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PHYSIOLOGY.
LONDON, SATURDAY, MARCH 7,
PHYSIOLOGY. LECTURES ON THE
PHYSICAL CONDITIONS OF THE
TISSUES
OF THE
HUMAN BODY
AS APPLIED TO THE EXPLANATION OF
VITAL PHENOMENA. Delivered at the BY F. Professor of
College of France MAGENDIE,
Physiology and Medicine College.
in 1834.
in the
LECTURE XXI. Bruits of Me Mouth and Nasal Fossce in Health and Disease.-Bruits i2?.dicativie Diseases of the Chest—Œgophony— 2%e Rdle Crepitant BroncophonyBruits which seem to issuefrom the Chest, but are caused by the Voice, in consequence
of
-
1835.
[1834-35.
but as every reed-instrument is composed of four distinct parts, it remains for us to see in what part of the vocal apparatus we can find a mechanism that may represent the porte-vent, which is generally a tube conveying to the exterior the sounds formed in the body of the instrument. It is evident, even on the most superficial examination, that the porte-vent is represented by the pharynx, mouth, and nasal cavities, for these are the parts through which all sounds formed in the larynx are transmitted to the external air, and thence to the organ of hearing; it is also easy to comprehend that various modifications of the parts just named must operate a corresponding change in the sounds passing through them ; however, very little importance has been attached to the bruits of the mouth or nares, indeed I might even say that they have been totally neglected by physiologists. Thus LAENNEC laid it down as a principle that " all the bruits taking place in the cavity of the mouth and nasal fossae have no influence whatever on the respiratory murmur," and the greater part of his followers would seem to have adopted the same opinion, if we are to form a judgment from the neglect with which they have treated this part of the subject.*
of Pulmonary Disease-Pectoriloquy.Causes of Respiratory Bruits.-Pr oduction of Pulmonary Râles by Artificial * Since the delivery of this lecture, M. means, after Narcotism affected witla Prussic Ether.-Tlte Murmur of Respi- BEAU of the Hopital Necker has read at ration, or Bruit of the Pulmonary Ex- the Royal Academy a very interesting paper
pansion.-Puerile aud Senile Respiration. on the causes of the respiratorv bruits Causes of their great difference.- Causes revealed by auscultation," &c., in which he which render the Respiratory Bruits very with attention different abnorexamines various in intensity.-Importance of the Study of the Râles, and its application mal conditions of the respiratory system, to Medicine. and endeavours to prove " that every reYESTERDAY, in considering the resem- spiratory bruit is the result of the echo blance which exists between the human (,’etentissement) of the guttural bruit in "
-
voice and certain instruments of music, we carried our examination from the reservoir of air, which is represented by the lungs, to the porte-vent, or trachea, and then entered into a brief history of the analogy existing between the larynx and the vibrating part of instruments & ancl&e; No. 601.
the column of air which fills the bronchi. The following are the conclusions at which he arrives. See the Archives Gen. de Mid. for August 1834 :lst, The different respiratory bruits not complicated with rales, are not produced
794 It is certain, however, that several mo- built. If, as you have already been shown, difications of structure in the pharynx and the sounds observed in the human body nasal fossae give rise to the development of are simply the result of the operation of
many bruits which are not heard in a state certain physical conditions, we cannot of health ; thus we have a sound charac- clearly have different bruits produced by teristic of angina gutturis, and, in general, one and the same state of any organ; we all inflammations of the pharynx exercise might as well expect three or four different an influence on the tone of the voice. You notes from the same chord of a musical have all, without doubt, witnessed cases of instrument. Whenever, then, we succeed polypi situated in the back of the mouth by observation in attaching any one sound and nasal fossse, and you must have re- to a peculiar condition of the organ, the marked how considerably the voice is rno- reproduction of that bruit gives a sure dified by any mechanical obstacle of that proof of the existence of the corresponding kind: finally, cancer of the tongue, amyg- change in the organization of the part; and dalitis, and various malformations of that whenever, in examining a patient, we find part of the vocal apparatus which we have nothing but the pure respiratory murmur, compared with the porte-voix, are known such as exists in people enjoying full to influence the respiratory sound, and health, we are entitled to conclude that the give indications which, when they shall organization of the pulmonary vesicles is have been studied with more care and unchanged and good, because any essential attention, will enlarge the sphere of our modification of structure, any obstacle to knowledge, and produce results of a highly the free passage of the air, would necesbeneficial nature. sarily give rise to some abnormal phenoBut we cannot afford to discuss minor menon with respect to sound. As the presence of the healthy sound details ; let us rather hasten to a consideration of the bruits developed in the bronchi, indicates a healthy state of the lung, so we pulmonary vesicles, trachea, and larynx. have a great variety of bruits which point The modifications which they present form out each a peculiar modification of the retnost important studies, not only for the spiratory apparatus, and thus direct us in physiologist, but also the pathologist and the diagnosis and treatment of diseases medical practitioner, because they are a which, before the application of what we faithful index of the various physical con- may call the physical method, remained in ditions of the respiratory system from a state of great obscurity. You have only which they result, and, as such, form the to read LAENNEC; or any other work on basis of a rational and correct diagnosis. auscultation, to find abundant examples of It is scarcely necessary for me to prove the importance attached to physical sympthe truth of the proposition which I have toms in diseases of the chest. Thus, sudjust now laid down, though it is evidently den effusion in cases of pleuritis is indithe ground-work upon which all our prac- cated by the sudden disappearance of the tice in diseases of the chest should be respiratory bruit over a large surface of the chest, and when the effusion is net by the frottement of the air against the so extensive, or the patient is examined at parietes of the bronchi, where they are an early stage of the disease, you have heard. aegophony joined to the absence of the re2nd, They result from the echo, in the spiratory sound. Inflammation of the pulmonary tissue is whole column of air expired and inspired, of the bruit produced by the frottement of also indicated, in many cases where the the air against the velum palati or neigh- other symptoms are so obscure and masked as to escape attention, bytherale crepitant, bouring parts. 3rd, That every bruit produced in the which always exists before the total disapupper part of the respiratory system, must pearance of the respiratory sound. When resound with its proper character and de- the inflammation has reached a certain gree of intensity in the bronchi. point, and the structure of the lung be4th, That in practice we should never comes altered by the solidifaction of the conclude the non.entrance of air into the pulmonary vesicles and smaller branches lungs, before we have examined whether of the bronchial tubes, producing that consome guttural bruit does not exist. dition of the lung which pathologits call 5th, That on destroying the guttural hepatization, the precise nature of the ’bruit, we can destroy the respiratory mur- organic change is indicated by a remarkmur, which is merely its echo, and thus able change in the stethoscopic symptoms; obtain in their purity certain bruits of the the rale crepitant that was so distinct in lung, pleura:, or heart, which are often an early stage of the inflammation graconfounded with it, and cannot be distin- dually declines, until the absence of all guished with accuracy until they are iso- bruit shows that the air no longer enters lated. smallest raiiiificatioiis of the bronchi,
the
795
