COLUMBIA LIBRARIES OFFSITE HEALTH SCIENCES STANDARD 11*081 .L47 Conlribulionstoltie RECAP ^^ ^X^ %. >. ,\- v^ N s\ ^^ X*V^' ^'^^. — Patient has slept during the night. The epilep- tiform seizures ceased at midnight, and the pulse has become regular without intermissions — 52 in a minute. After this the patient steadily improved, and one month afterward he walked to Dr. Cammann's office in Fourth Avenue. Dr. Cammann diagnosticated systolic ob- structive murmur, with hypertrophy of the heart, but believed the irregular action and peculiar symptoms were owing to functional derangement from indiges- tion. . He became well enough to attend to business until October, 1861, when he was again taken ill. There were then anasarca, dyspnoea, and laboring heart with obscure physical signs. He gradually failed, and died on November 26, 1861. Post-mortem on 27th, assisted by Dr. Loomis. Com- plete adhesion of the pericardium to the heart. There I/O DISEASES OF THE HEART AND LUNGS. was no free space, but in some parts the adhesions were stronger and apparently older than in others. The heart was largely hypertrophied, but was not weighed. The curtains of the aortic valve were thickened and shortened to incompetency, not holding water. The edges of the mitral valve were glued together, extend- ing into the ventricle like a funnel : complete stenosis. The opening very small, the valve and chordae were thickened and covered with plastic lymph, white and glistening. Case II. {Substance of Re7narks made by J AMES R. Teaming, M.D., before the Pathological Society on the Pre- sentation of a Specimen for a Candidate for Admission^ — Mrs. B , twenty-three years of age, native of New York, widow, called Dr. S , in April, 1869, for ad- vice as to cardiac trouble and swelled feet. The doc- tor found, on examination, a systolic murmur over the base of the heart, more distinct over the aortic valves, gradually disappearing to the right in the course of the aorta ; there was also a diastolic murmur. Diagnosis. — Aortic obstruction and aortic regurgita- tion, with hypertrophy of left ventricle. There were also casts in the urine and albumen. She became drop- sical, her condition gradually grew worse, and she died in September last. I saw the case with Dr. S , in May, and found no different conditions than those already discovered. There was no mitral 'inurmur of any kind. The speci- mens here presented show Bright's small kidney of advanced disease. The heart is hypertrophied mostly in the left ventricle ; the aortic valve is thickened at the base of the curtains ; shortened to incompetency — so far, agreeing with the diagnosis. But the mitral valve presents the most notable feature. There was no sign of disease of this yalve during life, and yet it is damaged DISTURBED ACTION OF THE HEART. 171 in a very peculiar manner. It is thickened by lymph- deposit ; its color white, opaque ; the edges of the curtain are adherent, and the orifice is narrowed down till it will barely admit the top of the index-finger ; and the whole valve extends down into the cavity of the ventricle like a funnel. The chordse tendinas were shortened and thickened by lymph-deposits, and the musculi papillares were thickened and lengthened. But every thing was symmetrical, viz., the funnel-like condition of the valve, the hypertrophy of the cardiac walls, of the musculi papillares, and of the columnae carneae. With all of the conditions for producing a so- called mitral direct murmtir^ there were neither mitral murmur nor first sound. Case III. {Copied froin Reports of the Pathological Society, published in the Medical Record in 187 1.) — Dr. Loomis presented a heart, with the following history, from Dr. Milliken, house-physician of Bellevue : " Henry Clemens, admitted April 11, 1871, aged thirty-two; single ; cabinet-maker by occupation ; nativity, Switzer- land. Patient gives hereditary history of pulmonary phthisis. Had an attack of articular rheumatism when seventeen years of age, from which he made a good recovery. States that neither at that time, nor since, has he experienced any precordial pain, but has noticed that after indulging in tobacco (for he has been an inveterate smoker) he would suffer from palpitation of the heart. He had had a cough, dating some time back, with some expectoration of a pearly white ma- terial, which he says he coughs up at night, at which time his cough distresses him most. About two weeks ago, for the first time, he noticed that the sputa were streaked with blood. His cough remained about the same in character until one week ago, when he expe- rienced a severe paroxysm of coughing, which was 172 DISEASES OF THE HEART AND LUNGS. instantly followed by haemoptysis, which continued for two or three days. Since the occurrence of haemopty- sis, he has had night-sweats, loss of appetite, deprecia- tion of strength, and experienced a feeling of general malaise, and inaptitude for any kind of work ; he com- plains also of insomnia and restlessness. His pulse is about 80, regular, but quite feeble ; respiration some- what hurried and easily performed. Heart: action regular, but quite feeble ; apex-beat on a level with nipple in fifth interspace. Heart-sounds feeble ; after repeated examinations, no murmurs could be detected'' The record proceeds to say that, while the patient was at dinner, he became suddenly unconscious and fell from his chair, and symptoms of paralysis continued until the i8th, when he died. Post-mortem showed em- bolism of middle cerebral artery of left side, with soft- ening of brain-tissue. Heart, fourteen ounces. Both right and left cavities contain large clot of blood ; sub- stance of heart relaxed ; stenosis of mitral orifice only admits little finger ; some shortening of chordas tendi- neae. The stenosis is due particularly to the thicken- ing, shortening, and adhesion, of the chordas tendineae of the valve. The anterior portion of valve forms a bony mass, occluding that portion of the orifice. On the auricular aspect, the surface of the valve is ulcer- ated, the bony matter laid bare, and soft, reddish vege- tations on the free border of the valve and upon the ulcerated surface. Puhuonary and tricuspid valves normal; little thickening at base of aorta." Dr. Loomis remarked, '' The case is of special inter- est, because with this marked stenosis no murmurs existed;" and Dr. Flint remarked that "the absence of murmurs might be accounted for — i. On account of rigidity of the valve not allowing a vibration ; and, 2. The smoothness of the ventricular surface of the valve," » DISTURBED ACTION OF THE HEART. 1 73 The first case is full of instruction in its facts as re- gards functional disturbances of the heart and proof as to the mechanism of the first sound. The long period of rest, sixteen seconds, is worthy of our earnest atten- tion. Observers who have watched the action of the heart in ectopia in an infant, as Cruveilhier, Bryan, and others, as well as when the heart has been exposed in experiments upon animals, tell us that the contrac- tions of the auricles continue regularly, although the ventricles may be in a state of rest. And in this case no doubt they did so, notwithstanding that there was no first sound, no impulse-beat, and consequently no contraction of the ventricles. The importance of this fact cannot be over-estimated, because it invalidates much of the theory in vogue in regard to the causation of murmurs. It proves that the auricular systole may take place regularly, even when the auriculo-ventricu- lar opening is very much contracted in stenosis of the mitral valve, without producing sound. Carefully lis- tening under favorable circumstances after the last impulse-beat and first sound, one contraction, presum- ably that of the ventricle, could be heard, without any vocal element of first sound, and was then followed by the long interval of silence, in which no contraction or sound of any kind could be heard. The second case is a demonstration of the cause and mechanism of the first sound. There was no mitral mur- mur. With stenosis of the mitral valve, if the chordae tendineae had not been rendered incapable of sound- vibrations, by being plastered over with fibrinous de- posit, there would have been a murmur, such as is usually heard in stenosis where the chord2e are free and uncovered. The first sound, and all murmurs con- nected with it, disappearing when the mitral valve and chordae tendineae are rendered incapable of sound- 174 DISEASES OF THE HEART AND LUNGS. vibrations, is as convincing proof of their cause as is the experiment of hooking up a curtain of the aortic valve proof as to the cause of the second sound. The second and third cases are confirmatory proof, by different observers, that the cause and mechanism of the first sound, and the murmurs connected with it, depend upon the state and condition of the mitral valve and its chordae tendineae. In the second case there was no ph37sical sign of disease of this valve during life, and yet it was found after death to be damaged in a very peculiar manner — thickened by lymph-deposits, opaque, its color white, the edges of the curtains adhe- rent, the orifice narrowed down, barely admitting the tip of the index finger, and the whole valve extending down into the cavity of the ventricle fixed and like a funnel. The chordse tendineae were shortened and thickened, some of them glued to the valve, and the musculi papillares thickened and lengthened, as the specimen which I now present to you demonstrates. This case, during several months, was under the obser- vation of the late Dr. Sprague, a careful and competent auscultator. The third case, which is reported in the Transactions of the New York Pathological Society, is also confirma- tory proof: " In the morbid specimen there was stenosis of mitral orifice— only admits little finger — some shortening of chordae tendinese. The stenosis is due particularly to the thickening, shortening, and ad- hesion of the chordae tendineae of the valve." During life, heart-sounds feeble ; after repeated examinations no murmurs could be detected. Could the proof be more conclusive? The following experiments by Dr. Halford, quoted in the British and Foreign Medico-Chirnrgical Review, April, i860, is singular proof of the physiological cause DISTURBED ACTION OF THE HEART. 1 75 of the first sound^: '' My proceedings were as follows : large dogs were obtained, and as in my preceding ex- periments (the animals being under the influence of chloroform), the heart was exposed and the circulation kept up by artificial respiration. A stethoscope being applied to the organ, the sounds were distinctly heard. The superior and inferior venae cavas were now com- pressed with bull-dog forceps, and the pulmonary veins by the finger and thumb ; the heart continuing its action, a stethoscope was again applied, and neither first nor second sound was heard. After a short space of time the veins were allowed to pour their contents into both sides of the heart, and both sounds were in- stantly reproduced. The veins being again com- pressed all sound was extinguished, nowithstanding that the heart contracted vigorously. Blood was let in, and both sounds were restored. I have thus frequently interrogated the same heart for upward of an hour, and always with the like result." The reviewer remarks : " There is an interesting cir- cumstance which took place at one of Dr. Halford's experiments, which appears to us of great importance. It shows that when only a small quantity of blood finds its way into the ventricles, the first sound is still pro- duced. The cavas and pulmonary veins having been compressed, Mr. Lane, at whose request the experi- ment was performed, listened to the heart during its contraction, and said he heard the first sound indis- tinctly, not so clearly as before the compression. On examination it was found that the vena azygos entered the right auricle by an independent opening, and was not secured : the vessel was compressed with the others, the heart contracted, no sound was heard." This experiment proves that the contractions of mus- cle of the heart give out no sound which may be an 176 DISEASES OF THE HEART AND LUNGS. element of the first sound ; for without blood moving through the heart it was silent. The remaining ele- ments, friction of the blood against the heart-wall and through the aortic orifice, and vibrations of the chordae tendineae and mitral valve, must give answer to the question. When there was no blood forced there was no sound ; and we have just shown, by pathological specimen, that when the chordae tendinese were ren- dered incapable of vibration, there was also neither sound nor murmurs. Consequently, the first sound and murmurs must be the result of chord and valve vibrations set in motion by the rushing blood. The blood is the bow applied to the strings to give vibrat- ing sounds ; and murmurs are sounds of individual chord-vibrations not in unison. One of the points I endeavored to establish in 1868 was that the presystolic murmur, called also the auri- cular-systolic and the mitral direct, is one of the intra- ventricular murmurs, caused by vibrations of chordae tendinese subjected to irregular tension, and not by blood bing forced through the contracted opening of the mitral valve in stenosis. Although frequently con- nected with that pathological condition, it is yet oftener an accompaniment of change of the mitral valve without stenosis. My argument was, as Dr. Cammann first con- tended, that the auricle was too feeble a power to force blood through the contracted opening of the diseased valve, so as to cause sound which may be heard through the chest-wall, even if empty, much less so when the ventricle is filled with blood ; and, lastly, I maintained that the murmur does not agree in length with the time of contraction of the auricle. According to the best authorities, the contraction of the auricle is instantaneous, while the murmur is of considerable DISTURBED ACTION OF THE HEART. 1 77 length.* If contraction of the auricle could cause the murmur, the two ought to agree in time. According to Bellingham, " the systole of the auricle is a quick, short, sudden motion." Lower says, '' Its rapidity equals the explosion of gun-powder, and immediately precedes the ventricular systole, the one motion ap- pearing to be propagated by the other." Marey assigned to it two tenths of the time of the heart-beat, which is probably ten times longer than the reality, and much less than the time of the so-called presystolic murmur. This murmur, too, has none of the qualities of sound which should be produced by blood forced through a narrowed opening in the valve. But all argument becomes unnecessary in presence of the foregoing pathological facts and clinical history. Dr. Frank Donaldson, Professor of Physiology and Hygiene, and Clinical Professor of Diseases of the Chest and Throat, University of Maryland, in a paper read before the Medical and Chirurgical Faculty of Maryland, annual session, April, 1874, on " Significance of the Presystolic Murmur," relates the following cases, with remarks: "Some years ago (in 1867) a case came under my observation, which made me question the explanation which I had adopted on the authority of Earth, Roger, Walshe, and Flint, of the sound which was described first by by Fauvel, in 1843, ^^^ then by Grisolle, as the presystolic murmur, afterward by Dr. Gairdner, of Edinburgh, as the auricular-systolic murmur, and by Dr. Austin Flint as the mitral direct murmur. '' These authorities claimed that this sound was heard just preceding the ventricular contraction, and was caused by the systole of the auricle forcing the blood * Harvey, Lower, Bellingham. 178 DISEASES OF THE HEART AND LUNGS. into the ventricle, through a diseased and contracted auriculo-ventricular orifice. " The case was a man sixty -four years of age, of grossly intemperate habits, who came to the Balti- more Infirmary with symptoms of advanced heartr disease — great dyspnoea, a small, contracted pulse, heart much hypertrophied, with a murmur of a rasping character, heard loudest between the second and third ribs at the base, not extending up the carotids, but down toward the base, and completely obliterating the second sound of the heart. The murmur was audible after the apex-beat and the systole of the ventricle, and was followed by the pause of the heart. The first sound of the heart was normal. The diagnosis seemed clear and unmistakable, and was recorded as insuffi- ciency of the aortic orifice, by means of which the arte- rial blood was forced back into the left ventricle. "Tho J>ost mortem showed atheromatous degenera- tion in the aorta above the semilunar valves extending to the sacs of Valsalva, and causing adhesion of one of the semilunar pouches of the aortic orifice to the wall, so bending it down that that portion of the orifice was unprotected. The second sound could not be produced, and the insufficiency of the valve was evident. '^ Thus far the diagnosis was correct, but on examin- ing the mitral orifice we found, to our surprise, that it was reduced by thickening at its base to about the size of one quarter of an inch in diameter. Yet, during life, there was no abnormal sound preceding or during the ventricular systole. With such a contraction of the left auriculo ventricular orifice, ought we not to have had a decided presystolic murmur ? The whole heart, auricle and ventricle, was enlarged and increased in force, and yet there was no murmur produced from the passage of the blood through an orifice so reduced in DISTURBED ACTION OF THE HEART. 179 size ! I could not help questioning the received opin- ion as to the significance of the so-called mitral murmur. As it is a physical sound, heard at a particular period of the heart's action, the physical cause which was said to produce it being present, it ought to have been heard, but it was not. " Hope, as far back as 1842, reports a case where the mitral orifice was so contracted that it would only ad- mit the little finger, yet there was no murmur during life, preceding the first sound. In his report he adds: ' I have frequently known a contraction of the mitral orifice to the size of only two or three lines, to occasion little or no murmur.' Dr. Stokes, in his work on * Dis- eases of Heart and Aorta,' relates two cases of extreme contraction of the mitral orifice found after death, but where, during life, there had been no murmur audible even to his practised ear. " Dr. Waters. His first case was where he heard a loud systolic as well as a presystoHc murmur. At the autopsy there were found insufficiency and slight con- traction of the mitral orifice. In the second case there was no presystolic murmur whatever, although the autopsy showed a constricted mitral orifice only admit- ting the tip of the index-finger. Next follow the details of four cases of extreme contraction of the mitral ori- fice, where, during life, there was no presystolic mur- mur audible. He candidly adds : ' I have given you instances sufficient to prove that great constriction of the mitral orifice may exist without there being any murmur produced by the passage of the blood from the auricle into the ventricle, and therefore that you must not look for a mitral-diastolic or presystolic as a constant sign of obstructive mitral disease. My belief is that this murmur is far more frequently absent than present, even when there is great great ob- l8o DISEASES OF THE HEART AND LUNGS. struction at the mitral orifice/ Dr. Waters accounts for the presence or absence of this murmur, as depend- ing on the greater or less vigor with which the auricle contracts." Dr. Donaldson sums up his relation ol cases and re- , marks : " Thus we have eleven cases of the lesion with- out the murmur, and three cases of murmur without the lesion" (quoting the latter from Dr. Flint). The diagnostic sign of mitral regurgitation, which has been and is still taught, is a harsh, blowing, sawing, or filing murmur, heard during the systole at the apex-beat. Upon the accepted authority of this murmur, which is so often met with, the great frequency of mitral insuffi- ciency has come to be considered as incontrovertibly established. The cases we have already related are proof that these murmurs are not heard when the chordae tendi- nese and valve are rendered unfit for sound-vibrations. J. S. Bristow, M. D., London, F. R. C. P., Physician to St. Thomas's Hospital, in an article on " Mitral Regur- gitation, arising independently of Organic Disease of the Mitral Valve," in the July number of the British and Foreign Medico-Chirurgical Review of 1861, gives six cases, with introductory remarks. With your permission I will read some of his arguments and quote points in the cases, for the purpose of showing that instead of proving that regurgitation may take place through the mitral valve without disease, as he imagines, they in reality disprove the theory in vogue, and confirm the doctrine of chordae tendineae vibrations as cause of the first sound. Dr. Bristow remarks : ** It may almost be regarded as an axiom in medicine that the presence of a systolic apex-murmur is positive proof of regurgitation through the mitral orifice. I have not hesitated to adopt it in DISTURBED ACTION OF THE HEART. l8l reference to the cases already detailed." The follow- ing are quotations from his cases : Case 1. — There was a distinct systolic murmur aud- ible at the apex of the heart. Post mortem, — The aortic and mitral valves were per- fectly natural. Case II. — There was an increased area of dulness in the cardiac region, and a systolic bruit loudest at the apex of the heart. Post mortem. — The muscular tissue and the valves appeared perfectly healthy. Case III. — The impulse was diffused and heaving, but not very strong. A systolic murmur was detected at the apex of the heart. Post mortem. — All the valves were healthy-looking. Case IV. — First sound at the apex was flapping and prolonged. Post mortem. — The valves were perfectly healthy in texture. Case V. — The cardiac dulness was enlarged, and a systolic murmur was audible with the heart's action, most distinct at a point an inch below, and internal to the left nipple. Post mortem. — All the valves appeared perfectly healthy. Case VI. — There was a distinct but not very loud systolic murmur, loudest in the usual situation of the apex of the heart. Post mortem. — The aortic and mitral valves were per- fectly healthy-looking, and doubtless quite competent. A tabular arrangement like the following, in classify- ing murmurs acoustically, may be useful : Valvular \ "^^^^^^ obstructive systolic, (all organic). l ^^^^'^ regurgitant diastolic. { Mitral regurgitant systolic. Intra-ventricular j Organic functional, (more or less functional). ( Inorganic functional. 1 82 DISEASES OF THE HEART AND LUNGS. These two great divisions are made in accordance with their acoustic differences. The sound in valvular murmurs is a friction-murmur, that of blood forced through an aperture. The intra-ventricular murmurs are mostly and distinctly chord-vibrations. The con- traction of the muscular walls of the heart and its fleshy columns, the friction of rushing blood among the chordse tendinese and against the tense mitral valve, being the occasion of sound vibrations, but is not the mechanism of the sound itself As great difference exists between these murmurs as between that of a whisper and that of the voice. The obstructive systo- lic aortic may be modified by irregular calcifications in the aortic valves, extending into the column of forced rushing blood. In this way a harsher character may be given to the murmur, or it may even become musi- cal. Vegetations also attached to the orifice or valve may be thrown into vibrations in the column of blood, and produce a musical murmur, but these are rare, mere possibilities. When musical murmurs occur they are almost always, if not always, vibrations of the chordas tendineas, some of which are under extraordi- nary tension. These sounds or murmurs may be illustrated by a stringed musical instrument. Every degree in quality of murmur or sound, from the softest blowing up to the harshest, sawing, rasping, filing, or when the vibrations become sufficiently rapid and regular, into musical sounds. The use of the term " bellows sound" by Laennec was unfortunate as applied to the murmurs of the heart, and much of the misunderstanding of mur- murs and their mechanism is due to it. It is true that it describes the friction-murmur of bipod forced through an aperture as in aortic regurgi- tation. It is like the sound of the air forced through DISTURBED ACTION OF THE HEART. 