnk- 
en, :i£ alwaya found in the cadaver. 

In aboat twu-thirdFt of all eases thfr^* U some diitparitv in sise in the 
two cavitifM, dne to dcllvution or to oatgrovthi from the bonr or cuti- 



Ful. rg— C»ni utntKm or Read, ukhiivo rtum axrvrnt «Antw*Kt»i4-& naUmU •»•}. gbow- 
)*)«: €t. a. mfaUk turUnatHl Iwflhw, h. t,. InTrrfor mrtMafttcd hnllea. r. r,c «thmnii| cHk; a.\t. uttfm 
• >r HIjrhtnon- ; r. r. nrinu : / «e|«uin : ff, hard |«U«tf 

'aginoui sepinm. Usually the turbinated bodies of one side are some- 
vhat swollen^ so that it i» exceptional to find the nasiil cskvities exactly 

posTFRioR Rnrxosropv. 

Posterior rhinojiropy, or inspection of the rauU of the pharynx and 
jKisterior nurwt, ii* prartiaed with instrumenta :Bimiliir to those used in 
the inspection of the larj-nx, and in much the same manner, excepting 
thut a eni:illor mirror is necessary, and its reflecting sur^co is turned 
upward instead of downward. 

A mirror from half to five^ighths of an inch in diameter is usually 
employed, and it is generally best to have a flexible stem, which may he 
reatlilv bent to conform to the floor of the mouth (Fig. 81). 

The mirror may be set at right angles to the stem, or at the same angle 
»8 the laryngeiil mirrors, or at an angle between these two; bnt this i^ a 
matter of little importance, as tho obliquity of the mirror may be easily 
dianoM'i \ty niising or lowering the handle. Special throat-mirrors have 



bQ constroctetl for rhinoscopy (Fig. 80), but ihuy arc not 8it|»erior 
to those alreo^ly de>8cribed. A ioDguo depressor will coniiuunly be 
needed in rliiiiogcupy, and vunoim forint< of bluut liook^ and ntlior 
istniments m;i_v be uw»d for holding the uvula; these latter jire rarely 
Iployefl and are seldom if ever of uee except during opemtions. 
In rhinoscopy, the patient should sit ereot, Hiid the hen*i nnif^t n^t be 
thrown buckw»rd, but nmy be slightly inclined forward. The phYsicinn 
should cake a position lui for laryitgot!i^py, or on a slightly hi);her level, 
and tho light eliuuld be placed ti^ fur inspection of the larynx, except 


>. 80.— riuKXKKL*s RHtKOBTupit. Ttip M«l« ot Uw mllTDr <a) ou b* elu&ff^ tt wiU hf morVOK 

itw alblliiR roil ml b 

t it should be on a level with the patient's mouth instead of hib eyes. 
The patii'iit's tongue ssIkhiM not be {irotruded, btit niUbl be left in the 
floor of the uiouth, where it will gencrnlly need to be held by a tongue 
ipressor, thougli some [>alietit» cau control it better without an instru- 

The rliinoscope in general use i» a number one or number two 
laryngeal mirror, the stem of which is bent to conform it to the Jloor of 
the mouth (Fig. 81). It is to he warmed and introduced with the same 
care as in laryngoscopy, wttli the retleeting surface upward. It should 
be carried Ixick to the posterior phuryngeul Wfdl, though it is better 
to avoid touching it. The surface of the mirror will then be at uu 
angle of abutit thirty degrees to a horizontal plane. The stem may be 
rested on the dorf^nm uf the tongue, hut rare muet be taken not to touch 
the base of this organ. I'he handle shuuJd be depressed nearly to the 
lower incisor teeth. A common cause of failure in this examination is 
holding the mirror handle too high. 

The mirror should be introduced first on one side of the unilu and 



t)ieu oil the other, to give a view of difTerent parts. In somo caeca a 
Urger mirror may be usetl if it is hold completely below the uvula. 

When the mirror is in position, if nnly the posterior wall of tho 
pharynx is seen, in order to expose the posterior nares, the handle must 
be still farther depressed, or tho mirror mni»t be withdrawn and beni 
more nearly to a right angle with the stem. If at first only the nvtila 
iind posterior surface of the palate are exposed, the handle must be ele- 
Tat«d to obtain a view of the posterior nares or vault of the pharynx, 




Tn. n.— Fourmr von RamoKorT, •■ovtxn >uo Ctrve ni Stkh or Mibiuml (TUshtlr «l»rad 

The mirror may be roLitcd slightly to obtain an image of the lateral 
walls of the pharynx or of the orifices of the Eustachian lubes. 


Some of the obstacles to rhinoscopy are the same'as those to kryn- 
goecupy, and demand ttimilar treatment. Thus, the uvula may he elon- 
gated and the fiiQcett iiulv be irritable. 

The principal difflouhies met in the examination of the posterior 
nares are: irrittxbility of the tongue causing the patient to retch when- 
ever nn »ttompt is made to depress it with the spatula; an elongated or 
sensitive uvula; irritability of the fauecs; too close approximation of 
the uvula and palate to the puHterior pharyngeal wall. 

Irritarilitv op the rosoL'E will :;umetimes prevent the uee of a 
toiigiie depressor, hut it may generally he employed if the ])hy«iciaa is 
careful not to allow it to slip too tar back on the base of the urg»n. In 
many ca«es ii is not neuesmry to depress the tongue with any instru- 
ment, if patients are instructed to allow it to remain passive in the floor 



of the motilh. A Iianil mirror, in which tho p»ttont can see his tongue-, 
vril) sometimes :ii(l him muteriHily in contrnHing it. In other oases tlio 
tongno may lie bold ns in hiryngoseopy. 

Somo ono of these methods will Tiearly nlwiiya overcome this diflR- 
ciilty; but if they should ull fail, the {Mitient must practise ut home be- 
fore u mirror until a sputnla cim be tolerated, or until the lougue can be 
J:«'d wiiliout one. 

Instruments have been eonstnioted which combine a tongue depressor 
and the thront mirror; but they are not neces&iry, for. whenuvcr the 
phyaician dcsiivs to use hotli hands, the care of the sp:ittihi amy be in- 
trusted to the ]Tqitient. Instruments of this kind are objectionable, aa 
the depressor necessarily greatly restricts the movements (if the mirror. 

An ELONGATED UVULA, SO relaxed us to become an obstacle to ilio 
n^e of the rhinoscopic mirror, may be contracted by astringents. It 
the imila is too long to be niamiged in this manner, it should be excised. 

Various instrninents have been devised for niieing the uvula tiiid 
driving it forward, but they are of very little service, as they usually 
cause so much irritation that they cuuuot be borne. 

Irritability of the PAUfES can be overcome iu many instincea 
by allowing the ])alicnt to 8uck liits of ice for ten ur fifteen minutes. In 
other cjises there muiit be prolonged practice by the patient ;it home in 
holding the tongue, and in touching the palate and pharyngeal widl 
irith a spoon-h::nd1e. 

In obstinate cases a solution of cocaine may be used us in laryngos- 

Closure of the post-palatixe space, by contraction of the pala- 
tine muscles, often occur;* the mumcnt a patient opens hi8-raoutb,:iud it 
eomotimes continues in spite of our best directed efforts to ovenrome it. 
Thi^ is the most common difticnlty with which we hnvo to contend in 
illuminiiting the vault of the pharynx and the posterior iiares. 

Sometimes this difficulty may be overcome by cautioning the patient 
to allow the fauces to remain passive when the month is opened, ur by 
directing him to Rimply 0]>eii the mouth wide without attempting to 
show the throiit. Then, by introducing tho mirror carefnlly so as not to 
touch any jiart of the fauces, and removing and reintrodnriiig it several 
limeit if necessary witbonl attempting to obtain a view behind the palate, 
the patient's confidence may be secured and the exflmination completed. 

If the patient can be taught to breathe quietly through the nose 
during the examination, the palate will hang loosely so fl« to cause no 

Sometimes a view may be secured by directing the patient to sound 
H or ng. Frequently a glimpse may be had if tho patient will atiem])t 
to exjiire through the nose. 

Various palate or uvula hooks have been constructed for the purpose 
of overcoming the difficult}'; bat, as has been well stated, the time spent 


in Lew-hing the putient to tolerate them is ueuallv more than ie neooe* 
eary to educate the throat to maintain a position which will require ao 
instrument. Timt.', {uitient^, and fre<|nent practice by the patient at 

Fir. eu. -RiTmm Palatc RmuoroK cM *'>•*) 

home must he the main dependence for auccesefiil examination in these 

When operations are to bo performed, the palate may be draim for- 


Fl». HL— Poicbek'b &ELr-axr.ktsaeQ Utula a»b Falatk KcnucroK (Hilae.) 

ward by the palate retractor {Fig. 82), or by tapes passed through 
the nares by means of a Bellocq's canula or a catheter, and brought out of 
the mouth and tied. Soft rubber catheters passed through the naros. 

Jio. S4.— PalaTx hzTRjtCZoa. !>« ku«j. 

brought out at the mouth, and tied over the Hp nrd very coDrenieut for 
this purpose ; or the palate may be held by means of a broad, strong 
palate retractor. The palate retractor onliuarily gold (Fig. 84) is only 

Fio. 6&— Rbiwokopi vitb Uvna Bou«R. 

hro-eighths or three-eighths of an inch in width, and is therefore too 
small for this purpose. Combinations of mirrors and uvula holders havd 
boon constructed, but they do not give general satisfaction. 


On Account of the small size of the mirror which we are generally 
iliged to use, ntu\ the limited 8[Hice through whieli tho rays of light 
can be reflected, it is im[H]ssible t<i libtain u com pie e imuge of the posterior 
region with the mirror iu uny single poailiou, but by slowly turning it 
from side to side, elevating or depret<sing the hiuidio, and introducing 
the mirror tirat on one side of the uvula uiid then the other, part after 
part c!in be brought into view. 

The natural condition of these parts should be thoroughly studied 
from diiigmms or models, before an 5ttempt is made to inspect them in 
the living subject, and the stndf nt should make hiraeolf perfectly famil* 
iar with the description of different parts. When the mirror is first 
carried into the throat, we usually see ia it tlio imago of the upper sur- 

rio. W— HemoaroPtr Ihaak. 1. Vomer or feeptuiti : n.a. fm ii|ini i rriiiiiiil|WijtiM . l,3,Mrp«. 
nor meanu: 4. 4. tntddl« roeavu»:&.nv superior tiirblitnu^^l b<Mly:(t,A. mldiileturUiict«dbodj ;?.7, ia- 
fanur lurbtlMtHd liudj' : H. B, pbArynffeol firtllnr ol Ktwtui-huiD hitie : II. 9, U|<fNfr purlliia nf fmsBi of 
RuMiuuueUer : n. tl. glaixlular tlmuH at th«> cuwrlor i>onbiuof tliATmullof tbe pbATjux : K, pos- 
lerfctr wutmix of veluui imUoU iLVjIwu), 

face of the palate, or of the posterior surface of the uvula, or of the pos- 
terior Willi of the phiiryn.T. If either of the first two is brought into 
view, we then elevati^ the handle of the mirror, or if the lost is soon we 
depress it, and thus bring into the field of vision the parts just above the 
soft palate. We then search fr>r the septum nariuui, which is to be 
takeu as a starting point for further inspeotiou. 

Having found Ihn sRptum, we truce it throughout its entire vertical 
length from the narrow lower extremity, where it joins the palate, to its 
upj»er broad base which arches outward on either side at the top of the 

,|K>8tcrior nares. On either side of the septum the irregular outer border 
the posterior ot>ening of the nasal cavity should be traced from above 

'downward past the projecting turbinated bodies to the orifice of the 
Eusturhiau tube, and finally to the jialale and lateral walls of the 
pharynx. The middle turbinated body is the most prominent object at 
the outer pnrt of the nasal opening ; but it seems overlapped at its 
lower part by the inferior turbinated body. 

External to the middk turbinated body, und just abore that portion 

aud uulward toward the vault and the posterior wuUs of tlii? ptmrynx. 
This groove is knomi as the fossa of Bosenml'I^ller or the KsrEsscs 


The choax^ or posterior openings of the nares are seen jn front of 
the rcbro-iiasal space. Tliey are of o\'al form and ufiually ulmui oiie-hulf 
an iucli wide Ijy three-quarters of au inch in heigjit U»rrij«on Allen 
(Tranmctions of the Aniericiin Larnignlogiciil AHsocintion, 1888) has 
ghown that they are not infrequently of inieqinil sixe, without deviation 
of the septum, the left being iisually the smaller. 

The sm:nioH H'RBiXATEn uodies are located at the upper part of 
the nasal fossae aud cannot be distinctly seen. They have the appear- 


ttrx. I'crten.jr wall i.r upti^r imrt .<f piinrjrnx 
(LiMcltkaj. t, I. Pli?r>'f<'<^») pn>(.-«Ba : 3. «ti.-tioii 

Um IUUbI fiMue ; 4. i, iihoryupfal urUI*.-e <<t tlie 
EuMaoliMD uibp : 9, oiilln' of tlic huraa pharyu 
fMi ; 0. 0, rwnsu!* jiliMryiigrii!! <tiiMU ot KtiMtl- 
inucU<*r'i: 7. mrvt1iitifi>MftrommI hy Cli>^ iul>>tiukl 
•ulMt«acet<f llutiuualpiinionor till* |>li«rjriix. 

Fra. i'- - [\i.!.\-i-)tAL Bobs*. Aowto-poMo- 
rtor «^:iMO (L-J»dil»>. l. Section of bMlUr 
prticpM vf Uie Dudptta) luine ; t. Ixvljr of qibv- 
notJ : 3, |iluih«ry irlNn>I: 4, ntWnold ■uImuoc* 
tit tbamult'if ttu*phiiryyx, brliliHl wbidttotMB 
a. tba itlutrrnirt^l him*. 

anoe of narrow triangular projections, the apices of which point down- 
ward and inward. Their color is dark red, like that of the base of the 

The si'PERiOB, middle, akd inferuir meatus are the spaces 
2ound between the turbinated bodies aud the external wall of the naeiil 
cavity. The superior meatus, wliioh is the largeaf, appears as ii large 
shadow at the upper i>Hrt of the fossa, just below the superior turbinateil 
body. The middle meatus is seen as a dark opening near the middle 
part of the fossa, external lo the middle turbinmed body. The inferior 
meatus, if seeu ut all. >;eueriilly appears simply as u dark line. 

The yAOLt of the pharynx U known also as the fornix pharyngis. 


and u lometimes fpoken of u the tonsilla phairngea. It is that por-' 
ticm of the pbarrngeal wall which begins at the posterior nasal orific«« 
and extends backward along the badlar process of the occipital bone, 
and tiien downward to be lost in the posterior pbarrngeal wall. 

In the perepectire riew, which we obtain of this part br rhinoscopy, 
it appears shorter than natunL The mncons monbrane is of a light 
red color, stodded with minnte whitish follicles, and broken on its rar- 
&ces into irregnlar, more or leas longitudinal fissures and ridges, which 
gire it mnch the appearance of the sor&ce of the foncial tonsil. This 
appearance of the sarfiice is caosed bj glandular tisrae which has re> 
ceiTed the name of toxsilla phabyxgea. Near the middle, at the 
lower part of this glandular tissue, is an opening about the sise of a pin's 
head, which leads np into a small cut de «ar. known aa the bursa 
phabtxgea. The posterior surface of the uTula, palate, and pillars of 
the fauces mar be seen below the nasal fossae. The palate appears in the 
rblD'r^copic image as a fleshy ledge ru nn in g at right angles with the 

Si/Hontfmit, — KrytLemjitou8 or cutarrlml sure throat, cynanche pharyn- 
geii, Hnd others. 

An ticute inflaminntion may nffect the mucous membrane of tho 
palate, pharynx, or toMsils, or all combine*!. Acute sore throiit is fouud 
ftDiODg people of all classes and occurs at all ages, bni most frequently in 
youug adults or children. It is said to bo more common in those who 
liave Buffered from syphilis or who huve been mercuriulized, and among 
those who fulluw sedentary occupations. It is most often observed dur- 
ing the changeable weather of spring or autumn. 

AsATouic-AL ASi> Patholuuio.vl CHARACTERISTICS. — There is at 
first simple active hypertemia of tho mucous membrane of the palate, 
pharynx, or tonsil, either circumscribed or diffused. Later, more or less 
swelling occurs, generally noticed at first in the uvula. In some cases 
the mucous membrane lies in thick folds, and occusionally the uvula and 
posterior pillars of the fauces are edematous. The superficial blood- 
vessels are frequently distended, and soon the muaculnr ami ghindnlar 
tissues become involved, and the setTetJons, primarily arrested, jire iiguiu 
established, but changed both in quantity and quality. In some oases the 
inflammation may terminate in suppnration. 

Ktiologt. — Acute sore throat is commonly caused by exposure to 
colds or draughts, eBpe<;ially In subjects who are living under the de- 
pressing influence of poor food, bad air, or scanty clothing; it also arises 
from sitting in warm rooms with heavy wraps, or working in a superbcat- 
«d atmosphere, and then going out into llie cold. Among tho occasional 
causes are extension of inflammation from tiurroundtng tissuea^ the iu> 
liulution of poisonous gnscs, the abuse of tobitcco, the inhalation of steam, 
the taking into the mouth of irritant poisons or of hot fluids, the im- 
piction in the fHUCcs of foreign bodies, and possibly the excessive use of 
spices. Over-use of the voice in poorly ventilated rooms or in tho open 
air, especially at night, nniy be an exciting cause. Among the [irmlis- 
posing factors arf^ the syphilitic, rhenmittii', and scrofulous diatheses, 

Symptomatolooy.— In mild cases the patient at first snffers simply 
from malaise, but soon experiences more or less headache and pain 
in the neck, back, and limbs. Jn severe easts the pain and constitu- 
tional syniptomij are marked. Karly there is irritation or a sense of 
itching in the throat, with pricking pain. A few hours later nain be- 
comes severe, especially as the patient attempts to swallow. 




When ths inflammation is in the upper iw4rt of the pharrnXf tlw pain 
often radiates toward the ears, and there is more or leu deuluett, Jae lo 
exteniiiuD along the Eustachian tubes. If the iufliuuniiition is stthe 
inferior portion of the pharrux, ihe patient suffers from morementi of 
the larrnx, which is uliio eensitirc on pressure. In eevere esses the skin 
ii hot, the tenipeniture ruiigiiig at alwnt IDS" F. Indeed, the oonftita- 
tional sjinptonie are out of nil nrupurtitm to the amount of inBanuuaUuii 
in the throat. The jmlse ranges from W> to 120 or even 140, attHirdiii^ 
to the extent uf inflammation and the susceptibilities of the indiTJdtiAl, 
all the symptoms being more marked in children tlian in adnlts. The 
Totce often hus a nasil tv:ing, due to swelling of the it:iI»Te and nmla 
and topreiijture on the pluiryngeal and palatine mn^'les brtheinflunniii* 
tory deposit. There is no hoarseness. Cough does not n«imllydistartith« 
patient, unleiu the uvula be<'onies nuu;h e1ongat«<1. There is, howetw, 
«n annoying tendency to hawk and clear the throat of the secretion^ 
throughont a conaidorable portion of the disease. At flrst there is bnt 
little expectoration ; later the secreiions are more abundant, thick uid 
tenacious, and hard to expectorate; finally they become mnco<panileiit 
The tongue is nearly always furred, the breath is feverish and oflentire, 
the bowels arc constipateil, and the urine is high colored. Ujtott eiuB- 
ination of the throat, the mucous membrune «*iU he found of a bright 
red color, which may be limiteil to patches or diffnsed over the whole 
earfuce. The superficial blood-vessels are often, though not always en- 
larged; the nrula is usually congested and Bwollen, and occasionally tli» 
same condition extends to the posterior pillars of the fauces. The £oft 
palate may also be considerably swollen, its edges having an oedematoas 
appearance. Whenever oedema occurs, the mucous membrane is some- 
what translucent and of a lighter red color. The infliunmutiou may 
extend orer the j>alate, tonsils, and pharyngeal wall, and sometimes the 
swelling of the mnoons membranes causes large longitudiiud welts back 
of tlie posterior pillars. Occasionally, in severe cases, the parts are al- 
most livid. The cerric-al glands arc very apt to be slightly enlarged. 

