Causes.—An exciting cause may be an impurity of the blood. More commonly it arises from indigestion, bronchitis or valvular disease of the heart. Hay asthma is caused by the inhalation of particles such as arise from dried hay. The pollen from flowers and also from dogs, cats and other animals frequently give rise to it.

Symptoms.—This disease comes on in paroxysms. The paroxysm may be preceded for a variable time by a sense of oppression and constriction about the chest, with wheezing respiration. In many instances, however, it develops without any warning and most commonly at night. The patient awakes suddenly, scarcely able to breathe, and is forced to assume the sitting posture, or even to stand erect, with the shoulders raised and fixed, the head thrown back, the mouth open and all the extraordinary muscles of respiration brought into play to assist those powers of the system which are usually sufficient for the purpose. The face, in severe cases, wears an aspect of terror, the eyes are widely opened, the skin is pale and dusky and often bedewed with sweat. The feet and hands are cold and the pulse small and quick. The breathing, however, is not hurried, but inspiration is short and jerky ,and expiration inordinately prolonged. On percussion, the resonance of the chest is found to be increased and auscultation shows the vesicular breath-sounds are weak or suppressed and attended with whistling or cooing noises called râles. Toward the end of an attack, which may last for several weeks, cough comes on with the expectoration of small, firm, solid pellets of mucus, in rare cases mixed with blood. The duration varies greatly, the paroxysm passing off in a few minutes or lasting for many days. When it continues long, or is left to itself, it is apt to subside gradually; but if brief or cut short by treatment, it often ends abruptly.

Diagnosis.—The diagnosis rests upon the paroxysmal and usually sudden nature of the onset, the absence of moist râles as determined by auscultation, and the complete recovery of patients in the intervals of their attacks. The cooing and whistling sounds heard all over the chest show the absence of any serious obstruction in the larynx and trachea, and the muscular effort being made for the purpose of inflating the lungs chiefly in asthma, from heart disease, instead of also in expiration as in the spasmodic form, which we are now considering, is another indication of value.

Treatment 1.—Among the most certain treatments are the inhalation of chloroform or ether and the hypodermic injection of an eighth or a quarter of a grain of morphia, either of which, in a majority of instances, may be depended on to relax the spasm and afford prompt relief.

2. Some of the most reliable internal remedies are chloral in fifteen-grain doses, which should be employed with great caution, or not at all if the heart is organically affected; ten or fifteen drops of tincture of lobelia or of ipecacuanha, as a nauseant or emetic, belladonna, valerian and strong black coffee.

3. The inhalation of the vapor of stramonium leaves, produced either by burning them on a red-hot shovel or smoking them in a pipe, and of the smoke of soft bibulous paper which has been soaked in strong saltpetre water and then dried, often affords relief, and, perhaps, as often fails in its desired object.

4. The treatment during the interval between the paroxysms must be directed toward building up the general health and fortifying the nervous system against the exciting causes of the disease. In some instances the action of small doses of lobelia is highly beneficial, and in others, patients who have been for years great sufferers from asthma enjoy a complete immunity from the malady as long as they keep themselves under the influence of iodide of potassium by taking from five to ten grains of it three times daily.

5. If medicinal treatment for the prevention of asthma proves unsuccessful, a change of climate and particularly a sea voyage should be undertaken, and it is claimed by some physicians in Colorado that the air of that region is almost a specific against asthmatic complaints.


Symptoms.—Hay asthma or rose cold, commonly called hay fever, is very prevalent form of asthma which comes on with symptoms of ordinary but severe cold in the head, constant sneezing, great discharge from the nose and in many cases intense difficulty of breathing. Many sufferers from this curious malady are perfectly well until a certain day in one of the months of June, July or August of every year, when they wake up in the morning, perhaps, with the symptoms above described.

Causes.—As already remarked, this form seems to be due to the inhalation of pollen from certain grasses or flowers, but when once commenced it may continue for several days, or even weeks, after its supposed cause has been removed.

Treatment.—The inhalation of sulphate of quinine in powder has been highly recommended in this affection, but the air (and other attractions) of various watering places seems to be the most popular and satisfactory remedy. The White Mountains or certain seaside resorts are looked upon by some patients as absolutely necessary for their health and comfort during an attack of this complaint.

Various Forms of Asthma.—Under the title of industrial asthma have been grouped several kinds of pulmonary disease, incident to different trades and occupations. These include saw-grinder's asthma, miner's asthma, potter's asthma and miller's asthma, caused by the mechanical irritation of minute particles of dust in the respired air, as already pointed out in Book III, Part II.


Symptoms.—This disease, so well known to every one as a common "cold in the head," is often epidemic, and is characterized at first by chilliness with sneezing and later by an abundant discharge of fluid from the nose. When severe it is attended with slight fever, pain and sense of weight in the head, pain in the limbs, prostration of strength, irritability of temper and inactivity of mind.

Causes.—Its origin can generally be traced to some imprudent violation of the laws of hygiene, such as exposure to draughts, insufficient clothing, sudden cooling when heated, and so forth.