1 83 the bellows ; but the bellows-sound is not so like the friction-murmur of blood forced through an aperture as is fluid forced through an elastic syr- inge, in which some obstruction is created by pres- sure upon the tube. But, to imitate the murmur exactly, a fissure should be made in the bulb of the syringe, and then compressing it with force, the fluid escaping will give the exact sound. The only friction- sounds in cardiac murmurs proper are where the blood is forced through apertures or past obstructions ; it is heard at the aortic orifice when there is obstruction, as by lymph-deposits upon the valve. It is at first un- complicated, the simple gushing sound. But in time the obstruction causes hypertrophy of the left ventricle, which having taken place, irregular tension of the chordae tendinese is the result, and vibrations out of unison with the first sound are carried with the cur- rent of blood, and both occurring in the systole are mixed together and form what is called the blowing murmur. It is now a sound of mixed elements, friction of blood against a solid, and vibration of strings under irregular tension. In order to have an intelligent understanding of these murmurs we must analyze them and separate the sources of sound. We are assisted in this by localiz- ing the sources. The blowing, sawing, filing, rasping sounds have their origin and cause within the ventricle ; they are intra-ventricular. Dr. Cammann called them mitral-non-regurgitant. They are heard over the base of the heart, but always with greatest intensity at the apex-beat. Friction-sounds are heard best over the orifices or in the direction of the vibrating column of blood. The aortic systolic obstructive murmur is heard over the aortic valves, and in the course of the column of blood. 1 84 DISEASES OF THE HEART AND LUNGS. The regurgitant aortic diastolic murmur is heard over the aortic orifice, and to the left and toward the apex- beat. The mitral aortic-regurgitant is heard behind on the left side near the spine. In this direction the blood is forced in regurgitation through the mitral valve ; impinging first against the auricular wall, lying against the oesophagus, and aorta, and intervertebral substance, it is conducted directly into the ear, giving the sensation of being shot into it. It may be heard a short distance from this point con- veyed through the chest-wall. It may be heard in front, at the apex-beat, by conduction through the substance of the heart, when there are no intra-ventricular mur- murs to destroy it or take its place. The discovery of this absolute sign of mitral regurgitation belongs to Dr. Cammann, and his last professional thought was given to its consideration. It is one of the most cer- tain of cardiac signs. This characteristic murmur, heard in the situation he has pointed out, is an unfailing sign of mitral regurgitation. It had been my opinion that this characteristic murmur was never heard in front at the apex-beat — as it certainly is not when the valve is diseased, and the loud intra-ventricular murmur drowns and supplants it. But the following case shows that it may be heard both behind and before in congenital mitral insuffi- ciency, without hypertrophy of the heart and without lymph-deposits upon the valve. Case VII. (December 12, 1870.)— W. S. R., New York, aged twenty-two ; mason, living in Yorkville ; is a fireman temporarily, and was a member of the old department. Has never been sick, except with chills and fever. Sent for examination by Dr. Charles Mc- Millan, surgeon of the department. There is a systolic murmur at the apex-beat accompanying the first sound ; DISTURBED ACTION OF THE HEART. 185 it is a soft, gushing murmur, and can be heard in the chest-wall more to the left than to the right side. It is heard also with directness and greater intensity be- tween the seventh and eighth vertebras, left side behind, near the spine. The murmur is shot into the ear when placed over this point. It can be heard some distance to the left, conveyed in the chest-wall. It can also be heard over some portions of the right lung posteriorly, at the inner angle of the scapula ; also at the lower angle, being a faintly-conveyed sound. One year after, examined him again. Signs un- changed. This murmur has the same quality in front as behind. It has none of the vocal element of apex- beat murmurs, usually described as diagnostic of mitral regurgitant murmurs. Yet I have no doubt that this murmur is caused by mitral insufficiency, which is con- genital, without hypertrophy of the heart, and without disease of the mitral valve. A great majority of cardiac murmurs, even of those accompanying organic disease of the heart, are in a manner functional. That is, the murmurs are not organic in the same sense that the valvular murmurs are ; which are organic murmurs because the structural change in the valve is part of the mechanism of the murmur. Intra-ventricular murmurs, even when the result of structural change in the heart, may be con- sidered functional, inasmuch as that they have their mechanism in vibrations of the chordae tendineae, which are themselves unchanged by any diseased action, but simply vibrate, giving out sound of high or low pitch, soft or harsh, feeble or loud, according to the degree of tension of the individual strings, and the force of the heart's contraction. The cause of irregular contrac- tion of the heart-muscles may be from disturbed nerve power, as well as from organic change. 1 86 DISEASES OF THE HEART AND LUNGS. Functional murmurs proper may occur in the healthy heart, are transient, passing away with the subsidence of the cause, which may be anasmia, hypersemia, sym- pathy with *brain- disease, stomach, liver, or it may be from disorder of the nervous system, the influence of tobacco, coffee, tea, or any narcotic or stimulant having influence upon the organic life of the body, of which the heart is the centre and citadel. Functional murmurs proper do not signify danger of sudden death, but nothing more alarms patients than disturbed action of the heart. When the heart seems to stop, and then to turn over and thump against the chest-wall, the sensation is not a pleasant one, even to a medical philosopher. It is no wonder that it creates intense alarm in the lay patient, especially if accompa- nied by prolonged palpitation or faintings. These conditions may be the forerunner of softening, or fatty degeneration, but they signify always that there is over-distention of the portal system, intermis- sion of the heart-beat and pulse, may be present for years, and be merely the result of functional disturb- ance from chronic indigestion. Intermissions of the pulse have been laid down in books as signs of heart-disease. Life-insurance com- panies, in printed forms, make it the duty of examiners to reject as unsafe those who have intermittent pulse. It is possible that this rule militates against the interest of the companies, and it certainly is a source of great alarm to the rejected applicant. The sign, of itself, is no proof of heart-disease, but is proof of indigestion. It is true, cardiac disease is fre- quently a cause of indigestion, and thus, secondarily, the cause of irregular pulse. But a confirmed dyspep- tic is usually a safe life, for he is not likely to commit indiscretions in diet, as he is continually warned to DISTURBED ACTION OF THE HEART. 18/ desist by functional disturbances. Proper medication will generally relieve intermittent pulse, even in ad- vanced cases of cardiac disease. A sedative dose of calomel will frequently set it right at once, and the intermissions will disappear. The late Dr. Samuel Henry Dickson stated that, during the first hours of sleep, children have intermit- tent pulse, which will disappear when they are awa- kened. This is true, especially with those children who are allowed over-stimulating food, but, as the night passes on, and the food becomes digested, the intermis- sions cease. In the adult, the occasion of a wine- dinner, with tobacco, is often followed by intermittent pulse, especially during sleep, when the circulation is sluggish. The cause of the rhythmic movements of the heart is debatable ground. That it is within the heart itself can scarcely be questioned, for, when the heart of some animals is dissevered from all connections, and taken from the body, it may go on performing its rhythmical movements. Still, the quality and quantity of blood influence them in an unmistakable manner. The fact that shutting off supply of blood to the structure of the heart will arrest its contractions was shown in 1842 by Mr. Erichsen. Dr. Brown-Sequard has attempted to explain the motion to be due to the carbonic acid pres- ent in the venous blood, and Dr. Radcliffe has also given a similar explanation. The experiments of Dr. Paget show that the power causing rhythmical motion does not reside in all parts of the heart alike ; that, in fact — " If, for example, the cut-out heart (of any of the am- phibia) be divided into two pieces, one comprising the auricles and the base of the ventricle, the other com- prising the rest of the ventricle, the former will con- 1 88 DISEASES OF THE HEART AND LUNGS. tinue to act rhythmically, the latter will cease to do so, and no rhythmic action can be by any means excited in it. The piece of ventricle does not lose its power of motion, for if it be in any way stimulated, it contracts vigorously, but it never contracts without such an cxt ternal stimulus, and when stimulated it never contracts more than once for each stimulus. '^ Other sections of the heart, and experiments of other kinds, would show that the cause of the rhyth- mic action of the ventricle, and probably also of the auricles, so long as they are associated with it, and not with the venous trunks, is something in and near the boundary ring between the auricles and ventricles ; for what remains connected with this ring, or grew with a part of it, in a longitudinally bisected heart, retains its rhythm, and what is disconnected from it loses its rhythm." If we take a merely material view of the subject, no doubt we have arrived at the solution as nearly as we ever will. But is it useless or absurd to look further? The experiments of the great Harvey with the egg of the hen show that active life remains inchoate in the punctum saliens or germinal spot until warmed into active life. This principle came into the egg organi- zation at the time of its fecundation. Its first life- motion is rhythmical movement of particles before any portion of the heart's structure can be seen. The little red point appears and disappears rhythmically, and thus the principle builds its house, the auricle being its first chamber. The very nature of this principle is rhythmical. Its special home is in the ganglionic ner- vous system, but it pervades the whole body ; wher- ever there is nerve-fibre accompanying the smallest capillary — the vasor-motor — it is present. Aberration from its normal life-action is disease ; and influences, DISTURBED ACTION OF THE HEART. 1 89 both outside and inside of the body, make impressions upon this life, helping to determine the character of the disease. Medicines act upon it, but their modus operandi is a sealed mystery. That they are purga- tive, emetic, stimulant, sedative, or alterative, we only know the fact. The heart, supplied with about three hundred ganglia, is the centre and citadel of this life, and its abnormal or disturbed action is sometimes mys- terious evidence of both intrinsic and extrinsic disease. Acoustic properties of the chest have not been dwelt upon as their importance demands. The diagnosis of murmurs within the chest is facilitated, or otherwise, according to its conditions as an acoustic chamber. The difficulty of hearing signs in the chest of a hunch- back is recognized ; it is also a well-known fact that, as the heart enlarges, the murmurs grow weaker, so that those which had been once easily detected become fee- ble, or disappear altogether. Still they have been ac- counted for, it seems to me, upon every other principle than the true one. In Dr. Cammann's last illness, by his request, I was called to examine him. After he had explained to me that I would find obstructive and regurgitant murmurs, of which he had been long cognizant, and of which he explained the cause and origin, and of their gradual in- crease, I found that I could but just hear the soft, feeble murmurs of aortic obstruction and regurgitation, but intra-ventricalar murmurs were not heard. I told the doctor that the regurgitant murmur which he had em- phasized in relating the case was slight : " Yes," he said, "it is but a chink." Dr. Peugnet told me that when he examined him at the beginning of his illness the murmurs were loud and easily heard. I felt morti- fied that my ear had failed me, as I supposed, caused by a long ride in the cold, in an open carriage. The IQO DISEASES OF THE HEART AND LUNGS. doctor had circumscribed pleuritis with effusion and pneumonia. In time the effusion was absorbed, and then the murmurs at the apex-beat were easily heard. Another case, of which I have no notes, in which I failed to make out a murmur where it should have been heard, and which afterward returned, as the inter-cur- rent pneumonia, became convalescent, also annoyed me, and ag-ain I blamed my ear. Not long afterward I saw in the London Medical Times a7id Gazette, or in the London Lancet, the question, '' Why do cardiac mur- murs disappear during pneumonia or pleurisy ?" I felt at once that the cause of my not hearing the murmurs more plainly in Dr. Camman's case, as well as in that of this other patient, was because they were obscured by some cause I then did not know. Other cases of cardiac murmurs disappearing or be- coming obscured during the presence of pneumonia or pleuritis led me to believe that it was in accordance with physical law. A patient with pleuritic effusion was sent to me by Dr. Otis for examination. I knew from a previous auscultation that he had aortic ob- structive and aortic regurgitant murmurs. At this time, however, they could not be heard. I wrote to Dr. Otis, stating these facts, and predicting that when the effusion was absorbed these murmurs would again return, which proved to be the case. On August 27, 1864, I saw Miss Hall, matron of the Home for Soldiers' Children, in Fifty-seventh Street near Eighth Avenue, with Drs. Charles McMillan, J. L. Smith and E. Krakowizer. There were no heart-mur- murs, but as all the rational signs of cardiac disease, with increased area of dulness under percussion, signi- fied hypertrophy, it was suggested that we should ex- amine her for pneumonia, and, upon raising her up and listening behind, it w^as clearly made out. I then pre- DISTURBED ACTION OF THE HEART. I9I dieted that, when the pneumonia was well, we would be able to diagnosticate her cardiac disease. This was afterward done, and Dr. J. L. Smith took notes of the examination, and upon her death, some months after- w^ard, was able to verify the diagnosis. He presented the heart, with history, to the Pathological Society, and a committee was appointed to examine into the facts concerning the disappearance of heart-murmurs during the presence of pneumonia and pleuritis, and to report. If my memory serves me, the committee reported in substance, in the summer of 1865, that in some cases observed in Bellevue Hospital, murmurs grew feeble or disappeared on the advent of pneumonia or pleurisy, but that it was the opinion of the committee that this phenomenon was owing to the feebleness of the heart and its frequency, for in the cases noticed the pulse was 120 or more per minute. These reasons I had myself considered and rejected, for at the same time that Miss Hall was ill I had an- other patient, O. B. H — , who had had for years a double murmur, which, when attacked with pneumonia, disap- peared. His pulse ordinarily was about 50 in a min- ute, but during the pneumonia it rose as high as 80, but no higher. Drs. Chas. McMillan and J. L. Smith were also both cognizant of the facts as narrated. The philosophical explanation of these phenomena occurred to me during the winter of 1S64-6C,, with the following proof and illustration. The chest is a musical cham- ber, and may be represented by a violin. When the in- strument is tuned and in order, its acoustic qualities may be considered as perfect. If a watch or music-box be placed within the violin, but not in connection with it, auscultation will reveal the slightest jar or noise made by the works of the watch, or bring out with distinctness the low tones of the music-box. But if, while the ear Ig2 DISEASES OF THE HEART AND LUNGS. or stethoscope is still placed upon the violin, water or sand be poured into its chamber, the sounds of the box or watch will grow feeble or disappear. The low notes of the music-box disappear entirely, as also does any jarring of the wheels of the watch. These phenomena are invariable because they are the result of acous- tic law. The application of physical law to art is to render it scientific, and scientific medicine is the imme- diate professional want of our time. If acoustic law is applied to auscultation in physical diagnosis, it will remove it from the domain of doubt or uncertainty, just so far as its principles are intelligently applied. NEW CLASSIFICATION OF PHTHISIS PULMONALIS. 1 93 X. A NEW CLASSIFICATION OF PHTHISIS PULMONALIS, WITH REFERENCE TO SPECIAL TREATMENT.* The tendency of the present time is to re-arrange and to classify specific divisions of medical subjects in order to their thorough elucidation. Not more than a quarter of century ago Dr. Samuel Henry Dickson, one of the most accomplished and schol- arly physicians of his age, and representing the advanced thought of his time, described typhus fever as one dis- ease, with lesions of the head, with lesions of the chest, and with lesions of the abdomen. These divisions included those which we now call typhus fever, typhoid fever, and typhoid pneumonia. But it was an intelligent attempt to bring order out of chaos. Dr. Murchison and others have shown since, that these divisions comprise separate unities widely differ- ing in causation, history, physical signs, and in patho- logical changes, and with the happy result of indicating more rational and far more successful methods of treat- ment. That which has been done for the family of typhoid diseases remains yet to be perfected in those of phthisis. Sydenham says : " There are several kinds of con- sumption. The first mostly arises from taking cold in winter; abundance of persons being seized with a cough upon the coming in of cold weather, a little before the winter solstice, which happening to such * Archives of Medicine, June, 1879, 194 DISEASES OF THE HEART AND LUNGS. as have naturally weak lungs, those parts must needs be still more weakened by frequent fits of coughing, and become so diseased at length hereby as to be utterly unable to assimilate their proper nourishment. " Hence, a copious crude phlegm is collected. The lungs, being hereby supplied with purulent matter, taint the whole mass of blood therewith, whence arises a pu- trid fever, the fit whereof comes towards evening and goes off towards morning, with profuse and debilitating sweats. And when the lungs lose their natural tone, tubercles ordinarily breed therein. . . . When this dis- ease is confirmed, it for the most part proves incurable." Is not this a good description of consumption for one two hundred years old ? Laennec and his followers classed everything in pul- monary phthisis as tubercular. " This," he says, " I think is the only kind of phthisis which we should ad- mit, unless, indeed, it were the phthisis nervosa and the chronic catarrh simulating tuberculous phthisis." Broussais held with the ancients that phthisis may re- sult from inflammation, but Laennec charged him with doing so by assertion and ratiocination, however, rather than by facts. The tide of Laennec's well-earned fame has floated some errors down to our own time, espe- cially one which throws contempt upon the observa- tions of his eminent compeer. Sir James Clark, Sir John Forbes, and other English writers who had learned immediately from Laennec and Louis, followed strictly in the line of the great French leaders, and created, so to speak, a tubercular public opinion. But now a wider and more catholic view is being taken by English and American physi- cians who are conservative and practical rather than hypothetical. Dr. Andrew Clark, of London, in a lecture at Bellevue NEW CLASSIFICATION OF PHTHISIS PULMONALIS. I95 Hospital last autumn, and which was reported in the New York Medical Record, divided phthisis into three, as he said, natural classes, viz.. Tubercular, Catarrhal Pneumonia, and Fibroid. Tubercular and fibroid rep- resent great natural divisions, and are descriptive of great pathological conditions and differences. In one there results death of tissues, in the other func- tional incapacity. In both there are cough, expecto- ration, and wasting — and there may be haemoptysis, but even in these particulars, common to both, they are in- dividually different as they are also in their grander distinctions. Indeed, they are opposing diseases of the same organ, which, did they not frequently coalesce, producing new diseases by their combinations, would be described always as distinct. Niemeyer, leading the modern school of pathological physicians, includes all these under the term Catarrhal Pneumonia, which name, I shall endeavor to show far- ther on, is not fully descriptive of the cause nor of the morbid results. The following classification is one which my clinical experience, confirmed by autopsical examinations, has led me to adopt : FIRST CLASS, OR TUBERCULAR PHTHISIS. First Division. — Uncomplicated Tubercular Lung. Second Division. — Lung with Tubercular Adherent Pleurse. SECOND CLASS, OR FIBROID PHTHISIS. First Division. — Adherent Pleurae, with Fibroid Lung. Second Division. — Adherent Pleurae, ^yith Tuber-. Gulated Fibroid Lung, 196 DISEASES OF THE HEART AND LUNGS. This classification may cover the whole ground — in- cluding accidents and complications. First Class, First Division. Uncomplicated Tubercular Lung. — Tubercular con- cretions and cavities in the lung without adherent pleurse or fibroid — sacculated tubercle — latent phthisis. This form of phthisis is rare. Louis' says : '' Nothing was so frequent as the ad- hesions of the lungs to the pleuras, for in a hundred and twelve cases there onl}^ existed one in which the two lungs were free in the whole of their extent. We have only found the right lung completely without adhe- sions eight times ; the left only seven, and in these cases there were either no tuberculous excavations, or only those of very limited dimensions." Laennec and Louis include all those cases which are obscure in diagnosis, especially in the earlier stages, under the term latent phthisis. *' These differences in the order and duration of the morbid phenomena do not interfere with the regular progress of the disease — do not, so to express ourselves, alter its physiognomy ; but there are instances when its characters are so com- pletely modified that its recognition is impossible be- fore its progress is considerable ; it is, in fact, latent for a longer or shorter period. At other times it assumes the form and progress of acute diseases, its different periods seem confounded together, and the diagnosis is not less obscure than the opposite condition." * The early history of the first division of tubercular phthisis is generally overlooked on account of the ob- scurity of the physical signs and symptoms, owing to * Phthisis: by Louis. Chap. VIIL, 372, (Translated by Chas, Cowan, M.D., Washington, 1876.) NEW CLASSIFICATION OF PHTHISIS PULMONALIS. 