Di.\(ixo?is, — Acute sore throat is to be distinguished from scarlatiiu* 
acute tonsillitis, and rheumatic sore throat The constitutional symp- 
toms in 9tarltttiiui are more marked than in acute sore throat, and usu- 
ally after a few hours a cliaracteristic rash appears upon the skin- 
There is at first con^^estion in ncntr toHKiIhlit and pain similar to thut in 
acute sore throat, but shortly the glands swell sufficiently to distinguish 
it from the disease under consideration. Again in acute tonsillitis the 
iutlammation is apt lo lie confimnl mostly to one side for the first two 
or three days. The pain is greater in anth rkruwalir mtn throat 
«od the congestion usually, thongh not invariably, Ie*« than in simple 
\U !*orp thmat, an<l there is nearly always a rlipiimatic diathesis 
history of previous attacks, which aid in esublishing the dUg- 



pRonxosis. — Acute Hore LUroat runs its couree in from seven to ten 
duya. ituil it; not tlaugeroufi to life; but often tliore remains » tendency 
to frequent recurrence of the uttncks. In verj* rare cu*t« it has proved 
tiaX by extension to the larynx. 
Treatmkxt. — Patients subject to acute sure throat should be espe- 
cially cautious about exposure; they should so clothe themselves aa not 
lo r(>el sudden change's of tCimjierature; they should not sit in diiinp or 
averhe;tted rooms, and, in a word, should iivoid all the known causes of 
the iifTet'iion. The cold sponge bath is of uniloubted etKcucy in prcvcui- 
ing the taking^ of colds. I direct patients to sponge the trunk vn<x a day 
with cold wnter as it comes from the hyilrant, either morning or evening 
as best auitn thctr convenience or inolimition. Fur the ru^igLd, the morn- 
ing epougo bath is, aa a rule, better, but for others I adrii^e sponging at 
night in a M-arm room. The bath t-liuulJ be taken quickly, and thu crkin 
nibbed vigorously witli a co;trse towel to establish reaelioii. Full doFes 
of quinine will sometimes abort an attack of acute sore throat. For this 
purpose, from six to ten gniins should be given In a single dojjp. act^ord- 
ing to the pconliuritios of the individu;d. Early iu the attuck. ice sucked 
t-'ontinuously or applied about the neck in a rubber bag will frequently 
uburt the inflummation. If the disease is not checked by these means. 
J advise small doses of opium, aconite, or belhulonna. admini.Blered as 
Xoliowf: the tincture of opium, one njinini every ten to thirty minnlvs 
ut fir»t, and less fre(pu-Titty as the patient experiences relief front the 
throat symptoms; or the tincture of aeonite, one minim every Hftecn to 
thirty minutes for three or fonr hours until perspimtion is eittablished, 
vheu tlie tliroat symptoms are generally relieved; subsequently once In 
one or two hours iiocording to the fever; tincture of belladonna is given 
in similar doses with benefit iu certain cases. I often rely upou potaa- 
sium bromide alone, or with small doses of opium when the latter is 
■well borne. Tho bromide is given in doses of ten or Bfteen gruins every 
three or four hours, according to the amount of pain. As the dieensc often 
occurs in persons of a rheumatic diathosi)^, uml since it is tiumetimes im- 
passible to determine whether or not the rheunmtic diathesis exists, a 
good practice is to alternate potassium bromide with sodium salicy- 
late in doses of seven and one-half grains or more every third hour. If 
the disease progresses, inhalations, from a steam atomizer, of solutions of 
the aqueous extract uf opium, or of belladonna gr. i. to ij.; or rarlmlicacid 
gr. ij. in four drachms eaeh of glycerin and water, will often br found 
very soothing. If there be constipation, it is desirable to give a saline 
cathartic. Some physicians favor a mcreurial purge at first, especially 
iu patients with engorgement of the portal system. It should be given iu 
B single dose — for example, calomel gr. v.. with sotlium bicnrboiuto gr. 
■»,— and followed after six or eiglit hours by a ajiline laxative. In nearly 
all afTet^tions of tho throat, potassium chlorate is commonly administered; 
it i» not certain that it has very much influence on these diseases: but 



F grene, characterizeil by a durk pnltacfous apjieumuce of the tuucnns 
I membrane and an odur peculiar to gangrenous ti&sue. 

Etiolokv. — This variety of sore throat is pr(Kluced by the same con- 
ditions that canse errsipelaa of the face or of other portions of the skin, 
and is sopposed to result from infection by a specific microorganism 
tlie streptot'ocoua erysipelatosus. The a£Fection is more frei^neiit during 
epidemics of erysipelas. 

SYMFTi)X.iT()i.uin. — In most cases the patient is attacked by facial 
eryeiitelas, nrhieli continues tvo or three days before the throat becomes 
involred. In rare inBtancei!, the inflammation starts in tlie fanvos. I*rc- 
eeding its development, the patient usually snfTers from malaise for throe 
or four days. Constitutional symptoms are more marked in erysipelas 
of the throat than in simpio facial erysipeks. 

Fever ranging from lul° to 104" B', sometimes occurs before conges- 
tion is observed either of the throat or ekiu. Often there is nausea, and 
pain at the epigastrium. The patient complains of dryness or a t>ting- 
ing pain in the tlirout with stiffness of the jaws, so that there is dillivnlty 
in opening the mouth. Usually there is swelling of the snbninxJllHry 
and cervical giauds. Deglutition becomes exceedingly ]>ainful, luid is 
sometimes dithcult on account of pure«i3 of the muscles. When the 
muscles of the palate alone are iuvolved, food will be partially regurgi- 
tated through the nose. 

DiAONusis. — Upon examination of the throat, in the erythematous 
variety, the mucous membrane covering the palate, tonsiU, and pharynx 
has n shining snrface and bright red color, or in severe cases displays a 
deep livid hue. In cases marked by phlyctipnulre or gangrene, the njipear- 
anee of the eruption or the color and odor of the dead tissue would sug- 
gest the charai'ter of llie attention; in those where the throat is attat^ked 
first, the speedy occurrence of an eruption upon the skin will clear up 
the diagnosis. Utinally the skin i^ tintt attacked, so that when the 
throat symptoms appear, the nature of the disettse is at once suspevled. 
I pRoososis,— The affection may run its course to cither recovery or 

death in two or three days, but in the majority of cases it lasts eight or 
ten days. Cue-haU of ibe patients die, and in those who recover resulu- 
tion is slow. In fatal cases, the disease may extend to the larynx, caus- 
ing suffocation, or the patient may succumb to blood {wisoning or ex- 
haustion, with or without the formation of abscesses. In gangrenoag 
cases, death is almost certain. 

THEATMEST. — lu a disease so often fatal, the treatment cannot be 
very sat itt factory, but anything which offers hope should be tried. An 
applicaiiou of a sixty grain solution of silver nitrate very eitrly in the 
attick h:is seemed to cut it sliort in some coses. Constant sucking of 
ice luis been found beneficial in moderating the severity of the inflam- 
matiun. and is to he recotunieinled, at least during the first few hours of 
the disease. As the patient suffers much from pain and restlessnisi^ 



opiftteshltoul'l bo administere*! in (^iifTicictit finnntityto giro relief, un] 
there is an idiosytinmsy to the <'ontr:iry. Bet^tanee of tlio teTidenoy of 
the disease to death bv exhaustion, gtiroii1aii>« and tonics are iiulic-ateU. 
Quinine should be given in doaes of two or three gmiiis, avei-uging about 
fi praiu for each huiir of tht- day and night. TUt' tincture uf ehlnride of 
irou hag seemed the best iiiternul romedy for cry»i|ichis of the skin, and 
is therefore recoinmendei) in erysipehttuus inniimm:ition of tlie thro t. 
It should he given in dones of ten or tifu-en minims iihont every two 
hours, dihited euffioiently to enable the pittii-nt to take it without pain; 
glycerin and Fynip of ginger best cover its taste. In cases whore ap- 
plieatioufi of cold do not check the infhttnmatiou.Maekenzii'rei-onrnieiids 
H'tirni funieuttitions and inbahitious of Hteani, or steum imprt-gnatud with 
soothing remedies, nnudynes, or carbolic acid and glycerin. Hot ap- 
plicatione ehuuld not bu made, howuver, until we have become cronvinctHl 
that the inflaainiation cannot hv itbortcd. Frequent gargling with a 
one per rent solution of cjirbolic acid \» itometimes beneficial. If much 
(edema of the thro:'.t occurs, scarification should Ive ptiictitied to relievo 
the tension of the tissues; and if the disease extends lu the birynx. 
UB it frequently does, tracheotomy mnst be performed. Unfortunately, 
however, tho operation is usually futile in this affection. In gungrenous 
cases, antiseptic washes of carbolic acid gr. vi. ad ; i., potassium per- 
manganate gr. v. to x. ad 3 i. or listerine 3 >>■ ad z >• should hu frequently 
used;, and we should urge the jiatieut to take freely of alcuhuliu slimn- 
lants and liquid food. 



Uheumatlesore thront may be considereil aa of two varieties, the acute 
and the chronic. The acute affprtion is often attended by marked cou- 
Btitutional symptoms and severe pain, and is efipeeially frequent in pa- 
tients of a rhoumatio diathesis. 

Anatomical and P.vtholocical Characteristics. — The throat ia 
more or less red and swollen, but usually much less so than in simple 
scute sore throat, and seldom sufficiently to account for the severe pain. 

ErinuiOY. — The disojise is produced by the same causes which set up 
rheumatic inflammation in other parts. 

Stjiptomatoixwy. — There is almost always a rheumatic diathesii^ 
the patient being subject to frequent attacks of muscular rheumatism, 
or having suffered at some time from the articular affection. 

An attack comes ou suddenly and is announced by severe pain in 
tho throat, which is soon followed by constitutional symptoms. Tlieee 
usnally continue for a couple of days, and then almost as suddenly dis- 
appear, the pain shifting from the throat to the muscles of the neck. 



Iw^k, or extremities. Occasionully the disease pusses 00* with acute urtic- 
ulur rlieuiimtism. Tlio pain is so peculiar thut [Hiticnts who have once 
hai3 tlie [li»uit{40 will iisiiully rccoguize it immetlintely fi'om the chnnicter 
of this i^yTn|)ti)iii. It is very severe upon lUteiiipts nt swulluwiu^ even 
ft;lWn* Sudden shifting uf tlie patu from the throiit to the ninscicB 
oi the neck or back, .ilKiut the «eitoin3 day, is tmo of the notnhle feature* 
of iho diseaae. Tlie tempeniture is raised two or tiiree dcgives iiud the 
pnlae is correspondingly quickened. U[Hm exumioiiig tlie fauces, we 
find more or lesa redneaa imd swtlling, which may be uniforni hut often 
consists simply of red stripeft running longitudinally Whind the posterior 
pillars of the fauces npon each side, wliile other portions of tin* tliroat. 
are but very slightly congested; yet the p:Ltient suffers intensely. 

DiA'iNosis.— Thp disease is not likely to l>e confouniled with nny 
oiher excepting simple lU-nle jtorr tlirunt. The distinguishing featureti 
are: the peculiar piiiii. the history of former attacks, the suddenness with 
vhirh the attack comes on, and the shifting of the p:iin after thirty-stx 
or forty lj<»urs to sumo uther portion of the body. TIiltu is generally 
much less of redtiej^a and swelling thuu in simple sore throat. 

pROOSosis. — The atfection usually terminates In from two to four 
djys. There is very little danger so far as life is concerned. F know 
of only one reported fatal case; in that, the diseiise extended to the 

TttEATMEN'T. — Prophylaxis is of first importance in this affection. 
Patients subject to it sliould wear citlier silk or woollen underdothing 
the year round, and should be citreful to keep the feet dry and warm, 
and i^^ avoid all undue e.xpO!<ure. £arly, an effort should be ni:idu to 
abort the attack by means of salicylates, alkalies, ur guaiacuin. .Siniir.m 
salicylate may be given in the manner recommended for acute sure throafe, 
or salicylic acid iu capsules or solution, iu dosca of five or ten gmins 
Bvery one or two hours. After a few dosea, the patient usually breaks 
out in a profuse pera]>iratiou, and the pain subsides. When this occurs, 
the dose should bo reduced one-half, and continued in that fpiantity for 
Ato or six doses, when it should be further decrejisetl or substituted by 
the alkalies. When this remedy is administercil in capsules, the patient 
should always tako freely of water with each dose, to avoid irritation ot 
the stomach. Potassium acetnto iu doses of twenty to thirty gnuns, or 
ammoniated tincture of guaiacum in doses of one drachm may be given 
every fourtli hour, or troches of guaJai^um maybe taken every two hours. 
On account of the severe pain, nnod_\Ties may be required; of these^ 
opiates are most efficient, bnt the peculiarities of many patients render 
this drug obnoxious, and therefore potassium bromide, phenucetine or 
nntipynne or similar substances are often preferable. Applications to 
the throat of warm fomentatious or poultices often iiave a bencticial 




SynonifTA. — Chronic rheumntic laryngitis. 

Chronic rheumtitic Rore throat is u. pninful affection varving niQch in 
severity from time to time and alteiidod by only slight physical c)iangi-s 
ill the jMirtfl involved. Though it usually affc-eis the hiriitix, and there- 
fore luui been deacribed as rhc-nmatie kryugitis, yet in ntatiy cases it tn- 
Tolvea only th** ftmcea, the hyoid bono, or ponaibly the tmcbea, without 
implicating the hirvnx; therefore the term chronic rheumatic sore 
throiit is preferable. It i« t'omi>arattvely frequent, and has probably n* 
ifited from time immemoriid. 

I huve been utmble to find any descni>tion oi it prior to that which I gnvcsl 
the Ninth International Meilical Congress, hrlil at Washington, D. C, in IWT. 

The affection occurs mainly in the spring and fall, but may also b» 
obflorTod during the winter, and there are occaeional cases in which it 
continues through the summer months. Thougii aETccting all claoM 
with the Hamc impartiality as rlieumatism of other parts, it is more fre- 
riuent in nien than in women, and all the eases I huve tseen hare been in 
adults from twenty to sixty years of age. 

Akatowical and Pathological CHAnACTKitiRTics. — No verj 
marked charucteristics appear, although there \a usually slight conges- 
tion, ctrimmscribed in chiiructer. but chaugeable. 

ErioLurtY. — The disease is due to the same causes as muscular or 
articular rheumatism. 

Symptomatolooy.— Chronic rheumatic sore throat comes on insidi- 
ously ill many cases, in others suddenly. Commonly the patient will 
have been compliiiiiing for mouths when heapplie-s to the laryngologirt 
for relief. Most of the eases I have seen have previously consulted *«- 
end physicians and huve received almost as many difTerent diagnoses, 
but all have feared either tuberculosis, sj'philis, or cjint-er, most of Ihciu 
having a filed dread of the latter affection. The general health is not 
imiKiiretl. The patient complains simply of a localized paiu, commonly 
referred to the comu of the hyoid boue; I have observed it moat fre- 
quently on the right side. Kext in frequency, pain is folt iu tbe-H 
larynx, as a rule upou one aide only. Occasionally, however, it is in 
the trachcA or tonsils, and sotuetimes in the side of the base of the 
tongue. This pain is increased by pressure in nearly all cases, perhaps 
in all. and it may be increased by jihonation or deglutition, but often it 
completely disapjiears while ilie patient is eating. In any case it is lia- 
ble to shift it« position from time to time, but it may persist for weeb 
in one pUee. Sometimes the person will complain of sensations of 
fnlneea or swelling or of dryness, itching, burniug, or an indescribable 
sensation of discomfort instead of an actual pain. ITsiiidly the voice is 
not affected, yet it is common for these patients to comphiin of £atigu« 
speakiuga^ijortliuu). There is no fevcr.andnoquickeningof iha 




pulse except from alarm. Usually there is do cough, hut in Bomo cases^ 
especially where the larynx is involved, an anni>ying, hacking cough ia 
a prominent symptom. The digeetivy organs may act pi-rfectly, but 
ordinarily the tongue is more or less covered with a whitish or yellow- 
ish whit« coating, and, although tho appetite is usually good> the patient 
is often troubled with flatus and eructations of gas from the stomach. 
Upon laryngoscopic examination, wo may find congestion, contined 
.generally to a small spot in the region of the pain, and sometimes slight 
swelling. This condition, liowever, is liable to diminish, disappear, or 
change to other localities after a few days, and there is nothing char- 
acteristic in the appeamnuc of the parts. 

Diagnosis. — The affeetiou is apt to be mistaken for neuralgia, for 
enlarged glauds or euhirged veins at the base of the tongue, for chronic 
follicular tonsillitis, gloesitis, or pharyngitis, for gouty syphilitic or 
tubercular sore throat, for tobacco sure throat, or for caucer. The 
essential points in the diaguosisare the uucomfortable seusatioos of paiu, 
which change usually with changes in the weather, the existence of the 
rheumatic diathesis, and the al^gence of auy distinct physical signs. 

Chronic rheumatic sore throat is to be diagnosticated from varioosi' 
veins, enlarges! glauds at tho base of the tongue, and from chronic fol- 
licular tonsillitis, glossitis or pharyngitis, all of which sometimes present 
similar symptoms, by a careful inspection of the parts, by the conrse of 
the disease, and by the reswUs of treatment. By inspection, we may 
at otice ascertain whc-ther the veins or glands at the base of the tongae 
are enlarged, but unfortunately we cannot tell whether enlargement of 
the glands or a varicose condition of the reins is the cause of the symp- 
toms. Some persons have these conditions and yet suffer no inconven- 
ience whatever, while in others serious discomfort arises. Therefore, if 
we find varicose veins or enlarged glnnds at Uie bnse of the tongue, 
with evidence of what seems rheumatic pain in this locality, these con- 
ditions must be remedied before we can be certain they are not the cause 
of the trouble. 

If careful inquiry reveals evidence of a rheumatic diathesis, it favors 
the diaguosis of rheumatic sore throiit. The signs upon inspection in. 
chronic follicular ionitillitis, ffiosaiHn, uud pharynptis are characteristic, 
and when they are fouud we may tistmlly take it for granted that tlie 
8>lDpton)B of which the patient ronipNiins are <hie to these iliscasea. 
We might possibly be mistaken in rase« of this sort, but, if &*>, a fiiilnro 
to relieve the symptoms by curing these conditiouB would soon clear 
up the diagnosis. Sometimes the diagnosis is extremely difficult; but in 
the majority of cases, having intiuired carefully into tho history and ex- 
cluded the affectiona here mentioned, we may come to an accurate con- 
clnsion. (Jouttf nffections of the throat as shown by S. Solis LVihuu 
(paper read at first Pan-.\nu licati (.'migress) painful symptoms 
similar to the rheuumtic aficctiou. They may be distinguished from the 



Utt«r by the anteco<lont liiatory and Iiy the presence of gouty noUule* 
and enlargement of the joints. The ulTet^liou may l>e distinguitilied 
from *.tfphi!ia by the history and hy the phyHital signs. In rhe eurly 
period of syphilis, and in the itewitidury and tertiary stages, there are 
Ufiually fharaoterialin physical sigiiiS which are not fimnd in chronic 
rlieiiiiiatic sore throat. Coses of syphilitic! gore throat oocnr, however, 
in whirh the signs are not chamcteriatic. bnt in these I have never 
known the patient to romphiin f\i the persistent pain or discomfort 
which chiimcterixes the rheumatic affection, and I have seen no reason 
for ooufonniling the two diseases. 

Wo niny disting^tish this sore throat from fubereuh«ii by the absence 
of confititiitionai symptoms in the rheumatic affection, and their great 
prominence in the tubercular disease; the rchitively moderate pain or 
discomfort and t)ie alH<euce of ulceraitun in the former and In the latter 
the ifvere pniu, with suiierficial ulcenition, whit'li may e.\tend over a 
considerable part of tho painful regiof, or occiisianidly deep ulcenition. 

Chronic rht'umalinaore throiit may bcdiittinguished from tfihatra xors 
ihroof by the history, and the absence of phn/t/e^ whicli very much 
as if the surface had been brushed over with silver nitrate; these arc 
common in tol>acca sore throat, though in some cases we find no physi- 
cal signs. With tobacco sore throat the patient cnnimonly cumphiinsof a 
burning sensation in the part, usuully relieved soon after the tobacco ia 
discontinued. If we find the jHttient a habitual user of tobacco, if stop- 
ping its nso relieves his discomfort, and if there are no symptoms of 
rheuniatisyi in other jmrts of the body, there will bo no difficulty in 
differentiating tiie disorders. 