Treatment.—The number and diversity of the infallible remedies for a common cold is sufficient evidence of their generally unsatisfactory nature, but as the natural duration of the disease is from three to five days, the third or fourth medicine which receives twenty-four hours' trial often gains the credit of accomplishing a cure. If, as is usually the case, the bowels are constipated, a saline purgative, such as a Seidlitz powder or a bottle of citrate of magnesia, will usually relieve the headache, and then light diet, abstinence from fluids for a day and ten grains of Dover's powder at bed-time often seem to hasten the departure of this unwelcome guest.


Three Forms.—This disease, which is one of the accompaniments of a common cold whenever hoarseness of the voice comes on, presents itself under three forms: First, the acute or edematous; second, the subacute or catarrhal, and third, chronic laryngitis. The first of these varieties may, if not properly treated, prove quickly fatal, by closing up the avenue of entrance for the air to the lungs and thus causing death by suffocation.

Symptoms of Acute Form.—Acute or dropsical laryngitis may commence as a slight catarrh, quickly followed by high fever. Speech, cough and respiration are all soon modified. The voice at first metallic, soon becomes whispering. The cough primarily clear and shrill, then harsh and croupy is also reduced to little more than a whisper, and a peculiar noise like a loud whisper accompanies both inspiration and expiration, which are, from the beginning almost, laborious and wheezing. As soon as the dropsical swelling comes on and still further narrows the opening of the glottis, the effort to breathe becomes exceedingly painful and difficult and the patient's countenance expresses great anxiety.

Treatment 1.—Since acute laryngitis in the adult may destroy life in a few days, or even hours, it should be treated actively from the first onset by bleeding, if the patient is robust, or by leeching, active purgation with five- or ten-grain doses of calomel and jalap and calomel in grain doses every two hours to the extent of producing slight salivation as rapidly as possible.

2. If the inflammatory swelling proceeds or if dropsy comes on and interferes with the respiration sufficiently to cause lividity or blueness of the lips, the operation of opening the windpipe should be at once performed. It is better to open the trachea or windpipe sooner than is absolutely necessary, than to postpone the operation until the blood has been rendered very impure by want of a proper supply of oxygen; yet even up to the last gasp and for, perhaps, a minute afterward, life may be saved by the surgical operation.

3. For children the danger to life from this malady is comparatively slight, so that bleeding and calomel may generally be dispensed with, and emetics, such as syrup of ipecacuanha or Coxe's hive syrup, in ten-drop doses every three hours for a child of three years old, with the inhalation of warm opiate vapors, as, for example, that from the spout of a teapot, in which has been placed with a small quantity of boiling water fifteen or twenty drops of laudanum, are generally sufficient.

Subacute Form.—The subacute form of laryngitis rarely passes into the acute variety, and is, therefore, of but little importance. If severe, the same treatment by expectorants, nauseants and anodynes, recommended in acute laryngitis of children may be employed. Complete rest of the voice should be enjoined and inhalations of the various anodyne and astringent sprays are of great service in chronic cases.

Chronic Laryngitis Symptoms.—Chronic laryngitis is accompanied with actual thickening of the vocal cords, which, if the deposit be not subsequently absorbed, produces a permanent change in the voice; The respiration is usually but little affected, yet there may be a little tickling cough, an expectoration of small fragments of mucus and an almost constant desire to clear the throat.

Treatment.—Rest, by the avoidance of speaking above a whisper, a warm, moist atmosphere and medicated inhalations, are the important elements of treatment in this affection in its simple form.

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The Laryngoscope.—By means of a small, metallic looking-glass, called a laryngoscope, a view of the epiglottis, the glottis itself, and, in favorable instances, the interior of the larynx, with some of the upper rings of the trachea, may be obtained. Such a view is given in the accompanying illustration.

Treatment of Throat Ulcers.—When, by means of the laryngoscope, the existence and seat of an ulcer can be established, it should be touched with a strong solution of nitrate of silver, in the hope of thereby promoting a tendency to heal; or inhalations of astringent solutions, such as that of the sulphate of zinc, or of copper, and of carbolic acid, may be employed.


For a full description of the causes and treatment of this disease see Book IV, Part XII, DISEASES OF CHILDREN.


Tumors in Vocal Cords.—The development of new growths or little tumors within the cavity of the larynx is a cause of local obstruction to the breathing, which is happily rare. The three different kinds which have been met with are, first, the warty growths, having a firm structure, and attached to the inner surface of the laryngeal cavity by a broad base; second, polypoid growths, similar to those already mentioned as occurring in the nose, of a soft and jelly-like consistence attached to the mucous membrane by a pedicle or stem; and, third, cysts or hollow bags, containing, in some instances, parasites.

Paralysis of Vocal Cords.—Paralysis of the vocal cords, resulting in aphonia or loss of the voice, is a very grave misfortune under certain circumstances, as, for example, to clergymen or lawyers.

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Changes in Vocal Cords.—The changes in position which these vocal cords undergo in the different processes in which they are concerned, will probably be understood by reference to the accompanying diagram. At A is shown the appearance of the chink of the glottis, formed by the edges of the vocal cords, as it appears when examined by the laryngoscope whilst the patient is engaged in singing. B exhibits the condition in which it usually appears during easy and quiet respiration; and at C is represented the arrangement during forced inspiration or drawing a long breath.