and instead of the respiratory murmur Thus you perceive how, as we advance the affected part develops a peculiar sound in the investigation of disease, we obtain called broncophony, arising, as we shall at each step new proofs of the importance have occasion at a future time to see, and advantage attached to the principle I from the physical condition in which the laid down in the commencement of the lung is now placed. Emphysema of the present course. Investigate for yourselves lung, effusion into the cavity of the thorax the causes of the phenomena which you accompanied by the circumstance of a com- observe, and whenever circumstances will munication existing between the bronchi permit, trace up those phenomena to the and the cavity, and several other affections physical conditions giving rise to them; which the time does not permit me to in this way you will be sure to acquire notice, are all characterized by peculiar knowledge of a solid useful nature, infimodifications of sound which, joined to nitely superior to any theory, no matter the rational symptoms, leave no doubt as by whom it may have been suggested ; for this reason I have laboured to discover to their existence. The different bruits of which I have the material causes of many phenomena just spoken take place in the lungs them- which my predecessors, regarding as vital, selves, that is to say, result from different have accepted without any examination, states of the pulmonary vesicles and air- and I have, I hope, succeeded in convincing tubes, influencing the manner in which you that the different sounds and bruits the respired air acts, upon their parietes; upon which we have dwelt in the last but there are several other bruits which, few lectures, are merely the result of cer4 though they seem to issue from a fixed tain modifications of a musical instrupoint of the chest, and are in reality con- ment, in a word, are the effects of certain nected with organic changes in the pul- physical conditions made sensible to the monary tissue, are yet nothing but the ear. resonance of the voice, and sounds formed This was particularly the object which in the larynx; or, to express myself with I had in view in my last lecture; when more precision, arise from the propaga- we entered into a pretty full examination tion of the voice along the trachea and of the different physical conditions prebronchi. sented by the thorax, and saw how it was In the normal state of the organs con- an instrument eminently fitted, both by its tained in the thoracic cavity, when you composition and the manner in which it is auscult the chest, you hear nothing but organized, for the transmission of sound; the pure respiratory sound ; you distin- we also entered into some details on a very guish the rubbing of the air against the interesting subject, viz., the analogy which cells, as it gradually enters during the exists between the human voice and reeddilatation of the chest, or is expelled by instruments (à ancke) . We drew your atthe elasticity of the lungs and its envelop- tention to the points of resemblance being parietes. If you desire the patient tween the two apparatuses, and signalized to speak, you do not hear any additional several particulars in which the human bruit; the voice, in a word, does not seem instrument infinitely surpasses any that to issue with intensity from the point upon art can produce. The vocal apparatus which the stethoscope is applied; but forms a most perfect musical instrument. when a portion of the pulmonary tissue It is most elaborately put together in all its becomes solidified, either by an inflamma- parts; and no other instrument can be tory affection, or in consequence of the compared with it for variety or perfection deposit of tubercular matter, &c., you of tone, or for the timbre and length of the often hear the patient’s voice as distinctly sounds which it is capable of producing. with the ear applied to the chest, as if you We have also seen, that the respiratory listened to him in ordinary conversation, apparatus gives rise to the development of this constitutes broncophony ; or when certain bruits, which it is of the utmost the substance of the lung is destroyed by importance to the physician to study, inthe resolution of tubercular matter, and a asmuch as they indicate with certainty cavity of any extent is formed, the voice the healthy or diseased condition of the of the speaker seems to arrive directly different parts from which they emanate. from that point of the chest to the ear, The material causes of these sounds are and the phenomenon called pectoriloquy very evident, and do not require any takes place. Finally, in cases of em- lengthened discussion: during the act of physema, hydro-pneumo-thorax, &c., we respiration the air is compelled to enter, have changes of structure in the musical and alternately to evacuate the lungs ;; instrument, if I may so call the chest, Itence.by a simple and natural mode of reawhich produce a change in its resonance, soning, we deduce the production of sound and thus more or less alter the nature of from the rubbing of the particles composthe sounds emanating from it. ing the atmospheric fluid against the side$
796 of the bronchial ramifications. Several of This exaggerated condition is called the bruits thus produced are of a curious, " puerile respiration." On the contrary, nature, and, as I before remarked to you, in old age the respiratory murmur bedeserve the utmost study and reflection on comes more and more feeble as the indithe part of the medical man, because they vidual advances in life; and, at length, afford one of our surest means of diagno- the bruit of the pulmonary expansion can sis of the diseases of the chest, and thus scarcely be recognised. In the language we call this"senile bruit" lay the foundation for a rational and suc- of stethoscopists, " cessful treatment. or senile respiration." You may now ask me, why does the reHowever, before I enter further this subject, 1 wish to direct your notice spiration of the child present this chato an experiment which I performed racteristic of intensity ? Why is the rebruit so insignificant and feeble lecture ; it was made with the object trying the effects of a new poison, or rather : in an advanced period of life ? We are to a new form of an old poison, viz., prussic look, Gentlemen, for the explanation of ether. Here it is in this bottle : the odour the questions I havejust put, in the difis strong and disagreeable, and in colour of structural arrangement prethe liquid somewhat resembles Madeirasented by the lung in different ages ; and wine. It appears to act exactly in the here remark another successful applicaof the principle of physical conditions, same way as prussic acid, but it is by no means so active as that poison. determining what are called vital phenoI have made a few comparative trials ofmena. There is, perhaps, no part of the both, and found the action of the ether animal economy in which the child differs more from the old person than in the more slow and much less energetic acid, like which it seems to affect, exclu- lungs. In the infant, the quantity of blood traverses the lungs in a given time sively, the brain and central nervous system. Here is the animal upon whom we is much greater than in the old person; have tried the effects of the prussic either. hence a greater quantity of air must na. The dog lies, as you see, in a state closely penetrate the vesicles, in order to approaching death; the only operate the necessary change in the blood, which is not destroyed is his slow and hence one cause of the increased intention. In other respects the animal is sity of sound. In addition to this, I may buried in a state of the deepest and most observe, that the extent of the bronchialramifications, corresponding with the extent perfect coma. Now to return to our subject. The first of the arterial, is much more considerable sound which presents itself for examina- in the young subject. On this account the tion is the " bruit respiratoire;" the na- atmospheric fluid enters more forcibly and ture of this sound is simple, and it very with greater rapidity, there is increased clearly results from the free passage and frottement, and this must, doubtless, be frottement of the air against the parietes enumerated amongst the causes of the inof the bronchi, their ramifications, and the tensity of the respiratory bruit in the pulmonary vesicles. It is easily clistin- child. guished by the naked ear, or with the In old age a portion of the bloodvessels stethoscope, applied to any portion of the is obliterated, the extent of the bronchial chest which is in contact with the lung. tree is comparatively small, the density of However, as the bruit is developed in the the lung is at its minimum, and large cells interior of the cavity, and transmitted with replace the innumerable small vesicles little intensity to the exterior, the normal which constituted it at an earlier period of sound is not heard at any distance; the life; the consequences of these conditions ear or stethoscope must be placed imme- are readily deduced: a small quantity of diately upon the surface of the chest, when blood circulates through the pulmonary the murmur of respiration is easily distin- system of the old person : the surface of guished, and we are then sure that the the vesicles is diminished, and receives a air enters freely into the vesicular ap- smaller quantity of air; hence there is paratus, and, consequently, that the lung less frottement, and the respiratory sound of the person whom we examine is sound. becomes more and more feeble, until it’ "But in some cases we find an alteration of assumes the fixed character of " senile." the bruit respiratoire, which, moreover, However, we must confess, that indshas peculiar characters at different periods pendently of the differences of age, there of life. Thus, for example, in the child, up are certain individual dispositions which to the age of ten or twelve years, the respi- give a variety to the respiratory sound, ratory murmur is remarkable for its greateven in subjects enjoying pc-rfeet health, degree of intensity, a degree so great that and apparently placetl in the eame 1)11).slow it may be perceived by a person whoI logical conditions. It is necessary for to bear in mind this remark, otherpractises auscultation for the first time.