It is often difficult to distinguish rhenmatic sore throat from neural- 
f/ia. The presence of slight congestion or swelling is of considerable 
value in the diagnosis, for in neunilgia there arc no local signs. In most 
cases of rheumatic sore throat, pressure increases the pain, while in neu< 
ralgia it does nut incrcjise but may relieve it. In rheumatic sore tlimat, 
changes of the weather from fair or clear to cloudy and damp almost 
always aggravate the symptoms, while in neuralgia they have but little 
effccl. In neuralgia the pain is commonly worse in the latter part of 
the day. when the patient is fatigutd; in rheumatic sore throat it is apt 
to be worse in iho morning, and is not particularly increased by faiigue, 

The physical signs dii^tinguish enaa-r. In most cases of cancer that I 
have seen, there have been in the eitrly stage more or le?s iniluration, 
with gra<lually increasing, irregular swelling, and finally deep ul(.'er»tion. 
These do not occur in rheumatic sore throat. In cancer, patients are 
not likely to suffer pain for any length of time before some of these 
physical changes occur; in the rheumatic trouble, pain is the essential 
8ymj)lom, and the physical changes are not marked. 

Pitotixosis. — We may expect the cases to continue for several months, 
or even for years. There is no danger so far as life is concerned. 



Trkatment.— In the trentment, our first nttention should be directed 
to prophylaxis. With this in view, thepitticnt must be v,o]\ clothed mid 
boused, mill protected from undue ox posti re. Khennintic pjitlents should 
■wear either woollen or silk next the body both night iind day thmughniit 
the yeur — light in summer and heavy in winter. They should be care- 
ful ilmtull the excretory organs perform their functions properly. They 
ehoulti eat sjuiringly of albuminouti siibfiLiiuces and live largely on vege- 
tables and fruit; tho vegetable Hcids are often advantageous, but, what- 
ever is eaten, it is especially imponanl that digestion Ix) perfect, so thi''; 
the formation of ptomaines shall be reduced to a minimum. Korthe locU 
treatment, sedative orslimnlunt applications may be made, with almost 
ct|ual chances of relief. Appliculious of the tincture of acoujte tu tho 
j)ainfulsi)ut fuur or Cv« times a day, of morphine in solution or in powder 
will sometimes give consideriible relief. I Ji::vo frequently observed much 
benefit from tb« application of such stiniiilanls as xino sulphate or 
chloride and copper >iulphate, in solution; but I have derived most ben- 
efit from a solution of morphine gr. iv., carbolic acid and tannic acid iSL 
gr, XXX., in glycerin and water uu3 iv. It is applied by spray, and ia 
frequently given to tho patient in one-half this strength to be used at 
home. In some cases swabbing the surface with strung titiclure of 
iodine or a iiixly-graiu solutiou of silver nitrate luis proved beneficial. 
These liittf-r applications apjmrently act much the gjime as blisters over 
rheumatic joints. The most important part of treatment is the internal 
metlication. Here salol, soi^lium salicylate, potassium iodide, guaiacum, 
Phytolacca, and the oil of guulthorium, one or all may be used at differ- 
ent times with bouelit; sodium salioylute may be given iu doses of seven 
to ten grains, the oil of guultheria in doses of fifteen minims, the am- 
mouiated tiucture of guaiacum iu doses of a teaspoonful udministfired in 
milk three or four times a d:iy. Tlio resin of guaiac in lozenges fre- 
<iuenily repeated is of considerable vulue. 1 have observed most benefit 
from the extract of phytolncca and salol combined, M gr. iij. to iv., with 
an occusionul laxalive; but somclimes they have been used conjointly 
with jwUutfium iodide, or with potajjsium bromide for its sedative effects, 
I occasionally give the salol in doses of ten grains. Tinctures of bryonia 
And of cimicifuga aro said to bo valuable remedies in rheumntism, I 
ha\'e used them both, with apparently slight benefit in some instnnoeSj 
bnttbe obstinate cjises have done better under phytolitcoa and salol with 
occHsional use of the other remedies already suggested 


Sore throat of small-pox isoharacterizei] by an eruption similar to that 
which occurs upon the skin. In many cases it appeiirs before the cntn- 
neous eniption, in others not until the third or sixth day of the original 



duoue. The extent of tbe eniption will varj according to the aeveritj 
of the Tariola. 

JkSiTOMiCAL iND Pathological CHABACTERisrirs. — Tbe mncoaa 
JMnbrsue is *irolleii, nud the iiecuU&r pustules are foaniJ,but wtthotit 
the contr»etv<], depressed centre that is seen ajwu tbe skin, becau^ the 
eoTenng launot become drj. The ulcention of the«e pDstulee fre- 
qoentlr extends entirely throagh the mncons membrane to the muscolar 
ttsrae. which is more or less inrolred in tbe inflammatorj actioit. It is 
probablj on thie account that patients experience socb severe pain in 

DiAG^osifi.— Tbe diagno«i« reeU upon that of the con»titutionit] 

pEOGS^osis.— The tbrout affection per se is not dangerons; in serious 
cue* of Tariota there are liable to be grave complications in the throat. 

Treathent. — LocalU, weak astringents and soothing garglea ara 



An eruption in the throat is present in nearly erery case of measlea 
msoneof the first indications of the disease, but it gouerally disappears in 
m fev days. It is usually a simple catarrhal iufiammation of the macous 
ntembmne, which may extend from the nostrils to the ultimate bronchial 
tabes. In comparatively nirt" wises there is a diphtheritic deposit. 

SYJilTOSiATouMn'. — On examination of the fancea, often one or two 
dftyi before the disease becomes well marked, several small rod points 
•re noticed on the palate, pillars of the fanoes, or the jihnryngeal watt. 
At the lime the eruption appears upon the akin, we nearly always find 
iDDch congestion of the tljroat. In diphtheritic cases there is a fibrin- 
ous deposit npon the surface. In some instances the inflammation 
extends deeply into the ti&sues, and abscesses result. Many cases of 
meules are attended by hoarseness due to biryngitis, which sonietimes 
becomes a serious complication, particularly where there is a fibrinous 
deposit. The inflammation and pain often extend to the ears. 

DiAOXosis. — The diagnosis will depend upon the cntaneons emptioD 
and the other symptoms distinguishing measles from other diseases. 

pROGKosis.— So far as the throat is concerned, we expect the ea- 
tiirrhal infiammiition to last seven or eight days in the majority of cufcs 
and tu terminate iu resolution. Where fibrinous deposit occurs, the 
prognosis i^ grave, especially if it extends to the larynx; of these cases 
eighty per cent die. In infancy there is peculiar danger from extension 
of the inflHnimation to the lungs. 

Tbeatuent. — The treatment for acute sore throat is appropriate, 
but often no trwitnient is necessary except tliat which may be indicated 
fur the const itutiuuul disease. 




Sore throat of scnrlet fever is characterize<l by congestion of the 
pftlate anil f»iices. wbicli occuri> early iu the attack and is presiMit in 
nearly every ca£e, even iu tm>se where the cutancoue eruption ie absent 
or Blight. 

Anatomical axd Pathological Chabacteristicb. — In 8ome in- 
fltances the congestion is flight, in others tlie parts are of a deep red or 
hrid hue, iiiid in anginose cases th^re is nuich swelling, and the puiatc, 
piiarynx, and tonsils are all involved in the inflammation and the o-dema 
If the process is intense, the swelling may cause almost complete closure 
uf the throat. The inflamniation lrer)Uontly extends to tin- submucoas 
liasucs, resulting in extensive suppuration, and nut infrequently abst^esaes 
o<;cur in ttlher portions of the body. In a large number of f!i»es the in- 
ifamnrntion extends alotig the Eustachian tube to the middle ear, not 
infrequently resulting in |>ermanent deafness. In some cases there is 
tliphtlieritic deposit, but it has not been tletermined wJiether this is a 
|>eculiar phase of the scarlatina or whether it is an associfition of the 
tvo diseases. 

Stmptomatologt, — The attack is usually ushered iu by vomiting 
and fever, and the patient complains of more or less stilTnesa of the jaws 
and acliing pain in the throat, which in scarlatina angiuosa may be very 
severe. The tonsils and mut^ous menihrarie are swollen, and the glands 
at the angles of the jaws are often considerably enljirgod. In many cascfi, 
in ibe beginning of the attack, the temperature rises to 105'' F., and oc- 
(sasiounlly even to lOG'. It usually continues high sevei-ul days, and is 
iiot apt to disappear before the ninth or tenth day. In severe cases, 
Kith much swelling, respiration may be seriously obstructed. The 
iongne at first has a peculiar strawberry like appearance, due to promi- 
itenco of the red papillse. which are surrounded by a white coating, but 
Jater it is red and glazed. The breath is offensive, particularly in diph- 
'-heritic eases, and in scarlatina anginosa. Disturbance of the stomach, 
'Ufficulty in deglutition, and loss of appetite are among the common symp- 
'oma. The degree of redness and swelling varies much. In simple 
oises there is a bright scarlet uppearaucc of the throat, sometimes ap- 
proaching a livid hue, and there may be very little swelling, but in the 
anginose variety the mucona membrane iind tonsils are so much swollen 
OS nearly to close the fauces. In many cases, during the first or second 
day u thin pseudo-membi-anous deposit occurs npon the inflamed tissues, 
and in some this becomes thicker and darker in color and tinully acqnirea 
the appearance of the membrane in <l iplitheriu. Occaeionally in the 
beginning the symptoms and signs are those of tonsillitis only. 

PiA«NORls. — The disease is tn be distinguished from acute sore 
throAt, from tonsillitis, and from diphtheria. The eKseniial poinltt in 
the diagnosis are the history and characteristic ernption of sftirlet fever. 



The nppetimncos aro much the same in acut« $ore thrttni as in scar- 
Utiua (luring the first two or ihreo dftys, but the constitutional synap- 
toins arc iiRiinlly lighter niid the siibsetjuent history different. 

There is apt to he more swelling in (uitHt'l/i/ix. whioh is often con* 
6ned to one side, aud there is no cutaneous eruption excepting in rare 

A tliiiik false membrane occurs early in dipfi/heria, while the temperii- 
ture is ooinjmnitivcly l»tw (101" to 102'' F.). and other constitutional eynip- 
toms are not severe; in sourlatinu there is high fever at first, with little, 
if any, fibrinous depasll: and Ihirk p?eud<)-niembra,ne, if developed at 
all, does not often ot cur until lato in the disease. 

PKOGXOSIS. — In niihl cases the lliroat symptoms usnally disappear in 
fruro six to ten days, but in scarhiiina anginosa or in malignant cases the 
throat may not he involved until iheeigblh or ninth day, hut then extvri- 
sivv swelling takes phiee in thcconree of a few hours, and in a short time 
extensive pseudo- membranous deposits may occur. In simple eases there 
is no danger so far us the throat is concerned; twenty-five pt-r cent of 
the HUginose eases die, and of diphtheritia cjtaes fifty i)er eent aro fat::i. 

Tkeatmest, — Emollient iipplieations and antiseptic gargles or spniys 
are nsually recommended. Solutions of earbolio arid gr. v. to viij. nd 
Z i. of glycerin and water, weak solutions of potassium permang:inato 
gr. V. to X. ad 3 i., or some of the other antiseptics may be employed for 
this purpose. As the patient progresses toward recovery, the feri-ugt- 
noas and bitterti>nies will be found beneficial. If there is much dejires- 
siun. alcoholic stimulants are indicated, and i^honld be given freely. 
Potassium chlorate has been recommended highly in the treatment of 
the throat alTecliou of smirlatina, in quantities prnpoi-t innate to the nge 
of the patient: for an adult, gr. xl. to Ix. daily in divided doses. It 
should be proniptly disoontiuued if it causes irritation of the kidneys. 


S^ttauyniit. — Herpetic sore throat, aphthous sore throat. 

This is a form of sore throat characterized hy the occurrence of 8i 
blisters and her|ietic patches in the fauces and on the pharynx, which, after 
a short time, nipture, and the surface becomes covc^re<I withan inflnmma- 
torii" deposit or false membrane similnr to the mombnine in tliphtheria, 
though less dense and much more friable. The affection occurs niojit fre- 
quently iu damp climates and iu the colder months of the year, particularly 
when there are sudden changes, as in the spring or fall. It is more fre- 
quent in women and children than in men, and is o)iserve<l oftenetit 
among those who are naturally delicate. It occurs fre'pientty duriiig 
epidemics of diphtheria, and is occasionnlly rssocinted with tnbercnlosia 
or syphilis. 

Anatomical .\sv P.vtholooicii Cn.iRACTF.niSTica.— In thelK-gin- 



ning nf th« Attack ibere are foand aertnH snull distended follicfoe* 
abaat the size of a pin> head, with mom or leas reddening and lamefae- 
tian of the sviToandiug mueous memKnine. Thi-se luajr ocear sinflr or 
in (Mtches^and may lermiiuite io one of tUive mtva: drsl. by n«4>rpth>n, 
in which cue thej muT diappear ia two or three dar$ and the uinrous 
membraue may be left in a beoltby condition: second, ther mar buret 
and small deep ulcen may remain, which mar either heal rapidly in 
twentr-fonr to forty-^ight hours, or may become corered with membra* 
nous deposit; third, several of these ulcers may coalesce, forming a large 
patch whic'i becomes covered orer with false uienibruiie. I have fre- 
quently seen, in the beginning of snch an attack. (Mitches five to ten mil- 
limeLrvs in dtumeter, covered with this false mfmbrane. which to nil 
appearances, were nut preceded by the email inflamed follicles. 

£tiui^oy. — The disease is attribated to exposure and to certain 
miasmatic influences not well understood. In occasional cafws occurring 
at the meuftirual jieriod it is attributed to aterinedisturbunces. Certain 
epidemic influences appear to favor the diseaee» for it is more frequent 
whcu diphtheria is prevalent. 

SYMiToiiATOLooT.^The attack usnally comes on with a slight chill, 
followed by fever and attended by sevi-re jiaiii in the throat. For Iho 
firftt day or two the patient eompluius only of the »yni[itnn]« of siniple 
acute sore throut. V^ually there is first a sensation of dryness^and after 
a short time a tievere burning or gnmrting juitt), which, so far as vp can 
judge from the patient's description, is more intense than that of .iny 
other acP.te affection of the throat. Thi-( pain !<ametinies nidiates townrtl 
the ears, and is sai<I to extend occasionally to tlie ita^^al cavities, and in 
rare instances to the larynx. Xearly always we find a herpeiic eruption 
upon the lips tit some time during the course of the disojise. The fever 
is occasionally very high for a few dayi<; in other instinct^ there is bnt 
very little elevation of temperature. The pulse is acceleratetl; the tongue 
is usually flaltby, indented nt (he edges by the trpth iind covered with a 
thick, whitu fur; there is great ditticnity in swallowing, because of tho 
pain, which, however, varies with the location of the diseased follicles 
or patches. Upon inspecting the parts, we find sinull inflamed follicles 
or pustulcii, often not mure than twu or three in number, ou the paJtite, 
fauces, or the side of the mouth; or in place of these small ulcers, or 
nicer? covered with false menibniue; sometimes the pustules and ulcers 
ar« found together, becauso the inllanifd fullicles come iml in succe«sive 
groups for four or five days. Often early in tlio attack there is general 
redness of the parts with localized pntohes of deeper congestion, M-hich 
may appcjir Ix-fore the pustules are developed. In the uinjority of cases, 
the most pronounced physical sign will be the presence of one or more 
pafclirs, round or oval in form, usnally from five to ten millimeirea 
in diameter bnt sonietiines a little larger, und covered by a thin yi-IIow- 
ish white fali<e rnenibnine which can be readily removed with a t^wab 



nf cotton. These aro found on the aide of the tongue* fauces, or inner 
surface of the cheeks, and somecimes even upon the lips. Under this 
iitembranc wu may find iin iiTitaie<l and easily bleeding surfHce. In 
sonio instances, ua removing it we find the niueoiis niembnint.* benenlh 
iu a perfectly hejiUhy condition. Oecusiouiilly early in the uttHck there 
it a thin uicmbrano spread over the tonsiU, iviLh very little t^roeion. 
Daring the ntt«ck fiilae niemhrono will sometimes form npon sores in 
other parts of the body. Utfimlly the diaejtse is more pronounced upon 
one side only, but it may t^preiid over both sides and the pharynx, aU 
Ibongh it seldom or never extends forward upon the hard palate. The 
tnenibntne is not apt to be continuous like that of diphtheria, but occuiii 
in scattered patches. 

DiAOXosis. — The disease is liable to be mistaken for diphtheria only. 
Late in the nttack it may sometimes be distinguished from dipbtheriii by 
the slight constitutional tiymptoms; though often there is high fever la 
the beginning of the attack. In simple membninous sore throaty herpta 
appears upon the li]>8 during the firgi three or four days; not so iu diph- 
theria. The membniue, in mi-nibrunuue) sore throat, is superficial uiid 
thin, about one millimetre iu thickness, and it may be easily detached, 
leaving beneath simply an exeoriated, congested, or sometimt'S heulihy 
surfiiee. In diphtheria the meuibraue iii tliree or four millimetres in 
thickneea, is detached with difficulty if at nil. seeming to extend into the 
originul tissues luid he a jwirt of them, and leaves an irregular and deejdy 
ulcerated surface. Menibninous sore throat is owasionally followed bv 
IMiralysis, leading one to question the accuracy of the diagnosia. In 
ionie cuses the symptoms uud signs are clearly those of niembranoua sore 
throiit, but after a few days diphtheria becomes iniplunted upon it. giving 
all the clmracleristics of the latter disi-ase. Some authors believe thes/» 
affections identical, but the weight of authority is against this view. 

Pkooxosis.— The disease may bo expected to terminate in recovery 
in from eight to ten days; there is sometimes, however, a teudencv Uj 
recurrence. We may assure the friends that there is no danger froiw 
the disease alone, but it is well to warn them of the possibility that diph- 
theria nuiy iMWonie implunted u(k)» it. • 

TKEATMr.NT. — In the treatment of the disease a medium dose of 
magnesium sulphate or citrate is desirable early. This may be followed 
by qninine and anodynes to relieve pain. Arsenious acid in small doses 
h-18 l»eon highly recommended. 1 have given potassium bromide inter- 
nally. for its anodyne effects, with benefit, and it is recommended in 
Bolotion as an inhulatiou from u steam atomizer. The vapor nf mm- 
jmund tincture of tienzoin, 3 i. ad O i. of hot water, is nlao reoommpnded 
as an inhnlatlon. Weak antiseptic gttrgles of pota&sium permanganate, 
carbolic acid, listerinc, or Dobell's solution are useful to clear the throat 
of the mucus. Charles K. Sajous recommends that the false membmno 
)y •! and the exposed surface touched every throe hours with a 


ten grain solutiou of potassium permanganate (Diseases of the Nose 
and Throat, 1885). I have derived most bene^t from a solution of 
morphine, tannic acid, and carbolic acid (Form. 139). Applied to the 
ulcerated surface, this will often give relief for ten or twelve hours. Oc- 
casionally solutions of silver nitrate act well, but in some cases I have 
been unable to find anything that would give much relief. The free 
use of demulcents, such as rice water, an infusion of slippery elm bark, 
or flaxseed tea, is soothing to the parts. With these may be combined 
a little lemon juice if more agreeable to the patient. Potassium chlo- 
rate has been highly recommended for this, as it has for nearly every 
other disease of the throat; but in every instance in which I have given 
it trial, it has caused intolerable smarting. In cases subject to frequent 
recurrence of this disease, J. Solis Cohen especially recommends touch- 
ing the spots with dilute nitric acid. Good diet is to be recommended* 
and the patient must avoid exposure. 




^yHOrtymj*.— Diphtheritis, uugina diphtbcritiea, anginu membriiuoeo. 

Diphtherui is a specific contugiotis diBOJisc, chiiraotorizeil by pro- 
nounced cwtistitutiunitl ^yiiiptuuiti uiid iutlumnmtioii uf liie 1111100118 mum- 
bnine of tho futires ami upprr uir patwugcs, wilJi exudutiuu of iij(!ui]i- 
niatory lymph, nliit^h rupidly l}L'ci>mcs formed into t&W^ inenibninc. It 
hits long bwt-n rfto^nizwl by the bei*t uiitboritJM af out' of ilip z-yniotic 
fever*. Kuny English authorities^ with wlioiii I lun fully iti accord, lonk 
upon thiti us H cDustttutiuUiiI Ui:ifiise with load munifebttitiuns, biil nmnr 
coiitineiitul iiuthors iiiitl some American writers regard It tis a priiiiury 
loot iifTec'tioit with sccundiiry eougtilutiuniil niiinifi-8tiitioii3. The ds.--- 
e:ise occurs spomdiciilly. ftnlcnuciLlly ur t'pidi-niimlly. and iippuars to 
have uo geogruphiciil limitutions, but U must frequent iu teuipemte 
climates. It is mn.<t common in cold, damp weather and during the 
spring or fall montlui. but is o fie 11 sieeii in winter, iitid not infrequently 
durinjz warm weather. lA^unox Browne states that thoee who have 
enlarged tonsils are e.-ipecially recopliu' of tliecontuKiuni (Diseaws of t!ie 
'i'hroat, -M 3d.). The yreat majority of cusi's iire n'j^erved in <'hildren 
under six yenrs. but adults are not e\empt. The d iseiisc is not often 
obtjcnod twice in the same individual. 