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Muscular Arrangement of Larynx.—The figure in the margin illustrates the arrangement of the muscles of the larynx, as seen after the membrane and elastic tissue constituting the vocal cords has been removed. Th represents the large and firm thyroid cartilage; Ary the upper ends of the arytenoid cartilages, to which the posterior ends of the vocal cords are attached; V indicates the position of the vocal cords. At Arp is represented the band of muscle called the posterior arytenoid muscle, which has the duty of pulling the arytenoid cartilages together, and so narrowing the slit of the glottis between the vocal cords as to cause the production of just the right sound for any particular note in singing. The mechanism of hoarseness in the voice or cough is simply as may be understood with ease from this diagram, that the edges of the vocal cords becoming thickened by congestion or slight inflammatory action can no longer vibrate quickly enough to produce the higher notes of the voice.

Loss of Voice.—In paralysis of the muscles of the glottis, which, small as they are, the explanation given a few pages back shows to be very important, not only is the power to produce audible voice sounds lost, but breathing is rendered difficult, and great distress is produced by the inability to take a long breath. Aphonia, or loss of voice, is of two kinds, the simulated and the true. An imitation of the real disease is generally hysterical in its character, and though it may last for a long time, is never really permanent; it may sometimes be recognized by the aid of the laryngoscope.

Treatment.—True aphonia is due to actual palsy of these little laryngeal muscles, is generally dependent upon some serious injury or disease, and therefore in most instances incurable. The treatment of the pretended aphonia is that of hysteria. In bad cases chloroform may be given with advantage. During the intervals between the attacks, the bitter tonics, cod-liver oil and iron, and treatment for any uterine derangement, as described in the chapter on Diseases Peculiar to Women, should such disorder exist, are strongly indicated and will generally accomplish a cure in the course of time,


Character.—This every-day disease is a subacute inflammation affecting the larynx, trachea, and larger bronchial tubes, sometimes commencing with nasal catarrh and traveling down, as it were, to the pulmonary organs. At other times, or in other patients, it appears to originate in the larynx, and does not affect the nasal passages at any time during its course.

Predisposing Causes.—The predisposing causes to this common affection are enumerated as being the loose flabby texture of tissue in certain individuals, especially those who are the subjects of the scrofulous diathesis, and rickety children; second, a previous attack, and third, effeminate modes of life.

Direct Causes.—The directly exciting causes are:

1. Chilling of a portion of the skin, and especially the change of temperature of a portion of the body produced by sitting in a draught of air whilst perspiring freely, or with damp clothing or wet shoes.

2. Irritants acting directly on the mucous membrane lining the air-passages, such as dust, acrid vapors, or hot and cold air, and the grinders, millers and stone-cutters.

3. Obstruction to the current of the blood through the great branches of the aorta below the origin of the bronchial arteries, such as may be caused by abdominal dropsy, accumulation of gas, or of refuse matter in the intestines.

4. As a result of morbid states of the blood, as seen when bronchial catarrh is a premonitory symptom of typhoid fever, measles and small-pox.

Symptoms.—The general symptoms of a common cold on the breast are so well known to every one that it is not worth while to occupy space in describing them, and yet, frequent as is popular acquaintance with this disease, few persons realize the terrible dangers which attend upon a neglected cough.

Treatment 1.—The most important thing in relation to this malady is to prevent its occurrence. This could probably be accomplished in four cases out of five by the exercise of a troublesome amount of prudence, which, however, would be well expended were young people willing to make the effort to escape this frequent cause of early death. When, however, a person is unfortunate enough to contract a cough by his own imprudence or otherwise, it may often be cut short by bringing on a free perspiration. A good way to accomplish this is to take a hot mustard foot-bath and ten grains of Dover's powder on retiring for the night, wrapping the throat up in flannel if it feels sore, and being very careful not to undo, and more than undo, the beneficial work of this treatment by uncovering oneself in the night, or by imprudent exposure the next day.

2. If this method is not resorted to early enough, or if it fails and the cough goes on unchecked, ten-drop doses four times a day of antimonial, or ipecacuanha wine, and nitrate of potash, or muriate of ammonia in quantities of five grains every three or four hours, are generally useful.

3. By the third or fourth day great advantage may be derived from the use of a mixture of half a teaspoonful each of syrup of squills and syrup of wild cherry with one-twelfth of a grain of acetate of morphia and the same quantity of cyanide of potassium every six hours. If this remedy agrees with the patient it may be taken more frequently or in sufficient doses to quiet the cough through the night, but it must be used with great caution, as it contains ingredients which are poisonous in over-doses.

4. Should the disease persist notwithstanding the employment of these various medicines, counter-irritation with croton oil and tincture of iodine applied to small spots on the upper part of the chest in front, or croton oil alone rubbed on the back, also with great caution, should be resorted to without that further delay during which the catarrhal irritation of the bronchial tubes might become chronic, as it is commonly phrased, and the cough get such a hold that it cannot be shaken off.