upon before
of spiratory
ference tion
.
than the which
functionturally respira-
you
797 wise you may be much embarrassed, per- form our diagnosis consists, not in an haps even led astray, in practice. In some alteration in the nature of the brnit, but individuals the lung is much rarefied, and in the circumstance, that a normal bruit the respiratory murmur distinguished with is heard more clearly and with greater inthe utmost facility; in others, on the con- tensity in certain points of the thoracic trary, it requires a great deal of attention cavity than in others. This is a grave question, and one surand habitude in the use of cylinder, to discover the bruit of the respiration, yet the rounded with many difficulties, but it is lung is all the time perfectly heatthy; of the utmost importance that we should be finally, in other cases, the intensity of the able to resolve it in a satisfactory manner, sound may be modified by different con- because it is connected closely with the ditions of the parts enveloping the chest: existence of solid tubercular matter in the thus, while your patient is thin, when the pulmonary tissue. We know indeed from anterior part of the chest, is only covered experience, that whenever a portion of with a thin laver of cellular tissue, skin, the lung is solidified by the deposition of the respiratory sound reaches the tubercular matter in &c., quantity, bronis to say, the ear directlv from the wall of the sonorous cophony takes place, cavity, and is heard in its full degree of voice resounds from that portion of the intensity; but let the same patient sud- chest in a very peculiar manner; the denly become fat (and we have examples vocal bruit is often extremely energetic, of this rapid change every day in the hos- but we do not know exactly the reason of pitals), let the patient, I say, become sud- the phenomena; the laws governing the denly fat, and the respiratory sound is transmission of sound through solid bodies, dull and obscure : the reason is obvious ; and the different circumstances favouring but it is well to put you on your. guard, or retarding such transmission, have not for the true cause of a phenomenon is fre- been,thoroughly studied by natural philo" quently mistaken or overlooked, merely sophers : on this account we have little or because it is trivial and insignificant. no data upon which to proceed; however, Here is an example before us of a tho- we know from common experience that rax which will serve to illustrate in some solid bodies act as excellent conductors of respect what we have just now advanced : sound. It was partly upon this principle the patient, when alive, was extremely that the stethoscope was invented: hence emaciated and thin. When the lung is in- if any portion of the pulmonary tissue be flated through the upper part of the tra- converted iiitoasolidmass byinflammatory chea, and the stethoscope is placed on any induration, or especially by thedeposite portion of the smface of the chest, I can of the hard, solid matter originally cornhear the bruit of the respiratory murmur posing tubercles, it is not surprising that a most distinctly; the sound produced by change of structure so remarkable should the entrance of air into the vesicles is here bring with it a change of resonance, and that in fact very intcnse; the integuments, as one of the normal bruits should be heard you see, have been removed from the front with increased distinctness and energy. of the thorax, and the muscular layer byBut remark, that in order to affirm the exwhich it is covered is extremely thin; istence of tubercular concretions from this hence any sound developed in the interior tethoscopic symptom, the broncophony of the cavity is conveyed through the must be extremely well pronounced, and elastic parietes to the ear, without losing even then we must seek the aid afforded any of its force or distinctness. I woulf) by concomitant signs. recommend you to make a similar prepaThus you see how a study of the normal ration, whenever an opportunity may offer, bruits of the respiration and voice may and accustom your ear to seize and appre furnish a diagnosis which it is much the ciate the various modifications of the more important to form because in an early respiratory murmur in its normal state; state of the disease, when alone we can for without a perfect idea of healthy re- hope to prevent its fatal development, the spiration, and an ear somewhat exer- rational symptoms are either very uncereised, you cannot expect to discriminate tain, or are rull. Every act of respiration the varieties of sound which present them- consists of two parts, inspiration and expiselves in abnormal conditions of the respi- ration; hence we may divide the normal ratory apparatus. In the living body the respiratory murmur into two parts also ; thorax is never seen so naked as the pre- one corresponding with the entry of the air pared one before us; however, it is well into the pulmonary cells, the other dependto remember the effect which different ing upon its exit from the same parts; in states of thinness, embonpoint, &c., may the first case the sound is much more produce on the intensity of the respira- clear and loud than in the second, because tory sounds. In certain pathological cases, it depends upon the agent which distends the phenomenon upon which we have to the lungs; because the pressure, frotte-
any that
798 ment, and resistance to the passage of the
we
will throw
a
quantity of
fluid into the
air, are greater : but in the return of the lung, and observe the phenomena which lung to its medium state, or condition of take place ; the poison has produced its neutrality between expiration and inspira- usual narcotic effects ; the circulation in tion, the sound developed is more feeble, the lungs for the last five hours has been because there is less rubbing of the atmo- very incomplete ; hence, from the obstacle spheric fluid against the walls of the vesi- to the free passage of venous blood through cles, from the ready exit afforded to the the capillary vessels, an abundant exhalaair through the mouth and nares. This tion has taken place into the substance of difference is easily perceived on listening the pulmonary tissue, and various abnor-
mal sounds will he developed according to the nature and extent of the obstacle. This, Gentlemen, is actually the case : when I place the stethoscope upon the animal’s chest, I hear a distinct rale rouflant; the effusion of liquid into the substance of the lung and pulmonary tissue prevents the free entry of air into the vesicles, the respiratory sound is confined to the larger tubes, and resembles suffibarely distinguishable. ciently the noise made by an individual The respiratory bruit thus produced by when he snores. I now throw in a quanthe passage of air to and fro through the tity of fluid made viscid by the mixture of air-cells, is modified during disease in a a quantity of white of egg, and on inflating variety of forms ; but let me remark from forcibly the lung, the stethoscope betrays the outset, that as the original sound the presence of the rale muqueux, which I have now fitted a s itself the consequence of a physical did not before exist. cause, so almost all (and if not all, we larger pipe to the trachea, and force in a must accuse the imperfection of our know- more considerable quantity of fluid; the ledge), so almost all the modifications it character of the rale has changed; the undergoes are likewise to be accounted viscid substance has no doubt been in part for by the existence of certain abnormal washed away, and we have a well-prophysical conditions, the result of disease. nounced rale sifflant. You know there These modifications, to which LAENNEc are three kinds of bruits which most has given the generic name of " rale," commonly fall under the