Anatomical ANi>.pATHoi,ocirAL Characteristics. — In the begin- 
ning of diphtheria there is congesiiun of the mucous membrane of the 
ftuiws, nsu:dly uniform, but occasionally in patches. Tins may gradually 
o\tcud tu tho entire mucous membrane of the tliroat, and it is soon fol- 
lowed by tho cjiudation of inQammutory lymph, whicli in most instiuices 
proceeds withiu a few hours tu the formation of false membmne. Thi> 
deposit originates generally in one placuand gradually exlends tu the enr- 
rounding tii^sues. but it may ronimencc in several spots at the samp time. 
It is usually first found upon one or both tonsils, from whicli it grad- 
ually cxicuds, according to the sevority of the disease, to tho palate, 
phnryux. naso-pharyux, and other portions of the air pasisage. Ri^relv. 
It is found lining llie a'sojihagus and other jHirt^* of the alimentary canal. 
Wounds upon the skin are li:tble to become covered by the same pro- 
cess. Extension of the disease to the air [lassages gives rise to dipb- 
tfauritic croup, or pulmonary collajHse, Blood clots iu the ventri4;les of 



the licftTt or large arteries are not infreqnently fnunil in poet-mortcm 
ex:iininutiou5. Enlarged lyniphntic glmuis are common, occasioually aup- 
purating^iiud in the umjurity of cases the kiilncy^ jvru congC'st4.Hl or uctu- 
ally inflamed. Various twittcriu have been found in the di]>htheritic 
nienthniue. hut nioi^t or all of these inhabit the mneoufl membrane of the 
niotitl) of lie:ilthy individuals. 

Etioloov. — The disease is generally conceded to be contagioue. and 
may be eomnumicnted from man to the lower animals and f(M rcr^rt ; it 
is believed by most piiysicians to be due to a specific micro-orgiuitsm. 
The researches of T. M. I'rudden {Amirkan Jour?tut of MeiUcal Srienres, 
April smd May, 1880) pointed to a Btreptocoecus us the probable e:mse 
of diphtheria^ hut the resulto of hia later iuveiitigiitions harmonize with 
those of moiit bacteriologists^ who now attribute the. disease to the 
Khdw-fji^iffler bacillus. This i« a microscopic rod nhout the length of 
the tuberi'le hiH'illus, but twire ics tliirkueas. It is usually more or less 
bent-, with rounded ends, one or both of whicli may be thickened, giving 
the club or dumb-bell a])|>ejir.ince; it is immobile and contains no spores. 

These buc-illi do not readily absorb the common aniline stains, but are 
easily colored by a solution of Lofflcr'a methyliii-bluc, the coloration often 
being ino^t intunsc at the extremities. Aceording to Annunil ItiitTer 
{/ii ilinh MefJiaiJ Jtturnat, July 2*Jtli, 1800), these bacilli are foun<i most 
abundantly in tlie superficial jmrtions of the false membrane, and ne;krly 
all experiments go to prove that they do not nsually enter the lym- 
phuiics or blood vessels; therefore, of itself the bacillus is innocuous, 
but it produL-L's a virulent ptomaine which is readily absorbed and which 
may cjiusc the constitutional symptoms of the disca^se. Numerous clin- 
ical observations and experiments, however, have demonstrates) with an 
c^fpial degree uf certainty that psemlo-inembranotis iiiftiuuination is often 
j)roduced independent of the Klebs-Luftler bacillus, as, for example, 
that re«ulting from surgical operations in the throat; or from injury 
inflicted, boiling water, steam, cantliarides^ chlorine, and ammonia; or 
the exudative inflammations supposed to be of niicrohic origin, fre- 
quently observed iu scarlet fever and measles. This hitter variety of 
inflammation is termed by Smith and AVarner [Amivitl of the f'tiitrr- 
mtl .Ucilintl Srifiiccfi, 1891) pseudo-diphtheria, and, a^ stated by them, 
cm only be distinguished from true diphtheria due to the Klebs- 
L&fller bacillus by the fact that it is not followed by paralysis and is 
not attended by a peculiar form of albuminuria nnassociated with 
dropsy or unemie i>oisoniug. The necessity for assnming that there are 
two varieties of diphtheria, one produced by the Klebis-LolHer bacillus, 
the other by other bacteria, seems to justify the etjitement, that the 
identity of the specific mtcro-orgauism, believed to eause the disease, is 
as yet uncertain. Itoux and Yersin {J/i'nion Meduale^ Paris; Annual 
of Ihe Universal Medical :^ience»y I8i>'i) report that iu the secretions 
from the moutlis of tifty healthy children, living in a village near the 



<!Out, where (li|)I)theriii(f-ui!uukiiuwu, they found ir, 53 {Krceut a bucilhia 
morphologieally i<leutical with the ordinary Klebs-Loffler boeillns and 
behaving in ciiIturL'a exactly like the latter, cxtei>tiug in the nuail)er of 
its colonii?8. This tliey iK-lifve to be the KIcbs-Luffler bacillus in a uon- 
virnlent condition. 

There can l>e tio doubt that primary simple inflammation favors the 
production of diphtheria, but it iii doubtful whether it is ever iu itself 
capable of pro<lucing the disease. Infection may occur from another 
patient or from articles contaminated by him. Commonly it« origin is 
referred to the use of certain drinking water or milk or the inhaU- 
tion of emanations from suffers, or from dump, nnhealthy collars or 
deoiying refuw. The must L-ommon jiredisposing cause, I believe, is lb» 
«HH)8ure of young children to the chilly utmoapbers of oar honges Vn 
the spring and fall months or during the warmer portions of winter, 
Tvhen Ares are not considered necessary by adults. 

Symptomatoloot. — After a period of incnbation varying from one 
to eight days, the disease usually commences in young children with well- 
marked constitutiomd symptoms, such as hcudachc, drowsinvsii, more or 
less fever, thirst, vomiting or diarrhiBa. and stiffness of the nock at the 
angle of the jaw, with more or less Boreness of the throat. In older 
children and adults, the invasion is more gradual. In from twelve to 
thirty-six hnnrs from the first symptoms, the false membrane can 
usually bo detected in the tliroat, and in some cases it is depositee! 
in considerable quantities before the porsou is thought to be ill. The 
patient usually complains of a sensation of dryness and a desire to hawk 
and clear the throat, with some paiu, cspcciully upon deglutition. Ex- 
ceptionally an erythematous eruption makes its aj>j)eanince on the skin 
during the first few huiira of tho affection. The pulse is rapid, small, 
uud feeble, and as the disease progi'csscs it may be intermitlcm, 
Finally, it grows exceedingly feeble aud slower than normal as deatii 
fTOMi exhaustion approaches. The temperature nBUiilly rises to 101** nr 
102'' F. during the tjrst houra of the uttacrk, but with the deposit of 
false xnembmne it generally falls and may even become subnormal. 
After two to four days it may again rise, iudicjitiug in favorable cuse^ 
enppnmtion and sepiinition of the faUe membraue, or in others an ex- 
tension of the disease to the larynx, lungs, kidneys, or other parte. In 
the later stages of the disease, sudden full to the subnormal point is a 
serious symptom indicative of fiiiling strength. The voice is often 
a]tere<1, weak, aud hoarse, even before the lar)Tix is affected, but when 
fidso membrane has exteuded to the glottis hoarseness becomes more 
pronounced or the voice may be entirely lost. With involvement of the 
larynx, dyspncpa appears, and it may steadily or suddenly increase, ag- 
gravated, however, from time to time, by spasms of the glottis. Respi- 
ration becomes noisy and stridulous, there is an irritating laryngeal 
con gb, and with the spasms of the glottis all the symptoms of suffoca- 



tion appear; the fulsc membmne niiiy be loosened, aud fragincnU of 
coiiBidcrablc size uro often oxpfctoruteil. Sometimes complete castii 
of the trachea or broiu-bi are thrown off in tliU way. When the disease 
extends to the niisu-pluiryn.\ and iiustrils, there 1^ ul>»trucli(>n uf the 
nose and a fetid, sauious discharge, frtiquently aeconi|uni«d iu p-ave 
[<raM8 by epistjaie. Tlie tongue is coated with thi^'k, yellowish fnr, and 
the breath \m\a a pm.'iiliar odor most cliaracteristic of the diseiise. In 
malignant cases tliis odor is so prononnced us to ]teruieato the entire 
apartment. The tpngiie is coiited from the tirst, and in unfavorable 
eased it bpeonies harsli nnd dry iind covered with a thick, dark eu:tt. 
The appetite is poor and in severe ciscs may be entirely lost; nausea anA 
YuniiLiug lire not infrequent, particularly wheu the kidneys are in- 
Yolvotl. Swelling ol" the cervical glands occurs in most severe c.ises, 
l«8peeially at the angles of the jaw; the submaxillary iind parotiil glnncf^ 
nre sometimes involved. The throat is at firat deeply congested, but. 
Boon tho false membrane is deposited, primarily upon one or both, 
tonsils. In tho beginning, this membrnneis white in color, bnt it soon 
becomes ycUowisii, and with the advance of the disease grayish, brownish, 
Ar even almost black. It has the apj>earance of involving the mueouA 
membrane and being slightly elevated above the surface. If the men:* 
farane ia exfoliated or forcibly removed, an ulcerated, graoulur, and 
bleeding surface remaini!, which is again soon covered with false 
membrane. This membnine is firmly adherent to the aarface, and can- 
not be removed by brnshitig with a swab of cottoTi, as can the mucus 
which collects in other forms of sore throat. With the laryngoscope, false 
membnine may be discovered in the unso-pharynxor the larynx. When 
the latter becomes obstructed, a sinking in of the softer portions of the 
[chest is noticed with each inspiration, well marked above and below tho 
f^aviclee, but especially at the lower part of the sternum. As the glottis 
1 becomes more and more obstructetl, the skin is pallid and bathed in 
cold perspiration, tho lips,, ears, and extremities appear blue; the \wu 
tient grows resitloss, throwing himself from side to side of tho bed 
every few moments, and with the paroxysms of dyspnoja he throws his 
arms about and clutches at his throat in tho vain effort to obtain more 
air. As the dlbease progresses, the signs of carbonic acid poisoning 
ire more and more marked, the patient becomes listless and drowsy, 
and finally dies in a comatose condition; or he may be suddenly carried 
off by a spasm of the glottis, a general convulsion, or heart failure. 

Diagnosis.— Diphtheria may be confounded with simple catwrrhal, 
or rheumatic pharyngitis; tonsillitis simple or follicular; erysipelas, 
scarlatina, und other constitutional diseases, or with simple membranous 
)re throat. The easential points in the diagnosis are tho history, the 
rapid progress of the case, the appearance of firmly adherent whitish or 
yellowish giay membrane in the throat, and the condition of the urine. 
In catarrhtrl or rhenmntit^ phartjrigiiis the temperature is higher, 
Itte pain is greater, and there is no formation of false membrane. 



Id fir If iti If etas of ihe ihrotti tlie eruption is developud more slowlv, aud 
the liiatory is cntirt-I)- ditli-reut. Srarhttiim is developed luuro rupidlv, 
the Iciupentture risi's uiirly to KCi" or 105° V. and remains so for several 
days; in diphtheria it seldom ritum higher than KU* or 103"^^ F. in the 
hogiiiniiig. Ill 3o:irliilina, after u short time a charactoristii- rash ap- 
[KMirs upon llie skiii ; itie upjK-urauce of tlie throat is not greatly different, 
iu the ounimonc^eiiiuiit, tlioiigh the congestion is geuerally more uuifoi 
than in diphtliL'ria, and iu nnix)mplioated cases there is no false mem- 

In iotisillitis the temperature is much liij(licr, the disease comes un 
more r(ipi<]lr, there is more pain in the throat, and neunlly there is 
difticnlty In ojjening the mouth whirh doe« not occur in diphtheria, lo 
simple touifillitis there is more sn-elling, but no deposit of inflammatory 
lymph. The liistory of foIHeuhtr tonsiltitia is essetitinlly that of tho 
Rimple form, hut numerous yellowish point)* or Ri>ote appear n]K}n the 
tonriilt) at tlie (iririres of the lacuiue. Tliew^ however, ditrpr from the 
upiwaranrc of diphtheritic membrane, in that they are more numerous, 
emaller, are not elevnte^l above the surface of the raucous niembniuet 
an< conHtiH) to the tonsil in the mujority of cawd, and never found upon 
the palate. 

SiutftU membrnnous $ore throaty if seen lit the beginning of the 
attack when the vesieica ftrst appear, is not very likely to bo miiitakca 
fur diphtheria; hut if tlie patient doe^ not imme under obtH*rvation until 
tti'o or thret) days later, the diiigno^is may he ditticnlt or even imjtogfliblCf 
especially if diphtheria is prevalent at the same time. In mo?t (•:««.'« of 
membntnons sore throat the patient complains of much more jtain and 
the ful(« membrane is more easily detached and ii> much tliiuner than iu 
diphtheria. Ju some cases a herfietic erudition iu the throat aud on the 
lips reveals the true nature of the di^'ase. 

In jthiefivivnous or ert/sipffofoii.t tore thntnl the patient suffers moi 
pain, the temperature is higher, and the tifwue--! are very o-dematous and* 
lirld, the inraeion and course of the disease ar&dilTerent, and diphther- 
itic memhtnnr is alisent. 

^KVHiNl>sl^. — The prognosis is always grave, for uo mutter how mild 
the case in its rommenremenl, it is im[M»i!i(ibIt> to predict what the com- 
plications tnay K; twfore it has run itii cour^'; aud alth(>ugh the largo ' 
majority of rai»M recover, it is never safe to make a favorable prognusu 
without warning tlie friends of possible danger. In fatal rases death 
oceasiitnally occurs within twenty-four hours after the first appearance 
of Ui« disease, and in the majority the fatal terniiuAtloQ is within fire 
day's; but in some the struggle for life continues five or six weeks l>e* 
fore the {utient succumlw. Iu favomble cast's convale«*cence is nni&lly 
Miabliithed aliont the end of the third week, but especially where com- 
plicatioos have existtxl. the duraflou may be much longer. As a rule, 
the youngs the |iatient Ih^ greater Ihr danger. Among the $ymplnm» 
and sigos indicative of gravity arr deposita nf merabrane in the vm^ 



plmrjuXf or iiit«fitincs; extreme pain in the eurg or throat, purpuric 
spots oil the »kiii, epistiixj^, and other hemorrhages, persistent iinorcxia, 
vomiting, iliarrhci'a, unil gTippreanion of the iirino. Asthenia, a typhoid 
condition, or uigne of heart faihire are often prernrsors of death. When 
the larynx is Involved, it is probable that witbunt Rurgiral interference 
the mnrtulity readies ninety-five per cent, and with it abont sixty per 
cent. Patients not infrc«inently die snddenly of heart failoro, and nfteu 
tlie pulse becomes weak and intermittent on the slightest efifort, and 
clearly pointi? to the necessity of relieving the heart from all undue ex- 
ertion in order to save the patient's Hfo. 

As the Wise progroaaes toward recovery, tho appetite returns, the tom- 
per.-turo diniinisbos, ditlitMilty with respiration disappears, and articula- 
tlonagiiin is normal; liowever, the difiirnlty in jtwallowingoften becomes 
greater, from exposure of ulcenited "surfaces which cause moro puin on 
deglutition, or from puresid of tliis deglutitory muscles. Not infrequently 
pnriiiytic symjitoms follow the attack closely, about tho end of the third 
week, but, except in cases where tho respiratory or circulatory ceutrea are 
involved, ifcuver)' usually occurs, though it may bo delayed for several 
weeks or even months. Owing to danger from the Hetfuels, especially 
heart fnilurc, we ran never fully relieve the anxiety of friends until our 
patient has been well for about thrco weeks. 

Tke,\,tment. — There are few diaoases in which the methods of treat- 
ment recommeuded are more numerous, a f:ict which is explained by the 
inutility uf a great majority uf the means adopted. Ko much depcuda 
upon the nature of the epidemic, the condition of thcjmtiont when 6rstat- 
iucked, and his t;urroundingi<, tliut it is very ditKcull lo arrive iit accurate 
4!onclu(tinna regarding the effects of remedies. During the earlier por- 
tion of many epidemics ii large proportion of those attacked die, and 
therefore whatever remedies have been used seem to be fruitless ; wliereas 
in the liilter part of the siuiiy epidemic :; brgo majority of the cases 
recover, no matter what treatment is employed, and the remedies in use 
at the time get iliTredit. Many jihysjcians have favorite prcscrijjtions, 
ou wliich they place great rtfliance until called upon U) treat serious 
fcasee; then, unfortunately, all methods often fail and the physician 
comes to believe that little can be accomplished by treatment The 
tncthods to bo adopted are: first, prophylactic; second, dietetic; third, 
local; fourth, interual or general; fifth, upenitire. 

ProphijUuis is of prime importiince in relation to diphtheria. The 
noet useful measuresconsistof thorough ventilation and proper drainage, 
pure water supply, proper clothing, and proper heating of jiving apartf 
mentR, and as far ns possible protection especially of children, fnirn the 
contagium. It must be romemliered that sometimes the specific poison 
may be carried from one to another by domestic animals, or in the rloth- 
ing, or about the person of one who has been visiting tho sick or at- 
tending funcraU. As the disease ie generally prevalent during the cool 



and ilamper portions of the ;ear, wbeii clie ueed of fires is iiot appreci- 
ated by adults, it is of special importance that childreu be cared Tor 
at this tiuie, thut they have projier clothing, and that a anitable 
tcinpc-niiuro of tlie liousc be laaiutaiiied. It hus ap[H:ured to luu 
thai during the spring and fall months children arc much riiorv 
liable to cfitch cold and consequently lo have diphtheria, in the hause 
with u temperature of iibout 06^ to 08" F. thun when the temjicruture is 
even colder. An effort should be inutle lo muinUiin the tempuraCDru uf 
the hou(!e as neiirly as pos^^lble at TO' F.. iind children should not bo 
allowed to run ubout in their night clothing nioniiiig and evening or to 
stand about while dressing with the teinp<>nitiiro at fromSo*^ to G5° F., as 
it is liable to be. They need to bo carefully protected ut night from 
exposure due to kicking off the bedding. If the disease hsa made Us 
pppeHrance in ii household, other children of the faintly must be pre- 
vented from iill intercourse with the patient, and tiie sick one should be 
given an airy, comfortable room, which may be frev]y veulilaled without 
exposing the patient to dniughts. Dniiicl K. Brower, of Chicago, advo- 
cates an excellent method of vpntilation during nn nttat^k of this dis- 
ewe, consisting of changing the pntient two or three times a day from. 
one room lo another, the vncnted room being thoroughly ventilated in 
the interim. It is u useful precaution to hang over the door of the sick* 
room sheets kept moistened with carbolic acid to prevent contamination 
of the iiir of the houso during the necessary opening of the door. The 
temperature of the sick room should be kept at from 70*^ to 75" F., and in 
«U e-ases an abundant sup]>U' of fresh air provided. All utensils or 
clothing used in the room idionld he diHtnfectod or destroyed, and finally 
tbo room should he thoroughly rumigntcil before it is again u«ed. 

Orancher, of Pflris {Rentp fV Hyrfipnr ft de PnUre ttnnitmre, Pecember, 
1890; AnnuulVnivtrisal Mftiictd S(\(uceK,is\\'i), expresses the opinion that 
in nearly fdl instances diphtheria is propagatod by infected clothing or 
furniture, lie states that in » diphtheritic ward in Paris, among 1,741 
iidmitted were 153 that did not have diphtheria at the time, yet none of 
lliem contracted it. The means of prophylaxis employed in this ward 
••■ere: a metallic screen about the bed; disinfection of articles tised by 
tu*; patient by boiling in ahciu a six per cent solution of sodium carbon- 
ate; disinfection of the bedding and clothing by heat, and of the walls 
and fnmitnre by washing with a solution of mercnry bichloride. At- 
iciidunts and doctors wear blouses that are disinfected by heat daily and 
wjtsh themselves in a bichloride solution or in a five per cent solation of 
carbolic acid. 