Auxiliary Treatment.—A very important part of the treatment is the breathing of a continuously warm, moist atmosphere, and for children especially, the prescription of one warm room is probably more conducive to recovery than any one of the medicines suggested. Particularly ought young children, in whom previous experience has shown there exists any tendency to croup, to be guarded against the development of that dangerous affection by even the slight additional exposure of passing through a cool entry to their meals. At the same time the apartment to which the invalid is confined must not be kept too warm, and due attention should be paid to its proper ventilation.


Character.—This disease, an inflammation of the bronchial tubes, or air-passages leading to the pulmonary vesicles, is characterized by hoarseness and moderate cough, with heat and soreness of the chest in front, all these being more or less intense according to the severity of the attack. In every common cough there is always some bronchitis, but the element of danger lies in the extension of the inflammatory action to the smaller bronchial tubes or bronchioles, and the approximation consequently to that fatal form of the malady termed capillary bronchitis.

Simple Bronchitis Symptoms.—Simple bronchitis is usually ushered in with a slight chilliness, general discomfort, and some febrile disturbance. A sense of constriction about the chest and some deep-seated soreness beneath the breast bone soon follow. The respiration is slightly increased in frequency, but no urgent dyspnoea is generally present, unless the patient is a sufferer from some chronic affection of the heart or lungs, as, for example, valvular disease of the former organ. Cough is uniformly present in bronchitis, is worse after sleep, and, as a rule, paroxysmal. The expectoration is at first scanty and viscid, but soon becomes more abundant, white and frothy, and still later yellowish or muco-purulent. In this latter stage the cough is looser, less painful, and the phlegm is expectorated more easily.

Capillary Bronchitis Symptoms.—Capillary bronchitis usually develops out of the simple form, and therefore its onset can hardly be said to be characterized by any well-marked symptoms. Occasionally, however, a sharp chill defines the date of its attack. When developed the patient breathes with difficulty, the complexion is dusky, and the countenance betrays anxiety. The superficial veins are over-filled, as a consequence of the obstruction to the pulmonic circulation, and the movements of the sides of the nostrils are exaggerated. The respiration and pulse are quickened, the former very much so, and out of proportion to the latter. The cough is almost constant, and the expectoration at first frothy, and after a time yellowish, is expelled with considerable difficulty. Troublesome pains in the intercostal muscles, brought on by the unremitting exertion of coughing, are of frequent occurrence, the temperature rises to a considerable elevation, and the restlessness is extreme; the renal excretion is scanty, and sometimes a little albuminous. In fatal cases the prostration becomes intense, the skin livid, cold and clammy. Dropsy of the feet and legs may come on, and at last fitful drowsiness or muttering delirium precede coma and death.

Acute Bronchitis Diagnosis.—The diagnosis of acute bronchitis is ordinarily not difficult. Capillary bronchitis must be distinguished from pneumonia, which can generally be done by the greater amount of fever and disturbance of the respiration as well as the dullness on percussion, tubular breathing, and irregular distribution over the chest of the latter affection. In acute tuberculosis, or galloping consumption, the violence and irregularity of the fever, the rapid collapse of strength, and the extreme dyspnoea, out of all proportion to the physicial signs, indicate the nature of the case in most instances.

Treatment 1.—A threatened attack of bronchitis may sometimes apparently be cut short by a hot foot-bath and dose of Dover's powder, as already suggested, and a full dose of ten grains of salicin or of quinine will perhaps aid the good work of this treatment.

2. After the disease is fully developed the remedies are chiefly palliative, and consist of opiates, such as morphia, belladonna, or preferably, in many cases codeia, in half-grain doses, to quiet the cough and promote the expectoration. The softening of the secretion, and easing of the incessant cough, are also promoted by keeping the patient in a moist atmosphere, as suggested in regard to croup.

3. Pain in the chest can often be relieved by mustard-plasters and stimulating liniments, or painting with tincture of iodine. Half teaspoonful doses of the syrups of squills, ipecacuanha and lobelia, every two, three or four hours, according to the urgency of the symptoms, are probably useful, and the iodide of potassium, in five-grain doses, if well borne by the patient without irritating the mucous membranes of the eyes and throat, as it sometimes does in a singular way, is highly recommended.

Diet.—There is no need of restricting the diet in this disease, and any wholesome food which the patient craves may be allowed. In the treatment of the capillary bronchitis of young children it is necessary to use opiates with much greater caution, and the occasional administration of an emetic, to aid in clearing out the accumulated mucus, is important. Counter-irritation by mustard or turpentine may be tried, and dry cupping often gives great relief.

Chronic Bronchitis.—Chronic bronchitis is a very common malady, its frequency increasing with the coming on of old age. It may be chronic from the outset, or be the result of the acute form. Chronic lung diseases generally are apt to lead to it, and so does the abuse of alcohol.

Treatment.—Chronic bronchitis, especially when in the form called dry catarrh, is often relieved by iodide of potassium and colchicum.


Causes.—This disease, called also lung fever, is the most serious of the common acute diseases of the pulmonary organs. Long continued exposure to cold is apt to be the exciting cause of pneumonia; but there are some reasons for supposing that it is, at least in many instances, a local manifestation of a general disease, perhaps contagious in its character. It often comes on in the course of other grave maladies and adds very much to their fatality.