attention of the consist in the transformation of the nor- physician, viz., the rale muquenx, the rale mal sound into another, the result of the bronchique, and the rale crepitant; this air passing through conduits whose cali- latter is exclusively confined to the pulber is diminished, or in most cases into a monary vesicles. sound resembling that of bullse passing These are all one and the same phenothrough liquids of different kinds. Thus menon, but occurring in different portions the healthy respiratory sound may be of the bronchial tree; thus if you have a changed into what is called the rale mu- quantity of mucus contained in the larger qucux, or the rale crepitant ; or, finally, in tubes, and this is agitated by the passage some cases may resemble a true siffie- of air through the viscid fluid, you have ment. I think it will not be difficult to the rale bronchique; in some cases this demonstrate that these several modifica- bruit becomes very intense, as, for example, tions are merely the result, as we have before death, when the sound is produced already said, of certain physical condi- even in the trachea and larynx, from the tions : the proof is, that we can reproduce great quantity of mucosities which collect the greater part of them in the human and block up those parts. It is easy enough lung, when separated from the body. If you to reproduce each of these sounds, and to introduce any viscid fluid into the interior show not only upon what physical condiof the bronchial ramifications, as I shall tions they depend, but what are the phypresently do, and thus imitate as nearly as sical causes that give rise to the points of possible the physical conditions that exist resemblance. Thus it is not rare in cerin certain states of the lung during life, tain cases of chronic catarrh to hear a you will develop various abnormal bruits, râle which may be very readily confounded such as the mucous râle, the rale crepi- with the râle crepitant ; this is the " rhle tant, &c. bronchique a bulles fines," which has for its seat the smaller ramifications of the I shall now proceed to perform an periment of this kind before you. Here is tubes, and is made up of the sum of the the dog on whom wetried before lecture bruits generated in them. As to the the effects of prussic ether; he lies, as rale crepitant, it evidently passes in the vesicles themselyes, and is prosec, in a state of the most profound
to the naked lung, as the one before me on the table; the air in entering has to overcome the great elasticity of the pulmonary tissue, which constantly reacts against it, and must of necessity give rise to a certain degree of pressure; during expiration, or, in the present instance, during the discharge of air from the cells, no such obstacle has to be overcome, the frottement of the air is insignificant, and the murmur is
ex-
small you coma;pulmonary
799
duced by exactly the same mechanism, Saxton, a coach-smith, 17 years of age. viz., the displacement of a viscid fluid About a fortnight before he entered the (mucus or blood) by the air entering the hospital, he felt symptoms of a severe cold; cells: the character of crepitation by these increased and were daily augmented which it is distinguished, may be well towards night. On the 20th, when he accounted for by the great number and came in, he complained of great lassiinfinite smallness of the little pouches into tude, pain in the left side, and a feeling
which the atmospheric fluid penetrates. of tightness across the chest. The pain This rale, as we shall by-and-by see, may was augmented on taking a full inspiraoccur under several different circum- tion ; and the breathing was also short and stances, but the essential one is the de- painful. The cough was frequent, and the posit of a fluid in the pulmonary vesicles. expectorated matter thin and saline. The mouth generally felt dry; the papilla: of the tongue were elevated, and an uneasy sensation was experienced at the epigastrium, which the patient referred to the CLINICAL MEDICINE. stomach. The bowels were open; the urine abundant but high-coloured; the LECTURES pulse 72, sharp and full; and the skin dry. He was ordered by the house-apoDELIVERED AT THE to apply a large blister on the thecary NORTH LONDON HOSPITAL, ! painful side; and to take a pill, consisting of one grain of calomel and one of opium; BY and on the following morning, before I A. T. THOMSON, M.D., saw him, he had taken a brisk purgative. 21. The pain of the side was not much Physician to the Hospital, and Professor of Materia relieved; percussion over the chest did not Medica in the University of London. detect any loss of resonance; and on applying the ear to the thorax, there was still the sibilant rhonchus, demonstrating, LECTURE XII. in my opinion, the congested state of the INFLUENZA.—Modification of the Disease, membrane, and the necessity for relieving in tlte Fovvn of Bronchitis. it by a moderate bleeding. The patient AN epidemic has lately prevailed in the was, therefore, ordered to be bled to the extent of xij; and the venesection to be metropolis ; and, as might be expected, followed by a pill, containing one grain of -we have had specimens of it here. It assumes either the form of acute bronchitis calomel, one of opium, and three grains or that of tonsillitis. It is not easy to of true James’s Powder. He was put upon explain this diversity of form and of lo- low22.diet. The pain of the side was much recality of the disease, in different iiidivithe cough had abated ; and hit lieved ; but I am of that dithese duals ; opinion versities are nevertheless the results of the chief complaint was weakness. 23. H.- :. as still better; but, as his application of the same exciting cause, whatever that may be, modified in its bowels wor confined, he was ordered a effects according as the individuals are black dose, and to discontinue all mepreviously predisposed to affections of dicine. 28. He is now in a state of convalesthe tonsils or to inflammation of the mucence, and complains of nothing but debicous lining of the bronchial tubes. lity. Let him take f.ij of infusion of tn the cases which I have seen in columba twice a day. vate practice, the degree of severity and Case 2.-The second case was more sethe continuance of the disease, whichever vere in its characters. The name of the form it assumes, seems to depend greatly patient is William Hadderman, an Irish on the activity of the treatment in the labourer, thirtv-six years of age. He commencement, although, undoubtedly, stated that he has suffered under the something is due to the constitution of the effects of frequent colds for the last thrce individual affected; those of a strumous months, which he ascribes to having disdiathesis suffering more severely than continued the use of a flannel waistcoat. others in both cases. In illustration of But he felt no inconvenience from these this remark, I shall first direct your at- attacks until Saturday the 15th instant, tention to the bronchitic form of the when he was forced to leave off work, and ease, in two individuals of opposite eon to keep his bed. He acknowledges that stitutions, in whom the same he is a very hard drinker, and that he means have been adopted. drank a pint of wine in the day on which Case 1.—The first case is that of Samuel he was taken ill. ’
pri-
dis=
remedial
PHYSIOLOGY. LECTURES ON THE
PHYSICAL CONDITIONS OF THE
TISSUES
OF THE
HUMAN BODY
AS APPLIED TO THE EXPLANATION OF
VITAL PHENOMENA. Delivered at the BY F. Professor of
College of France MAGENDIE,
Physiology and Medicine College.
in 1834.
in the
LECTURE XXI. Bruits of Me Mouth and Nasal Fossce in Health and Disease.-Bruits i2?.dicativie Diseases of the Chest—Œgophony— 2%e Rdle Crepitant BroncophonyBruits which seem to issuefrom the Chest, but are caused by the Voice, in consequence
of
-
1835.