197^ the fact that there are no adhesions to convey the sounds of morbid changes in the lung- into the chest-wall for easy recognition ; the first observed evidences of the disease being those connected with the formation of a cavity. Laennec says of latent phthisis : " It very seldom hap- pens that phthisis is latent through its whole course ; but it is by no means rare to meet with cases in which the characteristic symptoms show themselves only a few weeks, or even days, before death ; and which had been previously mistaken for diseases of quite a differ- ent nature." * These cases were evidently according to our classifi- cation — Class First, Division First — uncomplicated tubercular phthisis, until "the characteristic symp- toms" showed themselves "a few weeks or even days" before death, when they came under the second division of tubercular lung with adherent pleurae. Laennec nor Louis knew anything about the laws of acoustics, nor did they know of residual air, and consequently they lacked the elementary knowledge for correct diagnosti- cation of uncomplicated tubercular lung. It is not wonderful that these early auscultators to whom we owe so much should have been unable to diagnosticate uncomplicated tubercular lung, for there were no adherent pleurae for the ready conduction of sound — telephoniftg, as it were, from the interior of the lung into the chest-wall. Even now the auscultator who does not recognize the diagnostic value of true re- spiratory murmur cannot appreciate the delicate but absolute sign of centric tubercular concretions nor of centric pneumonia, which is simply to comprehend the fulness or absence of true respiratory murmur, without * Forbes' Translation, p. 327. 19^ DISEASES OF THE HEART AND LUNGS. which the evidence of the condition of the interior of the lung entirely escapes them. The predisposing" cause of uncomplicated tubercular consumption is a strong proclivity from inherited ten- dency. It occurs most frequently in early adult life or, in middle age, and its immediate cause is local or sys- temic irritation. Acute tuberculosis occurs in children, at the periods of dentition, at puberty, and in middle life. The relation of acute tuberculosis to tubercular con- dition of the lungs, to my mind, is not absolutely clear, but clinically children liable to head troubles in in- fancy, if they live to adult age, may have tubercular phthisis. Both in children and at adolescence the mani- festations of tubercular invasions may occur in persons of full habit, with abundance of adipose. At the first thought this seems incongruous, for tu- bercle is the feeblest of neoplasms and runs a rapid course of degeneration ; but we must remember that adipose is not of itself a sign of strength, but in tubercular cases it may exist at the period of inva- sion, connected with a marked prostration of vital power. Should a case be under skilled observation before the appearance of cavities, it may be noticed that there is deficienc}'' of true respiratory murmur, especially over the site of forming concretions, while at the same time there is slightly raised pitch under percussion. There are no rhonchi,"* rales, sibilus, or sonorous, and possibly no cough. But just so soon as the nodules or encysted tubercle begin to soften, there will be prostration, rise of temperature, quickened pulse and hurried breathing — perhaps cough and slight ex- pectoration if the concretions should be near bronchial tubes, but when the abscess opens into a bronchus there may be expectoration of characteristic matter, and there may be fatal pneumorrhagia, depending upon the ero- NEW CLASSIFICATION OF PHTHISIS PULMONALIS. I99 sion of an artery occurring at the same time. Then for the first time the physical signs of a cavity are discov- erable, but they are by no means so plain as when there are interpleural adhesions and fibroid lung. Healthy lung structure is a poor conductor of sound ; but an attentive ear will discover a low note of amphoric char- acter, especially in expiration. Should the cavity be large and connected with a large bronchus, there may be gurgling when it contains fluid. Coughing" and ex- pectoration are never excessive as they may be in fibroid phthisis. Wasting and loss of weight commence to rapidly increase after the occurrence of cavities, as do also hectic, night-sweats, loss of appetite, etc. Louis gives two varieties of the latent form of phthisis. One rapid in its course, ending in a few weeks without any arrest in progress, while the other may linger and for a time give some hope of recovery. I have seen both varieties. One, in which there was an arrest of pro- gress of disease in the lung, died with marked signs of meningeal tuberculosis. Laennec also refers to latent phthisis and acute phthi- sis, but not in so clear a manner as Louis, and without detailing physical signs or post-mortem examinations. Except incidentally in one case, *' a girl, eighteen years of age, who died in the hospital Cochin, without any emaciation, or other symptom except those of a severe feverish catarrh of less than a month's duration. Upon examining the body, the lungs were found filled with tubercles more or less softened, of a size almost uniform, and none less than a filbert or almond." * This case was, no doubt, one of uncomplicated tubercular lung. Rindfleish says : *' That tuberculous phthisis is only * Laennec. Forbes' Trans., 4th edition, p. 328 and 329. 200 DISEASES OF THE HEART AND LUNGS. a combination of scrofulous inflammation and tuber- cles." * " Nodules as large as a pea, or even a walnut, are not uncommon." f Treatment. — The early management of a case is in its prevention. Scrofulous diathesis indicates that the in- dividual should be kept under the best hygienic influ- ences, out-door exercise, pure air, and appropriate food, and that any local or systemic source of irritation should be removed. I consider chloride of ammonium as a preventive as well as a curative agent of- very great value. It may be used in baths, by inhalation and by enema, as well as by the stomach. Dissolved in bay rum it is a pleasant sponge-bath with a flannel cloth night and morning. By inhalation in all the catarrhal conditions of the nasal and upper-air passages. By enema in threatened meningitis of children, and by the stomach in deep-seated " colds." Should the disease have commenced, cod-liver oil, tonics, aids to digestion generally, change of air and scene in addition to hyg^ienic conditions and chloride of ammonium may be beneficial. Also, digitalis sus- tains the action of the heart when enfeebled ; atropia control night-sweats ; quinine and arsenic are anti-peri- odic, and may be adjuvant according to individual in- dications. I have no doubt also that iron and iodine may be of great value in purifying and enriching the blood. Recent excavations may be kept at rest, preventing extension of disease and of pneumorrhaghia by strap- ping the affected side with elastic adhesive plasters. Small blisters frequently applied over and around the *Ziemssen, vol. V., p. 635, American edition. f lb. id. p. 642. NEW CLASSIFICATION OF PHTHISIS PULMONALIS. 201 region of excavations assist in arresting progress of disease. Stimulants, when they promote sleep and digestion, should be taken at meals and at bed-time. Food should be abundant, easily digestible, varied, and moderately stimulating. Forced expansion of the chest when nodules are soft- ening, or after an excavation has been formed, must, of necessity, be avoided. But when the danger of hem- orrhage has passed, it may be gradually resumed. A fatal hemorrhage rarely takes place after a cavity is a week old. Eroded arteries contract speedily. Inhalations of medicated vapor may soothe irritation in the upper bronchias, prevent ulceration in the lar3mx and trachea, and may even reach excavations opening into large bronchise. A certain amount of medication may enter the system, especially chloride of ammoni- um, but we must remember that the residual air resists the entrance of irritating vapor into the true respira- tory system ; hence, there is generally disappointment where much benefit has been anticipated. Second division of the first or tubercular class. Tuber- cular nodules and cavities following pleural adhesions. The only difference of the second division of the tu- bercular class from the first is, that it commences with plastic exudation within the pleuras — sacculated or nodular phthisis very soon following. This division is larger than the uncomplicated tubercular, and is remark- able for the frequency in which it is terminated by fatal accidents, pneumorrhagia and hydropneumotho- rax. These accidents may occur in the first division as well as in the second or tuberculated division of fibroid phthisis, but in an experience of thirty years I do not remember a single case of fatal pneumorrhagia occur- ring in any but in the second division of tubercular 202 DISEASES OF THE HEART AND LUNGS. phthisis, at least none others were verified by post-mor- tem examinations. In the first division of the first class the occurrence of tubercle is apparently spontaneous. If pleuritic ad- hesions afterward occur, they are accidental, and ap- pear near the end of the disease ; but in the second class adhesions precede and seem to excite tubercular deposits. I am fully aware that this fact cannot be fully appreciated except by those capable of recogniz- ing the initial stage of interpleural plastic exudation.* However, if my position is correct, the immediate re- absorption of the plastic exudation may prevent tuber- cular deposits and its dangerous liabilities. The following history in fatal cases usually obtains : Plastic exudation takes place within the pleurae, over the upper half of the lungs, and tubercular concretions mostly centric are formed, and pass to the period of softening. Earlv in the disease one or more open into a bronchus, and if a branch of the pulmonary artery passing through the abscess opens at the same time, instantly blood will fill the air passages in that side of the chest, and, rising into the trachea, run over, fill- ing the air passages in the other side of the chest — a few mouthfuls of blood are expectorated, when the mouth and nose fill with frothy blood, the patient strangles — is literally drowned in a few minutes. f The fatal occurrence of pneumorrhagia is always a surprise to the physician as well as to the patient and his friends, as the first indications of danger are only recognized when it is too late. The formation of tuber- cular nodules, centric, in otherwise healthy lungs, un- * See Dr. Brown-Sequard's Archives of Scietitific and Practical Medi- cine, March, 1873; the Medical Record, May 25, 1878. f Case viii., Physical Signs of Interpleural Pathological Processes. Medical Record, May 26, 1878. NEW CLASSIFICATION OF PHTHISIS PULMONALIS. 203 derneath adhesions and thickened pleuras, cannot be easily diagnosticated, for there are no obvious physical signs. Post-mortem examinations show a few tubercular concretions, mostly central, near blood-vessels and bronchige, one or two of which have opened into a bronchus and into a branch of the pulmonary artery at the same time, and the bronchial tubes are filled with blood. Should a softening nodule open into the pleuras, let- ting in air and fluid, we would have hydropneumo- thorax. This accident occurs suddenly, causing great pain and dyspnoea. Sometimes the patient dies from the shock, or he may linger a few days ; occasionally months. Some have recovered. The diagnosis is easy. The sudden pain and dysp- noea direct attention to the affected side, and the tympanitic resonance under percussion, with amphoric respiration and metallic tinkling, are decisive. Treatment will consist in immediately strapping the affected side with elastic adhesive plasters, relieving pain and controlling inflammation. If the amount of fluid escaping into the pleural cavity is small, the open- ing through the pleura may be closed, the fluid ab- sorbed, and the patient live. The consideration of both divisions of the first or tubercular class fully justifies the popular belief in the fatality of consumption. Fortunately the number is much less than that of the fibroid class, which is amena- ble to treatment. SECOND CLASS. — FIBROID. First Division. — Adherent Pleurce, with Fibroid Lung, This division represents a disease entirely opposed to that of the first division of the tubercular class. 204 DISEASES OF .THE HEART AND LUNGS. In this there is loss of function only, in that necrosis of tissue, with loss of substance. Many times, doubtless, pure fibroid has been mis- taken for tuberculated fibroid phthisis, the second di- vision of this class, on account of the gurgling rales being misinterpreted as signs of cavernules in the lungs. The physical signs of plastic exudation are soft, tear- ing, crepitant and sub-crepitant rales near the ear — not more than five or six lines distant — which are often pres- ent without any expectoration or cough, and which are heard in the same place from day to day. If they were caused by mucus in the bronchial tubes, they would almost necessarily be accompanied by ex- pectoration and cough ; they would be at different dis- tances from the ear — never so near, and would change their locality and quality at each examination. I believe that nine tenths of all forms of phthisis com- mence with interpleural plastic exudation, which is re- movable, when fresh, by proper management. In consequence it is of the utmost importance that an early diagnosis should be made, in order that judi- cious but simple management, aided, if necessary, by positive treatment, may clear up all signs of the exuda- tion, and in accomplishing this, arrest the tendency to phthisis, diminishing the number of victims of the most common and the most fatal of diseases. The inherited proclivities in fibroid phthisis are gout, gouty rheumatism and syphilis — factors of vital depression favorable to plastic exudation. But many times the prochvity is acquired, where the heredity is of health. Anxiety of mind, mental or vital depression long continued, may inaugurate a tendency to plastic exudation in the most healthful organization. Instances of a surviving husband or wife, after long NEW CLASSIFICATION OF PHTHISIS PULMONALIS. 205 watching at the bedside of one dying- with phthisis, be- coming consumptive are not unusual. So frequent is this the case that the question of the transmissibility of phthisis has been mooted ; but a conclusive answer is, that whatever may have been the character of the lingering disease of the first, the second resulting, always begins with plastic exudation. Mental Depression. — Students, men of exciting busi- ness, and lovers, when unsuccessful, are liable to inter- pleural exudation, which may be the beginning of phthisis. Soldiers after a defeat are liable to phthisis or typhoid fever. Vital Depression. — Syphilis, or masturbation in those just arriving at adult age, smallpox, or other of the exanthematous diseases, a badly managed pleurisy or pleuropneumonia, malaria, a wasting ulcer, a capital operation in surgery may be followed by plastic exuda- tion, which may end in consumption. The depressing causes are so numerous that it is a wonder that these serious consequences from plastic exudations are not oftener observed. The exudation is no doubt much more frequent than we are aware, as many times it is immediately re-absorbed, and at other times, although becoming organized, it may be of such limited extent, and so placed, as to remain innocuous during life. The exudation is a makeshift, as it were, of nature, and it is only when she is unable to remove it again that it becomes a source of inconvenience or of danger. If not re-absorbed, it becomes organized, and contracts according to a natural law. The effect of which upon the pulmonary pleura is to press it down on the air sacs immediately underneath, closing them and arresting the cap-illary circulation, which is then thrown back upon its two sources of pulmonary supply that of the pulmonary artery and that of the bronchial, 2o6 DISEASES OF THE HEART AND LUNGS. through the nutrient arteries. The obstruction to the circulation of the blood from the pulmonary artery is not of much importance, but that of the capillaries of the nutrient arteries seriously interferes with the cir- culation through the bronchial arteries. The nutrient arteries of the true respiratory system of the lungs are derived from the bronchial. They have no venas comites to return their blood to the right heart for re- aeration, as all other arteries of the body have. The blood which they carry to the tissues of the true respira- tory system for its nutrition is re-aerated as it passes through the capillaries into the radicles of the pulmo- nary vein — never becoming venous in character. This anatomical peculiarity is the key to many other- wise inexplicable phenomena of diseases of the lungs and of the pleuras. It explains bronchorrhagia and bronchorrhoea. As before said, fibrination having taken place upon the pulmonary pleura, and contracting, the blood in the nutrient arteries, is " backwatered," so to speak, upon the bronchial, whose only relief is trans- fusion through the mucous membrane, of blood, fibrine, serum or mucus. Consequently the indications are that the bronchor- rhagia or bronchorrhoea following should be treated as effects, and not as diseases. They are the natural re- sults of the capillary obstruction. Such bronchorrhoea is different from primary catarrh, inasmuch as its pri- marv cause is not in the mucous membrane, but far re- moved from it. Also fibrination within the pleurse alone is not pneumonia, as has been mistakenly diagnosti- cated. A careful physical examination will show that at this stage all the changes that have taken place are within the pleuras. For these pregnant reasons I cannot accept the term catarrhal pneumonia as descriptive of NEW CLASSIFICATION OF PHTHISIS PULMONALIS. 207 its pathological processes. All of these signs and con- ditions are the accumulating results of obstruction of the capillaries immediately subtending the pulmonary pleurae. From time to time fibrination progresses induced by slight causes, until the patient yields to the crippling process of contraction, stoops forward, with hurried breathing and spasmodic cough. Old adhesions are reinforced by new exudation caused by colds, fatigue, emotion or ''worry." The second stage of the first division now com- mences when the inflammatory process begins to ex- tend into and through the lung itself, and portion after portion of the true respiratory system becomes involved in the contracting fibroid. The heart and lungs are displaced upwards, downwards or sideways, or are bound to the chest-wall. Cardiac murmurs result which may deceive the physician into making an error in diag- nosis of heart disease. The heart struggles, palpitates, sometimes hypertrophies or dilates and fails to properly carry on the circulation, stasis, increased fibrination, continually recurring, spasmodic, strangling, almost suf- focating cough, fill up a picture of a pitiable condition. Autopsies confirm the diagnosis in a remarkable man- ner. Adhesions within the pleurse fasten the lung to the chest- wall, sometimes to the mediastinum, the peri- cardial sac to the lungs, and all are drawn out of their normal position until the apex of the heart has been found on a level with the lower border of the fourth rib.* The earliest physical signs of fibroid are simply those of plastic exudation within the pleuras. The per- cussion note is slightly flat, and raised in pitch as if * Case IV., Phys. Signs, of In. PL Path. Process. The Medical Record, May 15th, 1878, 208 DISEASES OF THE HEART AND LUNGS. parchment or paper were spread over the chest-wall. The rales are fine, soft, moist, tearing. It requires a practised ear sometimes to discover these delicate signs, but even a beginner in auscultation will notice that the respiration is harsher over some one region of the affected chest than another ; let him fix his attention in listening to this rough respiration, and fill his own lungs at the same time and in the same way as does the patient, and after a little while he will be able to ana- lyze this roughness, and find that it is made up of innu- merable moist, soft rales, very fine and very frequent. At the same time he may hear the true respiratory murmur, when it exists, just beyond the interpleural rales, with just as much certainty in measuring the distance as he could do it by sight, welling up under the pleurae at the end of a full inspiration like the dis- tant roar of the sea. When he finally hears these rales and distinguishes at the same time the true respiratory murmur, he will be convinced of two important facts,' that there is lymph exudation within the pleurse and that the lungs are free. In time, these soft, almost un- recognizable rales become more distinct, even dry and crackling, and then all doubt of their existence is cleared up. There may be an abundance of rales with neither cough nor expectoration ; but unless the exudation is re-absorbed they will begin in time ; at first viscid mucus, colorless or slightly tinged with blood, but afterwards becoming profuse and assuming a greenish hue. The dyspnoea is frequently out of all proportion to the amount of pathological results in the pleurse or of the congestion of the lungs. If the serious mistake has been made of considering the early signs of plastic exudation as those of catarrh NEW CLASSIFICATION OF PHTHISIS PULMONALIS. 209 or of bronchitis, strong- adhesions may result and be- come a point of irritation, which may continually induce new exudation and increased disability. The physical signs of firm adhesions are greater flat- ness under percussion, and perhaps a shade of dulness over areas of thickened pleura or of condensation of lung, with a great variety of rales, fine, dry, moist, coarse, or a combination of all of these. The rational signs are distressing dyspnoea ; spasmodic coughing, with copious expectoration; irregular palpitation of the heart ; temperature varying from natural to 38.9°C. 40° C; variable appetite ; sometimes sleeping quietly when lying down ; in other cases catching what sleep they can in an arm-chair, or sitting up and leaning for- ward in bed ; progressive emaciation and debility, until a new cold, greater hyperasmia, fresh exudation, and the life is closed out. Louis notes that in autopsies it was found that fresh plastic exudation, occurring in the last days of exhausted vitality, was evidence of debility. No doubt it is so at the commencement as well as at the end in phthisis cases. Treatment of first division of the fibroid class is an easy problem at the beginning, but grows more diffi- cult every day of its after existence. Organization may take place very soon after exudation, but generally appropriate management will cause its speedy removal. Even when the exudation is some, weeks or months old, positive treatment will soon clear up the evidences of disability and disease. Regulated or systematic ex- pansion of the chest in the open air, with appropriate food, are of the first importance. Walking, or riding on horseback, in the country, and habitually filling the lungs and holding the breath a little more and a little longer than usual, with milk diet in abundance, is gen- erally sufficient in recent exudation without medication. 