The Stages.—The three stages through which this complaint passes in typical cases, are, first, that of congestion, where the lung is engorged with blood; second, that of red-hepatization, in which the inflamed lung is dark-red and solid like a piece of liver, sinking in water and breaking down readily under the pressure of the finger; and, third, the stage of grey-hepatization, in which the affected pulmonary tissue is still dense, but of a yellowish-grey color.

Symptoms 1.—The symptoms of an ordinary attack of pneumonia, coming on from exposure to cold, in a robust adult, are quite characteristic. The disease usually sets in with a single severe and prolonged chill, after which the temperature of the body rapidly rises to a high point and this rise is accompanied by the customary symptoms of fever. Pain is commonly felt about the region of the nipple on the affected side and is sharp, stabbing and aggravated by movement in breathing or otherwise, and also by pressure.

2. There is, likewise, well-marked dyspnoea, characterized by extremely frequent, shallow breathing, quite different from the kind of dyspnoea observed in bronchitis and in asthma; the rapidity of respiration ranges from twice to four times the frequency of health, that is, from about thirty to sixty per minute; and this increase in the number of the respiratory efforts is partly due to fever, partly to impurity of the blood and partly to the pain which prevents drawing a full breath. The sides of the nostrils are commonly in active movement at every inspiration.

3. The third prominent symptom is cough, generally frequent, hacking and constrained on account of the suffering which it causes. It is dry at first, but on the second or third day the patient commences to bring up at each paroxysm of cough, some of the peculiar, viscid material of exactly the color of rusty iron. This expectoration does not occur in young children, is often absent in secondary pneumonia and in the pneumonia of the aged. The fever usually attains its height on the second or third day.

4. The pulse is usually strong and full at the outset, but later on in the attack it becomes small and weak, partly as a result of the imperfect filling of the arteries from obstruction of the pulmonary circulation and partly from cardiac feebleness. The cheeks are flushed to a very marked degree and an eruption of little blisters, a variety of herpes, is sometimes

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present upon the lips, which are of a dusky hue. Prostration, feebleness, headache, restlessness and delirium at night are common. The tongue is dry and coated, the thirst is eager, but the appetite for food is lost and the bowels are costive.

5. In favorable cases, these symptoms which have been detailed gradually increase up to the fifth, sixth, or seventh day and may then rapidly subside, the temperature falling to the natural standard two or three days later, and the solidified portions of the lung clearing out occasionally with wonderful celerity. The cough and dyspnoea speedily abate, and the sputum becomes yellow and muco-purulent. When the malady ends fatally, death usually occurs about the end of the first or early in the second week, and results from failure of the action of the heart, or else from pulmonary embarrassment.

Treatment 1.—There is no doubt that the intense pain accompanying the onset of pneumonia can be promptly relieved by blood-letting; but since the tendency of the disease is toward death by debility and it is impossible to say in any given case how far over the pulmonary structure the inflammation will extend, we can never feel sure that the loss of the vital fluid abstracted will be safely borne by the patient. In very robust persons, in the prime of life, it is proper to bleed; because the chance of diminishing the violence of the attack thereby is at least equal to the danger of seriously decreasing the strength. In less vigorous individuals, leeching or cut-cupping, and in patients of feeble constitutions, dry-cupping, will generally afford considerable relief.

2. Large doses of quinine, even as much as twenty or twenty-five grains, may be given at the first onset, in the hope of cutting short the disease and later on for the purpose of reducing the fever, which in itself is a great cause of danger, as already explained. Opiates in the form of Dover's powder, the hypodermic injection of morphia, or of codeia in half-grain doses, when the latter medicine suits the patient, are of great service in diminishing suffering, procuring sleep and allaying cough.

3. Toward the latter part of a severe attack the chief treatment is that of nutrition and stimulation, and as there is often in this disease a great tolerance by the nervous system of alcohol, such as we see in typhoid fever, immense amounts of milk punch, or diluted brandy and whiskey, are sometimes consumed with apparent benefit. Alcoholic stimulants should never be given to the extent of producing symptoms of intoxication, but short of this point they are of great service in keeping up the action of the heart and thus preventing the fatal effect of cardiac failure.

4. Since the immediate cause of death in many examples of fatal pneumonia Is the over-distension of the right side of the heart, with consequent separation of fibrin in the partially stagnating blood constituting heart-clot, it is advisable to diminish this tendency to coagulation of the blood in the heart and the production of a thrombus by the administration of five grains of carbonate of ammonia every three or four hours, which, however, ought not to be continued for more than a day or two.

Diet.—During convalescence from inflammation of the lungs danger from relapse is not nearly so great as in many other maladies, such, for example, as diphtheria and hence free indulgence of the appetite for all wholesome food and out-door exercise, as soon as the strength permits, may be allowed.


Varieties.—The two varieties of emphysema are, first, the vesicular, in which the vesicles are distended and dilated, and the interlobular, in which the air has escaped from the air-cells in consequence of their rupture, and diffused itself through the connective tissue of the pulmonary substance. This condition is commonly the result of accidents leading to great straining in the respiratory muscles, as in the violent paroxysms of whooping-cough and of asthma, and men or animals who are the subjects of emphysema are popularly and very accurately described as "broken winded."