[1834-35.
but as every reed-instrument is composed of four distinct parts, it remains for us to see in what part of the vocal apparatus we can find a mechanism that may represent the porte-vent, which is generally a tube conveying to the exterior the sounds formed in the body of the instrument. It is evident, even on the most superficial examination, that the porte-vent is represented by the pharynx, mouth, and nasal cavities, for these are the parts through which all sounds formed in the larynx are transmitted to the external air, and thence to the organ of hearing; it is also easy to comprehend that various modifications of the parts just named must operate a corresponding change in the sounds passing through them ; however, very little importance has been attached to the bruits of the mouth or nares, indeed I might even say that they have been totally neglected by physiologists. Thus LAENNEC laid it down as a principle that " all the bruits taking place in the cavity of the mouth and nasal fossae have no influence whatever on the respiratory murmur," and the greater part of his followers would seem to have adopted the same opinion, if we are to form a judgment from the neglect with which they have treated this part of the subject.*
of Pulmonary Disease-Pectoriloquy.Causes of Respiratory Bruits.-Pr oduction of Pulmonary Râles by Artificial * Since the delivery of this lecture, M. means, after Narcotism affected witla Prussic Ether.-Tlte Murmur of Respi- BEAU of the Hopital Necker has read at ration, or Bruit of the Pulmonary Ex- the Royal Academy a very interesting paper
pansion.-Puerile aud Senile Respiration. on the causes of the respiratorv bruits Causes of their great difference.- Causes revealed by auscultation," &c., in which he which render the Respiratory Bruits very with attention different abnorexamines various in intensity.-Importance of the Study of the Râles, and its application mal conditions of the respiratory system, to Medicine. and endeavours to prove " that every reYESTERDAY, in considering the resem- spiratory bruit is the result of the echo blance which exists between the human (,’etentissement) of the guttural bruit in "
-
voice and certain instruments of music, we carried our examination from the reservoir of air, which is represented by the lungs, to the porte-vent, or trachea, and then entered into a brief history of the analogy existing between the larynx and the vibrating part of instruments & ancl&e; No. 601.
the column of air which fills the bronchi. The following are the conclusions at which he arrives. See the Archives Gen. de Mid. for August 1834 :lst, The different respiratory bruits not complicated with rales, are not produced
794 It is certain, however, that several mo- built. If, as you have already been shown, difications of structure in the pharynx and the sounds observed in the human body nasal fossae give rise to the development of are simply the result of the operation of
many bruits which are not heard in a state certain physical conditions, we cannot of health ; thus we have a sound charac- clearly have different bruits produced by teristic of angina gutturis, and, in general, one and the same state of any organ; we all inflammations of the pharynx exercise might as well expect three or four different an influence on the tone of the voice. You notes from the same chord of a musical have all, without doubt, witnessed cases of instrument. Whenever, then, we succeed polypi situated in the back of the mouth by observation in attaching any one sound and nasal fossse, and you must have re- to a peculiar condition of the organ, the marked how considerably the voice is rno- reproduction of that bruit gives a sure dified by any mechanical obstacle of that proof of the existence of the corresponding kind: finally, cancer of the tongue, amyg- change in the organization of the part; and dalitis, and various malformations of that whenever, in examining a patient, we find part of the vocal apparatus which we have nothing but the pure respiratory murmur, compared with the porte-voix, are known such as exists in people enjoying full to influence the respiratory sound, and health, we are entitled to conclude that the give indications which, when they shall organization of the pulmonary vesicles is have been studied with more care and unchanged and good, because any essential attention, will enlarge the sphere of our modification of structure, any obstacle to knowledge, and produce results of a highly the free passage of the air, would necesbeneficial nature. sarily give rise to some abnormal phenoBut we cannot afford to discuss minor menon with respect to sound. As the presence of the healthy sound details ; let us rather hasten to a consideration of the bruits developed in the bronchi, indicates a healthy state of the lung, so we pulmonary vesicles, trachea, and larynx. have a great variety of bruits which point The modifications which they present form out each a peculiar modification of the retnost important studies, not only for the spiratory apparatus, and thus direct us in physiologist, but also the pathologist and the diagnosis and treatment of diseases medical practitioner, because they are a which, before the application of what we faithful index of the various physical con- may call the physical method, remained in ditions of the respiratory system from a state of great obscurity. You have only which they result, and, as such, form the to read LAENNEC; or any other work on basis of a rational and correct diagnosis. auscultation, to find abundant examples of It is scarcely necessary for me to prove the importance attached to physical sympthe truth of the proposition which I have toms in diseases of the chest. Thus, sudjust now laid down, though it is evidently den effusion in cases of pleuritis is indithe ground-work upon which all our prac- cated by the sudden disappearance of the tice in diseases of the chest should be respiratory bruit over a large surface of the chest, and when the effusion is net by the frottement of the air against the so extensive, or the patient is examined at parietes of the bronchi, where they are an early stage of the disease, you have heard. aegophony joined to the absence of the re2nd, They result from the echo, in the spiratory sound. Inflammation of the pulmonary tissue is whole column of air expired and inspired, of the bruit produced by the frottement of also indicated, in many cases where the the air against the velum palati or neigh- other symptoms are so obscure and masked as to escape attention, bytherale crepitant, bouring parts. 3rd, That every bruit produced in the which always exists before the total disapupper part of the respiratory system, must pearance of the respiratory sound. When resound with its proper character and de- the inflammation has reached a certain gree of intensity in the bronchi. point, and the structure of the lung be4th, That in practice we should never comes altered by the solidifaction of the conclude the non.entrance of air into the pulmonary vesicles and smaller branches lungs, before we have examined whether of the bronchial tubes, producing that consome guttural bruit does not exist. dition of the lung which pathologits call 5th, That on destroying the guttural hepatization, the precise nature of the ’bruit, we can destroy the respiratory mur- organic change is indicated by a remarkmur, which is merely its echo, and thus able change in the stethoscopic symptoms; obtain in their purity certain bruits of the the rale crepitant that was so distinct in lung, pleura:, or heart, which are often an early stage of the inflammation graconfounded with it, and cannot be distin- dually declines, until the absence of all guished with accuracy until they are iso- bruit shows that the air no longer enters lated. smallest raiiiificatioiis of the bronchi,
the
795