2IO DISEASES OF THE HEART AND LUNGS. Case ist. — Rev. 34 years old, born in New Jersey ; father died at the age of 54 of phthisis ; family history otherwise good. During the great heat of last summer ministerial duties were heavy, was depressed about business affairs, and began to be ill. After feel- ing weak and ''out of sorts " for some time, was taken with hasmoptysis on the morning of July 13, 1878. Became apprehensive, sleepless, could eat, but had no appetite; fell, in weight from 122 to 117 pounds. Hawked up mucus, but had no cough proper. When lying down could hear whirring noises in chest. Had stitches mostly in left side about the heart, with palpi- tation. Physical examination discovered a few distinct rales over right lung ; left side a few rales at upper part, but in the lower part an abundance of fine, sub- crepitant rales back and front. Respiration feeble; could not fill the chest fully in inspiration ; no dulness, but a little flatness under percussion in lower part of left side. Diagnosis. — Plastic exudation within the pleurae, mostly in the lower part of the left. Directed system- atic expansion of chest in open air, walking, with milk diet. Took no medicine, except cod-liver oil ; rubbed down with English glove night and morning. Re-examined Nov. 7, 1878. Respiration and expan- sion improved, but rales remain. Re-examined March i, 1879. ^^ signs of exudation have disappeared. Allowed to return to his ministe- rial duties. Weight, 130 pounds. Eats well; sleeps well, unless excited, and feels well. Walks five or six miles every afternoon, in addition to out-door exercise in the morning; has walked ten or twelve miles in a day without over-fatigue. Chest was measured on the i6th of November last, and again first of April ; under the arms and under nipple. Gained under the arms, NEW CLASSIFICATION OF PHTHISIS PULMONALIS. 211 after exhausting- the lungs half an inch, in ordinary res- piration three fourths of an inch, and one inch and one fourth after full inspiration. Under nipple gained half an inch in forced expiration, one and three fourths inches in ordinary respiration and two inches in full inspiration. With mild medication the time of recovery may be shortened, and its use is advisible if there is doubt about the organization of the exudation. Case 3. — D. E. returned from Florida in the spring of 1878. Took cold about two months before leaving the South ; continued to cough, rapidly lost weight, from 180 to 160 lbs.; had two attacks of hasmoptysis. Physical examination discovered subcrepitous rales right side posteriorly ; appetite poor ; dyspnoea on ex- ertion. Advised to go to Harper's Ferry, Va., and commence walking eight to fifteen miles each day, sys- tematically expanding the chest, and living on milk diet, and in addition to take a cold infusion of wild cherry bark with chloride of ammonium — two ounces of the bark and one of ammonium in two pints of cold water ; tablespoonful about every hour. This was done strictly, and he returned in about three weeks. All signs of plastic exudation had disappeared ; had re- gained the weight he had lost; had no cough, no dyspnoea in exercise, and has remained well since. But should the system be in no condition to respond to those simple measures, or if the organization of the exudation has resulted in firm adhesions of the pleurae, with commencing consolidation of the lung, and the simple means fail, it may be necessary to resort to posi- tive medication by mercurials- — calomel and Dover's powder in small doses until the teeth are tender, which may be followed by bichloride of mercury in Huxham's tincture of bark in small doses, and may be continued 212 DISEASES OF THE HEART AND LUNGS. for months in addition to the chloride of ammonium, and systematic expansion of the chest in the open air, milk diet, etc. Case. 3. — A. R., native of Scotland, 39 years of age, clerk. Family history good. Weight in health, 165 lbs. Began to be ill in 1874. Frequently took colds; had " catarrh," but kept at business ; gradually grew worse. In 1875 had some inflammation of the chest, which was checked ; had severe coughing spells, with loss of strength and short breath ; all symptoms grow- ing gradually worse until October, 1878, when he came to be examined. Pulse frequent and irritable ; breathing hurried ; con- stant coughing ; expectorating yellowish thick mucus ; appetite poor; disturbed sleep; weighed 130 lbs. Physical examination. — Almost no expansion in right side ; restricted on left ; dulness over right lung, espe- cially over middle portion ; not so great over left ; fine dry rales over right side, especially over middle por- tion ; some crackling rales at summit of right lung ; softer tearing rales over left side. Diagnosis. — Extensive adhesions in both pleurae ; old and organized in the right, with consolidation of middle portion of lung ; fibroid phthisis, second stage. Placed him at once on calomel and Dover's powder, to make the teeth sore ; then to follow with chloride of ammonium and wild cherry bark, cold infusion, and fre- quent small blisters ; systematic expansion of the chest in the open air, freedom from business, milk diet, etc. The mercurial treatment was resumed three times, and car- ried to the point of mercurialization, followed by blis- ters, etc., with marked improvement of rational and physical signs ; chloride of ammonium and wild cherry bark, with bichloride of mercury, one thirty second of NEW CLASSIFICATION OF PHTHISIS PULMONALIS. 21^ a grain three times daily in a compound tincture of Peruvian bark were continued afterwards. He was permitted to return to his business in January. Re-examined April 22, 1879. — -H^^^ gained twenty pounds in weight since October last. Has no cough ; pulse natural ; respiration quiet ; temperature, 37° C, (98.6 F.). Physical examination shows increased expansion o£ chest ; no dulness ; a little flatness ; some thickened' pleurae still remains over middle portion of right lung* behind ; no rales on either side. Has not regained full strength, although very much improved ; a little short breathed on severe exertion ; eats well, sleeps well, and feels perfectly well when not over exercising, When the fibroid is extensive both in the pleuras and in the lung, as in the above case, mercurialization to the point of salivation may be absolutely necessary to relieve the patient. The result in case 3 was excep- tionally favorable, and cannot be regarded as the rule for all cases of fibroid in the second stage. Yet to save one such case from among a number is very encourag- ing. The careful physician, who knows how to use his tools, will have no fear of doing injury. He will carry the use of this powerful remedy just so far as is neces- sary to accomplish the desired end, and no further. The blister will be most efficient when the system is under the influence of the mercurial. Systematic expansion of the chest must not for one moment be lost sight of, no matter what form of medi- cation may be adopted. Indeed it should be considered that all medication is auxiliary to expansion-^to make expansion possible. Gently fiUing the lungs, holding the breath, depend- ing upon the rarefaction of the cool, inspired air after 214 DISEASES OF The heart and LtTNGS. mixing with the heated, residual air, to dilate the lungs' and gain expansion of the chest. When there is no irritation of the lungs or pleurae the air may be forced into the lungs and held as long as possible, that con- tracting adhesions may be overcome. Accurate measurements of the chest should be made and recorded at intervals, that progress may be ascer- tained and patient encouraged. Perhaps no simple method of gradual expansion is more effectual than rid- ing on a fast walking horse. The instinctive balancing of one's self on the horse in the rolling motion of fast walking keeps the chest expanded, and systematically exercises all the muscles of the body without fatigue. In forcible expansion care must be taken not to do harm. Adhesions must not be violently torn nor put upon the stretch, or the result may be extension of in- flammatory action and further disability by new exuda- tion. The pleura has been torn from the lung by the accident of falling, and death has resulted from hem- orrhage resembling pulmonary apoplexy. In connection with systematic expansion the subject of climate is important, as expansion in pure air is more beneficial than in bad air. Change of scene and of ac- customed thought is desirable, also out-door exercise ■and cheerful amusement with a congenial friend in a cool equable climate free from malaria, in balsamic forests. But even then change should be had. The patient does best who goes from place to place. The influence of change upon the digestive organs is a mat- ter of common observation. Sea voyages for those liv- ing inland, to the mountains for those living by the sea, even from a good to a poor climate may give a temporary benefit. I have known patients to improve rapidly by coming from healthy hill countries to New NEW CLASSIFICATION OF PHTHISIS PULMONALIS. 21^ York, which certainly cannot boast of perfect climate for a phthisis patient. Any one locality, however good, should not be re- commended for all. One whose taste runs in that direction will do best where there is hardship and roughing it, with plenty of incident, while others, and especially women, may do better in congenial society, surrounded by the elegancies and comforts of fashion- able life. We have on our continent every variety of climate and scene, California, Colorado, Minnesota, Canada, Texas, Florida, North and South Carolina, Georgia and Virginia, or the Adirondacks. Short voyages also bring us to the Bermudas and West India Islands. But if there is progression in fibrination, the time may come when the patient must desist from exercise, and keep his room or even his bed for a lengthened period, using the gentlest means to keep the chest expanded, living upon the most nutritious and stimulating food* Using rectal alimentation with defibrinated blood, intel- ligent mercurialization, •blistering, and tonics to cause re-absorption of newly exuded matter which may so free the lungs again that out-door .gentle exercise may be resumed when summer has set in. From the latter part of February until the first week in June a phthisis patient who cannot seek a better climate should keep his room by a cheerful fire, and take only such exercise as he can indoors. Second Division of Fibroidy or Second Class. Tuber- culated fibroid Phthisis, To this division belong the great majority of the cases of phthisis which come under our observation, too late for curative treatment. The disease is essentially fibroid ; the tubercular ele- ment is a complication, and is accidental. Niemeyer 2l6 DISEASES OF THE HEART AND LUNGS. says that the fear in a case of catarrhal pneumonia is that it may become tubercular. Substituting fibroid for catarrhal pneumonia, I would entirely agree with his anxiety in regard to this complication. The low- ered vital power in a fibroid lung or pleura, with the constant irritation caused by the interplural adhesions, invite the exudation of tubercle. A scrofulous diathe- sis with fibroid lung is almost certain to become tuber- culated, and it is this fact which makes it so necessary to watch and to remove the first beginnings of the fibroid condition. The causes, history, physical signs and treatment of this division up the time of tuberculation have already been glanced at in the consideration of the first division of the fibroid class. The new physical signs denoting the advent of tuberculation will need to be watched for with great assiduity, for upon their appearance or non-appearance depends very largely the hope or des- pair which will govern the efforts for cure or for palli- ation. These signs are areas of duhiess which raised pitch under percussion, with loss of true respiratory murmur, followed by bronchial breathing, bronchophony, raised temperature, hurried pulse, and respiration. Decided exacerbations, chill, fever and sweating, periodically returning. The cold sweat coming on after midnight is like the approach of death, and is horrible to the patient. When the tubercular masses soften and open into a bronchus, the characteristic expectoration may an- nounce the formation of a cavity, or the expectoration may not be observed. A general amelioration of all the symptoms may occur at this period. The chills and fever may subside, the pulse and temperature may fall to normal, the respiration become slower and fuller, NEW CLASSIFICATION OF PHTHISIS PULMONALIS. 21^ the hectic and night sweat disappear. Perhaps the patient begins to eat and sleep well, and from this time forward there may be continuous improvement. Great injustice may happen to the attendant phy- sician should he be changed for another a short time before the formation of a cavity, for the great improve- ment of all the symptoms will naturally be attributed to the new doctor. Many patent medicines have gained great popularity from having been '* tried'' in the right time. But, unfortunately for the patient, such com- plete rehef is not always obtained. Other tubercula- tions may also be going through the same process of softening, and the amelioration may be but partial and only for a short time. The physical signs of a cavity are made exceedingly plain by the good sound-conductirg quality of fibroid lung and adherent pleurae. The cavernous or amphoric respiration, and the reverberations or echoes of rales and gurgles in the cavities with pectoriloquy, vocal and whispering, leave no doubt of what has taken place. Auscultation may discover remaining concretions which may soften in time and repeat the same signs and symptoms until they also are discharged. The condition of cavities may be studied for the bene- fit of the patient: As to whether they are empty or filled or partly filled with fluid. Also as to the manner of their opening into a bronchus, from the walls of the cavity or from the roof or from the floor. Should the opening be from the bottom of the cavity, it will always be empty when the patient is in an upright position. Should it be from the top of the cavity it may be overlooked during examinations made in the middle of the day, the usual time of visits, but may be readily discovered early in the morning, or after the patient has retired in the evening, times when the 2l8 DISEASES OF THE HEART AND LUNGS. cavity will be partly empty from the recumbency of the patient. A knowledge of these simple facts, gained by careful auscultation, may be utilized for the comfort of the suf- ferer. Learning the manner of the connection with a bron- chus may enable us to relieve distressing night-cough without the use of opiates. A patient may sleep quietly after retiring, for some hours, and then be awakened and kept awake by cough the rest of the night, or he may commence coughing the moment he lies down or turns upon one side, and he instinctively seeks the position which gives him most ease from strangling cough, and submits to a constant teasing cough that only yields to large doses of opium. After examination, teach him to take that position which will soonest empty the cavity and keep it, notwithstanding the coughing, until the cavity is thoroughly emptied, then he can take his usual position and sleep quietly until morning. These practical facts were embodied in a paper pre- pared for the Academy of Medicine, by the late Dr. Geo. P. Cammann, and which I had the honor of read- ing before the Academy after the writer's death. Cavities in the lungs are not always of a tuberculous origin. A portion of lung tissue may necrose from strangulation by contracting fibroid and become gan- grenous, and a cavity result which may remain open, or even enlarge by wasting from its walls, or it may be of traumatic origin. I have known one to occur from tapping with a trocar into a lung bound to the chest- walls by adhesions. A ball of lead has been the cause of a cavity after having been in the lung for many years. From whatever cause, a cavity in the lung is a grave accident. NEW CLASSIFICATION OF PHTHISIS PULMONALIS. 219 Dry crackling rales from old pleuretic adhesions are loudly echoed in a cavity near the surface of the lung-, and assist in differentiating it from a dilated bronchus, in which they are much feebler, if heard at all, and the sound seems to escape, while in a cavity they are de- fined and echoed from the walls. Cracked-pot sound is also easily distinguished when the cavity is near the surface, but even when centric the expert ear may catch the peculiarity of the double- echoed quality of sound with that of the sudden expul- sion of air into the bronchus. Treatment of the tuberculated division of the second class must be a judicious combination of that already given for fibroid and for purely tubercular, with the hope of delaying progress, if not arresting it alto- gether. The earliest signs of plastic exudation within the pleurae must be heeded and removed is the lesson that the consideration of this formidable disease im- presses upon us, but if the fibroid lung has be- come tuberculated, there must be a double endeavor to prevent the extension both of fibroid and of the tubercular. The resort to mercurials must be more sparingly made than in the purely fibroid, and yet they must not be wholly disused. The bichloride of mer- cury, with tonics, will be the principal resort. Chlo- ride of ammonium will be of more value than in either the pure tubercular or fibroid alone, as it meets the indications in both. The exercise must be adapted to the conditions, and too forcible expansion must not be made. Milk diet in large quantities must be encour- aged and insisted upon. Lord Bacon says, in effect, that many believe they cannot take milk without becoming bilious, because they take but little at a time, which coagulates, but 220 DISEASES OF THE HEART AND LUNGS. that if they take large draughts, the acid is diluted, and digestion will take place. I have repeatedl}^ demon- strated the truth of his observation. In order to take large quantities of milk, it is necessary to proscribe other kinds of animal food. Two or three quarts of good milk may be taken daily for weeks, even by a feeble person. The stomach must be educated to re- ceive this quantity, and it must be done gradually. In fibroid phthisis the patients are apt to be carnivorous, and have contracted stomachs, so that at first they are unable to take a large amount of food at one time. But system and perseverance will overcome this difficulty. By the constant use of milk the stomach dilates, and the blood-vessels enlarge, and more nutrition is carried to the capillaries, and weight of the body will be in- creased. The increase in weight, which comes to drinkers of large quantities of any liquid, is owing to this acquired capacity to receive nutrition. Large quantities of milk at regular intervals, with systematic expansion of the chest, stands first in importance in treatment of all forms of fibroid phthisis. The deposit of fat in the system is an assurance that phthisis is held in abeyance. Oc- casionally a change may be made, and a mixed diet of more stimulating food may be allowed, to continue only for a short time, again to return to strict milk diet, until health is restored. The subject of tubercle I have not attempted to dis- cuss, and the same may be said of minute pathology and histology, except in a clinical and practical way, leaving the niceties to be settled by those who are making them a subject of particular study. THERAPEUTICS OF CHLORIDE OF AMMONIUM. 221 XT. Therapeutics of Chloride of Ammonium. Sal ammoniac, muriate of ammonia, hydrochlorate of ammonia, or, properly, chloride of ammonium, are the designations of the salt some of the remedial powers of which I propose to consider in this paper. Our pharmacopoeia presents us with a variety of medicinal agents, and each has its measure of power, each acts in a specific way peculiar to itself or its class upon the living organism, and is beneficial, or other- wise, according to the wisdom of the practitioner di- recting its use. Our knowledge of therapeutics is mostly empirical ; a priori reasoning has little to do in determining our choice of agents ; a knowledge of their intrinsic value is approached only, after many trials by different observ- ers under many and different circumstances. In this view, it may be asserted that all the remedies in com- mon use are still upon trial. In endeavoring to esti- mate the value of a remedy by the light of experience, in order to prevent hasty conclusions, it is well enough to premise that many of the sick calls any practitioner may attend are either wholly imaginary, or of that class of diseases called functional, in which the " medi- catrix naturce' is frequently competent to perform a cure, especially when stimulated by the imagination ; but that when a material, potent substance is requisite to remove a morbific cause, or impress a vital change upon the system, the domain of fancy ends, and that of material facts takes its place. 222 DISEASES OF THE HEART AND LUNGS. The idea that all medicines are still and ever must be on trial till we have arrived at perfection in our knowl- edge of therapeutics is illustrated in opium. How long has the poppy been the sweet soother of pain and care, giving balmy sleep to the wearied, excited brain, and rest to the tired limbs; when fever rages, and every fibre of the body is quick with anguish, how blessed is the repose it gives, how delightful the forget- fulness it brings ! and yet it is but yesterday that one among us taught us its power in arresting certain forms of inflammation. Opium, one of the oldest medicines in use, is still on trial. Clark, even now, superintends its use at Bellevue, and shows the young physician that with it he can reduce the respirations to seven, and even to five, in a minute, and thus hold back the dart of the destroyer till the inherent power of nature comes in to assist in the restoration of the patient to her family and friends. Possibly, we do not even yet know all about opium. The use of ammonia as a remedy may be as ancient as that of opium, but of that we are not assured, for, ac- cording to Stille's Therapeutics, *'The sal ammoniac of the ancients is supposed to have been rock salt, and to have derived its name from the circumstance of its being procured near the temple of Jupiter Ammon of Lybia. " The temple itself was called after the province Am- monia, in which it was situated, a name which signifies sandy. In the middle ages muriate of ammonia was known as sal armoiacum, or Armenian Salts, in refer- ence to one of its commercial sources. The Arabian physicians speak of its preparation from the soot made by burning (camel's) dung ; of its application to the eye for the removal of leucoma; of its use to cure relaxa- tion of the palate, and of its power of determining the THERAPEUTICS OF CHLORIDE OF AMMONIUM. 