Symptoms.—The symptoms of emphysema are in direct proportion to the amount of lung-tissue affected, and consist of dyspnoea which resembles that of asthma and is unlike that of valvular disease of the heart in being especially marked during the effort at expiration. Cough is usually present, but is not attended with expectoration, unless the disease is complicated with chronic bronchitis, as is frequently the case. In bad cases of emphysema the interference with the aeration of the blood is so great that the complexion is dusky and the patient languid and dull.

Treatment.—The treatment of this disease is limited to palliating the symptoms as much as possible, and remedying the maladies, such as chronic bronchitis or asthma, with which it is frequently complicated. Anodynes, which appear urgently called for to relieve the pain and distress must be employed with caution, on account of the imperfect aeration of the blood, which is already an element of danger. Dry cupping between the shoulders is often of service and the use of quinine, iron, and strychnia, as directed in anemia, is beneficial by improving the general health. Change of residence to a warmer and more equable climate than that of the northern United States is probably the best remedy we can urge upon patients afflicted with emphysema.


Character.—Tubercular phthisis or true pulmonary consumption is that form in which the peculiar tubercular matter is deposited in the lungs in small masses or tubercles, varying in magnitude, but generally about the size of a mustard seed. Such tubercles become centres of irritation, inflammatory action and suppuration, or formation of abscess, and these processes end by destroying a smaller or larger spot of the lung-substance, and leave a cavity or vomica in the pulmonary structure.

Causes.—The disease is constitutional, apparently hereditary, and according to the researches of Dr. Koch, the celebrated Berlin miscroscopist, contagious, the whole malady being the result of development in the lung of a very minute bacterium, named by Dr. Koch the bacillus tuberculosis. In America it is usually developed between the time of puberty and the twenty-fifth year, and in nine cases out of ten seems to be primarily lighted up by a cold or some depression of the nervous system.

Early Indication.—Hemoptysis or spitting of blood, usually in small quantity and only serious as a symptom of very grave import, is often one of the earliest indications of pulmonary consumption.

Galloping Consumption.—Acute phthisis or galloping consumption is the most rapid form of this terrible disease, and has been known to prove fatal in the short space of six weeks. It usually commences with chills and fever of the hectic type. Cough, dyspnoea on very slight exertion and out of all proportion to the apparent amount of disease in the lungs, is almost a characteristic of the complaint. The expectoration soon becomes profuse, and is frequently tinged or streaked with blood. This blood is never mixed throughout the sputum so as to give it the color of rusty iron, which is so indicative of pneumonia. The pulse is frequent and feeble, the tongue red and furred, the appetite poor or absent entirely, and there is often a tendency to diarrhoea.

2. In the rapid progress of the disease there is, after a few weeks, great exhaustion, profuse sweating, speedy emaciation and restlessness, amounting in persons of nervous temperament to delirium. Acute phthisis coming on in this way is almost without exception fatal, but in rare cases there may be a decrease in the violence of the symptoms, and the patient enjoys a temporary improvement, only, however, to pass into the ordinary condition of chronic consumption.

Treatment.—The treatment of some of the very few cases which have ever been reported as cured was that of rest in bed, a liberal supply of fluid nutritious food and stimulants, frequent application of iced-cloths to the chest to subdue the fever, these being at once removed if there was any tendency to faintness thereby produced, hypodermic injections of atropia to check the sweating, and pills or powders containing two grains of quinine, a half grain of digitalis, and opium in amounts of from a quarter to half a grain, four, five or six times daily.


Symptoms 1.—The onset of chronic pulmonary consumption is generally gradual, and marked by one or more of the symptoms of progressive debility and by loss of flesh, chronic dyspepsia, diarrhoea, alterations in the voice, and in females suppression of the monthly periods. In more than half the cases spitting of blood occurs, and a cold or cough is apparently the starting-point in very many instances. A dull, aching pain just below the collar-bones in front or the shoulder-blades behind is very often complained of, even whilst the amount of tubercular deposit is small, and is probably due to little spots of pleuritic inflammation. Muscular pains in various parts of the frame are often present. The short, dry, hacking cough of early phthisis is usually referred to some irritation about the larynx or trachea, but is, in reality, due to irritation of the bronchial mucous membrane.

2. Weakness of the voice and hoarseness are very common, and a purplish mark upon the edges of the gums, where they come in contact with the teeth, is often observable, and is thought by some physicians to have considerable diagnostic value. In at least fifty per cent. of the patients spitting of blood appears early, and recurs at various intervals, giving the first positive evidence of the existence of consumption. Very rarely, however, is the expectoration of blood in the early stage of consumption directly dangerous to life.

3. Among the other symptoms loss of strength is one of the most constant. The patient soon finds that slight exertion, such as ascending a little hill, or even a short flight of stairs, causes fatigue, hurries the breathing and often gives rise to palpitation. The uterine functions in women are apt to be disturbed, and the liver becomes congested and tender. The tongue gets red and irritable, and little sores called apthae form upon its sides and on the mucous membrane of the fauces.