and instead of the respiratory murmur Thus you perceive how, as we advance the affected part develops a peculiar sound in the investigation of disease, we obtain called broncophony, arising, as we shall at each step new proofs of the importance have occasion at a future time to see, and advantage attached to the principle I from the physical condition in which the laid down in the commencement of the lung is now placed. Emphysema of the present course. Investigate for yourselves lung, effusion into the cavity of the thorax the causes of the phenomena which you accompanied by the circumstance of a com- observe, and whenever circumstances will munication existing between the bronchi permit, trace up those phenomena to the and the cavity, and several other affections physical conditions giving rise to them; which the time does not permit me to in this way you will be sure to acquire notice, are all characterized by peculiar knowledge of a solid useful nature, infimodifications of sound which, joined to nitely superior to any theory, no matter the rational symptoms, leave no doubt as by whom it may have been suggested ; for this reason I have laboured to discover to their existence. The different bruits of which I have the material causes of many phenomena just spoken take place in the lungs them- which my predecessors, regarding as vital, selves, that is to say, result from different have accepted without any examination, states of the pulmonary vesicles and air- and I have, I hope, succeeded in convincing tubes, influencing the manner in which you that the different sounds and bruits the respired air acts, upon their parietes; upon which we have dwelt in the last but there are several other bruits which, few lectures, are merely the result of cer4 though they seem to issue from a fixed tain modifications of a musical instrupoint of the chest, and are in reality con- ment, in a word, are the effects of certain nected with organic changes in the pul- physical conditions made sensible to the monary tissue, are yet nothing but the ear. resonance of the voice, and sounds formed This was particularly the object which in the larynx; or, to express myself with I had in view in my last lecture; when more precision, arise from the propaga- we entered into a pretty full examination tion of the voice along the trachea and of the different physical conditions prebronchi. sented by the thorax, and saw how it was In the normal state of the organs con- an instrument eminently fitted, both by its tained in the thoracic cavity, when you composition and the manner in which it is auscult the chest, you hear nothing but organized, for the transmission of sound; the pure respiratory sound ; you distin- we also entered into some details on a very guish the rubbing of the air against the interesting subject, viz., the analogy which cells, as it gradually enters during the exists between the human voice and reeddilatation of the chest, or is expelled by instruments (à ancke) . We drew your atthe elasticity of the lungs and its envelop- tention to the points of resemblance being parietes. If you desire the patient tween the two apparatuses, and signalized to speak, you do not hear any additional several particulars in which the human bruit; the voice, in a word, does not seem instrument infinitely surpasses any that to issue with intensity from the point upon art can produce. The vocal apparatus which the stethoscope is applied; but forms a most perfect musical instrument. when a portion of the pulmonary tissue It is most elaborately put together in all its becomes solidified, either by an inflamma- parts; and no other instrument can be tory affection, or in consequence of the compared with it for variety or perfection deposit of tubercular matter, &c., you of tone, or for the timbre and length of the often hear the patient’s voice as distinctly sounds which it is capable of producing. with the ear applied to the chest, as if you We have also seen, that the respiratory listened to him in ordinary conversation, apparatus gives rise to the development of this constitutes broncophony ; or when certain bruits, which it is of the utmost the substance of the lung is destroyed by importance to the physician to study, inthe resolution of tubercular matter, and a asmuch as they indicate with certainty cavity of any extent is formed, the voice the healthy or diseased condition of the of the speaker seems to arrive directly different parts from which they emanate. from that point of the chest to the ear, The material causes of these sounds are and the phenomenon called pectoriloquy very evident, and do not require any takes place. Finally, in cases of em- lengthened discussion: during the act of physema, hydro-pneumo-thorax, &c., we respiration the air is compelled to enter, have changes of structure in the musical and alternately to evacuate the lungs ;; instrument, if I may so call the chest, Itence.by a simple and natural mode of reawhich produce a change in its resonance, soning, we deduce the production of sound and thus more or less alter the nature of from the rubbing of the particles composthe sounds emanating from it. ing the atmospheric fluid against the side$
796 of the bronchial ramifications. Several of This exaggerated condition is called the bruits thus produced are of a curious, " puerile respiration." On the contrary, nature, and, as I before remarked to you, in old age the respiratory murmur bedeserve the utmost study and reflection on comes more and more feeble as the indithe part of the medical man, because they vidual advances in life; and, at length, afford one of our surest means of diagno- the bruit of the pulmonary expansion can sis of the diseases of the chest, and thus scarcely be recognised. In the language we call this"senile bruit" lay the foundation for a rational and suc- of stethoscopists, " cessful treatment. or senile respiration." You may now ask me, why does the reHowever, before I enter further this subject, 1 wish to direct your notice spiration of the child present this chato an experiment which I performed racteristic of intensity ? Why is the rebruit so insignificant and feeble lecture ; it was made with the object trying the effects of a new poison, or rather : in an advanced period of life ? We are to a new form of an old poison, viz., prussic look, Gentlemen, for the explanation of ether. Here it is in this bottle : the odour the questions I havejust put, in the difis strong and disagreeable, and in colour of structural arrangement prethe liquid somewhat resembles Madeirasented by the lung in different ages ; and wine. It appears to act exactly in the here remark another successful applicaof the principle of physical conditions, same way as prussic acid, but it is by no means so active as that poison. determining what are called vital phenoI have made a few comparative trials ofmena. There is, perhaps, no part of the both, and found the action of the ether animal economy in which the child differs more from the old person than in the more slow and much less energetic acid, like which it seems to affect, exclu- lungs. In the infant, the quantity of blood traverses the lungs in a given time sively, the brain and central nervous system. Here is the animal upon whom we is much greater than in the old person; have tried the effects of the prussic either. hence a greater quantity of air must na. The dog lies, as you see, in a state closely penetrate the vesicles, in order to approaching death; the only operate the necessary change in the blood, which is not destroyed is his slow and hence one cause of the increased intention. In other respects the animal is sity of sound. In addition to this, I may buried in a state of the deepest and most observe, that the extent of the bronchialramifications, corresponding with the extent perfect coma. Now to return to our subject. The first of the arterial, is much more considerable sound which presents itself for examina- in the young subject. On this account the tion is the " bruit respiratoire;" the na- atmospheric fluid enters more forcibly and ture of this sound is simple, and it very with greater rapidity, there is increased clearly results from the free passage and frottement, and this must, doubtless, be frottement of the air against the parietes enumerated amongst the causes of the inof the bronchi, their ramifications, and the tensity of the respiratory bruit in the pulmonary vesicles. It is easily clistin- child. guished by the naked ear, or with the In old age a portion of the bloodvessels stethoscope, applied to any portion of the is obliterated, the extent of the bronchial chest which is in contact with the lung. tree is comparatively small, the density of However, as the bruit is developed in the the lung is at its minimum, and large cells interior of the cavity, and transmitted with replace the innumerable small vesicles little intensity to the exterior, the normal which constituted it at an earlier period of sound is not heard at any distance; the life; the consequences of these conditions ear or stethoscope must be placed imme- are readily deduced: a small quantity of diately upon the surface of the chest, when blood circulates through the pulmonary the murmur of respiration is easily distin- system of the old person : the surface of guished, and we are then sure that the the vesicles is diminished, and receives a air enters freely into the vesicular ap- smaller quantity of air; hence there is paratus, and, consequently, that the lung less frottement, and the respiratory sound of the person whom we examine is sound. becomes more and more feeble, until it’ "But in some cases we find an alteration of assumes the fixed character of " senile." the bruit respiratoire, which, moreover, However, we must confess, that indshas peculiar characters at different periods pendently of the differences of age, there of life. Thus, for example, in the child, up are certain individual dispositions which to the age of ten or twelve years, the respi- give a variety to the respiratory sound, ratory murmur is remarkable for its greateven in subjects enjoying pc-rfeet health, degree of intensity, a degree so great that and apparently placetl in the eame 1)11).slow it may be perceived by a person whoI logical conditions. It is necessary for to bear in mind this remark, otherpractises auscultation for the first time.