223 humors to the surface of the body. They also refer to its being- mixed in a liniment of oil and vinegar, for the cure of itch. In modern times there is but little recorded of its use as a medicine until the last century, when it became a favorite remedy with German physi- cians, and continues to be regarded by them as in many cases a profitable substitute for mercury, antimony, or iodine." In the fall of 185 1 my attention was drawn to the use of muriate of ammonia by reading in Watson's Practice of Medicine an account of his use of this salt in a cer- tain form of face-ache which he distinguishes from neu- ralgia and tic douloureux, and then says: " I allude to this for the sake of saying that some years ago I was in- structed by an experienced old apothecary that this face- ache might be almost always and speedily cured by the muriate of ammonia ; a medicine that is seldom given internally here, although it is so much used in Germany ; and I have again and again availed myself of this hint and been much thanked by my patients for the good I did them with this muriate of ammonia." Dr. Watson gave it in half-drachm doses three or four times daily in solution. As my object in this paper is to bring this practical subject before the profession in a strong light, and give all the information I possess of the curative power of this valuable remedy, I do not know that I can do so more readily than by putting my own experi- ence in the form of a narrative. I had just been appointed visiting physician to the Northern Dispensary, and I had abundant opportunity of testing the muriate of ammonia, not only in the face- ache described by Dr. Watson, but also in other forms of neuralgia, even when of malarial origin. In most cases I was delighted with the speedy relief it afforded. I was myself a martyr to the form of hemicrania called 224 DISEASES OF THE HEART AND LUNGS. migrain, and frequently have been obliged to leave my work on account of it, and go home and take one or two doses of half a drachm each at an interval of half an hour, after which I was generally able to resume my duties. I had during that fall a number of typhus fever patients, and I noticed that many of them, on the second or third day after taking to bed, became unconcious and had low muttering delirium, etc., the usual symp- toms of ship fever. It occured to me that the muriate of ammonia might relieve these symptoms ; I used it it and I believe with salutary effect ; it would fre- quently arouse them to consciousness. I gave ten grains in solution every half hour with beef tea and brandy, till the patient would awake and be able to answer questions. I believed also that those treated with the ammonia were less liable to inflammatory com- plications, and that it had a permanent and happy effect till convalescence was established. This experience seemed to me to prove that this agent had a power not generally known, and that it must act on general prin- ciples, and I determined to test it in other and different cases. During the following winter there was an epi- demic of scarlatina throughout my district, of a mild tvpe, which I treated, as my predecessor had done be- fore me, with chlorate of potash and anointing the body with lard. The success was remarkable, for out of more than 170 cases I reported but three deaths. It seemed to me then that this was nearly a perfect treat- ment for this usually dreadful disease, but the following year there was another epidemic of more limited extent, but the mortality was frightful. In my despair I sought other remedies, and it occurred to me to add muriate of ammonia to the chlorate of potash, and the result was eminently satisfactory, for' the disease was cer- tainly more under control with this combination than THERAPEUTICS OF CHLORIDE OF AMMONIUM. 225 with the chlorate of potash alone, especially when the treatment was commenced early, in the anginous form ; the enlargement of the glands and tumefaction of the neck were less, and there was less tendency to deep ulceration in the throat. Its effect in neuralgia about the head, and also its effect in typhus fever, determined me that if sunstroke or insolation should come again under my care, I would use with hope for relief muri- ate of ammonia. During the summer of 1852 a num- ber of cases of sun-stroke occured in my practice, and I treated them with this salt, in solution, in ten grain doses every fifteen minutes. The result was happier than I had dared to anticipate ; all the cases treated with the ammonia, thoroughly and promptly, when not actually moribund, speedily recovered. Many of my medical friends also used the muriate of ammonia in insolation with happy effect. 1 furnished a very imper- fect account of the cases which I treated during that and the following year which was published in the N. Y. Journal of Medicine for 1854. Having, in the foregoing experiments, satisfied my- self of the power of muriate of ammonia to effect vital changes in the human system when under the influence of disease, I conjectured that it must be by rapid ab- sorption into the blood, and thus by being carried into every part of the body, and by being brought into con- tact with the capillary nerves, it, in some unexplained way, changed the altered condition of the blood, and at the same time controlled the circulation. In ex- plaining these views to my associates at the Northern Dispensary, I stated that should Asiatic cholera come again into my hands I should expect happy effects from the use of the combination of muriate of ammonia and chlorate of potash. It was not long before an opportu- nity was afforded me. On the 23d of May, 1854, I was 226 DISEASES OF THE HEART AND LUNGS. called to see an Irish emigrant who had landed the evening before, and was then staying with friends liv- ing in the rear of 86 Seventh Avenue. He had cold tongue, sunken eyes, sodden fingers, with frequent dis- charges from the bowels, which his attendants told me were bloody, and they said he had dysentery. I was unable to make a clear diagnosis at the time, but pre- scribed calomel and opium and made an appointment to call again next day ; but the family becoming fright- ened took him to hospital, and he died on the way thither. On the 25th of May I was called to the same family to see a little girl ten years old, and found her in collapse. Mustard was applied externally, and stimu- lants were attempted to be given by the mouth, but she died a couple of hours afterwards. The following day I was called to see the mother of the child and found her exhibiting the usual signs of cholera. I hesi- tated to give her the mixture of muriate of ammonia and chlorate of potash, and prescribed, instead, acetate of lead and opium. She died the next day. I now re- solved that the next case should have the benefit of the mixture of the chlorates, In a few days I was called to gee 9, German emigrant on the corner of Tenth Ave- jiue and Twenty-first Street, and found him in a back basement, badly lighted and without ventilation. He was in collapse, was vomiting frequently, and had rice water discharges from the bowels. I prescribed the following mixture : R. — Ammon. murias., drams 2 ; potass, chloras., dram i ; aqua camph., oz. 4; spts. eth. nit; tr. opii camph. aa., oz. i. S. — Tablespoonful every half hour. When I visited him in the evening of the same day the vomiting had ceased, there was sensible reaction, but he still had occasional passages from the bowels. The next morning he was convalescent After this I THERAPEUTICS OF CHLORIDE OF AMMONIUM. 22/ steadil}^ used this mixture in cholera with gratifying" success. Some of the gentlemen connected with me at the Northern Dispensary also used it and were pleased with its effects. It evidently stimulated the secretions, especially those of the liver and kidneys, and its effect on the circulation in collapse was notable. The late Dr. Cammann told me that he was called up in the night, that summer, to see one of his neighbors in Fourteenth Street, in consultation with the attending physician. The patient was in collapse and was sinking. Dr. Cammann advised the mixture of muriate of ammonia and chlorate of potash. The pulse was absent below the bend of the elbow, but after taking a dose of the mixture it could be felt creeping again down the artery to the wrist, when after a little while it would again dis- appear. This fact was noticed by both physicians for an hour or two, but in the end the medicine ceased to have its effect, and the patient died. In many of the successful cases under my care it was the only medi- cine given, whilst in others it would be instantly reject- ed from the stomach, and persistence in its use had but little effect till after the exhibition of a full dose of calomel, when the mixture would be retained, and as far as I know there were no bad results from the use of the two remedies at the same time. About this time I learned from my friend Dr. G. C. E. Weber of the use of muriate of ammonia among German physicians in bronchitis and throat affections, and I began its trial in treating these diseases in combi- nation with chlorate of potash, and was pleased with the result. In croup I had been in the habit of using large doses of calomel according to the method of Dr, Bay, of Albany. In many cases it was speedily success- ful in arresting the disease, in others a larger amount of mercurial had to be given, and in one case, at least, 228 DISEASES OF THE HEART AND LUNGS. where, although the croup yielded, consequences fol- lowed that caused me to hesitate in repeating the treat- ment, and subsequently I tried the mixture of ammonia and chlorate of potash instead, and I Avas surprised as well as delighted to find its power as an antiphlogis- tic and defibrinating agent quite as manifest as that of calomel without any of its danger. In two years I noted twelve cases of croup in dispen- sary and private practice treated with the mixture with but one fatal result. In all of these there were inflam- matory symptoms, and I considered them all to be true croup, although I had the positive evidence of seeing membrane in but two or three instances ; still there was a marked difference between these and false croup. A little girl, five years of age, the daughter of one of my neighbors, had been suffering with hoarse cough two or three days, and was given domestic remedies, as it was considered only a cold, but at four o'clock in the morning she became so much oppresed with croupy cough and breathing that her father, becoming alarmed, called me up. The cough and breathing were charac- teristic of croup, the skin was hot and dry, the pulse full and frequent, the fauces were reddened, but there was no appearance of membrane. I sent for the fol- lowing mixture : R. ammonias muriat., drs. 3 ; potass, chlorat, dr. i ; aqua-cinnamon, oz. 2 ; syr. g. acaciae oz. 2 ; syr. senegae, oz. i ; and gave her a teaspoonful every five minutes, staying with her until she had taken it a number of times ; then, instructing the father to con- tinue it in the same way until there should be either evi- dent relief or vomiting, I went home. At eight o'clock a.m., I saw her again ; the cough was still hoarse, but was accompanied with moist rattles. The father told me he had continued the remedy as ordered for about two hours, when there was coughing- with strangling, THERAPEUTICS OF CHLORIDE OF AMMONIUM. 22^ and he showed me the basin containing the ejected mat- ter ; floating in mucus were pieces of ragged softened membrane, one of them about two arid a half inches long, and a little more than half an inch wide, and there was also what appeared to be the detritus of membrane. She had croupy cough throughout the day, and the medicine was given every hour or two, but the next day she was fairly cotivalescent. I cannot doubt that this was a case of true membranous croup, and as no other medicine was used, the effect of the mixture as a defibrinating agent was, so far, positive evidence. Such happy results in so short a time however, are the ex- ceptions and not the rule. Usually a longer continu- ance of the mixture is necessary before the appearance of loosened membrane is manifested. Sometimes in croup, as in cholera, the mixture had no other effect than to irritate the stomach until after a large dose of calomel was given. A boy twelve years old, at the Protestant Episcopal Orphans' Home and Asylum, was noticed to be croupy on Wednesday, and was" told by the matron to take the mixture, which is always kept in the institution ready for use ; he did so and seemed to be relieved. On Thursday evening he was again croupy, and was again ordered to take the mixture ; being old enough to wait on himself, he was not watched, and as the medicine was very disgusting to him, he took it sparingly. On Friday morning all the croupy signs were increased. It was the day for the ladies to meet and sew. A messenger was sent to me, but in the meantime, at the suggestion of many of the sympathizing ladies, he was given jCoxe's hive syrup, and syrup of ipecac and squills, alternately till when I arrived his stomach would keep nothing at all. I immediately gave him a large dose of calomel, after which he took the mixture and retained it. He was in 230 DISEASES OF THE HEART AND LUNGS, a state of excitement with a constant cough of a ring- ing, brassy character ; breathing was difficult and he spoke only in a hoarse whisper ; the fauces were red but no membrane could be seen. The medicine was con< tinned at frequent intervals all night, and on Saturday morning he was spitting up small pieces of softened membrane ; the breathing was less difficult and the cough had lost its brassy character, though still some- what croupy. The medicine was continued through the day and the next night, but at longer intervals, and there were more or less evidences of expectorated membrane, till Sunday morning, when he seemed much better ; the croupy cough was gone, he could speak in his natural voice and his breathing was but little affected. The medicine was discontinued and he was ordered nourishing food alone. Still the boy was very much depressed in spirits and expressed his beliei that he would never get well. About two o'clock on Monday morning I was called in haste and found him with livid lips and cold extremities, struggling for breath ; while flapping rattles were heard over the chest; still his voice was not gone. He died in about an hour after I arrived. This was a case of true membranous croup, the mixture of muriate of ammonia and chlorate of potash had but little effect till after the exhibition of the calomel and then its action as a defibrinator was clearly manifes- ted. On Sunday morning the larynx and upper part of the trachea, at least, were cleared of membrane, and the fatal onset of suffocative dyspnoea was owing to occlu- sion of the smaller bronchiae, either from membrane be- coming loosened or from the bronchia being closed with tenacious mucus. I could mention many other cases of croup treated with the mixture of muriate of ammonia and chlorate of potash, all showing more or less power of the remedy to relieve the little sufferers. THERAPEUTICS OF CHLORIDE OF AMMONIUM, 23 J but I deerri these two cases sufficient to establish its Value, as they are in a good degree a type of the others^ Iri 1859 diphtheria made its appeafarice in New Yorki I had diligently tead the British medical journals^ noticing the many communications describing the dis- ease and relating the effects of the different medicinal agents used iri conlbatting it ; a careful study of these cases had produced in riiy mind the conviction that the most effectual medicines employed were the chlorates in some form, and especially the chlorates of soda and potash with the muriated tincture of iron. Conse- quently I was prepared to use what my experience leads me to consider by far the most effectual combi- nation of chlorates, the mixture of muriate of ammonia and chlorate of potash. I treated the first cases that came under my hands with the mixture and I was not disappointed in the good results I had hoped from it. I sometimes added to the mixture muriated tincture of iron, and sometimes gave iron and quinine in another form separately, always giving stimulants and nourishment, but the benefit of the mixture was notable, and occasionally marvellously prompt in removing membrane from the fauces in a few hours, but generally about two days of medication was required, while in some long and persistent treat- ment was necessary. I saw it both in private and dis- pensary practice, and it appeared as an epidemic seve- ral times at the Orphans' Home. I varied the treat- ment myself by using that which had been much praised by others, and watched the effect of other modes of treatment in the hands of other practitioners, but I have not yet seen any one form of medication that in my estimation filled all the requisities for suc- cess so well as the mixture of ammonia and chlorate of potash. 232 DISEASES OF THE HEART AND LUNGS. There is a form of diphtheria in which the tendency is for the membrane to extend into the larynx and air passages, and has been termed, I think properly, diph- theritic croup. When the membrane appears in the air passages below the epiglottis it differs in no way, so far as I know, from the membrane of croup, and I consider it quite consistent with the existing facts that there should be true diphtheritic membrane above the epiglottis and true croup membrane below, during the same attack. No one who has seen much of this dis- ease need be told that when in a case of diphtheria the voice becomes hoarse and whispering, the breathing difficult, and the cough croupy, that the case is one of great gravity, for these signs indicate the presence of membrane in the larynx ; in fact they are the signs of membranous croup. I have seen cases in diphtheritic croup, as in true croup, get well using no other medicine than the mix- ture of muriate of ammonia and chlorate of potash, but I have also seen others die under the most persistent use of this medicine. On account of the disease being diphtheria, I had hesi- tated to use calomel as I had done successfully in true croup, but a number of unfortunate cases determined me to use more decided measures ; to give calomel and tartarized antimony in combination, in one or two doses, and, after thus forcing an entrance into the system to complete the treatment with the muriate of ammonia and the chlorate of potash. Such a case occured to me in January last. A little girl, eleven years old, had sore throat and swollen tonsils on the i8th of January. She was given the mixture. On the 20th of January membrane covered the tonsils, and was continuous over the walls of the pharynx. The mixture was ordered in larger doses, and at more frequent intervals. The pulse was THERAPEUTICS OF CHLORIDE OF AMMONIUM. 233 full and bounding, for the child was naturally robust. On the evening of the same day the symptoms had rapidly grown alarming ; the voice was husky, and the breathing was becoming difficult. It seemed to me that the ammonia and chlorate of potash did not enter the circulation. I prescribed two powders, each contain- ing two grains of calomel and one-sixth of a grain of tartarized antimony, with ten grains of pulverized sugar, to be given at an interval of three hours, the mixture to be given in the meantime every half hour, one tablespoonful. In the morning she was weary, but the voice was clear, the breathing was improved, and the appearance of the fauces was changed, being of a brighter red color, and the membrane was becoming detached. She continued the mixture one tablespoon- ful every two hours, and made a rapid recovery, for on the 22d she was fairly convalescent. The following notes were made by Dr. Cummings, the able House Surgeon of the Demilt Dispensary, in two cases lately occuring in his practice, and as they are independent testimony, coming from an observer without theory or prejudice, I offer them as corrobo- rative of the value of the mixture of muriate of ammo- nia and chlorate of potash as a remedy in serious forms of diphtheria. Case I. — Diphtheria a ffecti7ig the larynx terminating in recovery. — December 25th, 1863. Saw for the first time a boy, August Weber, aged three years and four months, who had been ill for four days, complaining of symptoms referable to the throat. It was eleven o'clock at night when I first saw him ; parents stated that he was much worse this evening than he h^d been previously. Croupal respiration and cough were both well marked ; face expressive of much anxiety and lips livid; pulse 120 per minute and weak. The submaxil- 234 DISEASES OF ttlfe MEAkt AND LUNGS. lary region was much swollen ; the voice also hoarse and indistinct. On opening the mouth the tonsils were seen to be tumefied and covered by a false membrane of a whitish color ; the pillars of the palate were like- wise covered with false membrane. From the fact that the disease was so advanced and the laryngeal symptoms so severe, an unfavorable prog- nosis was given. The child was ordered four grains of the chloride of ammonium and one and one fourth grain of the chlorate of potassa every half hour, in a teaspoonful of camphor water, also five drops of the chloride of iron every four hours. Fomentations were likewise directed to be applied to the neck. December 26th, 9 a.m. Found the patient a Httle more comfortable, but the fauces presented pretty nearly the same appearance as on the previous night; the face was very pale, but had not quite that lividity which was observed at the former visit; child took liquid food greedily, and had experienced great desire for sleep during the night. The same medicines were continued, and beef tea and milk punch also ordered. Saw the child again that night ; cough and breathing distinctly laryngeal, yet the obstruction to respiration did not seem quite so great as on the preceding night. December 27th. Patient was decidedly easier ; had passed a tolerably comfortable night. Respiration less stridulous ; cough had a little more of a moist charac- ter ; membranes seemed to have diminished in extent, and to appear thinner and somewhat detached at their edges; appetite still good; directed to continue the same medicine. On the 29th of December the tonsils and throat had become completely free of the false membranes, and the child was still improving, although the croupal cough remained. tHERAPEUTICS OF CHLORIDE OF AMMONIUM. 23$ Chloride of ammonium and chlorate of potassa were ordered in the previous doses every two hours. Qui- nine was also given as the appetite of the child w as fail- ing ; iron continued. January 3d. Bronchitic rales were now heard. These disappeared in a few days under the influence of general counter-irritation and expectorants. The croupal cough continued until Jan. 7th, when it had entirely disappeared and the child was dismissed from my care, with directions to take the iron a week longer. Since then I have heard from the child, who remains in perfect health. I would add there were in the house where this boy lived four other children suffering with pharyngeal diphtheria, under my care, at nearly the same time, all of whom recovered, the same treatment having been pursued. Case II. — Diphtheria involving the larynx terminating fatally. — December 30th, 1863. Was called to see Margt. Quinn, aged four years and eight months. This child had been suffering with sore throat five days ; could not learn that she had experienced any fever. This patient exhibited decided stridulous breathing, inspiration and expiration being both very much pro- longed, a ringing croupal cough, and the voice was quite extinguished. The lips were livid, the eyes prominent, the head thrown back, and the whole ex- pression one of great distress. The pulse was frequent and feeble. On inspecting the fauces, a dense grayish white membrane was seen covering the tonsils and pillars of the palate, not patchy, but continuous ; there were also bridles across the posterior pharyngeal wall, and the uvula was enveloped by a layer of membrane. An unfavorable prognosis was made in this case. Death seemed imminent from the obstruction in the larynx. 