Ice taken frequently in the mouth tends to relieve thirst and redui>e 
consrostifm. When children will not take this, Ixunox Krnwne (Disejwes. 
of tlic Throat, ^d wl.) recommends the use of frozen milk or froxen 
beef t«a. Of nutritious drinks, ntilk is the mnet important;, beef ti>A 
and the various broths may be given in aildition when the child will 




take them, and these may be supplemented by rice water or barley water; 
tbe latter is sometimes taken more readily if flavored with leoiou jnice. 
As MKin as tbe appetite l)ecomea impaired, tbeae liquid nntrimjtf* must 
be given at regular intervals, and in aa great a quantity ae the patient 
can be induced to take. To a child ton years of age us much as haU a 
pint of milk or its equivalent shniild if possible Iw given, every third 
honr night and day. .Sometimes with children it is necessary to with- 
hold water in order that they may take the liquid nourishment 

Fontaine, acting on the principle that germs cannot exist in acid 
solutions, recommends freqnent drinks or gurgles acidulated with citric 
acid. On the Siiuie principle, pineapple juice liod lately been liighly reo- 
ummended, particularly by the luity. M'heu patients cannot lake food, 
or when it will not be retained by the stoiiiuch, nuci-itive enematji become 
j)eoo8s:iry; in tbitf case the various pre|mrutiona of peptonized meat ore 
exceedingly useful. 

Alcoholic stimulation is of great importance, and is usually recom- 
mended early in the attack, but I donbt its value at this time. The form 
in which it is administered is of little importance, so long a£ it ia accept- 
fcBl)Ie to the iMitient; whisky or brandy is most commonly used, but 
children will generally take much mure readily alcohol diluted with two 
|)arts of syruj) of tolu, given iu as much water iis desired. 

The early continued application of cold externally is often of the 

itest service; for this purpose the throat nuiy be tilted with a coil of 
ibber or metallic tubing through which a cnrrent of ice water is kept 
constantly passing, or the ice bag may be used. When the ktter is em- 
ployed, the ice should be broken into small pieces and changed about 
once an hour; the bag should nut be more thuu half tilled, so that it 
may bo &4.-curately applied to the surface. When the false membrane 
begins to separate, hot applications have seemed more beuefioial than 
cold, and occusionnlly, even in the early part of the attack, the patient so 
Beriously objects to tbe cold that hot applications may be used instead, 
the effect being much the same providing the application is continuous 
and as hot as can be borne. 

7'opiof Treat men f. — A variety of substances have been used with the 
hope of removing the false membrane. Tbe simplest uf these is steam, 
applied either with the croup tent or the steam atomizer. This may be im- 
Ipregnated with the time honored Hmc water, or with various other sub- 
atances according to the fancy of tbe physician. There can be no doubt 
that lime water is capable of dissolving the false membrane when the 
rtter is immersed in it for a snfflcient length of time, but probably it 
laa very little intliienec upon the nicmbnine in the throat. Liquor 
pota88a,onc part to four of water, may be used with equally good results. 
Mackenzie (Ditteases of the Tliroat and Xose) highly recommended 
lactic acid applied freely with a brush or pledget of lint. He did not 
state, but left us to infer that it was applied iu full streugth. Ho 



oJassed it aa among the niu^t reliable mlveiite of diphthcriTJc meiubrane, 
Lennox Brownu recouiniouda li Milutiuu of lactic acid to be applied every 
two or tbrcti himra by the miriw in from one to six parta of water, and 
to be used pure oiict or twice » day by the surgeon. Trypsin, papain, 
fiiid resurcia haveall been recommended f(>rtl)eirt!np]N>sL*d solvent effects. 
Tannic acid, alum, and sulphur have beiiiiided in the form of powder by 
ni:i:iy phygic-iaiis, but are of doiihtful utility. Various local anti^eptio 
sppliwitinns are UBefnl when they can be made without too niocb objec- 
tinu by the patient; but I nhntever is used ebon Id l>e so uiild 
aa t(» cause but little paiu, otiierwisf it is apt to do more harm than good. 
Of these, mercury bichloride, rarliolic acid, potiisttinm permangauaCc, 
jMwliuui cidorate, glyuerole of bonis, nhlnral, and the tincture of iron are 
moat efficieul. The fir«t i^used in the proportion of 1 to 4,000 of water, 
fir even «b strong as 1 to l.OtN), but this is too strong for ordinary 
Tiw. Carbolic acid is nsed in tlie strength of from one to five per 
cent; the latter is especially reconnnended by Oertel (Ziemssen's C^FC^l>• 
pa'dia, English trannlation. \'(d. 11.). Potassium pprniangaiuite may be 
used in the strength of gr. v. ad \ i., the liquor soda» clilorata.' four 
drtichms to ten ounces, or potJis^ium chlorate a saturated solntioD. 
H-gli ITeniming. of Kindiolton, Englind, advocmtes the synip of 
rhb.ral. gr. xxv. tii\ 7i., applied every nne or two hour^. Suiplmrons 
acid properly <ltlnteti is also lieneficial. Hydrogen peroxide has l>ecn 
highly rertuumemied ;ih a sjjray either in its full strength (Marohand's) 
aa obtained from the dri'ggist, or diluted acconling to the degree ot 
amarting i)rodured. l*nro alcohol is used by some as agarglc or spray, 
with apparent advantage. Tincture of myrrh has also been extolled a& a 
locid application. Tincture af the chloride of iron may be used either 
in the form of a spn*y or by rnoAns of u swab. 

G. V. UIack,of Jacksonville, III. (/>?«/«/ /y^We/r, March 15th, 1889, p. 
128), has shown that the officinal cinnamon water, although harmless to 
thepatieut, is one of the most efUcacious antiseptics; and Koaxand Yersin 
{Anmtln de (ft/ufvohgic d iVOft^tclru^vt^, September, 1889; Paris) 
have demonstrated that the toxicity of cultures of diphtheritic bacilli 
is greatly diminished by the addition of carbolic acid, borax, or bortc 
acid; I have, therefore, been iiiduct'd to try as a local iii)pIication a siit- 
nrated solution of boric acid in cinnamon water. This is neither pain- 
ful, unpleasant, nor dangerous, and has seemed to me more efffoiont 
than other locfll remedies which \ have empli>yed. Any of these appli- 
cations may be of more or less value when the patient does not rebel 
against their use; if a contest becomes necessary every time the 
remedy is applied, it will probably do more harm than good. The tinc- 
ture of iron, when administered internally frcptenlly and in corn]>ani- 
lively large doses as recommended below, lias all of llie local influence 
that is usually necessary, and obviates the necessity of sprays or gargles. 
When the diphtheritic process extends to the nose, the nares shoald be 





lahed throe or four times daily with a &atnnitcd solution of boric ncid 
some mild alkuiiue wush, which shouiil always he used wiirm. The 
washing may often he accomplished by an titomizcr. Wliencver it is 
Uecesaary to employ a syringe, the pnlienl should be placed f:icc down- 
ward 80 that the fluid will not run into the thruut iiiid cituse MtraugUng. 
After the washing, a powder consisling of iodol, sugar of mil k, and pa- 
pain — equal parts, may be freely blown into the nose. 

hiternai Treatment. — Physicians generally are agreed that the treat- 
ment of diphtheria should be tjuppurtiug and stimubiting from the he- 
ginning. With this in view,iron,quinine,8trychiiine, and alcoholic stim- 
ulants have been employed for genenitions, and they still hold the firet 
place with a majority of the profession. No internal remedy has seemed 
to be more effective than tincture of the chloride of iron given in fre- 
quent and comparatively large doaes, amounting to about one minim of 
the medicine for each year of the child's age admiuistered every one or 
two hours, according to the severity of the case. I Dsually combine it 
with a Bmall quantity of glycerin and sufficient syrup of toln to make 
one drachm, and direct the patient to take it without dilntion, provid- 
ing it does not caune smarting. As the throat becomes more sensitive, 
the remedy is diluted sufficieutly to avoid much discomfort. To pre- 
vent any irritntion uf the stuuuich, it is well for the patient to take a 
drink of water before the medicine is given, and aa much more as desired 
five minutes afterward. Quinine may be given at the same time, prefer^ 
ably in pills or capsules; otherwise the patient may become so disgusted 
as to refuse it altogether. Alcoholic stimulants should be given freely 
when the pulse becomes weak and the vitality diminished. If there 
is a tendency to heart failure, no remedy is of greater value than nnx 
vomica in some form, iitrychuiue may be given, but ihc tincture of 
nux vomicji has seemed to me more effectual, and it should be given 
in compnmtively hirge doses, sometimes as much as half a miuim for 
each year of the child's age, being required every one or two hours. 
Within t}ie paist few years mercury bichloride has been largely used in 
the treatment of this disease with apimrcnt success, and other prepara- 
tions of mercury are recommended by variona authors. Pilocjirpine is 
advised by Oertel, who believes that it hastens separation of the mem- 
brane but its depressing effect upon the lieart is a serious objection to its 
use. Among other remedies which have received the sanction of good 
authority arc eubebs, copaiba, potassium chlorate, the sulpho-cjirbolates, 
sodium and potassium sulphites, salicylic acid, the salicylates, and ])nla8- 
tium, sodium iind ammonium benzoates. Indeed, there are few remedies 
of any potency in any disease that have not been tried for this affec- 
tion, and which have not, for a time at least, received unmerited praise. 
When the disease extends to the larynx, remedies calcuhite<l to re- 
move the membrane or to prevent spasm of the muscles Jiave been rcc- 
omroended. For this purpose emetics are chiefly employed; among 



thoae in common use are alam, ipecarnanha, tartar emetic, zinc snlphatep 
copper sulphate, npomorphine, and turpeth minoml. Of tliese, ipccaon- 
cnlia and uliim are the simplest and safen, though the tnrpeth mineral 
IB largely employed, and copper gulphato is highly reeomn.ended by gooil 
ftatboritii-a. These, however, should only be employed early in the nttuelc. 
I fnlly indorse the ancient belief that in this condition mercnrials have 
coDBiderahle j>ower in preventing the deposit of memhnine, snd remov- 
ing thtit which hns already been formed. I prefer the mild rhlorideof 
mercury, administered in doses of about half a grain for esich year of the 
child's age, every one or two houre until it acts upon the bowels. The 
frequency of the dose is then gnulaaUy diminished^ and, as soon aa 
dyspntpa has been relieved, the drug is withdrawn. It is surprising 
how slight its effecta are upon the bowels iti this condition; a child 
two years of age will frequently take twenty t<i forty grains of calomel 
without serious disturbance of the bowels. 1 have never seen any 
ill effects from its use in this way, and I believe it can do no harm. 
As obstruction of the glottis increases, the lips and finger nails be- 
come blue, there is recession of the softer portion of the chest walls 
during inspiration, with labored and stertorous respiration^ and other 
aigUM of approiiching sutToration. At this time operative measures 
should not he delayed. The openition to be preferred depetids 8ume- 
whut upon the age of the child and its surroundings. Other things 
being eqnal, in children under five years of age, 1 decidedly prefer in- 
tubation by O'Dwyer's method. In olderchildren, intubation is not quite 
Its satisfactory as tracheotomy, still it has been found useful in many 
cases, particularly where the graver operation will not bo j>ermitted; 
therefore I would advise that it be tried first; it doee not preclude th6 
sub^queut perforinartcc of tracheotomy. These operations are described 
under the treatment of membranous croup. 






Acute folliculnr pharyngitis is an acute iuflammation of the follicles 
in the iiiuc'oiia ineinbrunc of thu pliaryiix, oc(!tirring most frequently in 
cold and damp climates, and iu young or middle-agftd people. Thos© 
Baffering from ii riieiimati:! diathesia are peculiarly prone to it. 

Anatomical and Pathological Characteristics.— As a result 
of the infiammtttion, the mncous follicles bccorao cloaed and finally dis- 
tended by their altered secretions, in some eases the distention becom- 
ing 80 great that the folliclo i& ruptured and a small ulcer results. 

Etiology. — The most frequent cansea are: exposure to inclemency 
of thti weather; the abuse of tobacco; and excej^Rive use of the voice in 
badly ventilated rooms or out of doors, especially in the night air. The 
inhiUattou of irritating particles of dust or of smoke is an occasional 
CI use. 

SYMrroMATOLOGY. — Mild coses begin with malaise, which mny last 
for a few day«. the patient eouiplaintng in the mean time of some little 
fever and more or less diatromfort in the throat. Early in the attack, the 
patient uaually experiences drynesH, smarting, or pricking sensjitione. hi 
severe cases pain and swelling are excessive and the constitutional syinp- 
toms very pronounced, the fever ruuuiug up several degrees. There es 
often a slight hacking cough, with expectoration of a small amount of 
glairy, tenacious mucus. Hoarseness is present in most inst'inces, due 
to extension of the inflammation to the larynx. TTpon examination of 
the throat, the mncous membrane is found coiigeste<i: and in patches, 
corresponding to tlie follicles, there is swelling and deeper congestion. 
Several of these swollen follicles may be visible, especially just back of 
the posterior pillars of the fauces. Soiue are ronud, others oval, and, 
all more or less elevated above the eui-face. Some with yellowish sum- 
mits look like pustules. xVt other points where rupture of the futlicles 
and escape of their contents has occurred, small nlcers are visible, and 
remain for a few days. Where the contents of a follicle are retained for 
a number of days, they become somewhat cheeay. 

DuoN'OSis. — Acute follicular pharyngitis is apt to be mistaken for 
simple acute sore throat. The essential points in the differential diag- 
nosis are the round or oval follicles more or lees elevated above the sur- 
face, accompanied by pustules or small ulcers. 


PRonxosis. — The diBeou uinall.T terminates in resolntion within s 
few days. In most caws, hovever, there is a tendency to recnirence, and 
thf iittacTt may be repeated many times. I hare seen one patient who 
hatt hod an uttaek every three or fonr weeks during the lact two years. 
Noorly always there is some disease of the tuual passages or o( the naso- 
pharynx associated with this predisposition to acute follicular pharyn- 

K Trkathekt. — In cases where the portal circulation is alnggiEh, the 
H^auDimistration of salines and an occasional mercurial cathartic will work 
much benefit. In lien of mercurials, the mineral acids, especially hydro- 
chloric, will be found useful as hepatic stimulants. Many of these patients 
^ire troubled with poor digestion, which may be best relieved by the 
^nso of bitter tonica. Qnininu is useful, more especially in uUra-malariul 
districts, but under ordinary conditions! have found hydrastine muriate 
and extract of nnx vomica more efncient; but whuterer bitter tonics are 
^{prescribed, the doses should be small. The local treatment, which has 
the prestige of antiquity, consists of the application of solutions of silver 
nitrate in strength of from gr. iix. to en. ad i i. It should be made 
rith an absorbent-cotton swab or largo brush, satarated with the solu- 
hut not so wet that drops fall from it. The tongue should be de- 
as far as possible, and the application made quickly from the 
lower part of the pharynx upward, by which procedure the whole 
pharynx can be treated at once. Applications of silver nitrate often 
cause strangling, even if applied only to the pharynx; they Caste badly 
and cause prolonged smarting if used in strength sufficient to be of 
value. For these reasons I seldom employ this remedy, and I have an 
impression that it is of no more therapeutic vutue than leas disagreeable 
agents. In these cases the astringent and sedative spray containing 
morphine, carbolic acid and tannic acid (Form. 93) has not been disa[>- 
poiutiug. In obstinate caaea some authors recommend the actual 
cautery, in the form of a amall wire with a little bulbous end, which is 
heated and touched to the inflamed fullicles. This results in a more 
acute inflammation for a short timu, followed by thorough resolution. 
The gulTano-cantery is much more easily applied than the actual cautery, 

I and is to br^ recommended when needed. In cauterizing, not more tban 
two or at most three small spots should be touched at a time, otherwise 
too much inflammation will be caused. The cautery is not often needed 
In acutu cases. 


Sifnonyim. — Granular sore throat, clergyman's sore throat, chronio 
'pharyngitis, sometimes knoirn as hospital sore throat. 

disease is u chroiJc infiAmroatiou of the pbarynf;eAl mucous 
the brunt of which is expended upon the follicles. It is 





p.t<*r'^*€rK^ by hypertrophy of the mucons membrane and irregular 
plastic exudatlou upon it, occurring in patches, especially about the fol- 
licles. It is most murlccd in damp und chilly climatoE, occurs moat 
often ia those of deiiotte constitution, und id perhaps the most frequent 
of all chronic ufFectious of the fauces or throat. Three varieties of the 
disease have beeu described: the liyper trophic, the moat common; the 
atrophic, not very frequent; and the exudrtive, which is rare. Lennox 
Browne does not recognize an exudative form, but I hare seen several 
well marked costis. 

Anatomical axd Pathological Characteristics. — In the hyper- 
troplii*; variety the mucous membrane of the pharynx is studded with 
swollen follicles varying from two or three to ton or twelve in number. 
These are red or yellowish red in color, oval or round in shape and ele- 
vated one to three millimetres above the surrounding sprface. Those cf 
A yellowish red color sometimes apjiear like small blisters, with gelati- 
nous contents. Often two or three of these follicles are grouped closely 
together or united; this is much more frequent at the angles of the 
pharynx just back of the posterior piilars, where they often form long 
red welts. One or more of tlie superficial veins are usually enlarged^ 
sometimes to a diameter of one or two millimetres, and they occasioualiy 
seem to terminate iu the enlarged follit-Ies. Where the infl.immatiou 
has existed for a long time, it finally results in more or leea atrophy. 
Some of the enlarged follicles may remain, but the mucous tnembrrne 
between them looks thin and whitisth and sometimes seems to bo covered 
with muco-pus; an appearance due to the atrophied wbiiuued tissue 
shining through the secretions. In tlie hypertrophic form, the bulk of 
the enlarged follicles Ims beeu found microscopically to be made up of 
swollen epithelial cells. In the exudative form, yellowish spots will be 
seen at the mouths of some of the follicles, similar to the yellow spots 
teen in chronic foUiculur tonsillitis, due to cheesy accretiona from these 
diseased glands, mingled with viscid mueus. 

Etiologv.^ — The disease may be tmused by the constant inhidation 
ftf vitiated atmosphere, by frequent exposures to cold or dump, und by the 
tise of tobacco — particularly, there is reason to believe, by excewtive smok- 
jTig. Occasionally it seems to have been caused by the inhalation oi 
acrid fumes, as for example, those to which tinsmiths are exposed. Over- 
use of the voice, particularly iu badly ventilated rooms or in the open 
air, is evidently a frequent cause. The ingestion of spices is possibly an 
occasional cause of the disease. It has been attributed also to digestivo 
disturbances, with which it is frequently associated. The most cuiiLmou 
cause is obstruction of the nasal passages by swelling of the turbinated 
bodies, polypi, and deflection or exostosis ( f the septum. As .1 result of such 
obstruction, normal nasal respinition gives pl«ce to mouth-breathing, 
which by rarefaotior nf air in the>-pharynx with each inspiratioUf 
finally causes cougestiou of the throi-t, and if prolonged terminates ia 


disease of its mucoue membrane. That the affectiou is hereditary in 
some instances there cau be no doubt. It is claimeil that the arthritic, 
rbeumatiL-, and scrofulous diathei>es favor tlie [irodiicti<i]i of this disease. 
The frequent recurrence of licute attacks u apjNirt'ntly tlie cause in some 
iufilances. Chronic follicular pharyngitis is sometimes found following 
one of the eruptive diseases. It is favored by chruuie alcoholism, and 
expoRuVe to prolonged dry hunt is a not very umiummou cause. Mental 
dejiression, portal congestion, and torpor of the liver may be put down 
as among the rare causes. 