upon before
of spiratory
ference tion
.
than the which
functionturally respira-
you
797 wise you may be much embarrassed, per- form our diagnosis consists, not in an haps even led astray, in practice. In some alteration in the nature of the brnit, but individuals the lung is much rarefied, and in the circumstance, that a normal bruit the respiratory murmur distinguished with is heard more clearly and with greater inthe utmost facility; in others, on the con- tensity in certain points of the thoracic trary, it requires a great deal of attention cavity than in others. This is a grave question, and one surand habitude in the use of cylinder, to discover the bruit of the respiration, yet the rounded with many difficulties, but it is lung is all the time perfectly heatthy; of the utmost importance that we should be finally, in other cases, the intensity of the able to resolve it in a satisfactory manner, sound may be modified by different con- because it is connected closely with the ditions of the parts enveloping the chest: existence of solid tubercular matter in the thus, while your patient is thin, when the pulmonary tissue. We know indeed from anterior part of the chest, is only covered experience, that whenever a portion of with a thin laver of cellular tissue, skin, the lung is solidified by the deposition of the respiratory sound reaches the tubercular matter in &c., quantity, bronis to say, the ear directlv from the wall of the sonorous cophony takes place, cavity, and is heard in its full degree of voice resounds from that portion of the intensity; but let the same patient sud- chest in a very peculiar manner; the denly become fat (and we have examples vocal bruit is often extremely energetic, of this rapid change every day in the hos- but we do not know exactly the reason of pitals), let the patient, I say, become sud- the phenomena; the laws governing the denly fat, and the respiratory sound is transmission of sound through solid bodies, dull and obscure : the reason is obvious ; and the different circumstances favouring but it is well to put you on your. guard, or retarding such transmission, have not for the true cause of a phenomenon is fre- been,thoroughly studied by natural philo" quently mistaken or overlooked, merely sophers : on this account we have little or because it is trivial and insignificant. no data upon which to proceed; however, Here is an example before us of a tho- we know from common experience that rax which will serve to illustrate in some solid bodies act as excellent conductors of respect what we have just now advanced : sound. It was partly upon this principle the patient, when alive, was extremely that the stethoscope was invented: hence emaciated and thin. When the lung is in- if any portion of the pulmonary tissue be flated through the upper part of the tra- converted iiitoasolidmass byinflammatory chea, and the stethoscope is placed on any induration, or especially by thedeposite portion of the smface of the chest, I can of the hard, solid matter originally cornhear the bruit of the respiratory murmur posing tubercles, it is not surprising that a most distinctly; the sound produced by change of structure so remarkable should the entrance of air into the vesicles is here bring with it a change of resonance, and that in fact very intcnse; the integuments, as one of the normal bruits should be heard you see, have been removed from the front with increased distinctness and energy. of the thorax, and the muscular layer byBut remark, that in order to affirm the exwhich it is covered is extremely thin; istence of tubercular concretions from this hence any sound developed in the interior tethoscopic symptom, the broncophony of the cavity is conveyed through the must be extremely well pronounced, and elastic parietes to the ear, without losing even then we must seek the aid afforded any of its force or distinctness. I woulf) by concomitant signs. recommend you to make a similar prepaThus you see how a study of the normal ration, whenever an opportunity may offer, bruits of the respiration and voice may and accustom your ear to seize and appre furnish a diagnosis which it is much the ciate the various modifications of the more important to form because in an early respiratory murmur in its normal state; state of the disease, when alone we can for without a perfect idea of healthy re- hope to prevent its fatal development, the spiration, and an ear somewhat exer- rational symptoms are either very uncereised, you cannot expect to discriminate tain, or are rull. Every act of respiration the varieties of sound which present them- consists of two parts, inspiration and expiselves in abnormal conditions of the respi- ration; hence we may divide the normal ratory apparatus. In the living body the respiratory murmur into two parts also ; thorax is never seen so naked as the pre- one corresponding with the entry of the air pared one before us; however, it is well into the pulmonary cells, the other dependto remember the effect which different ing upon its exit from the same parts; in states of thinness, embonpoint, &c., may the first case the sound is much more produce on the intensity of the respira- clear and loud than in the second, because tory sounds. In certain pathological cases, it depends upon the agent which distends the phenomenon upon which we have to the lungs; because the pressure, frotte-
any that
798 ment, and resistance to the passage of the
we
will throw
a
quantity of
fluid into the
air, are greater : but in the return of the lung, and observe the phenomena which lung to its medium state, or condition of take place ; the poison has produced its neutrality between expiration and inspira- usual narcotic effects ; the circulation in tion, the sound developed is more feeble, the lungs for the last five hours has been because there is less rubbing of the atmo- very incomplete ; hence, from the obstacle spheric fluid against the walls of the vesi- to the free passage of venous blood through cles, from the ready exit afforded to the the capillary vessels, an abundant exhalaair through the mouth and nares. This tion has taken place into the substance of difference is easily perceived on listening the pulmonary tissue, and various abnor-
mal sounds will he developed according to the nature and extent of the obstacle. This, Gentlemen, is actually the case : when I place the stethoscope upon the animal’s chest, I hear a distinct rale rouflant; the effusion of liquid into the substance of the lung and pulmonary tissue prevents the free entry of air into the vesicles, the respiratory sound is confined to the larger tubes, and resembles suffibarely distinguishable. ciently the noise made by an individual The respiratory bruit thus produced by when he snores. I now throw in a quanthe passage of air to and fro through the tity of fluid made viscid by the mixture of air-cells, is modified during disease in a a quantity of white of egg, and on inflating variety of forms ; but let me remark from forcibly the lung, the stethoscope betrays the outset, that as the original sound the presence of the rale muqueux, which I have now fitted a s itself the consequence of a physical did not before exist. cause, so almost all (and if not all, we larger pipe to the trachea, and force in a must accuse the imperfection of our know- more considerable quantity of fluid; the ledge), so almost all the modifications it character of the rale has changed; the undergoes are likewise to be accounted viscid substance has no doubt been in part for by the existence of certain abnormal washed