4. Hectic fever coming on toward evening and giving a deceptive appearance of the flush of health to the emaciated countenance develops. There is a total loss of appetite with great thirst, and the loss of flesh is almost visible from day to day. The hair grows thin and loses its attachment to the scalp. The debility is extreme and exhaustive night sweats make their appearance. In females there is a total cessation of the menses, which is a most discouraging evidence of failure in vital power. An unmanageable diarrhoea often sets in and conspires with the other causes of debility to utterly prostrate the unfortunate invalid. The lower limbs become very painful, and dropsical swelling of the feet and ankles appears, constituting what is vulgarly called the bloating consumption.

5. Toward the close, cough and abundant expectoration become, if possible, even more troublesome. Great nervous restlessness, cramps in the legs, pain about the loins, distress in passing water, utter prostration and the ever present difficulty of getting the breath, tend to render the last few nights of existence most agonizing.

Diagnosis of Consumption.—It is so important that the diagnosis of consumption should be made at the earliest possible period, when the chance of life by change of climate is greatest. After the disease is fully developed, and the abundant expectoration, great loss of flesh and strength, night sweats, and associated sore throat from laryngeal tuberculosis manifest themselves, there is often no room for doubt that consumption has developed, even without the aid of auscultation and percussion; but in the incipient stage just grounds for suspicion are furnished by the presence of slight hacking cough which has resisted the usual remedies, a little spitting of blood, provided the patient can be sure that it does not come from the gums or from the back part of the nose, and marked dyspeptic symptoms with loss of flesh and strength out of proportion to the length and apparent severity of the illness.

Treatment 1.—The treatment of consumption consists in the palliation of symptoms and the administration of tablespoonful doses, thrice daily, of cod-liver oil, the phosphates or hypophosphites of iron, lime, and the alkalies; the internal and external use of iodine, and last but not least, of persistent counter-irritation over the diseased spot in the lung, generally near its top and just below the collar-bone, with tartar emetic ointment. Nearly all the cases of recovery from well-defined phthisis, coming under the observation of the writer, have been apparently due in large measure, to this system of treatment.

2. In the second stage of consumption, that is, after the deposit of tubercular matter has begun to soften and before any large cavities have formed, the prospect of cure by this or any other treatment is diminished; but even from the third stage—that of the formation of large cavities and extensive destruction of lung-tissue—recoveries occasionally occur.

3. The palliative treatment of consumption, further consists in relieving the cough and pain in the chest by expectorants and anodynes, improving the appetite and strength by tonics and stimulants, controlling the diarrhoea with astringents and correcting the derangements of digestion with antacids and other anti-dyspeptic remedies.

4. Most patients afflicted with phthisis will find themselves for a time benefited by, first, a cough mixture composed of acetate of morphia, cyanide of potassium, syrup of squills, and syrup of wild cherry or syrup of tolu, as already suggested, used chiefly at night to promote sleep in the nocturnal hours and allow the expectoration necessary to relieve the lungs from their accumulated load of sputum to be carried on in the daytime; second, by a pill of two grains of quinine, half a grain of digitalis, and one-fortieth of a grain of strychnia, with the addition of half a grain of iron, should the condition of anema exist and there is no tendency to spitting of blood to forbid its employment; third, by a mixture of a teaspoonful of syrup of krameria, five grains of prepared chalk, twenty drops of compound spirit of lavender and ten of wine of opium, to check diarrhoea when that appears; and fourth, by powders containing five grains each of bismuth, soda, charcoal and pepsin, or ten of lacto-peptine, with wineglassful doses of the infusions of gentian or columbo, as may be found best adapted to the particular case as stomachics.

5. For patients with whom morphia or opium disagrees, codeia, lactucarium, chloral, bromide of potassium, or hyoscyamus may perhaps be substituted, and in some instances morphia, where illy borne alone, becomes quite acceptable to the stomach when associated with one one-hundredth of a grain of atropia, or with twenty grains of bromide of potassium.

6. When obstinate diarrhoea torments the invalid, the metallic astringents, such as half a grain of sulphate of copper, or one-quarter of a grain of nitrate of silver, thrice daily, are frequently useful, and occasionally a teaspoonful of powdered resin succeeds in controlling the intestinal disorder when all other remedies prove unavailing. The profuse and debilitating night sweats may be often checked by sponging with finely-powdered alum and whiskey, by full doses of quinine, or by hypodermic injections of the sulphate of atropia.

7. Seeing, however, that the prospect of curing consumption by medical treatment is so mournfully gloomy, it becomes doubly important to urge that every patient whose circumstances will admit should resort to a change of climate. And this migration ought to be made with scarcely a day's delay after some amply competent authority has determined by thorough examination the necessity of such a change in the colder seasons of the year.


This disease is an inflammation of the pleura, or delicate membrane which surrounds each lung.

Causes.—Pleurisy presents itself under two forms—the acute and the chronic. Its common cause is exposure to cold, but sometimes it arises from injury, as, for example, from the pleura being wounded by the jagged end of a broken rib; or, secondarily, adjacent inflammation, such as takes place around a nodule or tubercular deposit in consumption, or in the course of some other disease, for instance, Bright's disease or scarlet fever.