SYMijToMATOMHi Y. — Usnnlly there is at Brst passive congestion, which 
may run into the chronic condition of inflammation without greatly at- 
tmctiug the patient's attcniicin. The first complaint is liable to be of 
slight discomfort in the throat, whicli may bciv feeling of simple dryness, 
ursome peculiar sensation, or may amount to actual pain. Patients usually 
B|>eak of drynesti or pricking sensjiliuns in the fauces, sometimca of a 
hair, or lump, or burning pain, which may bo continuous or only occur 
at periods during tiic day. IVorniunccd instances uf this character are 
mortT prone to occur in the exiid.iTivo variety of the disease. Partial 
deafness sometimes occnrs, and it may even become complete. This is 
due to an extension of the induniniutury process into and along tlio 
Kustachian lubes. The giving way of the voice is usually, however, the 
first thing which admonishes the patient to seek medical advice. When 
the voice Ih lined mure or less cuntinuouslv for half or three-quarters of 
an hour, the person Iwcomes fatigued, and ilio piinnciation is likely to 
fail. AlthoUL'h hoarseness is not a constiint feature, yet nearly all pa- 
tients are troubled with it to a greater or less extent npan slight expo- 
sure or free use of the voice. Short of hoareencBs. the expression of the 
voice will be found feeble or mufHeJ, and the singing voice is generally 
lost. A few patients may even suffer from complete aphonia as a result 
of the extension i>( the disease to the larynx. AH the symptoms are 
variiible, and are apt to change in the same patient; they are gener- 
ally intensifieri during the cold and changeable seasons, while an im- 
provement occnrs in the summer. In nearly all cases, careful investi- 
gation will lead to the discovery that there is ond respiration. Many 
{^Mitieuts, who aRirm that they breathe perfectly, will be found to breathe 
with the mouth u|KML,jmrticulurly during the latter portion of the night. 
The conjttitutinnal effects of follicular pharyngitis depend upon the im- 
peded nas.'d respiration, or upon the digestive disturbances which may 
be a causative factor of the disease. The frequent hawking attempt to 
clear the throat is often one of the most noticeable snnptoms of this 
affection, and is duo to the uncomfortable sensation produced by the 
tenacious mucus adhering to the palate or pharynx. In a few cases there 
is severe cough, particularly in the morning, and mucous pelletn are 
expectorated early in the day, more especially when the disease has ejt- 
tended to the larynx. In some cases there is muco>puruleut expectora- 
tion, and tMxasiunally the spatnm is etreakeil with blood ; this, however^ 



is of DO consequence in the diaguoBis or prognosig, though it is often 
alarming to the jmttent. In nmny v:A!f»& the BecretioiiH whicli furm in 
the naso-pharynx and nose gradually find their way downward and bnck- 
Trard into the pharynx, or even into the larynx, and may be Bt»en adher- 
ing to the posterior pharyngeal wall aa thick, dry or moist scabs, or they 
may hang in stringy masses from the edge of the palate. There will 
usually be found a oousiderablo amoant of mucus iu the naso-pharynx, 
and some adhering to the mueoas membnino of the larynx, where it may 
cause cough. Commonly there in a coated tongue, togetlier with otlier 
evidences of digestive derangement. Where pain is experienced, it may 
te during the act of sw.illowing, but in some cases thi/ !> iifort may 
be relieved by deglutition, and not reap- 
pear uutil an hour or so after eating. 
Liquids are e.-tsily swriUnwed by some p«- 
tientij, but solids L-uuse pain; with others 
the opposite \» true; while to still others 
neither will c:iuse any discomfort. Upon 
examination of the throat, the enrfoce 
(Kig. SO) will be found congested and swol- 
ien in pak-hes, the blood vessels in many 
cases enlarged, and the follicles of abnor- 
mal devclopiMfiit. About the latter there 
is usually a narrow zone of congestion. At 
the base of the tongue diseased follicles 
similar to tlioso upon the pharyngeal wall 
may !»e observed. In the exudative type 
of the affection, two or three yellowish 
points similar to those of chronic follieuhir tonsillitis may be seen 
at somo part of the pharynx. Small ulcers are described by Cohen 
And others as being present occasionally, thongh I have never seen, 
them. The tonsils are often involved, in either chronic follicular 
infinmniation or simple hypertrophy. The palate may be relaxed and 
the uvula elongated; and the larynx is not infrequently the seat of more 
•or less congestion, more particularly the posterior ends of the vocal 
<'ord8, efippcially after using the voice. Examination of the naso-pharyiii 
will reveal congestion of \i» muuoiis membrane, with, generally, abundant 
secretion. Often there is submucous thickening at the sidea of the 
vomer, which may appear gniyish white and slightly nodular, and ia 
fiomctimes sufficiently large tn almost occlnde the posterior nares. Such 
obstruction may also result from hypertrophy of the posterior ends of 
the turbinali^d bodies. When the secretion is scanty and the mucous 
membrane dry and thin, white atrophied tissue is seen between the follicles 
— a condition known as jifutrt/nfji/i^i /tia-a, or atrophic fa) (it: ular pharyn.' 
fitiU. Sometimes the entire pharyngeal wall will be found covered with 
dried secretions. • 


Fio. St.— CtauKiD TauJOOLUt 
PBAHTMaiTU (Ooasv). 



DlAOjrosis. — Syphilis is the only disease with whirh the nffeolion is 
likely to be coiifouiuleO. When there is simple congoftcjon, with very 
slight eulargemeut of the follicles, it may be diftieiilt or impoeaible to 
difiiinguish it from some oases of syphilitic sore throat, but in the latter 
there are naually either the mucous patches of the secondary sluj^c or 
the ulcers or scars of the tertiary period, llie presence of which rendera 
the diagnosis plain. The remote poasibility of mistaking the ulcer of 
chronic follicular pharyngitis — which is very rare — for that of syphitia 
ntiiy be remembered. Chronic follicular pharyngitis may possibly be 
confounded with tubtfrcnlar sore thruttl, but in this the ulcers are super- 
ficidi and irregular, and the edges not distinctly marked: whereas in 
chronic follicular phuryngitis they occur, if at all, but rarely, and then 
only as small, round ulcers where distended follicles have ruptured. 
The presence or absence of the constitutiuntil evidences of tuberculosis 
will have great weight in determining the true nature of the disease. 

ruoiiNoms. — Chronic follicular pharyngiiiit may continue for years 
unless efficiently treated. In many cases the inflammation gradually 
extends to the ear, or to the larynx, giving rise to deafness, or to loss of 
^oico. Again, the hypertrophic form of the diuase may terminate in 
the atrophic^ which is far more troublesome to the patient and very ditfi- 
cult to euro. The exudative form of the affection is geucrally more ob- 

Tkbatmest. — The old adage that an ounce of prevention is worth 
» pound of care conld well be applied in this disease, were it not that 
the op|»ortunity is generally lacking to the physician, inasmuch as the 
patient does not preseut himself soon enongh. A caution should be 
giveu, however, regarding those exposures already mentioned which are 
knitwn to exert a damaging influence upon the part-i;, for they not only 
cuuxe the disease, but favor its continuation. Faulty digestion and elim- 
ination should be corrected. In many case^ a conrse of diuretics and 
bitter tonics is indicated. Arsenions acid is often of special service. Those 
predispoeod to rheumatism must have appropriate constitutional treat- 
nsnt. tiocally, silver nitrate is an old time remedy, but one which I 
trnftfly recummond. It may be applied in strong solution or in the solid 
itick, but, if the latter, only a small area should be treated at one sitting. 
I have hud excellent results from powdered hydnutine (Form. 174) by in- 
ttifllution into the naso-pharynx in cases presentingsereral fnlsrged folli- 
t\v* of a deep pink color, providing the surrounding mucous membrane 
tt inoint.ami the secretion— except in thenaso-pharynx — is not excessive. 
1'Ih> piiwder remaius in the nasu-pharynx several hours, gmdually work- 
HtH down the pharynx and thereby prolonging the effect. At first only 
« iuiiill rgiuintity should he used, in order to ascertain the susireptibility 
tfl Iho |uit ictit, since in some cases the remedy applied in this way causeft 
f^yont |Hiiu. Ordinarily it produces nodiscomfort 
. Ill mil' md oft«n in those more severe, local astriDfenls are 



desirable, and troches of kmrnerU, either simple or compound (Form. "SA 
and 41), will be most conreuientW a»ed by the putieut. Spmrs to th« 
oro-pbarrnx of copper sulphate in solution of ten or twenty grains ad 7 1., 
tine chloride or tine snlplmte in the aame proportion, or meroury bichlo- 
ride gr. 68. ad I i. are also usefnl. Somewhat weaker solutions of the same 
may be used for the naso-phurynx, which in nearly all itistauce« requires 
treatment; indeed, it is often more important to mediczite the uaao- 


Tie. W.— Inoau)' MoDin^ATinif or Srcrlt'b BA-mmT, Thin hu two Iwm oHla. Tb« H» 
rmdU ciidmIbI 'if larx« *i«c a"<I i-wlmu pUtnt, wlilub nuy bi* dvptvwwri In uny di^ml ilrptb hj- thu 
aerewiih'iwo to th«>c«Dirp Tliitit ibfcurrvut tn>y Im accuntrlj' rvA-iiIiit«<1. IIki c«iihT)r battery 
brft- Khiiwn I hav<> impiI tiarymr* «rlih ntu<4iMlh>fatftlr>ii.Ui<>tucli Inr thi-|iai>t Iko jrvanl )iarr> »it>rv> 
oommonlr rrapVtj-rd a, stomp' hAlhTT w> oonDKlml that I cut Cttsil)' charx« It from tli« Edunu 
enmtil. Ic U winifwhiit conrmirnt, frbrn workioit wi>U, tlinn tlx^ luUrrj' hvn chawo, but 

pharynx tliun the other parts. When the follicles arc much enlarged, 
the above treatment will not be sufficient, anil there will be no great relief 
until they are cured. To accomplish this, they may be cauterized with 
nitric acid, chromic acid, or London pa^te, a smull quantity being applieil 
directly to the surface of the folHole, not to the surrounding mcnibrune; 
only two or three of the follicles should be treated iit eiich sitting. This 
procedure nmy be repeated every four or five days until ull are removed. 
Sometimes it is well to split the follicle with u sharp knife, and then 
crowd into the incision the pointed end of a stick of silver nitruta. 



fSnroo are in favor of scraping off these follicles with a curette. The 
'nctnul cautery miiy be emiiloyed — as recommende^l for acute follicular 
pharyngitis— hut the galvauo-cautery (Figs. 00 and 01} is the iMSt mttons 
for getting rid of the hyjiertrophied follicles. In using it the electrode 
is applied cold, the current is then turned on for a second and the fol- 
licle destroyed. The next day after using the cautery, a whitish pel- 
licle is observed about this cauterized point, which may extend for fonr 
(»r five millimetres in every direction from the burn, and appears very 
much like a diphtheritic membrane. This remains from five to even 
twelve days, depemllng upon the rapidity of the reparative process and, 
perhaps, atmospheric conditions. Frequently the patieuU retch, and 

Fia. SI.— TxDAi^' CAtmatv EutrrwooBa (S-Salse).' 1, nttmrtlKl dMnrmlA mmmI fnr mqMrflcW 
«AUlvfiiAlb>iii 111 hmyivv^t ; -i. kuUt'-Ukr f-Uvtivdr WMyi la hri'rniV'phie rLloill* : 8. 4. and 3. rlcctrodBS 
for cauteHiiiiK th« lonaUs. follk-lr« in pbnonx, aad imMU i>pi>l>t in llir niwp ; \ ploctrodf for b«ae of 
touftuts (If. «l>Mi §w>'*l'^ by k |ii«w of mtcAolls nbr«, for ttano-iihrnrfuk ; \ fl, nod 7, tubular Heo 
iTotlcs. iDU} which rmrtotis cbspMl poinUof rkilnucn wtn may tut inBrrtc>] (or m-totu purpo*e». 

gag easily, and in such coses it is evident how difficult it wonld be to use 
the actual cautery. Where there are enUi-gcd veins, it is better to cut 
them off with silver nitrate or the giilvano-cantery — the latter being 
much the more satisfactory iu its action. Though the exudative form 
of the disease has been considered peculiarly obstinate, it lias, in my ex- 
perience, proved less Btubboru thim some other forms, when treated by 
the galvano-cautery in the manner just described. Cases of simple 
chronio congestion without enlargement of the follicles are most difficult 
to cure. In these all sources of irritation must be avoided, and the 
patient should make applications to the pharynx of some mild astrin- 
gent two or three times daily. Sometimes such patients will find it neo- 
e«stiry to remove to a different climate before relief is found, but ordi- 
uarily it is not well to adviw: such a course, for the climatic iuflueuco ia 
very uncertain. 




Acute follicular glossitis \% an inflammation of the folllrles at the 
base of the tongue, in which severe pain \a caused b_v an attempt at 
deglutition, lit) causes are probably not nnlikB thotte of atrntt folhc^ 
ular pharynpilis, and its jiathology la uUo similar. 

Symitomatology.— Pain is felt not onl}* in the throat, bnt ntUiating 
to the ears, and some patients speak of it as being almost altogt-tlier in 
the eara, or near the orifices of the Eustachian tubes. Upon t'xumina- 
tion of the ]mrts, we may find seveml aniall. rounded elevations of a 
whitish huH somewhat resembling pustules, which may be digtribnted 
all over the hum of the tongue, or confined to one or the other side, 
particularly to that portion of the base which is often hidden from view 
by contact with the external vail. 

In some cflses, instead of these small follicles, one or more superficial 
ulcere are to be found. 1 have seen one at least a centimetre in diume- 
ier, where small ulcers had coalesced after rupture of eeverul folliclm. 
These ulccrg are more apt to be found at the side of the base of the 
tonguo, where they may escape notice except npon cjireful inspection. 

rtl.*<iXOSis. — The disease is liablo to bo mistaken for inftammation 
in the nasn-pharynx, buciinse the patient often refers the pain to that 
locality. The diagnosis will be made by a careful laryngoscopio inspec- 
tion of the base of the tongue, particularly of its sides, which must be 
exposed by crowding the orgaii over with a spatula. 

pRUGKo.«is. — Left to itself, the condition lasts a week or ten days. 

Trkatmest. — Tlie most satisfactory treatment consists in the appli- 
cotion of a sixty grain solution of silver nitrate to the follicles or super- 
ficial ulcers. The rapidity with which the affection may be cured by 
this method is soQietiines surprising. I recollect one case especially, 
where an ulcer a centimetre in diameter was found, in which the paia 
was relieved within a few minutes after the first application, and in 
forty-eight hours the nicer practically healed. 


Chronic ftdlicular glossitis is nuL infrequently associated with chronic 
tODsillitis, and is cbanictorized hy chronii^ inflammation <»f the follicles 
at the base of the tongue, which become more or less filted with secre- 
tion producing numerous yellowish white spots similar to diseased folli- 
cles in the to u si Is, and atteudcd by various uncomfortable sensutiona 
referred either to the tonsils or, nioru iicuunitely, to the base of the 
tongue. The nature of the affection Is tjaseiitially the &ime as that of 
chronic follicular inflammation of the tonsils, and it is appareutly dfr- 
pendent upuu like causes. 



SrnpTOMATOLOGy,— The principal symptoms of which the puiient 
ooinpIuiD5 are sensationB of pricking or of a foreign body in the tbrout, 
which uiuy be ]>re&eiit eontinuoaslj or only a part of the time, and which 
mttv ur muy not U' ii^rgnivmed by the act of deglutition. 

Dli.oSosis. — 'J'he diugnosis is made by an examination of the buae of 
the tongue with the larvugeal mirror, without which it U seldom possi- 
ble to see the diseased follicles. 

Pbooxosis. — The affection tends to run on for many months or years, 
during which time the patient is much annoyed by offensive breath and 
by harassing fears of tuberculosis or cancer. 

TttEATMENT. — When due to u rheumatic diathesis, or to distnrbimce 
of the digestive organs, the treatment suited to these disorders is indi- 

Locally, astringent troches iia represented by the troches of krameria 
(Form. 38 and 41) are sometimes beneficial, and applications of more 
active astringents, of stimulants, or of strong solutions of silver nitrate 
Bometiun-'S prove curative. A more efficient method, and one which 
finally must bu the resort in most ca8e8,is cauteriziilion with the galvauo- 
cantery. This is usually followed by the most satieifui^tory results. Two 
or three foltirles should be (cauterized at ea<;h sitting, by a small electrode, 
vhieh should be passed to the bottom of earh, and the operation should 
not be repeated until two or three days after all soreness from the previ- 
ous cauterization has disappeared. This treatment should be euntinuod 
until all of the diseased follicles have been dealt with and a cumjdttte 
eure may be confidently predicted. 


1«MJ I 


Scrofulous sore throat is a chronic inflammation, sometimes observed 
in scrofulous children, which in the simple form has the appearance of 
ordinary catarrhal inflammation; when more pronounced, it resemblea 
the inflammation of tuberculosis or syphilis. In many instances it con- 
sists of simple inflammatory thickening of the mucous membrane of the 
fauces and naso-pharyni or palate, but in the more atlvanced conditions — 
which, indeed, arc the only ones rightly classed under this head — ulcer- 
ation occurs. This at first superficial and always indolent, finally be- 
comes extensive, sometimes spreading over a large portion of the pharynx 
or involving the palate, and causing perforation, or even destruction of 
the nvula with considerable portions of the velum. 

Etioloot. — J. Solis Cohen (Diseoaed of the Throat) believes that 
most of these are cases of simple chronic tufiammatiiju occurring in 
those of inherited syphilitic taint, while others regard it as a manifesta- 
tion of lupus. Still others ascribe some of the cases to tuberculosis or 
the rheumatic or arthritic diatheHis. Whatever the remote cause, it is 
certain that a low form of inflammation, with ulcenitiou, occurs in chil* 



dm preseniing «hat v«s formerij knovii as Kbe Bcrofntoas diaUieM; 
aeh] it u more ibtm poecible that, in most of these, hereditary svphUia or 
tuberculosis cotUd be traced if a& accaiate h»iOfj eoald tw obtained. 

STJirTOMATuLor.T. — There are no potttire qmploBu or signs ot thia 
affection, hot nsuallT the chUd ii pale and leu vigoroas than other chil- 
dren of the same age and surronudtngs; there is jometimes a tendency 
to clear the throat of secretions fret^aently, but n^aallv this is not a 
pronounced symptom. And even vheu extensive ulcemtiou ha« taken 
pUce the patient does not comphun of pain. Diffimlty in deglutition or 
alteration of the voice may be caused by partial destruction of the soft 
palate or extensiTe ulceration of the pharynx. Sometimes a history of 
inherited syphilis or tubercnlocis can be obtained, and npon examination 
of the fauces more or less extensire ulceration will be found. These 
nlccrs are at firpt superficial., but later are deep, with beTellod edges, in- 
dolent surface, and slight discburge. 

Diagnosis. — Scrofulous sorothront is to be distinguished from lupus, 
tuberculosis, and syphilis. 

External manifestations which may at once decide the diagnosii, 
nearly always attend lupus. Cpon the base and about the edges of the ■ 
ulcer are red nodules, which do not appear in the scrofulous ulceration. 

Scrofulous sore throat is distinguished from iuttfrcHit>sis by the 
comparative absence of pain, by a well marked instead of an indistinct 
bonier, by the absence of fever and other evidences of tuberc^ulosis. 

Scrofulous sure throat is diatingnished from g^phiiitir nlceration of 
the throat by the absence of a syphilitic history and the general signs of 
the disease, by the age of the patient, slow progress of the ulceration, 
slight discharge and bevelling of its edges, which do not have the puiiohed- 
out uppearance common in &yphilis. 

Scrofulous sore throat and lupus of the pharynx present the following 
points of difference: 

O^nemlly in younj; ai)ii1t«. U*iially 
associated with diHvuBo rif the tit(N>. 

Congested, irregular nodule* about 
elites or on base of i(kx*n», tvliith iii« 
iisuiiDy oxlpiuliii^ in ^4.>llle plnces* 
while lieahng nl noino other [i«rt of 
their border; usually old ricalrirrs, * 

Scrofnions sore throat and syphilitic sore throat can be diftcrentiatod 
as follows: 


Oenetally seen in chiEdren. Uftuatly 
evidences of constitutional disturb- 

Ulcers supei-flcial or deep, with bev- 
elled edges, indolent buse, and slight 
discbarge; do cicatrices. 


Genorally wen in children. Ulcer in- 
dolent and usually lius u bevelled edge 
not iniluruted or undermined. 

Syphiutic aoES throat. 
Qeiierally seen in ailiihh. Uloor 
sharp 4'ut, induratedi ttuiuuilnjtB uu> 



Tho difTereiitial diugnoais of tuberuuLir sore throat uid scrofulous 
sore throat, will be furtliLT considered under tlie head of acuto tubercular 
sore throat. 