away, and we have a well-prophysical conditions, the result of disease. nounced rale sifflant. You know there These modifications, to which LAENNEc are three kinds of bruits which most has given the generic name of " rale," commonly fall under the attention of the consist in the transformation of the nor- physician, viz., the rale muquenx, the rale mal sound into another, the result of the bronchique, and the rale crepitant; this air passing through conduits whose cali- latter is exclusively confined to the pulber is diminished, or in most cases into a monary vesicles. sound resembling that of bullse passing These are all one and the same phenothrough liquids of different kinds. Thus menon, but occurring in different portions the healthy respiratory sound may be of the bronchial tree; thus if you have a changed into what is called the rale mu- quantity of mucus contained in the larger qucux, or the rale crepitant ; or, finally, in tubes, and this is agitated by the passage some cases may resemble a true siffie- of air through the viscid fluid, you have ment. I think it will not be difficult to the rale bronchique; in some cases this demonstrate that these several modifica- bruit becomes very intense, as, for example, tions are merely the result, as we have before death, when the sound is produced already said, of certain physical condi- even in the trachea and larynx, from the tions : the proof is, that we can reproduce great quantity of mucosities which collect the greater part of them in the human and block up those parts. It is easy enough lung, when separated from the body. If you to reproduce each of these sounds, and to introduce any viscid fluid into the interior show not only upon what physical condiof the bronchial ramifications, as I shall tions they depend, but what are the phypresently do, and thus imitate as nearly as sical causes that give rise to the points of possible the physical conditions that exist resemblance. Thus it is not rare in cerin certain states of the lung during life, tain cases of chronic catarrh to hear a you will develop various abnormal bruits, râle which may be very readily confounded such as the mucous râle, the rale crepi- with the râle crepitant ; this is the " rhle tant, &c. bronchique a bulles fines," which has for its seat the smaller ramifications of the I shall now proceed to perform an periment of this kind before you. Here is tubes, and is made up of the sum of the the dog on whom wetried before lecture bruits generated in them. As to the the effects of prussic ether; he lies, as rale crepitant, it evidently passes in the vesicles themselyes, and is prosec, in a state of the most profound
to the naked lung, as the one before me on the table; the air in entering has to overcome the great elasticity of the pulmonary tissue, which constantly reacts against it, and must of necessity give rise to a certain degree of pressure; during expiration, or, in the present instance, during the discharge of air from the cells, no such obstacle has to be overcome, the frottement of the air is insignificant, and the murmur is
ex-
small you coma;pulmonary
799
duced by exactly the same mechanism, Saxton, a coach-smith, 17 years of age. viz., the displacement of a viscid fluid About a fortnight before he entered the (mucus or blood) by the air entering the hospital, he felt symptoms of a severe cold; cells: the character of crepitation by these increased and were daily augmented which it is distinguished, may be well towards night. On the 20th, when he accounted for by the great number and came in, he complained of great lassiinfinite smallness of the little pouches into tude, pain in the left side, and a feeling
which the atmospheric fluid penetrates. of tightness across the chest. The pain This rale, as we shall by-and-by see, may was augmented on taking a full inspiraoccur under several different circum- tion ; and the breathing was also short and stances, but the essential one is the de- painful. The cough was frequent, and the posit of a fluid in the pulmonary vesicles. expectorated matter thin and saline. The mouth generally felt dry; the papilla: of the tongue were elevated, and an uneasy sensation was experienced at the epigastrium, which the patient referred to the CLINICAL MEDICINE. stomach. The bowels were open; the urine abundant but high-coloured; the LECTURES pulse 72, sharp and full; and the skin dry. He was ordered by the house-apoDELIVERED AT THE to apply a large blister on the thecary NORTH LONDON HOSPITAL, ! painful side; and to take a pill, consisting of one grain of calomel and one of opium; BY and on the following morning, before I A. T. THOMSON, M.D., saw him, he had taken a brisk purgative. 21. The pain of the side was not much Physician to the Hospital, and Professor of Materia relieved; percussion over the chest did not Medica in the University of London. detect any loss of resonance; and on applying the ear to the thorax, there was still the sibilant rhonchus, demonstrating, LECTURE XII. in my opinion, the congested state of the INFLUENZA.—Modification of the Disease, membrane, and the necessity for relieving in tlte Fovvn of Bronchitis. it by a moderate bleeding. The patient AN epidemic has lately prevailed in the was, therefore, ordered to be bled to the extent of xij; and the venesection to be metropolis ; and, as might be expected, followed by a pill, containing one grain of -we have had specimens of it here. It assumes either the form of acute bronchitis calomel, one of opium, and three grains or that of tonsillitis. It is not easy to of true James’s Powder. He was put upon explain this diversity of form and of lo- low22.diet. The pain of the side was much recality of the disease, in different iiidivithe cough had abated ; and hit lieved ; but I am of that dithese duals ; opinion versities are nevertheless the results of the chief complaint was weakness. 23. H.- :. as still better; but, as his application of the same exciting cause, whatever that may be, modified in its bowels wor confined, he was ordered a effects according as the individuals are black dose, and to discontinue all mepreviously predisposed to affections of dicine. 28. He is now in a state of convalesthe tonsils or to inflammation of the mucence, and complains of nothing but debicous lining of the bronchial tubes. lity. Let him take f.ij of infusion of tn the cases which I have seen in columba twice a day. vate practice, the degree of severity and Case 2.-The second case was more sethe continuance of the disease, whichever vere in its characters. The name of the form it assumes, seems to depend greatly patient is William Hadderman, an Irish on the activity of the treatment in the labourer, thirtv-six years of age. He commencement, although, undoubtedly, stated that he has suffered under the something is due to the constitution of the effects of frequent colds for the last thrce individual affected; those of a strumous months, which he ascribes to having disdiathesis suffering more severely than continued the use of a flannel waistcoat. others in both cases. In illustration of But he felt no inconvenience from these this remark, I shall first direct your at- attacks until Saturday the 15th instant, tention to the bronchitic form of the when he was forced to leave off work, and ease, in two individuals of opposite eon to keep his bed. He acknowledges that stitutions, in whom the same he is a very hard drinker, and that he means have been adopted. drank a pint of wine in the day on which Case 1.—The first case is that of Samuel he was taken ill. ’
pri-
dis=
remedial