Symptoms 1.—The onset of acute pleurisy may be insidious, but generally, when arising from its usual cause, exposure to a very severe cold, it is rather sudden and marked by repeated chills. As soon as the patient reacts from these, the temperature begins to rise and thus furnishes a distinguishing symptom which often enables the complaint to be discriminated from pneumonia.

2. At the same time, or very soon after the rise in temperature, pain, cough and dyspnoea are observed. The pain is almost always referred to the affected side, a few inches below the nipple, and is sharp and darting, described as resembling a stab with a keen knife, especially on trying to take a deep inspiration or to cough. As a rule, the difficulty of breathing is slight and mainly due to the pain in the side and to the febrile excitement in the system. The cough is short, hacking, and accompanied with little or no expectoration; the pulse is quickened; the tongue is somewhat furred, the appetite impaired, but the thirst is increased, and the bowels are confined.

3. After a variable period, averaging, perhaps, between one and two weeks, the attack usually terminates in recovery, with or without a contraction of the wall of the chest on the affected side, according as the lung is able to expand after being compressed by the effused fluid; or the malady may end in the chronic form of pleurisy, or very rarely in the uncomplicated affection it may have a fatal result.

4. In chronic pleurisy the effused liquid remains in the pleural sac, without becoming absorbed. It is especially apt to become purulent in a short period in children, or in persons whose health is impaired from any cause. When this degeneration takes place there is always more or less febrile disturbance of a hectic type set up in the system generally. The skin of the affected side after a while becomes, over the seat of the effusion, reddened, tender, swollen and dropsical. The finger nails are often clubbed, as in consumption, and night-sweats are not infrequent. Cough is apt to be troublesome and may be accompanied by an expectoration of muco-pus, which in rare cases possesses a putrid odor.

Diagnosis.—The diagnosis of pleurisy without the aid of auscultation and percussion, must often be difficult, at least for the first few days of the attack, but it can sometimes be made from pneumonia by the lower grade of fever, the small amount of dyspnoea, and the total absence of rusty expectoration. It can be distinguished from bronchitis by the small amount of cough, and the sharpness of its pain, and from acute phthisis by the strength being but slightly diminished.

Treatment 1.—The treatment of pleurisy in the first stage, when acute pain is the most prominent symptom, is bleeding, leeching or cupping over the affected side, if the patient is robust and previously in good health. In persons of feeble constitution it is better to apply ten or twelve dry cups, and then use hot poultices with laudanum for the further relief of pain, than to deplete the system. If suited to the patient, hypodermic injections of morphia are of great service. After the second day free watery purgation by a tablespoonful of rochelle salts, epsom salts, or a bottle of citrate of magnesia, and a restriction of the amount of fluid taken into the stomach, are advisable, in order to limit the tendency of effusion into the pleural sac as far as possible. If the febrile movement runs very high, veratrum viride or aconite, in three- to five-drop doses of its tincture, may be given to reduce the pulse and heart's action, but this is rarely necessary.

2. In the second stage after effusion has occurred, the chief indication is to reduce the amount of this serous liquid as speedily as possible, and for such a purpose diuretics and saline purgatives or elaterium, in quantities of half a grain every three hours, or so as to cause abundant watery discharges, may be given; counter-irritation by iodine and small blisters being kept up over the diseased side of the thorax. If the liquid is effused in large amount and causes much interference with respiration, it may be necessary to draw it off by means of an aspirating apparatus.

Diet.—As the cure progresses tonics, good nourishing food and early exercise in the open air in suitable weather, are highly important.

Hydrothorax.—This is the name applied to that diseased condition where there is an accumulation of water or serous fluid in the cavity of the chest. It may be the result of pleuritic inflammation, but not unfrequently occurs in dropsy without inflammatory action. Sometimes it increases to an enormous amount, pressing on the lungs and displacing the heart, with such great interference to the respiration and circulation as to prove the immediate cause of death, unless removed by aspiration, or exhaling the breath through an opening in the pleura.

Pneumothorax.—This is the term applied to the morbid state in which air has entered and partly occupies the cavity of the pleura, compressing the lung in the same way though less forcibly than does a watery effusion. This accident sometimes occurs from the rupture of the vesicles of the lung through the pleural membrane into the cavity of the pleural sac. At other times it results from some injury to the chest, such as a gun-shot wound or the fracture of a rib. Where closure of the aperture by which this air found an entrance can be secured, it may be necessary, in order to relieve the oppression of breathing, to pump out the air by means of the aspirating apparatus.

Emphysema.—This is the accumulation of air under the skin in the subcutaneous connective tissue; it is a curious result occasionally met with from wounds of the pleura, such as those produced by compound fractures of the ribs and other causes. This distension of the integument with air may progress until all semblance of humanity is lost and yet entire recovery takes place. It may almost always be prevented by proper attention to the primary injury.

Other Diseases of the Pleura.—The membrane of the pleura may be affected with cancer, simple tumors, tubercle and parasitic growths, but these are very uncommon, except as secondary manifestation of extensive disease of the same kind in other portions of the body, in which cases the latter are consequently the proper subjects of whatever treatment becomes needful.

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