Prognosis. — If left to itself, the ulceration gradually extends, and 
maj continue for many months; I hare seen ctoes which had lasted for 
oyer a year. AVith improvement of the general condition and appropri- 
ate local irtjatnient, huallng may he ex|HK:tod within a short time; 

Teeatment. — Good hygienic surroundings and tonics are most im- 
portant. Calcium iodide and chloride internally in moderate doses are 
beneficial, and cod-liver oil is generally recommended. The local treat- 
ment consists of fnH)nent cauterization or stimulation by less active 
agents. In practice, the thorough application uf strong tincture of 
iodine to the ulcer two or three times a week has given best satisfaction. 
Under its iullucnoe and the general treatment, healing soon begins., and 
an ulcer an inch in diameter may be expected to heal within six or eight 


Acute Lubercnhir sore throat is a rare affection occurring in about 
one per cent of all cases of tuberculosis of the respiratory tract (Browne, 
Diaoasesof theTliroat, third edition). It runs a rapid course, being char- 
acterized by ulceration and great pain and the constitutional symptoma 
of tuberculosis. 

Anatomil'al and Pathological Cjiaeacteristics, — At first there 
appear numerous small, gray granulations grouped in patches beneath 
the epithelium, and if abundant, closely resembling the mucous patches 
of sypliiliSf hut they lock the inllnmmMtory areolae which are found about 
the latter. These granulations arc 8:tid to bleed easily when touched, 
but this has not been my experieuce. They may be located upon the 
palate and the pharynx, and late in tho disease may be found on the epi- 
glottis and in the larj'nx. As the affection progresses they lose their 
transparency, become hidden in a purulent or pultaceods covering, and 
finally undergo ulceration. These ulcerations are shallow, hove no well 
marked borders, but rather a worm eaten, irregular edge, and bleed easily 
vbeu touched. 

Ktioloot. — The cauae is the same as that of tuberculosis in other 

RYMiTOMATOLooY.^tJaaally there are evidences of primary pulmo- 
nary or laryngeal phthisis. The consumptive appearance, persistent fever, 
rapid pulse, congh with or without expectoration, anorexia, and other 
■ymptoms of tuberculosis are apt to be marked, but the pharyngeal 
lesions may be independent of laryngeal or pulmonary diaeose, these 
subsequently suixirvening. The one ]>rominetit. sometimes the first, 
symptom of tubercular sore throat is inteii«e-pHin, sometimes experienced 
upon phonation and upon attempts at deglutition. It becomes agonizing^ 



largely preventing the taking of food, with consequent speedy losg of 
etreugtli and rapid advance of the disease. Au early examination may 
reveal congestion of the pharynx similar to tliat found in simple 
inflammation, but in most caaeti tlie muL-oui< memhnino presents a 
oharacterifitic grayish pallor with numerous somi-tntiispareut granula- 
tions -which speedily give place to ulceration. The tubercular ulcer is 
Bupcrficial, vith Irregular ill detiued borders, which are not umlermined, 
and it is sontclimcs Burrounded by u faint blush, though usually there is 
no areola of hypenumin. The floor presents indolent, gray granulations) 
and scanty secretions. 

In exceptional cjises the tuheri'ular ulcor hns a shtu-ply defined 
border, which m.iy be slightly thickened and congested; it has a depth 
of about one and one-biilf millimetres, and its base is covered with ft. 
grayish white coating presenting an uppenrunce about midway between 
that of the ordinary snperficial ulcer described above and the deep ulcera- 
tion of favphllis. 

DiAoyosis. — Tubercular sore throat msy be mistaken for syphilitic 
or scrofulous sore throat. 

Byphilitic sore thraat is not accompanied by the excessive pain, the 
feter, and the constitutional symptoms of the tubercular affection; and 
instead of the marked anaemia of the mucous membnino and small gray 
grunuUtious, or shallow irregular ulcers with ill detlned, pale borders, 
and scanty, graylsli, viscid secretion, it is characterized by the large, 
sharply defined infiummatory ulctii-a of the secondary stage, or the deep 
nlcers of the tertiary form with raised and often undermined edges, 
granular floor, and profuse purnlent secretion. As also noted by 
Lennox Browne {op. cit.), tlie enlargement of the parotid^ submaxillary, 
and cervical glands, both superficial and deep, so commonly obsen-ed 
in the tubercular affection, is. relatively infrequent in the latter part 
of the secondary, and in ttie tertiary stage of syphilis. 

From syphilitic sore throat, tubercular sore throat may bo distin- 
guished as follows: 


No.«yphilittc history, QcuenUly in 

Marked coDsUtutional symptoms. 

Fever, rapid emuuation. 
Severe local pain. 
Aphoaia, dysphagia. 

Uloer usually superflciaJ, with gray- 
lab, worm eaten appearance and rapidly 

Short duration. 

Stphiutic »ori thboat. 

Sypliililie history. U hereditary, it 
may appear in children ; otherwise in 

Constitutional symptoms may be 

Usually no fever. 

Fraqueulty no puin. 

Hoarseness, but usually ao aphonta. 
or rtysphag'ia. 

ITlcpr sharp out, with areohiof red- 
d<^nMl. thii^kened tijtsue about it, some- 
times umi»!iniined edffe. 

May profi;ress mpidly but usuaJly 
Telntively-IonjifV in dmiitron. 


f Srrnfuhns norr thrmt, nnliko the tubercular, occnrs in childreo in- 
stead of yoniiar ndnlts, ami lacks the severe puin^the fever, Bnd the irreg- 
ilar, ^upiTtiiMai, poorly deiiiicd ulcers of the latter affectiou. 

Between tubereulur aore throat and scrofulous sure throat the follow - 
ig are the chief points of differeuoe: 


Rarely seen in childi-en. Ulcersiiper. 

liaj, wiih poorly deflaed bordeni. 

Hectic fever Considerable cough. 

Kupid eniociatioD. 

Severe i»ain. ft-equeDtly Uio first 

Oyspuoro, dyftphonia or aphonia, 



Generally seen in children. Ulcer 
deep, with sharply defined edg^s. 
No fever. Little or no <:ough. 
Slow pliy&icttl change. 
But little or no pain. 

No dysphonia, aphonia, or dyspha. 
Ho signs of pulmoaary tubercukma. 

f Pboonosi& — Tubercular aore throat usually runs its course in from 
six to twelve weeks, and nearly alw.iys termiimtes fittally. In exceptional 
instances the duration is an much hs six mouths, iind in extretnely rare 
Ciiees recovery may occur, or the disease may progresB slowly, the jiatient 
under fiivorable conditinnfi living for sevend years before Buccumhing to 
the constitutional disease. Death is caused rommonty by nsthenin. 

Tbeatment. — The treatment recommended by Kraiise and Ilerying, 
by thorough curetting the ulcers, followed by the application of lactic 
ftcid, with occftsional use of the gal v an o- cautery, has elTe^ted a few curea 
(Oleitsmann, Sew York MwUcai Journal, lB!>I), and similar results have 
been attained by the use uf lactic acid alone in solutions varyiug in 
strength from twenty to seventy-five per cent. !:jedative apjijications are 
of mucli beneBt, chief among which are 'steam impregnated with bella- 
donna, hyoscyamns, stramonium, or opium, as recommended (Form. 5(i, 
67, and 59). Sajons (Dieease-B of the Noee and Throat) recommends a 
ten per cent solution of cocaine applied often enough to relieve ))ain; but 
the evil effectsof this drug are so pronounced that extreme caution should 
be used in its employment. Painting the throat with solutions of silver 
nitrate as advised by some, has usually proven more hurtful than other- 
wise. I have found most satisfactory, for relieving pain, a spray of mor- 
phine, carbolic aoid« and tannic acid (Form. 93). This may be used by 
the patient also, diluted, with one or more parts of water, according to 
the amount of smarting occasioned. Troches of morpliinc or Jactui-a- 
rium, or althea (Form. *^o, 'i9, and 36) are sometimes efficient in reliev- 
ing the distress, but the good effect of opiates is uRiially counteracted by 
the excessive dryness which they cauM*. When dyaphagia bet-omes ex- 
treme, the feeding bottle may be used, as recommended by Delavao 
stions of the Ninth American Laryngological Aasociation) or 

ari'U/Liric suJiK throat. 


nntritive enemuta niuy be employed, but tu vcU marked caa«8 all that 
we oun hope for is to render tbo intient as comfortable as poBsible. 


SvplnliB mily affect tlie fftncfg in Any of its three stages, bnt the 
caHii'al iiiiiiiifestrttion is seldom seeu iu tbu tliroiit, Ibough tht «-condiiry 
and icrtiiiry furuia are comiuou. The chancre or priuniry lesion cif 
(lypbilis. when prewnt Iu tlit; mouth, is similar to that which niuy oecur 
in other parts, and Uists for live or six weeks; in the secondary stage ll:e 
€rytheni:it<>u8 or niucous jMitrhep, and in the tertiary stage gunmiaLi L.r 
deep ulcere, are cbanicterislic. When the diGmise is inherited, the seo-, 
ondiirr symptoms nsnally occur wiibin two to six weeks after birth ; tlioi 
tertiary, in early childhnod or at any time before the sixteenth ywir. 

Anatomical and Patholcxjical CuAnAcxEHisTics.— Whoa chan- 
cre occurs in the throat, it is nearly iiln-i;ys located ou one tonsil. la 
the ^coiidiiry affection, uttually at first the fauces present a uniform dull 
red erythema; llnK in |iart gnidually f;iili-a away, leaving erythematous 
pfltohes which tend to symmetriwd arr.mgement upon the two sides of 
the palate or pillars of the fauces, and sometimes upon the pharyngeal 
wall. These ptitcbea are sepumted from healthy tissue by a distinct line 
of demarcation. Mucous patches (also termed mucous tubercles or 
broad condylomata) when uL-curring in iuffints, ure usually found in tbd 
upper j>arl of the pharynx ami on the fnuces; but in adults on the pillars 
of the fauces, or the velnm palati and the sides and base of the tongue. 
They are circular or elliptical in form, slightly elevated, at first of a deepi 
red, later of a gmyish white color, and, as a rule, symmetrically sitaatedJ 
on e"oh side of the throat. These subsequently become the seat of 
superficial ulcers; thoir borders i:rc distinctly marked and surrounded 
by an areohi of hyperaemia, slightly elevated, and from three to five* 
millimetres in width. Occasionally deep and rapidly extending ulcera- 
tion follows; these ulcers are two or three millimetres in depth, with a 
light pinkish or grayish surface, and have sharply defined bnt not in- 
dunited edges. In the tertiary stage, ulcerations are deep and usually 
preceded by gummata. A gumma,, situated as a rule under the mucous 
membrane, is at first small var)-ing from three to eight millimetres ia 
diameter, and wnses no disturbance, but as it increases in size the 
mucous membrane covering it becomes congested, and finally, as the 
gumma softens, a yellowish spot appears at the surface, soon to be fol- 
lowed by ulcenitioii. 

Two varieties of ulceration occur In this stage, the superficial and the 
perforating. The former is most fre<|uently found on the veinm, but 
is also seen upon the pillars of the fcinces and tonsils; often having a 
depth of one or two millimetreB. The ulcers have irregular, sharply 
defined borders and secrete foul, dirty pus, which when cleared away 



TOTeaU a floor jmle and itninoth, with here ant3 there fiinpoifl (^'annlniiona. 
FisrfureB eometiineK extend from the edges into the flurronnding tii^ue. 
Deep ulcera situated on any part of the fauces or pharynx «ie eom- 
monly from three to five millimetreg in depth with cbtir-cui edges, often 
undermined and indurated. Ulcers of the tliini Btaw;e, wtitther R'/gtielw 
of gunimata or uoi^ uro apt to extend nipidly, destruring all ti»8tie in 
continnity, not excepting eartihige and hone. Kreijnently perfontinn 
of the p&Iate occurs (Fig. nui) as if hy magic, sometimes as the rognlt, 
of a gamma, vhich in the palate occnrs preferably npun its upper snr- 
faoe. Such Diccration may destroy a couaideriible portion of the velum 
ftithin ten or fifteen days. 

Etioloot. — Syphilis, whether inherited or acqaired, is probably duo- 
to a epeciBc virus, u«t yet identified. 

SvMPTfJMAToLOOY. — The primary affertion usually causes no symp* 
toms, in the throat unlosti phagedenic ulceration ooenrs, giving rise to 
pain and fever. lu the secondary stage, there is dryness of the throat> 


m. m-i . 


with more or less aoreness and oconsionally a slight fe1>rile reaction, 
•ome cases, owing to the location of the ulcer, there is great pain upon 
^deglutition. Papillary eruptions upon the skin usually appear at this time. 
The tertiary form sometimes develops insidiously, and may have produced 
great mischief without having caused the patient much discomfort. In 
other cases, owing to the location of the ulcer, severe pain u experienced, 
especially on deglutition. In such cases constitutional symptoms ore 
thoji apt to bo pronounced, and after a few weeks the patient may prc^eul 
much the same symptoms, with fever and emaciatiout as one suffering 
from advanced tuberculosis. 

DiAitxofiis.— The primary aPTection le apt to escape observation, but 
careful examination of the throat may discover a small ulcer sitoated 
on :in indurated base surrounded by a slightly ecdematoas, elevated 
mucous membrane. If this is associated with a suspicious history, aud 
n>inaintt obstiu:ite to all tre:(tnient for four or five weeks, we may bo 
zieitrly certain of our diagnosis 

The secondary affection, in the beginning, is liable to be mistaken for 
etUarrhal xorf throat., but after three or four days the derelopmeni 



of symmetrical, erytliemutous patches distinctly outlined, or the grayish 
elevated mucous palchea ur siiperlictal ulcers, witli areolee of iuilumnm- 
tiou. will at once suggest the trite nature of the disease. However, even 
then it is poasihie to confound tlie aHei^lioii with ^imph mtmbraimus or 
hei'i^iit^ nore throat : hut the ?pecitic hiitory, if it can be obtained, or, 
if not, the progress of the case for the next few <lny«, will settle the diag- 
nosis. The RUperficiul ulcenition of this st:ige fihould not he confounded 
with ncute tnl>erctil!irttoTe throat, if the lii8tury,coustitulianitl symptoms, 
and appeuranc-e of the ulcer are taken into account. 

The tertiary stage is liable to he mist-iken for grrofxttaux or tuhe-r- 
euittr sore tlirimt, the distinctive features of which were pointed out iu 
considering these diseases. The characteristic features of tertiary 
syphilitic uluerutiou of tlie throat are: commonly uheonco or insigniti canoe 
of pain unil ut eou:<tttuliuual symptoms: also the edges of the ulcer are 
sharp cut, indunitcd, and sometimes undermined, uud the process is rapid. 

In a very rare form of dtp lithe roii3 KVphiHt't; iilcemtion of tite throat I have 
seen three cases that have beea uilstukea for diplitlivriu. 

PHOON03I8.— The primary disease continues five or six weeks, and 
then terminates spontaneously. The secondary alTeetion usntdly comes 
on in from six to twelve weeks after inoculation, and, as a rule, dlsa])- 
pears iu from six to eight weeks, or sooner under proper treatment; but 
sometimes renewed eruptions make their appouranee from time to time 
for several nionlhs. The gummata of the tertiary stage sometimes dis- 
appear ax ihey eaime, but uttiially soften and ulcerate, the ulcers spread- 
ing rapidly for two or three weeks afterward; suhaetjuently thay may 
continue to progress more slowly for several months if left tu tht-ni- 
selve*. The primary affection makes little impression on the general 
hetdth; the secondary is sehlom dangerous Iu life, but the tt'rtiury is 
often grave. The ulceration in the latter may perforate the hard palate 
and destroy large portions of the »oti tissues, and may sometimes cunse 
i^eath hy erosions of a large blooil vessel or by tiarrowing of tlie air passages, 
(lioitrizatlon after uleeration frequently narrows or completely closes 
the opening to the nnso-jdiarynx or causes stenosis of the larynx, iuter- 
Jering with respimtion and phouation. Destniotion of the ]>alate in- 
terferes with phoiuition, and with deglutitiou by allowing fluid to re- 
gurgitate through the nose. Adhesion of the base of tlie tongue to the 
j)haryngcal wall soir.Rtimes seriously interftTes with both respiration and 
deglutition. In one oa«ie which has come under my observation, an 
opening was left only two or three millimetres in width by six or eight 
iu length. L'nder appropriate treatment the majority of eases can be 
relieved and the disease checked, but sometimes, in spite of everything, 
it goes on or the exacerbations frequently recur until death results. 

Treatment. — For tlie primary affection cauterization is recom- 
mended bv Boaie, while others favor a negative t:ourse. Even for the 



aecoDdary lesions Bome are in faror of confining the treatment in 
the majority of nutoe to local raeaenree. Mackenzie (DiHeaeeB of the 
Tliroat and Nose, Vol. I.) stildom uses conatitutional remedies iu the 
secondary stage, relying mninly upon local applicatinns of the zinc chlo- 
ride gr. ji., ftd^i. for the erythematons eruption, or tho tincture of 
iodine for muuoas patches, bnt he recommends mercuriaU for the in- 
herited syphilis and in obstinate cuoea of the HC<|uired affeetion. Sajons 
(Uimmses uf the Noae tiud Throat) advises (or the ttecondaryaffeotioa 
local applications of silver nitrate, iodoform, and tincture of the chloride 
of iron. For the secondarj- affection, I nsiniUy employ a spray of zinc 
chloride gr. xxx. nd ? i. two or three times a week, directing the p*- 
lifut to use ut home the same remedy twice daily in the form of spruy 
gr. X. ad 3 i. For the mucous patches I sometiniets rely upon these np- 
pHcations, and at others I use the strong tiiictnre of iodine or a solution 
of copper sniphate gr. xx. ad 3 i., haviug thu putieut use tho sytmy at 
home as just recommended. Usually small dories of mercury bichloride 
and potJissium iodide are admiuistere^l itfLer each meiil, and in many 
cases femiginons or bitter tonics are given before eating, depending 
npou the patient's general condition. For the ulcers of tertiary syphilis 
the strong tincture of iodine is the most elTlcient application, though 
occflsionally the sulphste i»f copper, as recommended above, will be found 
useful. Much, I believe, depends tipon the manner of applying the 
tincture nf iodine. The nicer should be touched repeatedly at each 
sitting (four to eight times), and a minute allowed between each applica- 
tion for the piwta to dry. When the application is completed the sur- 
face of tho ulcer should appear dry and glazed and of a dark brown 
color. These treatments should be repeated <laily for ten to ftfteen days 
and sniieeqnently less frequently nntil the parts nre healwl. .At the 
same time the patient should be given the iodides of swlium aiul fKitas- 
sium in doses of from 5 to 10 grains each three or four times a day. 
Under this treatment even large chronic nlcers may l» expected to 
heal in from two to four weeks. II there is a tendency to clcuure 
of the entrance to tho naao-pharynx, or other vicious adhesions nro 
forming, bougies should he passed frequently until complete cicatriza- 
tion has occurred; but this should not be attempted until the reparative 
process has been fully established. It is especially important to be 
faithful in dilatation just as the last vestiges of the nicer are disappear- 
ing, for at this time contraction takes place with wonderful rapidity. 

Syphilitic sore tbroat ix infants, is » congenital manifestation 
of syphilis usnally characterized by ulceration, the favorite seat of which 
is the palate, naao-pharynx, or posterior pharyngeal wall. According to 
J. X. Mackenzie, of Baltimore, nearly 6fty per cent of the cases occur 
within the tirst year of life, and as many as thirty-three per cent within 
the first six months. In some, however, the development is delayed nntil 
near the nge of puberty. 



AsATOMicAi- ASn Patholoqical CHARArTERlRTlOfl. — Mucous 
patches ure rare, this KUge having jirubably been ]Hidseil in intra-nUsrine 
life; whon found, the^e patches arc apt li> be luimled in the upper jmr- 
tiou of the pharynx. Ulcemtion is more coinmonty present, it* favorito 
sent in order of froqueTicy bfing the fauces, uaKo-pharynx, posterior 
pharyugeal wall, nasal foesw.gqittim, tongue, and finaHy the gums. The 
ulcers present the appearance of tertiary syphilis in adults, already de- 
scribed, uid are peculiarly prone to attack the bones and cartilugea, 

Etiowiot. — The affection is either inherited during the intra-uterine 
life or contrncteil during parturition. 

SYMPTOHATOLtxiY. — This condition of the throat is usually associated 
with syphiUticlesious iu theuoee, giving rise to eiubarrassuieut uf thenuaaL 
respiration antJ difficulty in nursing. This in a sliort time is followed 
by a serous di»chnrge from the nose, that becomes thick and purulent, 
sometimes sangninolent within a few days. The lips are frequently ex- 
coriated, and specific fissures, pustules, and ulcers develop upon the alfl& 
of the nose, the lips, and angles of the month, extending outward upon 
the cheek. Ulceration of the pharynx also may seriously interfere with 

DiAONOsia. — The diaease is distinguished from nimph raiitrr/utl i«- 
Jtammation by the profuse disclmrge from the nose, the obstmction to 
nasal respiration, the occurrence of pustules and ulcers upon the lips, 
and the peculiar ulceration in the pharynx. 