236 DISEASES OF THE HEART AND LUNGS. The patient was given five grains of chloride of am- monium and one grain and a fourth of chlorate of potassa every half hour, in a teaspoonful of syrup and water. Five drops of the chloride of iron were given, in the same vehicle, every four hours ; milk punch and beef tea were also ordered. The next day, when the child was visited, its general appearance had a little improved, although it had experienced several attacks, threatening suffocation, during the night. The respi- ration seemed a little less difficult than on the preced- ing day ; not much change was observed in the condi- tion of the throat. The respiration now continued steadily to improve, and on the 2d of January the membrane was evidently disappearing on all parts accessible to the eye. The chloride of ammonium and chlorate of potassa were now given in half of their previous doses. The iron was continued as before. As soon as the difficulty of respiration was somewhat relieved, the child exhibited a great ten- dency to sleep, both day and night showing the severe toxasmic effect of the diphtheritic virus. On January 4th no membrane was visible, and the breathing of the child had become perfectly calm ; all cough had likewise disappeared. There was now noticed on the left tonsil a small perforating ulcer, look- ing as though it were bored or punched into the gland. There was also paralysis of the muscles of the palate, occasioning much difficulty in swallowing, producing a cough and regurgitation of food through the nostrils ; a muco-purulent discharge, at times streaked with blood, also issued from the nostrils. Quinine, in ad- dition to the iron, milk punch and beef tea, was now given; the chloride of ammonium and chlorate of potassa were discontinued. Jan. 6th the ulcer con- tinued to increase in extent and depth, and other ulcers THERAPEUTICS OF CHLORIDE OF AMMONIUM. 237 were seen starting around the original one ; discharge from the nostrils more streaked with blood ; moist bronchitic rales were now heard for the first time, ap- parently not much embarrassing the respiration. Pa- tient continued weak, but took medicine and nourish- ment very well. For the bronchitis gentle counter-ir- ritation to the chest, and stimulating expectorants were employed. January 8th. * Rales distinctly heard, seemed to in- volve the smaller bronchial tubes on one sidfe ; no dulness on percussion ; no great difficulty in respira- tion; child pale and weak; pulse frequent and feeble; same treatment continued, with injunctions to give an additional amount of stimulants. January 9th. Visited the child at 12 M., who seemed rather more comfortable than the day before. The child continued quite comfortable, as I understood by the parents, until 6 p.m., when immediately after taking food it died, dropping off as though in a state of syn- cope. These two cases seem to me to illustrate the efficacy of chloride of ammonium in promoting the separation of the diphtheritic membranes as well as in relieving the swollen condition of the parts on which they rest. In the last case the relief to the laryngeal obstruction com- menced almost immediately upon its administration, although the child subsequently died of blood-poison- ing. I am in the habit of employing it in all cases of diph- theria, as I know of nothing that answers the above- mentioned indications equally well." Isaac Cummings, M. D. Demilt Dispensary, Feb. ist, 1864. * These rales were undoubtedly interpleural plastic, but at that time I had not yet learned their true signification nor had Dr. Cummings, 238 DISEASES OF THE HEART AND LUNGS. I have been constantly in the habit of giving muri- ate of ammonia, alone or in combination, in all forms of inflammation, not depriving myself, however, of the choice of more actively efficient agents when the cases seemed to require them. In pneumonia it acts promptly and efficiently, and also in sub-acute pleuritis ; in congestion of the brain it frequently affords prompt relief. Even in acute men- ingitis of children it acts with apparent benefit, lowering the pulse and preventing convulsions. In tubercular diseases of all forms I deem it decidedly beneficial, and especially in phthisis. During the last five years I have had large experience with the muriate of ammo- nia as a remedy in tubercular phthisis at the Demilt Dispensary, in the class of chest diseases, with the re- sult of confirming my confidence in its remedial power. No other single agent has been so beneficial in my hands. I prescribe it with wild cherry bark in cold in- fusion given at frequent intervals.* I believe muriate of ammonia to be essentially a blood medicine ; it must enter the circulation to pro- duce its effect, and this is the only explanation I have to offer for its apparent benefit in diseases of such oppo- site types. I believe it acts as a catalytic and also as a resolvent ; that as a catalytic it accomplishes its work of arresting inflammatory action without any such destruction of blood corpuscles as is done by mercury. Mialhi estimates that one third of the blood corpus- cles of the body are destroyed by placing the system under the influence of mercury. If that be true, chlo- ride of ammonium is much the safer agent, especially in debilitated constitutions. As a resolvent it is believed * 5 Ammon chlor. § i. cont. P. Virgin, ^ ij. M. Cold infusion by percolation two pints, S. one tablespoonful every hour, THERAPEUTICS OF CHLORIDE OF AMMONIUM. 239 by German physicians to act upon glandular swellings and recent tubercle, and my favorable experience with it leads me to adopt that view. I have mostly used it as an internal medicine, but in some cases I have thought it produced good effects in the bath. *' Dr. Giesler used it in the form of vapor by inhalation in chronic catarrh and never found it useless." He also recommends it in some forms of rheumatism, and in strumous ophthalmia. Dr. Noegge- rath, of New York, has used the vapor of muriate of ammonia successfully in some cases of diphtheria. It is readily vaporized by placing it on a hot metallic sur- face, and it strikes me that this mode of using it, in some cases at least, must be preferable to any other. Some years ago. Dr. Batchelder, of New York, men- tioned to me that the iodide of potassium was more energetic and produced its characteristic effects in much less time than usual, when mixed with an equal or larger amount of chloride of ammonium. I have satisfied myself many times since of this fact, and also that it energizes the action of other remedies when in combination, as in chlorate of potass., nitrate of potash and the muriated tincture of iron. A mixture of muri- ate of ammonia, nitrate of potash and senega root, colored with cochineal, is sold as a common remedy for influenza or cold in the head, I am told, from the drug- shops in the towns along the upper part of the Hudson River. It was a favorite prescription of the late Dr. White of Hudson, and is known as " White's Red Salts." Half an ounce each of these articles, with liquorice root to disguise the taste, may be infused in a pint of water ; dose one tablespoonful every fifteen minutes for an hour or two before going to bed gener- ally relieves a patient with commencing influenza, and he awakes in the morning well. All surgeons are 240 DISEASES OF THE HEART AND LUNGS. aware with what energy a saturated solution of muriate of ammonia and bichloride of mercury will act as an escharotic. Muriate of ammonia has been held in high estimation by German physicians for more than a hundred years. At the close of the last century Gmelin said of it, '' that it is by far the most powerful of saline preparations, whether as an internal or external agent." " Bocker considers its therapeutical action to depend upon its quickening the moulting or waste of mucous membrane, and on this account its protracted use in young people especially is to be avoided." This view I believe to be mere hypothesis, for it is not borne out by my experience. *' Osterlin states that by mistake one of his patients took two ounces of muriate of ammonia at a single dose without any other result than trifling colic and some watery stools." *' It is praised by Gmelin for its effi- cacy in intermittent fevers." " In 185 1 M. Aran ex- perimented with it and considers that the results indi- cated that it possessed some and not a little power over intermittent fevers." " Jacquot, also, in 185 1-2 used it in treating soldiers of the French army occupying Rome. The results consisted in the abrupt cessation of the paroxysms in six out of twenty-one cases, but in two of the six cases the attacks returned." In 1855 Dr. Alexander Lindsay published in the Glasgow Medical Journal, an article on the " Physio- logical and Therapeutical effects of the Chloride of Ammonia." " Dr. Lindsay and two intelligent pupils made experiments on themselves, taking the chloride in medicinal doses, being in a state of health, and care- fully regulating their diet, etc. On the second day after beginning the medicine a buoyancy of the system was experienced that rendered the ordinary pursuits a pleasure, and fitted the body and mind for increased THERAPEUTICS OF CHLORIDE OF AMMONIUM. 241 exertion." " The feculant discharges were in all much augmented, the appetite was much improved. In two the force and frequency of the heart's action were di- minished. The rate of the pulse in the gentleman em- ploying the smallest dose was accelerated. In all the urinary secretion was increased. The dose was, in one 18 grains per day ; the second, I3-J grains, and the third nine grains." This is the only record that I am aware of in which experiments have been made with chloride of ammonia on healthy persons. Dr. Lindsay used the remedy in many and various diseases, and is much pleased with the results. He combined it with tartar- ized antimony and morphia. Dr. Walshesays, ''Muriate of ammonium has appeared to me to be useful in two ap- parently opposite ways — by promoting expectoration when deficient, by controlling its amount when exces- sive." In the " Astley Cooper Prize Essay," for 1856, on " The Cause of Coagulation of the Blood," by B. W. Richardson, M. D., it is shown by a number of experi- ments that fresh-drawn blood gives off free ammonia during the process of coagulation. . It is also shown that the addition of ammonia to the blood retards the coagulation according to the amount used ; that am- monia added to coagulated blood will cause j^t to again become fluid, and that it will again become coagulated when the added ammonia has passed off in vapor. " That ammonia is evolved from the blood," says* his reviewer, " on its being withdrawn from the vessels and exposed to the air, has been proved most satisfaC' torily by Dr. Richardson's experiments, which have been so multiplied and varied as to exclude all sources of fallacy." These experiments go to show that ammonia is neces- sary to healthy blood ; that in excess it is rapidly thrown off in th^ excretions, and in this w^y it is not allowed to 242 DISEASES OF THE HEART AND LUNGS. accumulate unduly ; that ammonia, taken into the system in whatever form, is thrown off as free ammonia, and this may explain why its combination with other agents so increases and energizes their characteristic effects. Dr. Ozier Ward, in the '' London Lancet for April, 1859," says: ''Ammonia had never been considered to be a normal constituent of the blood, as its presence had not been detected except after death, in cases of typhus, cholera, melaena, and other diseases of a putrid character, until Dr. Richardson's recent discovery that healthy blood owes its fluidity to the presence of am- monia.'* In speaking of its therapeutical effects, he says, finally : " The hydrochlorate, which is the least easily decomposed, is probably the most useful of the salts of ammonia, as it not only possesses the stimulant, resolvent, secernent properties of the others, but, owing to its combination with chlorine, is endued with tonic powers, by which its prolonged use, unlike that of the other preparations, is attended with invigorating effects both to mind and body, and that it forms an excellent substitute for mercury in cases where this medicine is inadmissible from its tendency to produce cachexia." Perhaps this record of my own experience, with notes of that of other observers at different times and in dif- ferent places, may help to show that muriate of am- monia, known to the ancients, much valued by the Arabian physicians of the middle ages, and again intro- duced into practice by German physicians a century ago, is still upon trial, and that facts are accumulatmg which promise to elevate it into a promment place in our pharmacopoeia.* * After so many years since the publication of this article I have it still in constant use. In cold infusion of wild cherry bark, sixteen to twenty grains to the ounce, half ounce doses of the mixture, it is of great ser- vice in interpleural plastic exudation, and in the early stages of fibroid phthisis. Many cases get well with no other medication. IS CONSUMPTION COMMUNICABLE? 243 XII. Is Consumption Communicable?* From the earlier days of medicine to the present time there has ever been a popular belief that consumption is communicable. Such a widespread and general opin- ion, continuing- for ages and in many countries, must have some foundation in fact. Cases of consumption have followed each other under circumstances which have impressed observers as proof of its infectious char- acter ; as when a husband or wife has watched with the deepest solicitude the long-continued and vacillating illness of the other, to be finally overwhelmed with grief at the fatal result, and then to sicken and die un- der similar conditions. The profession has at times inclined to the popular faith, and again has rejected it. The discovery of true tubercle by Bayle in 1804, and of the methods and value of auscultation by Laennec, published in 18 19, threw new light upon diseases in- cluded under the common name of consumption. It did more — it filled the professional mind with the idea of tubercle, to the exclusion of other and common forms of consumptive diseases. The very important doctrines taught by Broussais, in Laennec's time, because they were not all of tubercle, were overshadowed, obscured, and misunderstood. The immense advantage of physical diagnosis by auscul- tation and percussion in getting a true mental picture of the pathological conditions of the chest was certainly * New York Medical Jmirital, December i, 1883. 244 DISEASES OF THE HEART AND LUNGS. weakened by the adoption of the exclusive doctrine of tuberculosis. The erroneous interpretation of the respiratory act and of the significance of its murmurs, as taught by Laennec and his followers, confirmed them in the patho- logical error that all forms of consumption must neces- sarily be tuberculous. But the fashion of careful post- mortem examination grew in favor, and the microscope vastly extended our knowlededge of pathological re- sults, and has established the fact that the tubercular is not the only form of phthisis. Still we are groping among the debris of protoplasm, cells, and proliferation, anxiously searching for the specific evidence of tuber- culosis as an entity self-existent and self-propagating — something which has a separate life from the life of the body, and which is independent of it, antagonistic to it, and which overcomes it. This view differs from that which considers con- sumption, either tubercular or fibroid, as inherent in the life of the body, which is excited to activity by irri- tation or depression, either physical or mental. It is said that the giant cell characterizes tubercle and the spindle-shaped cancer, and that by them we are able to distinguish tubercular and cancerous products. But this knowledge of them does not determine the life-pro- ducing origin of tubercle nor that of cancer; whether they have a distinct life outside the life of the body, and have only an accidental connection with it, or whether these morbid cell-forms are merely the materialized expres- sion of disease-action of the immaterial life of the body. Animals have been experimented upon by inoculation of tuberculous matter, and tubercle has been the result, and it has been claimed that the question was solved in the affirmative. But, again, these same animals were inoculated with non-tuberculous matter, and the result IS CONSUMPTION COMMUNICABLE? 245 was tubercle, proving- that the character of the inocu- lated matter had nothing to do with the tuberculated results, but that irritation was the sole cause, and the result would be tubercle or cancer, according to the inherent tendency of the individual either to tubercle or to cancer. The irritation of teething endangers tubercular meningitis in children, and tuberculated phthisis may result from the irritation of adhesions of the pleura. Had not this theory of tubercular inocu- lation disestabhshed itself by these experiments, it would still remain an essential fact that inoculation is not in- fection, that poisoning the system by inoculation of any materies morbi is not conveying a germinating parasite into healthful respiratory organs, and producing disease in them of its own kind. But lately the medical world has been set wild by the publication of the discovery of Professor Koch of the presence of bacilli in tubercular cavities and in tubercular sputa. It has been shown, too, by experiment that these in- dependent life-forms may propagate themselves outside the body and in other menstrua than the debris of de- caying tubercular cavities. ^ , These facts appear to be^demonstrated and accurately proved by other careful observers. But the deductions of Professor Koch are that these self-producing life- forms are the cause of tuberculosis and of tubercle, and propagate their kind in a healthful human lung, and, thence taking wings, are carried to and transplanted in other healthful lungs. Their propagation being rapid and abundant, and the medium of their conveyance the air we breathe, the danger therefrom becomes appal- ling to fearful minds, who dread the ravages of this most deadly of human diseases. To be entirely consist- ent, the germ theorists must deny the influence of heredity and external conditions, of local irritations or 246 iDtSEASES OF THE HEART AND LUNGS. the depression of vital dynamics, as causes of consump- tion. If it were not for the adoption of Professor Koch's theories, as well as the acknowledgment of his dis- covery of bacilli by gentlemen of high scientific attain- ments, such as Professor Riihle, of Bonn, and others, controversy would be unnecessary ; but, as it is, we must examine the subject critically but dispassionately. So far as I am aware, fibroid phthisis is not included in the forms of consumption claimed to be propagated by bacilli. The germ theorists appear to assume that all forms of phthisis are tubercular. But a large num- ber of cases are fibroid, pure and simple, in which the diathesis is gouty or rheumatic, and not scrofulous. This large number are exempt from suspicion even. Again, a vast majority of cases of tuberculated phthisis commence with plastic exudation within the pleural cavity. These are called by Niemeyer '' catarrhal pneu- monia," and he says "the great fear is that they may become tubercular.'* This fear is born of experience, and should direct us to proceed energetically, at the same time judiciously, to remove the plastic exudation while it is easy of accomplishment. Now, as long as the cases are not tuberculated nor tubercular, they can- not be influenced by bacilli, for as yet there is no nest prepared for them. It may be well to state here that we make a distinction between tuberculosis and tubercu- lated phthisis. Tuberculosis is the systemic disease which gives birth to true tubercle — the miliary tubercle of Bayle. Tuberculated phthisis is the result of cheesy degeneration, in which cavities take place as a result of tuberculosis or other causes. The number of uncom- plicated cases of tubercular phthisis — that is, of tubercle forming into concretions or nodules and being encapsu- lated, with no pleuritic adhesions and without fibroid IS CONSUMPTION COMMUNICABLE? 247 in the lung, is extremely small. In a practice of more than thirty years in dispensary, hospital, and private, I cannot remember more than a very few cases. Laennec and Louis evidently refer to these cases under the term of latent phthisis and acute phthisis. This small number, commencing centrally in the lungs and not involving the pleura, are the only ones which could have had a parasitic origin. But even in these it is doubtful whether bacilli have anything to do with their tubercular origin. I do not doubt the discovery of bacilli in tubercolous cavities nor in the sputa of tubercular consumptives, but I cannot accept the inference that they are the es- sential causes of tubercle. They may find in a tubercu- lous cavity a fit soil or home where they may grow and multiply. There may be spores, eggs, germs, laid there by their parents, which, when perfected, may fly away to seek other tuberculous cavities in which to lay their eggs, etc. Is there not analogy in the green-bottle fly that seeks carrion in which to lay its eggs, where they are hatched into maggots, which may increase the rapidity of the destruction of the carrion during their growth, but, becoming full-grown — they fly away to seek other car- rion to plant their eggs, and thus continually propagate their race ? The bacillus of Professor Koch may be the maggot state of a distinct life, born of an egg or germ, and may perfect itself into another form which may fly away to find other tuberculous cavities, fit homes for the propa- gation of its kind, as germs, bacilli, and of the perfected life-form which will again fly away to find other tuber- culous homes. It is not probable, nor according to analogy, that the bacillus was always in that state, or that it will always 248 DISEASES OF THE HEART AND LUNGS. remain as such, to be transplanted to healthful lungs and to cause tuberculosis ; for it is not the disease, but a parasitic life which grows and perfects itself in the de- cay and debris of tuberculous cavities. It may increase the rapidity of decay in the necrosed lung, as the mag- got does in the carrion, and it is our duty to prevent this if we have the knowledge and the power. But the bacillus is not necessary to explain the occurrence, cause, and course of phthisis — fibroid or tubercular. As has been stated, all but a very small number of cases commence as fibroid — that is, with plastic exudation within the pleura, in which the bacillus is not a factor. This primary condition of phthisis may be the result of depressed vital power from various causes, long-con- tinued and violent emotion, anxiety, worry, grief, or disappointment, as well as from catarrhal causes. Or it may, but in a less degree, be the result of adhesions from acute pleurisy, which are a physical cause of vital depression. A mother, after watching her children, three or four in number, through scarlatina of a severe type, began to cough, lose weight, and finally died of phthisis. She was well when the children were taken ill ; she was a loving, anxious mother, and as they were attacked suc- cessively the time of her anxiety was prolonged. The children all recovered, but the mother was sacrificed. She was not aware of having taken cold. The cough was so insidious that no one could tell when it commenced. Had there been the same prolonged anxiety over a case of phthisis, followed by inconsolable despair at the loss of the loved one, it would have seemed to prove the com- municability of consumption. Scarlatina germs do not originate phthisis, nor do bacilli — it is the result of natural causes. Failure in business after a prolonged struggle in a con- IS CONSUMPTION COMMUNICABLE? 