Pkoqnosis. — When occurring within the first year of life the disease 
is nearly always fatal. Older children may reco?er, but are apt to be 
luft with disfigurement of the nose and partial destruction of the imlate 
with consequent interference with the voice and respiration. Often deaf- 
ceas results. The later the appearance of the diseaw, the better the 
cbaiice of cure; but It is apt to break out anew from time to time. 

Trkatmkst. — The treatment is eaaentially tlje same as for adults, 
tliuugh children bear mercurials better. Local applications should be so 
mild as to cause but little jtaiu. 




odematous iuflAmmatioa of the uvula is a raro affection ex- 
ntttRMiHUil with pUurvugilis or tonsillitis. It usually causes bat 
ittle i>ain, but is atteudtid by some diseomCort in eating and by frequent 
lesire to swalluw. The uvulu when u*demalous soinctiinua becomes so 
torge H8 to interfere with respiration, and if it bo lon^ enongit lo toucli 
the bftso of the tongue or epiglottis it causes an irritating throat cough. 
^Kxhe affection is not diflicult of recognition. 

H[ Trkatmest.— The ]>ropur trciitment consists in the application of 

Htatriugent sprays or the use i>f astringent troches or gargles, and, if the 

XBdeniH is groat, a few punctures may b« made near the lower end of 

the nvula to allow the serum to escape, but the organ should not be cut 

off during the acute inflammation unless it seriously interferes with 

^respiration or deglutition., and then only a part onght to be removed. If 

[the punctures iire not sufllcieut to allow the serum to escape, the re- 

[moval of a, small bit of mucous membrane from the tip of the organ 19 

generally effectual 


Elongation, though sometimes o<:curring without chronic inflamma- 
tion, is generally associnteil with it. It is apparently due to the same 
tusos 08 chronic pharyngitis or tonsilliti*. .Sometimes it takes place 
vithoat any appreciable cause. Xn itealth iiu.- uvula is from one-foni'th 
to three-eighths of an inch in length. Sometimes when diseased, it may 
become ihree-fuurths of an Inch in length without causing iuconveuience; 
but in other patients, ovpn moderate elongation causes frefjuent desire 
to clear the throat, with expectonttion of small masses of mncns, and an 
irritating cough which occasionally becomes so excessive as to interfere 
with the jMtient's rest, and in rare instances, by this means, to bring on 
symptoms similar to those of serious pulmonary disease. An elongated 
uvula sometimes oanaes spasmodic attacks of retching and vomiting and 
ocoasionally reflex spaun of the glottis. The symptoms are usually 

vorse when the patient lies clovn. In a fow ciises it gives rise to pain 
and fntigne nft^r using the voice, and more rarely to hourseness. 

niAososis. — ELougation of the iivuiii may be easily detected by in- 

TiiKATMENT. — \Vliou ull Other causoa of the symptoms have Iwen 
eschided, llie sujwrfliioua part of the orgiiii should be removed by the 
uvniatome, scissors (Fig. 93), or the niisal snare (Fig. 808). Varioufl uvuLi- 
tomes Imve been devised for tlie purpose, but they are not better iliaii the 
scifi8urs shown in Fig. i^S, which iiro simple und well suili-il to the 
purpose. The nasal anure will !h* found much more nunvGniont. By 
it, »l>8ciesion ojin be done more arnurately, Jind fxnpsnive Ideedini; i« 
less likely to occur. Tlie snare for tliis purpose is arnied with Xo. 5 
steel wire, a loop JTiett large enough to esi^ily endoce the tip of the 
uvula is formed, the physiciftii depresses the tongue with one hand, 
and with the other slips the enure under the tip of the uvula, carrying 
it up to within from one-half to three-eighths of an inch of its base. If 

r the uvula appears swollen at the time, less should Im removed than 
otherwise, and it is best never to make it ghort<»r tlmn norraiil. The 
wire is tightened dowii nnl-il the tissue is secured, then tin- tongue 
depressor is rerauvefl, and the physician, seizing the crnss bar of the 
snare with his left hand, suddenly draws upon the wire with the 
combined strength of the fingers of both hands, cutting through the tis- 
ane as quickly iis by a knife. After the operation, the patient should 
be supplied with troches of althea to use as often as desired to soothe 
the pain, and a one jwr cent gargle of earbolic acid may be iidvnnta- 
geoQsly used sevenil times daily until the wound has healcii. In a few in- 
stances alarming bemorrhago has takou place after cutting off the uvula. 

Flo. n.— arHwoRH r»B AHprrATma thi Uruu, l||jto»>. 


The uvula may be asymmetrical or absent, bnt the most frequent 
malformation is bifurcation. This requires no treatment unless tho 
organ is also elongated, when a portion should be reinored. 

FapiUart/ i/roivthjf are not infrequently found on the uvubi, and if 
large, by their mechanical effects they may give rise to the sjime symp- 
toms IIS elongation. They are easily diagnoetioated, and may be readily 
removed by the snare. 



Malignant groKths mrely, if over, first attack the nvula, though it 
mav be involved by cxtcimion of thediseuse frum the tousils and pulucc. 
The orgnn ia oft^ii involved in syphilitic iuflninmutiou und uh-erutioUr 
but these cases require no special consideration, a« they were auffieieutly 
described in speaking nf diseases of the adjacent piirta. 


5yn0nyrfiJ(.— Leucoplakia buccaUs et Uugnalis. iobtbyosis linguae. 

Leucopliikia buccidts is u chronic affection of the buccal nuicou& 
nerobrane. characterized by thickening of the upithelium and the furmii- 
tion of vrhite^ opaline, elevated patches, which usually become fiasurf>d 
and ]minful. and, after continuing for a long time, are inclined to ter- 
minate in epithelioma. The di^iease is very rare, occurring almost iu- 
Tiiriably in men over forty years of age. 

Akatomic.vl akd PATHOLooirAL CHABAfTERisTics. — The pntchea 
are limited to the buccal cavity, and are generally found on the dorsum^ 
of the tongue or inner surface of the cheeks and lips, but seldom, if ever, 
on the lower surface of the tongue or Iwick uf the anterior pillars of thu 
fauces. They consist of one or more small, irregular or oval spots wliii^h 
may become confluent. A considerable portion of the tongue alone may 
be involved, or the dorsum of the tongne, bnrcal mucous momhi-une. and 
the game, one or nil may be aflfwted. The first apiKrarance of tlu^ wliite. 
patch is preceded by hypericmia. and subsequently in the early stages a. 
hypenemic areola is found about its borders. Before long the ]nitcli 
itself becomes thickened, sometimes to the extent of kIx or tight milli* 
metres, and the epithelium whieli has become hard and dr^' may be easily 
removed, or in spots it may be spontaneously exfoliated, leaving the »]>- 
pcamnce of an ulcer. The snrfuce of the patch is marked by numoroua 
fine lines or furrows which by intersecting each other divide it into 
small polygonal spaces. Some of tlieso lines may eJitcud as deep fissures 
down through the thickened epithelium.involviug the submucous tissue in 
a painful uxco rial ion. In cases of long standing, thf.< papilla' may be munh 
enlarged, giving the surface a warty appoaniuce. t'nder the microscope, 
the epitbelium is found greatly thickened, the pajtillw enbirged and 
flattened, and the blood vej<*<elif diluted, with an accumulation of lnucocytcs 
about their walls. The auperficinl layer of the mucous corium is infil- 
trated with embryonic cells, and the deep layer is involved in vusoular 

Ktiology. — Excessive tobacco smoking is ranked as one of the mo«t 
frequent causes of the disease, but it is probable that prolonged irrita- 
tion of any character may have a similar effect on those predi«posed to 
it. Thus, highly spiced food and alcoholics seem to excite it in some in- 
8t-inces; and the occurrence of the affection in several meuihers of the 
same familv led Bazin to believe that it is often the result of constitD- 



tional syphilis. It is also attributed to the arthritic or dartrous diath- 

Syhptomatoukit. — The clinical hiRtory of tho disease ifl not defi- 
Bltelj known, becauso genemlly it has been dispovei-od Hccideiitully and 
found to have exist^ii for some months or yonrs before it ha^ come under 
the physician's observation. This is due to the fact tliut ut tirst the 
affection causes no inconvenieiure. The small patch which tir^t appeiirs 
gradually increases in size and at length stitTness occurs or painful tis- 
snres form which first attract the patient's attention. Ultimately, in 
the majority of cases, epithelioma results and rnns its usual course. 
Sometimes the affection remains stationary for months, or uiidyr the in- 
flueuL-v of some irritant it may rapidly progress, hut it uiny again boconio 
dormant if the irriUiut Is removed. Ga«ea auociated with syphilid or 
that have develojied into epithelioma are attended by much swelling of 
the purt», and sometimes deep ulceration, which may erode the vessels- 
and cause severe hemorrhage. In these, the lymphatic glands soon be- 
ciime inv<.Ived, a sign not observed in the earlier stag^^s of idiopathic 
leucoplukist. Often the first symptom is merely an uneasy seiisation^ 
hut in others the mucous membrane early becomes moro or less jMiiiifully 
sensitive to spices, hot food or drinka. alcoiiolics. or tobacco. With the 
occurrence of iiti^ures, pain may become more intense and almu)«t con* 
gtant. uUhough in soniB it i» prcBeiit oidy at intervals. There are no 
ooiistitntional symptoms until epithelioma is (]evelope<3. r>:ite in the 
disease, speiiking, mastication, and swallowing usually become (Iiffii:iilT» 
especially when epithelioma occurs. In such cases also profuse saliva- 
tion is often a veiy annoying symptom. 

Diagnosis. — Leuooplakiu nuiy he misinterpreted for what Guinand 
has termed the professional patches found in glass blowers, for smokers' 
pat4-rhc6, mereuriul patches, psoriasis liiigwEe, syphilitic patches, and epi- 
iheliomn unconnected with leucoplakia. The pro/efiswnal patches 
occur indyiti old glass blowers. pitrticularly bottle-makers. and are found 
symmetrically upon both sides of the muuth, on the hiterul surface of 
ihe gums, and around Steno's duct. Smiii-pr's palchtJt are more irregu- 
lar (h:in thnse of leucophikia, and are commonly located near the com^J 
miesurep of the lijw, hut not upon the tiorsum of tlie tongue or the inner' 
side of the cheek. Again, the epithelium covering their surfaces is thin 
and closely adherent, so that it cannot be removed, as in the diseafw na* 
der cnnsideration. Meminni puti'hes are not so thick as those of leuco- 
plnkia, are never quite white, and are found on all part^ of tlie tongue, 
but particularly whore it is pressed against the teeth. \x\ pmnamsliHyna 
which sometimes accompanies psoriasis of the skin, the patches of epithe- 
lium assume a white, opaque appearance and after a day or two they ai 
thrown off, tbeepitlielium being speedily restored ; but soon other putcheft^' 
appear and go through a like conrae until after a time a large part of the 
dorsum of the tongue may become denuded and of a uniform red color^ 



with crcsccutic markings or depressions entirely tmlilco the a|ipOar:incO 
«( leitcoplakiii. Syphilitic /talchea are not bo white iw those of leiicu|ita— 
kin; they ure nsuaily round or ovnl and more regular in form, seldom 
occurring on the check, but found principally upon the tip or margiu of 
tlw tougne and often on its lower surface, which is never inrnUwl hj leu- 
ooplukiu. The syphilitic patches are thiuner than the patclies of leuco- 
ptakia, and the lymphatic glands are much ijouner involved. The pain is 
more severe in leucoplakin than in tlie Hvphilitic diwu^', and anti-^ypbi* 
litic treatment causes no improveaieat, but on the contrarv may aggravate 
the affection. When syphilis and leueoplakia coexist, the dia^uo^i^ is 
diflicult. Concer arising without previous leucoplakia ia distinguujhed 
from the latter by its history ; the induration of the tissues and the final 
ulcemlion are not preceded by the chronic white patch, but are attended 
by more constant pain, with profuse salivation and a very ofleusira 

PnooKOSIK. — The duration of the disease varies from a few months 
to fieverni years. The majority of cases ultimately terminate in epithe- 
lioma, which runs ita course to a fatal is^tie. 

ThkaTJJEXT. — All sources of irritation, [mrtirulariy theuseof tolmrco, 
alcoholic stimulants and strong condimenls, should be at once removed. 
If the digestive organs are deranged, thev should receive proper uttentinn, 
Asi<le froiM these measures, mo»<t authors lM>lieve treatment to I>e of little 
or no avail. Araenious arid, the alkalies, mercury, and the iodides have 
been recommended, though in the absence of syphilis the latter seem to 
bft injurious. For local application various rausties, sul-Ii as silver nttrat*, 
zinc chloride, tincture of iodine, and the solution of mercnry nitrate have 
been recommcnde*!, but none of them seem of any value except in rases 
complicated by syphilis. On the contrary, siKtthing applications tteem 
to have been the most lieneticial, though giving only temporary relief. 
I have succeeded in curing one well-marked case by repeated careful ap- 
plications of the galvano-caut«ry, made to a small spot at each sitting and 
in such manner as not to destroy the healthy tissue beneath. 

Fsr a more c-omplele expofiition of this subject the stwlent is ivfenTd to my 
iv, Leuco|ilHkiii BurcitliH, eU-.. in the Traosactioas of the Amerk'au Luiya- 
r^ologlc&l AssoclatiOQ for lt<H5, pu^ &7. 


Sffnonpfns. — Amygdalitis, eyuanche tonsillaris, quinsy. 

The tonsils, which are located between the pillars of the fauccA, are, 
the nornuil condition, scarcely visible and never large enough to project 
beyond the edges of the anterior pillars. They are essentially lymphatio 
glands, but their function is unknown. It is believed by some that they 
absorb a portion of the starchy foods, which their secretions are capable 
>f converting into sugar, but this is certainly an unimportant function. 



rpon the fr« surface of these glands are the ori6ces of from twelve to 
eighteen lacnnee or crypts which are lined with a continuation or pouch 
of the niucoas membrane and surrounded by numeroutt (spherical and 
lymphoid follicles. These, together with softer lymphoid Lissne, consti- 
tntc the substJiDce of the tonsil, and arc the parts more or less involred 
in the diseast* under considcrution. Acute tuiiKillitis is most prevalent 
in humid climates and duriog the spring und wiDter months. It is 
more frccjuently observed between the ages of fifteen and thirty years, 
cspeciuily in subjects of the rheumatic diathesis. It is jwculiarly prone 
tu attack those patients in whom the tonsils art' hypcrtrophiwl; and those 
who have oiiim; Buffered from it arc liable to rttpeutnd attacks. It is onl/ 
occasionally mtnessed in yonng children or the aged. 

Anat<imh:ai. AXh pATiiOLOiiirAi. Chaka< TKKisTics. — The inflatn- 
mation may attack the muciins membrane covering the surface of tho 
tonsils, it m:iy be mainly confined to the follicles, or it may involve tho 
whole subntiuice of tho gland, with or without tho peritonsillar connec- 
tive tissue. It is frcfjnentiy confined to one side, but in many wisetr, 
when the disease has nearly run its course in one gland, the other will 
become likewise affected. Tho mucous membrane covering the tensity 
the pillars of the fanoes, and a jwrtion or all of tho pharvnx is red anit 
swollen. The uvula is generally swollen and eIongatec3,jtnd is freciueutly 
seen adhering to tho affecteil tonsil. In the follicular variety of the dis- 
ease, tho oritiees of the crypts may become occluded and the lactinie dis- 
tended by tho changed secretion, in which event rupture may ilnally 
occar, with a discharge of tlie contents, or, on the other hand, the pen): 
up secretions may become the centre of a suppurative process leading ti> 
u tonsillar abscess. 

ETiorxnn'. — The disease is usually attributable to exposure, the rheu> 
matic diathesis, or chronic enlargement of the glands. Among the oc 
casional causes of theattackare: errors of diet, suppression of tbenipnsfs, 
a strumous constitution, and heredity. Uigston Fox (Tninsactinns of 
the Medical Society of Ltjndon, Vol. IX, p. 2aT\) believps that, wbero 
both glands are simultaneously involved, the diaea^o \n almojit invnna- 
bly of septic origin. Tlie follicular variety of the dimease Is ihoiight by 
some authors frequently tu result from diphtheria. This view, however, 
does not accord with the experience of the great majority of phyfJciane, 
though undonbtc<Uy a few cases are of diphtheritic character. 

SYMPTOMATOLutiY. — Most patients give a history of previons similar 
attacks. The disease is usually preceded by malaise for seversl huura 
and attended by acrhing of the hack and limbs, and is often uRhrred 
in by a slight chill and f.ver. Thii U speedily followed hy sensations 
referable to the throat, with swelling of the glands and more or less 
pain and difficulty in moving the jaw. In the later stages of severe 
cases there may he great depression, cold perspiration, insomnia, rcst- 
leesnesc, and sometimes delirium. The patients are usually worse during 



the night, and experience moat pain enrljr iu the mnrning on nnconnt of 
the dryness of the throat In the inception of the attnck there iire usu- 
ally sensations of dryness or pricking in the jtarts, soon fnllotrod hy pain, 
which is aggravated by deglutition and after a time becomes ren.' severe, 
even on attempts at awatlowing the saliva. This pain is referred to the 
region surrounding iho angle of the jaw, and radiates toward the ettrs. 
Oooasionallr there is severe headw^he, winch i^aggruvated hy movement^ 
of the head. Owing to the tumefaction, the patient is frequently nnnble 
to open his mouth more than half an inch; partial deafness is common; 
und the senses of taste and smell arc stimetimes obtonded. The face be- 
comt!s pufly uud awoUeu, the skin hot. the pulse rapid, and the temper- 
ature may rise to 103", 104^ or 105° F. A high temperature is more to 
bo expected in children or in persona suffering their first attack. Artio 
alatjon is ditliciilt luid enutmintiou muffled. The swollen glands m:ty 
seriously interfere with nasal and oral respiration, so much so that 
patients frequently fear suffocation, which indeed in extremely rarft 
cases, is an actual danger. There Is little or no congh, but the patient 
Is frequently impelled to clear the tliroat of a thick, viscid sccrelioa 
which causes much discomfort. The tongue is coated with a yellowish, 
white fur. while the breath is ven.' offensive. There is increased thirst, 
and UHtially loes of Bp[>etite. Even when there is a desire for food, the 
pnlient can seldom take it on account of the painful deglutition, while 
attempts at swallowing tluida oftentimes result in their regurgitation 
througit the nose. The bowels are nearly always constipated. Upon 
examination of the fauces, the congestion and swelling of the parts uiU 
be readily distinguished, li is often dcfiiruble to make the e::amination 
with the aid »f a luryngoscupic reflector, for the patient is unable to 
open the uiuitth sufficiently to permit a thorough iuspectiou with ordi- 
nuiy illumination. In the fullicitliir type of the disease, the orifices of 
the crypte may be tilled with a yellowish white secretion which causes 
round or oval patches from four to eight millimctrca iu diameter. In 
exceptional inGt:ince< a rush has been observed upon the skin. 

DiAOSosis.— Acute tonsillitis is to be distinguished from scarlatina, 
diphthi^ria, piilegmoiious tonsillitis, and syplilli.B. Thc> essentiul poiuts 
in the disgnosiii ure the hititury. swelling of the part^, diltirulty in opf*n- 
ing the moath, mid severe pain on deglntition. 

In children, j«r«r/«/i'H(» is usually ueliered in by vomiting, which is 
not the cjiso with tonsillitis. The fever is often higher, is always more 
iwrsistent. and after a few bonrs a bright red rash appears upon the sur- of the body. Usually the congestion of the fauces is mnch more 
diffuse in scarlatina thuu in tonsillitis, and the swelling of the pnrts is 
mocli less. The |)««uliar appearance of the tongne in soarblina is not 
obsened in tonsillitis. 

Acute tonsillitis may be distinguished from scarlatina as follows: 



Inflnnnnation and swelling oftoiuula. 
But little rednesAuf pharynx or palate. 

Pain about ang'le of jaw, ort«n re- 
ferred to tiie ears. 
DitHculty in openiag^the mouth. 
Tongue coated jellow. 
Usually noerupUoD on s(da. 


Ooni-ral redness u( fauces, sotnd^ 
times appearinf; in patches, »onietiuieti 

little or nohWelMn^' of tonsits. 

Pain, usually conrtn^d