249 scientious man may be, and frequently is, followed by phthisis. Disappointment in the young, where there is intensity of grief, is often followed by phthisis. In all of these cases, whether fibroid or tuberculated, the disease commences with plastic exudation within the pleurae. Even in tubercular phthisis, for a considerable time the disease is simply fibroid — preventable phthisis. One word for the poor consumptive. Morbidly sen- sitive to all unpleasant sights, smells, and surroundings, and whose greatest comfort is kind and sympathizing companionship, is it not the refinement of cruelty to drive away from him unnecessarily" those who should minister to his suffering ? Quotations from Current Literature in regard to Bacilli^ with Notes by D. M, Cammann^ M,D. On March 24, 1882, Dr. Robert Koch communicated to the Physiological Society of Berlin the result of a series of elaborate investigations into the etiology of tuberculosis. He believes tuberculosis to be caused by a parasite, the parasite being a bicillus and being distinguished from other bacilli by its behavior towards the coloring agent **vesuvin." The tubercle bacillus is slender, rod-shaped, about five times as long as it is broad, and varying in length from one quarter to the whole dia- meter of a red blood corpuscle. The method pursued in finding the bacillus was as follows : "The tuberculous substance was either spread out upon a cover-glass, dried and exposed to heat, or a piece of tuberculous organ was placed in alcohol, and afterwards cut into fine sections. A particular solution of methylene-blue was made, a weak solution of potash being added, the cover-glass coated with tuberculous matter (or a section 250 DISEASES OF THE HEART AND LUNGS. of the organ) was then placed in the solution for twenty or twenty-four hours, but half an hour sufficed if the solution were warmed in a water-bath up to 40° C. The cover-glass, which comes out a deep blue, is then treated with a concentrated watery solution of * vesur vin' for one or two minutes, and is afterwards washed with distilled water. The blue of the mythelene has visibly changed to brown ; under the microscope all the amorphous detritus and fragments of tissue spread out on the glass are brown, but the tubercle bacteria remain blue!' — Braithwaite s Retrospect, July, 1882. The bacillus was oftenest found in the interior of giant cells. Not every giant cell or group of cells con- tained it, but those which were free were old cells which had once held bacilli and had gotten rid of them. They may become few or disappear entirely. They are usually found in large numbers in cavities. To show that the bacillus is the cause, and not a mere accom- paniment, of tuberculosis, Koch proceeded to separate it from other substances by a series of " cultivations." He took the blood-plasma of the ox or the sheep, and after repeated applications of heat, he boiled it to a coagulum, '' at the same time inclining the test-tube so that the coagulum might cover a considerable surface. It was on this nutrient soil that he proposed to * grow' the tubercle-bacillus without the intervention of moist- ure." After taking a piece of tuberculous substance — usually from the lung of the ape or of man — and care- fully washing it several times in a solution of corrosive sublimate, the outer layer was removed, and from within was taken a portion '^ into which it was to be expected that no bacteria of putrefaction had penetrated." The piece of tuberculous substance was then broken up and thrown over the surface of the coagulum, and the test- tube kept at a uniform temperature of 37° to 38° C. If IS CONSUMPTION COMMUNICABLE? 2$ I during the first week any activity showed itself, it was supposed that the bacteria of putrefaction were present, and the experiment was not continued. Usually about the tenth day could be seen on the surface of the coagu- lum " a number of very small points or dry-looking scales which surrounded the pieces of tubercle that had been laid out, in circuits more or less wide, according to the extent of breaking up and dispersion of the tubercle fragments at the time when they were sown.' These dry scales were taken to be colonies of the ba- cillus. After a few weeks the scales cease to enlarge, and they are transferred on heated platinum wire to another test-tube prepared in a similar manner. This series of '*' cultivations" is continued through ten or a dozen times, and for a period of four or five months. With these dry scales numerous animals were inocu- lated, and without a single exception all the inoculated animals acquired tuberculosis, the tubercles having the structure of the original tubercle. Dr. Koch claims that these results are due to the introduction of the ba- cillus per se. Since Koch announced his discovery his experiments have been repeated by several observers. That the bacillus is, as a rule, found in the spute of persons hav- ing tubercular phthisis is confirmed by Ziehl, Fraentzel and Balmer, Belfield, Hierchfelder, and many others. Dr. Spina of Vienna, while agreeing with Koch in always finding bacilli in the sputa, denies that they oc- cur constantly in the tuberculous organs of man. He could never find them in the tubercles, which stood in no connection with the open air, and he concludes by saying " that the bacilli of tuberculosis are the result, not the cause, of the disease." Cases of miliary tuberculosis are recorded by Prud- den {Med. Record, June i6, 1883, p. 645) in which "no 252 DISEASES OF THE HEART AND LUNGS. bacilli could be detected by the most exhaustive search." Considerable evidence is available to show that the ba- cillus is less frequently found in tubercle tissue than in the sputa of phthisical persons, and that in the former it is chiefly found in the walls and contents of cavities, and in cheesy areas, especially in those that are disin- tegrating. BRONCHITIS. 253 XIII. Bronchitis. Bronchitis may be divided into three varieties. 1st. Simple, or catarrhal, affecting only the bronchial mucous membranes ; is always acute and self limiting ; not extending over two weeks. The rise of temperature is but little, frequently none at all. It is popularly con- sidered as " only a cold, let it go as it came." 2d. Severe or inflammatory ; affecting both the mucous membrane and the fibrous sheath. The temperature may run high ; it may be irregular in its continuafice, and be of serious importance, frequently complicated, or compli- cating pneumonia and pleurisy. It may occur in the course of pneumonia. In which case if it be during the convalescence it may be surprisingly and speedily fatal. It may extend beyond the fibrous sheath into the peri- bronchial spaces, then it is called peribronchitis. It is frequently, if not always, complicated with plastic exuda- tion within the pleurae ; the physical signs of which are mistaken for the disease itself. 3d. When it becomes peribronchial or interpleural in its complications it is called chronic bronchitis, for the in- flammatory and plastic conditions have a tendency to con- stantly recur and the plastic pathological products are more or less permanent. Catarrhal Bronchitis. Uncomplicated, this disease affects only the bronchial mucous membrane. Its causes are sudden changes of temperature from hot to cold, or from cold to hot, or e^^^ 254 DISEASES OF THE HEART AND LUNGS. posures to wind, or dampness with insufficient clothing. Or it may occur from local irritation of the mucous mem- brane, as from dust or other extraneous matter, or it may- be from irritating gases. Its site is the mucous mem- brane of the tidal air passages. It does not extend into the true respiratory system, which is constantly occupied by the residual air. Its limitation is anatomical. It only affects the mucous membrane supplied by the superficial bronchial arteries. It has but little, if any rise of temperature, and is un- accompanied by constitutional symptoms. It does not affect the appetite nor digestion. It is sometimes epidemic in its character, affecting mostly the mucous membrane of the air passages of the nose, pharynx and larynx. It is called influenza or grippe, in which case it differs from catarrh from ordinary causes. Catarrh is only the more prominent symptom of an epidemic disease affecting the organic life of the body. Physical Signs. There are two stages of simple catarrhal bronchitis. First or dry stage, in which there is no secretion. The broncho-respiratory murmur is harsh in character and somewhat raised in pitch. It can be heard every- where over the chest, but with greatest distinctness in the neck and in the upper part of the chest. There are no rales, that is, there are no interrupted noises like tearing of cloth or paper. There are some- times sonorous and sibilant rhonchi, continuous sounds, but these are adventitious and are confined to the second stage. The broncho-respiratory murmur of the first or dry stage, is a dry murmur whenever it is heard. It is loud. BRONCHITIS. 255 harsh and near the ear in the neck and clavicular region. It is consonated in 'the true respiratory system. The sound vibrations formed by the air-and-tube friction, above static air, pass downwards through the columns of static air in the convective tubes and are delivered through the air-sacs into the chest wall as in a speaking tube. It alters and obscures the normal broncho-respiratory murmur, for it is harsh, dry and raised in pitch. In the second stage the breath sounds become moister in character. When mucous collects in the upper pas- sages in sufficient quantity to be moved backwards and forwards by the tidal air there will be mucous rales, — always large, and heard over different parts of the chest. Having no points of greatest intensity except there be pleuritic adhesions to convey them into the chestwall with greater intensity and clearness. These mucous rales, also, are intermittent, for the ac- cumulation moves backwards and forwards only a few times before it is loosened sufficiently and is expectorated, when the rales cease. But in a short time the mucous collects again, and the rales reappear. They are always distant from the ear unless brought directly to it by ad- hesions. They are heard over a large space, if not* over the whole chest, and are always distinguishable from simi- lar rales heard from interpleural causes. Interpleural rales are heard only over the site of their formation. In- terbronchial over a large space, if not over the whole lung. Interbronchial or true mucous rales are intermit- tent, and soon change or pass away. They can scarcely be distinguished from mucous rales in the nasal air-pas- sages, as both are consonated in the true respiratory sys- tem and are heard over a large space. But this can be done by auscultating the neck with a stethescope. If they are nasal or pharyngeal, or laryngeal they will be heard in the neck, but not if they are interbronchial. 256 DISEASES OF THE HEART AND LUNGS. Treatment of Simple Catarrh or First Division OF Bronchitis. During the dry or inflammatory stage, the treatment should be for this purpose : First of abortion ; second of hastening and promoting secretion. Abortion to be successful must be attempted very early. In ordinary catarrh it may be affected with quinine and Dover's powder or other preparations of opium, given after a foot bath. The patient should be placed in bed^, and kept covered, but should not be loaded with covering. The object is gentle perspiration. This will be promoted by using a snuff composed of salicine one drachm, chlorate of potash one scruple, and pulverized gum acacia half an ounce. This may be drawn up into the nasal passages by snuffing, or be thrown up by an instrument. If taken early the attack may be aborted. If, how- ever, the opportunity of abortion is neglected, the next best thing to do is to hurry the natural method of cure by promoting free secretion. In addition to the abortive methods warm vapor may be inhaled, and attention should be paid to the digestive organs. Judicious stimulation may also assist. A mixture of chloride of ammonium three drachms, chlorate of potash one or two drachms, cinnamon water six ounces, syr. senega and sweet spts of nitre, each one ounce, with extract of licorice to disguise taste, may be of great benefit, when the throat is severely attacked. This may be given, tablespoonful to an adult, every half hour or every two hours, according to the results obtain- able. Influenza or grippe, may be broken up, if taken very early, by the following prescription : Half an ounce of choride of ammonium, half an ounce of nitrate of pot- BRONCHITIS. 257 ash, half an ounce of senega root, and one ounce of lico- rice root ; one pint of boiling water, infusion. If the patient toasts his feet before a brisk fire, or places them in a hotfoot bath, and takes of this infusion one tablespoonful every half hour during an afternoon and evening, and then retires to a comfortable bed, he may arise the next morning entirely free from the attack. The early and efficient treatment of acute bronchial catarrh is but prudent forethought. It is true that an attack may run an even and uncomplicated course with- out medication, ending in perfect recovery, but there is always danger that the inflammation may extend to the fibrous sheath, which may be the beginning of serious complications, ending in fibrous phthisis. Severe or inflammatory bronchitis is characterized by higher temperature, severer constitutional symptoms, and graver complications than the conditions of simple catarrh. The inflammation extends into the. fibrous sheath, and frequently beyond it into the connective tis- sue of the peribronchic spaces. Peribronchitis with in- flammation of the fibrous sheath, has no regular course, but may continue for months or years, and then it is called chronic bronchitis. It does not extend through the whole of a bronchus, but is confined to points of limited extent. It results in stricture and correspond- ing dilatation of the bronchus, and is always compli- cated more or less with interpleural pathological re- sults, adhesions, and thickened pleura. In post-mortem examinations the evidence of simple catarrhal bronchitis may entirely disappear or be so faint as to escape detec- tion. But inflammation of the sheath leaves the mucous surface deeply stained with blood extravasation extend- ing down into, the sheath. This complication rh ay take place during convalescence in pneumonia. Occurring then ^58 DISEASES OF THE HEART AND LUNGS. it is generally speedily fatal, and its existence is not easily diagnosticated. It may be that our knowledge of it may be acquired only at the autopsy, for its presence is not made known by physical signs during life. The fibrous sheath is sup- plied by the deep bronchial arteries, being allied to, and yet different from, the mucous membrane which is sup- plied by the superficial bronchial arteries. The deep and the superficial, however, have the same origin, and thus are nearly related. They have another bond of union in the fact that both contribute to the formation of the nutrient artery of the true respiratory system. The nutrient arteries of the lungs have no returning veins, consequently disease of the true respiratory system or plastic exudation upon the pulmonary pleura must affect both the mucous membrane and the bronchseae, and also the fibrous sheath, producing peribronchitis and chronic catarrh. We often hear the terms catarrhal pneumonia and broncho-pneumonia used by those who scarcely com- prehend the anatomical conditions of their pathology. It is not possible that pneumonia nor plastic exudation upon the pulmonary pleura should take place without engaging the vessels of the bronchgepe, both deep and super- ficial, and consequently causing more or less bronchor- rhoea. And yet for a time, perhaps a long time, there may be no mucous secretion, no expectoration, but a dry and ineffectual cough- Eventually there will be secretion and great relief thereby. The interpleural and peribronchial complications are so constant and immediate that we must take note of them at once, even while considering the primary lesion. They are so intimately connected that signs of plastic exudation within the pleura and in the peribronchial spaces become the physical evidences of commencing fibroid phthisis. Should an attack of simple catarrh BRONCHITIS. 259 be extended in time, with higher temperature and greater constitutional disturbance than usual, we must search for physical signs. These consist in greater intensity of the exaggerated breath-sounds in inspiration, and a distant sound like a suppressed moan in expiration. When these signs are heard we need not wait for further physical evi- dence, but proceed at once to more vigorous treatment. Antiplastic remedies, mercurial, or the salts of potash or ammonia, should be given at once, for delay is danger- ous. Exudative inflammation having taken place, its re- sults may be difficult to remove. They establish a proclivity to further attacks of like character. When treated vigorously primarily no secondary results .ensue. It does not become chronic bronchitis. But should the proper treatment at the proper time be neglected, there will occur organized plastic exudations peribronchial and interpleural, and what is called chronic "bronchitis will be the result. The proper name for this pathological condition is fibroid phthisis. It is progressive in its character. It extends into and destroys more and more of the true respiratory system, causing functional death. There is loss of weight, frequent and difficult respiration, expectora- tion of yellowish, grayish bronchial mucous, sometimes haemoptysis. When a portion of the lung becomes con- soHdated it may become tuberculated, with cheesy degen- eration and cavities or tubercular nodules may be formed in the lung, which softening and opening into a bronchus may cause pneumorrhagia or fatal haemoptysis. Or they may open into the pleural cavity, causing hydro-pneumo- thorax. Simple catarrhal bronchitis may thus end. 26o DISEASES OF THE HEART AND LUNGS. XIV. Chronic Pleurisy. If we may include under this term all of the patholog- ical causes and results of interpleural effusions of fluids and of exudations of plastic, fibroid, albuminoid, and Other exudative matter ; whether as the result of inflam- mation or of simple atony of tissues, then the subject is comprehensive and makes it necessary to glance hurriedly at the formative causes. There may be three divisions of this subject. The acute inflammatory, the sub-acute inflammatory, and the passive or non-inflammatory. Acute Inflammatory Pleurisy comes suddenly with a chill followed by violent pain and high temperature, and may end fatally at the onset, or favorably with effusion of serum into the pleural cavity. Its formative history goes back but a short time, and generally where fluid is effused and is removed there fol- lows speedy convalescence. But causes may intervene to prevent or retard recovery. The fluid may become purulent, or a large amount of al- buminoid and fibroid exudation may have taken place and then we have chronic pleurisy with its complications and disabilities. Sub-Acute Pleurisy. — Plastic exudation within the pleu- ral cavity is one of the commonest pathological results of what we call a succession of colds and bronchial attacks. The physical signs of sub-crepitant rales, generally mis- interpreted as being evidence of bronchitis, are really in- terpleural and denote plastic exudation and should be called plastic rales. CHRONIC PLEURISY. 261 Usually the fresh exudation is rapidly re-absorbed, but if the patient is reduced in vitality it may remain and be- come organized as adhesions or thickened pleura. Wise management and medication may hasten and en- sure its re-absorption when recent, and for this reason bronchial attacks should receive careful attention ; for while many times they are but temporary indispositions, yet at others assistance is necessary, and the longer it is deferred the more difficult it becomes. The Sub-acute form of pleurisy occupies a place mid- way between the acute sthenic form and simple plastic exudation in which there is no rise of temperature nor pain nor any of the accompaniments of inflammation; which is the third division of this subject. Plastic Exudation^ Non-Inflammatory. — The etiology of plastic exudation from mental or nervous depression may extend backwards for months or years, or it may have resulted from intense sorrow of shorter duration. Any cause which depresses the vital power and lessens the vitality of the blood may result in plastic exudation, the lax condition of the tissues favoring the transudation. Worry, disappointment, despair, are the emotional factors. Atmospheric influences, of a depressing char- acter, greatly add to the mental causes. It is character- istic of this disease that exudations occur periodically, which at first are like thin glue, almost as fluid as serum. But organization commences immediately. I have had the opportunity to observe a plastic hypersemia of the lung in progressive pleuro-pneumonia in a cow. It was of only a few hours continuance, yet there were already signs of fluid plastic exudation within the pleural cavity, which could be heard as muffled moistened respiration. At the same time a slight tearing sound occurred at inter- vals, as the ear passed over the surface, like the tearing of wet paper. 262 DISEASES OF THE HEART AND LUNGS. The post-mortem which immediately followed the physi- cal examination showed, as was diagnosticated, a thin ; fluid exudation covering the pleural surface. There were slight filaments of forming membrane branching in dif- ferent directions from a central point. They were scat- tered here and there, and could be lifted upon the point of a knife. The movement of the lung in respiration^ parted these filaments and caused the slight tearing rales:- Organized plastic matter becomes adhesions when at-- tached to both pulmonary inter-lobular surfaces, or to the pulmonary and costal pleura, or to the pericardial sac. If attached to one surface only, it becomes t/iukened pleura. All of these forms of exudative pleurisy have similar interpleural pathological products, and permanently lower the vital power of the individual. They lessen the capacity for blood-aeration and consequently the amount of blood lessens and the patient loses weight and strength, and ability to assimilate food, and in this state slighter causes increase the pulmonary hyperaemia and new plastic matter is thrown out to increase and to ex- tend the disability. The organized exudation which was caused by mental depression primarily, becomes itself a presistent physical factor of vital depression and results finally in progressive fibroid phthisis. Peribronchitis at the same time is also progressive as a part of the same pathological processes. The organized exudation continues to contract, obeying- the natural law, and if it covers a large surface of the lung, it thereby shuts off the capillary circulation both of the pulmonary and of the nutrient arteries, which imme- diately subtend the pleural surface so covered. At the same time the inflammatory products in the fibrous bron- chial tube and the peri-bronchitis more directly obstruct the bronchial and pulmonary nutrient arteries. This untoward state of things gives rise to many inter- CHRONIC PLEURISY. 263 esting phenomena not fully understood, except by those who search for primary causes and look beyond the im* mediately obvious for the essential causes of disease. In this way not only does the contracting pseudo- membrane lessen the area for capillary distribution of pulmonic blood for aeration, but it also shuts off the cir- culation of the nutrient artery of the true respiratory system. The nutrient artery is derived from the bronchial artery with additions from the mammary and the inter- costal, but has this unique peculiarity that I'c has no venae comites or returning veins. The capillaries of this artery after performing their office of nutrition in the true respiratory system, pass their blood into radicles common to themselves, and to the capillaries of the pulmonary artery — the radicles of the pulmonary vein— which carry all the purified blood to the left heart for systemic circulation. All varieties of chronic pleurisy have one common effect, that of interfering with the aeration and circulation of the blood, and also lowering of the vital capacity of the patient. They differ in these particulars that, acute sthenic pleurisy when it becomes chronic, generally affects but one side, and may give rise to curvature of the spine, but is not so liable to end in pulmonary phthisis. The depressing causes which were mainly or wholly efficient in the sec- ond and third varieties in precipitating the primary at- tack have but little to do as causes in the first, but con- tinue to act as depressing factors in the second and third, — more especially in the third — and it is in these two last that I am especially interested, for the knowledge of them comes to the physician as well as to the patient and friends as a surprise. Frequently in the subacute inflam- matory variety the bronchial attack has been forgotten, and the attention Is only drawn to the rational and phy- 264 DISEASES OF THE HEART AND LUNGS. sical signs of interpleural plastic results which are apt to be mistaken for ^* tuberculosis," especially if bronchor- rhagia has taken place. The malign effect upon all concerned of such a mis- take is to prevent the use of effective means to pre- vent the phthisical result whilst it is yet remediable. For the tendency of the results of both the second and the third varieties, is to end in phthisis, either fibroid or tuberculated fibroid. I would make this distinction, that fibroid, which is frequently lingering, and more amenable to rational treatment is yet often fatal, but never be- comes cavicular, except it first becomes tuberculated. In my experience and judgment uncomplicated tubercular phthisis is a rare disease, and the few cases which I have seen, presented none of the physical signs which are de- pended upon in making a diagnosis of phthisis. F'or without adhesions of the lung to the chest-wall there is no telegraphy nor phonographic relations established by which centric changes may be comprehended. The treatment of the first variety should be prompt at the outset, and if possible abortive. But if effusion of serum take place, the system should be allowed to rest for a week or more with palliative medication only, un- less there is great suffering from dyspnoea. If that is the case it will be best to draw off a portion of the fluid at once. It is better not to interfere, however, unless the dyspnoea be great, as keeping the pleurae apart for a time prevents adhesions, and subsequent disability. If the fluid is not absorbed or lessened in a week or ten days it will be best to interfere and withdraw it. Per- haps not all at once but gradually. Many times after a partial withdrawal with aspirator or trochar, the re- mainder will be speedily absorbed and healthful condi- tions will be resumed. When, unfortunately, adhe- sion and interpleural pathological products remain from CHRONIC PLEURISY. 265 whichever variety, nature may need assistance to remove them. Fresh air, out-door Hfe, will do much, and may be sufficient. But if these fail, after a short trial, vigorous anti-plastic treatment should not too long be delayed. The best medicinal treatment is the mercurial, in small doses in combination or otherwise, until slight constitu- tional effects are produced. Then changing to chloride of ammonium, or iodide of potash. Alternation of the mercurial and salt solvents should be continued until the lungs are free in their movements. Outside medication should not be omitted. Spirits of turpentine is the best for recent exudation, then iodine, and lastly cantharides. Tonics should be given where indicated. The lungs should be systematically expanded by filling them constantly with air and holding the breath. The food should be nutri- tious and of easy digestion. Milk is the type of best food. It relieves the kidneys too, which have the great labor of carrying out of the system the tissue detritus. 266 DISEASES OF THE HEART AND LUNGS. XV. Therapeusis of Mercury. The physician needs powerful medicines to control disease ; none the less because he believes in ** vis medi- catrix naturas." We require of the surgeon that his knives be sharp and that he have skill to use them — that he should not use them on wrong or slight occasions. In the armamentarium of the physician there is no other agent having the powerfully sedative and at the same time the delicately alterative effects which belong to the dif- ferent preparations and doses of mercury. It has been said of the steam engine that its adap- tativeness is universal. It can be made to engrave the delicate tracery of a seal, or to lift a man-of-war out of the water. We may say the same of electricity, its power is unlimited, its control and adaptativeness to nice re- sults is marvellous. So also may we say of mercury. Yet there is no other remedy against which there is such a violently unreasoning, and unwise prejudice as against mercury, especially against the most useful of all its preparations — the mild chloride, calomel. How absurd would be popular prejudice against the steam engine or against electricity ? Are they not pow- erful for destruction of human life if misdirected ? Yet they are our obedient servants for good under intelfigent direction. So is calomel. Calomel may be given in drachm doses, and save life when no other remedy can do it, and no harmful result follow. It may be given in one hundredth part of a grain doses with the nicest ascertainable effects. It THERAPEUSIS OF MERCURY. 26/ Simply heeds to be wisely adapted to the necessities for its exhibition. Pleuro-pneumonia as it has prevailed for twelve or fifteen years in New York is controllable in some cases only by the sedative action of calomel. This agent is the shears that may clip the locks of the destructive Samson, and render it a mild disease amenable to simple nursing and gentle management. Dr. Graves, on large doses of calomel in acute inflam- mation, says {"A System of CHnical Medicine," Dublin, 1843): ''The following remarks derived from very ex- tensive opportunities of observation apply not to the treatment of chronic diseases, nor to that of inflamma- tions, either slight in degree or occupying parts not essen- tial to life, but to those violent attacks of inflammatory action which so often prove fatal in the course of a few days or even hours by destroying the texture and func- tion of vital organs. " If a person is seized, for example, with very acute peri- carditis, how unavailing will be our best directed efforts unless they be seconded by a speedy mercurialization of the system. If, on the contrary, the practitioner defers the exhibition of calomel or insufficiently tises it, then will he have occasion to regret the consequences, and witness either the speedy death of his patient or his con- demnation to the sufferings entailed on him by adhesions, valvular disease, and other sequelae of badly-treated peri- carditis." I well remember my astonishment when thirty years ago the late Dr. G. P. Cammann ordered a large dose of calomel in an attack of intercurrent pneumonia in a case of chronic phthisis ; and my gratification at seeing the disease successfully controlled thereby. It was, perhaps, the most practical of all the valuable lessons which I re- ceived from him. :i6S DISEASES OF THE HEART AND LUNGS. Dr. Graves considered the speedy merGurialization of the patient as necessary. He quotes Dr. Johnson, in his classical work on the Diseases of Tropical Climates, who says '* we ought to affect the constitution decidedly and as speedily as possible by means of calomel given, not in small doses often repeated, but in doses of a scruple, once or even twice daily." But in the sedative action we do not contemplate mer' cttrialization in the sense of ptyalism or salivation. And if that should occur it is accidental and unneces- sary, and is due to the unfortunate idiosyncrasy of the patient. The admirable sedative effect of calomel when needed is best seen when it is placed dry upon the tongue of the patient ; then, like the touch of the wand of the magi- cian, it instantly changes the conditions of death to those of life. There is no absorption of the medicine, no ex- hausting purgation, no salivation. The temperature at once begins to fall, the heart to gain strength, the plastic exudations upon vital organs to be reabsorbed, and the course of life again runs smoothly on. Of course it should not be given in any case where simpler means would answer. We may say the same of any medicine. But some forms of inflammation of vital organs ; of the brain, of the heart, of the lungs or kidneys, or some forms of dysentery or fevers, may be speedily fatal, if not arrested early in the attack. In that supreme moment there is no choice; there is but one remedy. If the physician hesitates then or searches for other remedies in obedience to pop- ular prejudice, the favorable moment may pass and the patient be lost. But even the accident of salivation is nothing, even when severe, in comparison with the death of the patient. Loss of teeth, or necrosis of the jaw, or cancrum oris, are not accidents of the use of the sedativ£ THERAPEUSIS OF MERCURY. 269 action of calomel. Those follow only the abuse of the poisonous effect of calomel, given in repeated smaller doses. There was a time when abuse of this powerful remedy was not uncommon. But such is not the case now. The accident of salivation which may occur when one or two large doses may be necessary is not destruc- tive to tissues, bones, or teeth. It is simply an annoying inconvenience. The poisonous effect of mercury is not its sedative ef- fect. Any one who has seen twenty, thirty, or even sixty grains of calomel placed on the tongue, at the right time, in a case requiring its use, cannot help being gratified at its beneficence and its power to save. It has no unpleas- ant effect, simply the patient gets well,«and the change is so quiet and so complete that we feel doubt almost that there ever had been such danger. When in the judgment of the physician the time has arrived for the use of this great remedy, it should not be delayed, and the dose should not be scrimped. The dose should be ample. Our fears of public preju- dice make us cowardly, and we sometimes make the mistake of giving too little, and so may do harm. The small dose is dangerous. It may let the only success- ful time pass. It may have to be repeated, and the poi- sonous effect of mercury may take place. There is no danger in the largest dose when it is needed. It is not absorbed. It acts upon the organic life of the body, and may strengthen the heart's action, lower the temperature, in a few minutes after being placed upon the tongue. Small doses given in combination with opium, may be very serviceable. Calomel one half a grain, with five grains of Dover's powder may be of decided benefit, given according to the needs of the case in progressive inter- pleural fibrination, or fibroid phthisis. 270 DISEASES OF THE HEART AND LUNGS. But the combination of calomel, tartar emetic, and ni-^ trate of potash, mentioned by Dr. Rush in 1800, as the fever powder of Pa. Genl. Hosp., and which he used in treating successfully what he called consumption in the third stage, is admirable in fibroid phthisis of any stage. This combination may be given with effect when the calomel may not exceed the one hundredth of a grain. In the Polyclinic Dispensary we have this combination ready in the form of tablets for convenience. The stronger tablets contain one fifth of a grain of calo- mel, one thirtieth of a grain of tartar emetic, and five grains of nitrate of potash. The tablet is made up with sugar, gum, acacia, and licorice. The second in strength is just half the amount of the first, and the third one fourth. They are allowed to dis- solve on the tongue. Bichloride of mercury dissolved with muriate of am- monia, in Huxham's tincture of bark, is also a very service- able combination, and may be given alternately with iodide of potash, as in syphilis. Fibroid phthisis is fre- quently the result of syphilis. But whether a given case is so or not the treatment is equally beneficient. Mercurial inunction I have used more frequently form- erly than at present. It is not so manageable and the dose is not so sure as when given by the mouth or on the tongue. But it can be used, as may also the mercurial vapor, in .some case^ with singular benefit. THUJA OCCIDENTALIS. 2/1 XVI. Thuja Occidentalis. Arbor-vit^, or American white cedar, has for more than a hundred years been a remedy in use for a variety of ailments. It grows indigenous over the Canadas and the United States. The terminal twigs and green leaves may be made into a tincture with alcohol (95 per cent). From this a fluid extract or an elixir may be formed, and used as a medicine, or by external application. As an ointment or as tincture it has been applied to indo- lent ulcers, to warts, and to polypi with supposed bene- fit. The tr. or fluid ext. applied to an indolently in- flamed pharynx, with engorged tonsils, on cotton or by the spray, gives immediate relief. A method of applying it is to wind some cotton batting upon the end of a wire or a probe, and charge it with the tr. or fluid ext., then requesting the patient to take a full breath, and while holding the mouth open, to quickly pass the charged cotton over the tonsils and pharynx. Upon withdraw- ing the probe let the patient shut his mouth and breathe slowly out through the nose. When there is laryngeal and nasal catarrh combined with engorgement of the pharynx the vapor reaches dis- tant parts in the nasal passages in breathing out, as well as in the larynx in breathing in, and gives relief. The engorgement and color of the pharynx and tonsils are instantly affected, as can be seen, and the catarrh much relieved. This remedy has been used with supposed benefit in certain forms of malignant diseases characterized by en- 2/2 DISEASES OF THE HEART AND LUNGS. gorgement and hemorrhage. I have seen cauHflower ex- crescence disappear in a short time under its influence, and it seems to arrest the tendency to bleed. In the early stage of fibroid phthisis characterized by sudden attacks of congestion, haemoptysis, and plastic exuda- tions within the pleural cavities, I have seen these alarm- ing conditions disappear in a very short time while giving the patient twenty or thirty drops of the strong tr. or the fluid ext. on sugar or in oil or in cream every three or four hours. When the pulmonary congestion is complicated with suppression of the menses the exhi- bition of thuja may give relief to both conditions speedily I have known cases of pulmonary engorgement, with haemoptysis, with moist and abundant rales over the chest to be greatly relieved with two or three days' use of the thuja supplemented with terebinthinate applica- tions externally. The abundant moist rales disappearing so speedily would seem to indicate that this remedy has power over recent plastic exudations for their removal, and in this way arrests hemorrhage. Although not a specific for cancer, or tubercle, or fibroid, so far as I know, it may be found to be of great service in control- ling these diseases by relieving the system of hyper- aemia and hemorrhagic tendencies. INDEX. Adhesions, dangers of, 24 Adhesions, depressing vital power, 27 Adhesions, expanding chest for, 64 Adhesions, firm, physical signs of, 209 Adhesions, pleural, cases of, 85 et seq. Adhesions, seat of conservative, 28 Anatomy of convective system, 36 Anatomy of respiratory system, 36 Aneurism impairing acoustic qual- ities of chest, 140 Anti-plastic effect of pure air, etc., 63 Ammonia, muriate of, as defebrin- ator, 23 Bacilli, tubercular, 245 Bayles' discovery, 243 Bean on respiratory murmurs, 33 Breath sounds, Laennec's descrip- tion of, 32 Bristow on apex murmurs, 180 Bronchitis, 253 Bronchitis, capillary, pathology of, 95 Bronchitis, catarrhal, 253 Bronchitis, catarrhal, physical signs of, 254 Bronchitis, catarrhal, treatment of, 256 Bronchitis, inflammatory, 257 Bronchitis, inflammatory, treat- ment of, 259 Bronchitis, severe, 257 Bronchitis, simple, 253 Broncho-respiratory murmur, 51 Bronchorrhagia, 97 Brbnchorrhagi-a in cancer, 103 Bronchorrhagia in cirrhosis, loi Brbnchorrhage in emphysema, loi Bronchorrhagia, treatment of, 108 Bronchorrhagia in tumors^ 103 Broussais' classification of phthisis, 194 Calomel in plastic exudation, 63 Calomel, sedative and absorbent action of, 69 Cammann on cardiac murmurs, 163 Cammann on minute anatorhy of lung, 39 ' Cammann on respiratory mur- murs, 33 Cardiac disease, complications of, masking signs, 141 Cardiac movements, course of, 187 Cardiac murmurs, functional, 142 Cardiac murmurs, 142 Cardiac murmurs, 132 Cardiac murmurs, variety in inten- sity of, 189 et seq. Cardiac sounds, Halford on mech- anism of, 175 Cardiac sounds, rhythm of, 132 Cardiac valvular disease, danger in, 156 Chest, acoustic properties of, 71 Chest, the, as an acoustic instru- ment, 138 Chloride of ammonium, therapeu- tics of, 221 Cholera, muriate of ammonia in, 226 Clark's classification of phthisis, 194 Consolidation impairing acoustic qualities of chest, 140 Corrigan on respiratory murmur, 34 Crepitant rale, almost always inter- pleural, 23 Crepitant rale, analysis of, 49 Crepitant rale, cause of, 19, et seq. Crepitant rale, mechanism of, 49 Crepitant rale, seat of, 49 Croup, muriate of ammonia in, 228 2/4 INDEX. Croup, muriate of ammonia in, 229 Diagnosis of adhesions between pericardium and lung, 91 Dickson on pleuro-pneumonia, 117 Diphtheria, chlorate of potash in, 231 Diphtheria, muriate of ammonia in, 231 Diphtheritic croup, muriate of am- monia in, 232 Diphtheritic laryngitis; recovery, 233 Effusion, removal by trocar, 29 Effusion, when to operate for evac- uation of, 29 Emphysema impairing acoustic qualities of chest, 140 Expiratory murmur, velocity, the cause of, 43 Exudation, non-inflammatory, 261 Exudation, plastic, 261 Exudation, plastic, etiology of, 261 Exudation, removal of by vital forces, 62 Face ache, muriate of ammonia in, 223 Fibroid phthisis, cases of,2io et seq. Fibroid phthisis, causes of, 205 Fibroid phthisis, climatic treatment of, 215 Fibroid phthisis, expansion of chest in, 214 Fibroid phthisis, haemoptysis favor- able in, 66 Fibroid phthisis, treatment of, 209 Fibroid phthisis with adherent pleura, 203 Gerhard on respiratory murmur, 311 Gmelin on muriate of ammonia, 240 Haemoptysis, 97 Haemoptysis as a result of adhe- , sions, 85 Haemoptysis, differential diagnosis, 106 Haemoptysis, prognosis of, 98 Haemoptysis, sources of, 97 Halford on mechanism of cardiac sounds, 175 Hasse on pathology of pleurisy, 83 Heart, disturbed action and func- tional murmurs of, 165 Heart, mechanism of first sound of, 132, 133 Heart sounds, mechanism of, 167 Huxham on weather changes, 117 Hydro-pneumothorax, case of, 73 Interpleural mumurs, Stokes on, 55 Interpleural murmurs, Walshe on, 55 Interpleural pathological processes, diagnostic signs of, 95 Interpleural pathological processes, physical signs of, 71 Interpleural source of rales, cases in proof of, 59, et seq. Koch's investigations, 247, et seq. Laennec on phthisis, 194 Laennecon respiratory m.urmur, 33 Lindsay on muriate of ammonia, 240 Lung, convective system of, 20 Lung, respiratory system of, 20 Lung, uncomplicated tubercular, 196 Medicated vapors, cause of non- success with, 45 Mercury and ammonia as escharo- tics, 240 Mercury, Mialhi on, 238 Mercury, sedative action of, 268 Mercury, therapeusis of, 266 Mialhi on mercury, 238 Muriate of ammonia, Gmelin on, 240 Muriate of ammonia, Lindsay on, 240 Muriate of ammonia, Richardson on, 241 Muriate of ammonia, Walshe on, 241 Murmur, anaemic, 143 Murmur of adhesions, 144 Murmur, aortic diastolic regurgi- tant, 147 Murmur, aortic systolic obstruc- tive, 146 Murmur at apex, Bristow on, 180 Murmur, apex beat, 154 Murmur, diastolic, cause of, 148 Murmur, functional, in chorea, 145 Murmur, functional intermittent, 142 Murmur, mitral non-regurgitant, 157 Murmur, mitral regurgitant, cause of, 149 INDEX. 275 sympathetic functional, systolic, of rheumatism, Murmur, mitral regurgitant, site of greatest intensity of, 151 Murmur, mitral regurgitant sys- tolic, 149 Murmurs, organic cardiac, 145 Murmur, plethoric, 142 Murmur presystolic, 158 Murmur, presystolic, significance of, 177 Murmur, 142 Murmur, 143 Murmur, tricuspid intraventricular, i6t Murmurs, cardiac, Camraann on, 163 Murmurs, cardiac, classification of, 181 Niemeyer's classification of phthi- sis, 195 Phthisis, acute, 199 Phthisis, adhesions a cause of, 28 Phthisis and cirrhosis; differential diagnosis, 102 Phthisis, Broussais' classification of, 194 Phthisis, Clark's classification of, 194 Phthisis, fibroid, not propagated by germs, 246 Phthisis, Laennec on, 194 Phthisis, latent, 196 Phthisis, new classification of, 193 Phthisis, Niemeyer's classification of, 195 Phthisis, Sydenham's division of, 193 Phthisis, tubercular, treatment of, 200 Physiology of respiration, 43 et seq Plastic adhesions as cause of phthisis, 65 Pleura, anatomy of, 71 Pleurse in health, 71 Pleurisy, chronic, 260 Pleurisy, chronic, treatment of, 264 Pleurisy, dry, 54 Pleurisy, effusion in, conservative, 65 Pleurisy, Hasse on pathology of, 83 Pleurisy, sub-acute, 260 Pleuritis, 24 Pleuro-pneumonia, abortive treat- ment of, 25 Pleuro-pneumonia, calomel in, 122 et seq Pleuropneumonia, Dickson on. 117 Pleuro-pneumonia, effect of civili- zation on, 120 Pleuro-pneumonia, endemic, 114 Pleuro-pneumonia, frequency of, 26 Pleuro-pneumonia in 1812, 116 Pleuro-pneumonia, new phase of, 116 Pleuro-pneumonia, typhoid type of, 121 Pneumonia, cause of exudation in, 17 Pneumonia, discussion of Dr, Clark's paper on, 17 Pneumonia, non-purulent exuda- tion in, 17 Pneumonia, physical signs of first stage, 19 Pneumonia, physical signs of sec- ond stage, 19 Pneumonia, physical signs of third stage, 19 Pneumonia, seat of inflammation in, 17 Pneumonia, signs and symptoms of complicated. 20 Pneumonia, statistics of, in New York, 115 Pneumorrhagia, 97 Pneumorrhagia, 103 Pneumorrhagia, sudden death from, 105 Pneumorrhagia, treatment of, 106 Pulmonary circulation, mechanism of, 98 Pulse, intermittent, as sign of car- diac disease, 186 Pulse, intermittent, calomel in, 187 Rale, mucous, interpleural. 77 Rales and expectoration, 78 Rales, mucous, cause of, 79 Rales, site of, 56 Regurgitation, frequency of, 155 Regurgitation, tricuspid. 161 Residual air, forces acting upon, 41 Residual air, molecular motion of, 46 Residual air, motion in, 21 276 INDEX. Respiratory murmur, analysis of, Respiratory murmur, Bean o^^ 33 Respiratory murmur, Cammann ReTp'irSory murmur, Corrigan on, Respiratory murmur, composite character of, 49 ^o;tir^n Respiratory murmur, composition Re^spi^atory system, currents of air Respiratory murmur. Gerhard on, Res1>iratory murmur, Laennec on, ResVratory murmur, reason for analysis of, 34 - Respiratory murmur, Salter on 35^ Respiratory murmur, Sanderson Respiratory murmur, Skoda on, Respiratory murmur, true 51 Respiratory murmur, Walterson, Res'piratory murmur, Walshe on, ResVatory murmur, Williamson, liXirCSt^ofammo- Sate on' respiratory murmur, 33" Sanderson on respiratory murmur, Scarlatina, muriate of ammonia in, Sko'dl on respiratory murmur^^ 33 Stokes on interpleural murmurs, 55 Sunstroke, muriate of ammonia in, SydlVam's division of phthisis, The^rlpeutics of the chloride of am- monium, 221 Thuja occidentalis, 271 Tonsils, ulceration of, 236 True tubercle, genesis of. 240 Tubercle following adhesions, treatment of, 203 Tubercle following pleural adhe- sions, 201 t r,AA Tubercle, inoculation ot, 244 Tubercular crackling, 5° Tubercular phthisis 195 Tuberculated fibroid P^ J/s^s, 215 Tuberculated fibroid phthisis, signs Tuberculated fibroid phthisis, treat- ment of, 219 ^ ^^t;^n m Tuberculosis, plastic exudation in, Tumors impairing acoustic qualities Typhus?e^ver, muriate of ammonia in 221 Valvular lesions without murmurs, Walshe' on^nterpleural murmurs. wllshe on muriate of ammonia, Walshe on respiratory murmur, witters on respiratory murrnur, 33 Waters on minute anatomy of WeTthe^'changes, Huxham on, White's red salts, 239 ^„^^„r Williams on respiratory murmur,. 33 ^^7 §^'- ; ! ^ ' J. \ ^v^J ?«al^^.i ?^,f" V .• ,t T' *- • • . , . .\ *, s V ■