RE-AGENTS
MEDICINAL NAPHTHA. NON MEDICINAL.
Dissolves half asmuch Readily dissolves, again, and more
readily.
lodiiie,
Essential Oils, Fixed Oils (Boiled
on)
Strong Sulph. Acid,
Converted in choco- CFocolate-brown li-
late brown liquid, quid.
Sol. Oxal. Ammon,
Sol. Nit. Barytes, Combustion,
Wbite cloud, Wbite cloud.
Aqueous residue. No residue.
Tbe most ready test is, tberefore, to be found in litmus paper, wbicb is reddened by tbe non-medicinal, but is unaffected by tbe médicinal. Tbe otber différences are ratber in degree tban kind — proving tbat tbe non-medicinal specimen, wbicb I bad previously found to act injuriously, is a stronger spirit, and an acid préparation, wbilst tbe médicinal is strictly neutral.
Ejfects of Médicinal Naphtha on Tuhercle. — Dr. Hasting^s experiments sbow tbe solubility of tubercle in napbtba. In my post-mortem examinations of fatal cases, I cannot say tbat I bave observed any peculiar appearances of diseased parts. But tben, among tbe patients wbo bave been taking napbtba, none bave died, except wbere tbe changes of pbtbisis bad been very extensive and very far advauced — cases, in fact, wbicb did not admit of any curative influence being exerted.
Tbe reviewer of Dr. Hasting’s work in tbe Provincial Medical Journal (Dec. 23rd, 1843,) states tbat be bad an opportunity of examining tbe lungs, post-mortem, of a patient wbo bad been taking tbe pyro-acetic spirit two montbs previous to bis deatb. “ Tbe medicine was not administered witb tbe^expectation of its effecting a cure, tbe case being perfectly bopeless from tbe period we first saw tbe patient. Tbe lungs presented a very peculiar appearance. Tbere was a large cavern in tbe upper lobe of tbe left lung. Botb lungs were studded witb tubercles of a
small size, varying from that of a filbert to that of a smalî pea, These presented a remarkably dry appearance, closely resembling tbose found in the mesenteric glands, which rarely suppurate, and of that character which tubercular matter assumes when in a state of transition from a crude to a cretaceous condition. None of them where in the slightest degree softened, and they did not seem as if they would ever suppurate. The large cavern in the left lung did not présent any unusual character.” — page 332.
From the effects of the médicinal naphtha on the cases of tubercular accumulation (which I shall presently narrate), I am led to believe that the majority are absorbed, and the remainder brought into a condition which rcsists the usual changes of softening and suppuration — the irritation and inflammation of the surrounding tissues being at the same time relieved.
As regards the real nature of the médicinal naphtha, I believe that it must be regarded as pyroxylic spirit; being one of the products of the destructive distillation of wood. Pyroacetic spirit obtained as a product from the destructive distillation of acetic acid, or of the acétates of lime or copper is a much more expensive substance (seven or eight times as expensive, — the pyro-acetic acid and being about 2s. the ^i, médicinal naphtha 17s. the gallon). Hence, from the difîerence of price alone, it is obvions that it cannot be the pyro-acetic spirit. Pyroxylic and pyro-acetic spirits do not differ essentially in their physical properties, and chemical peculiarities ; the atomic constitution of pyro-acetic spirit being Cs Hs O., and that of pyroxylic spirit C2 Hs O, Aq. Dr. Hastings informs me that he has used the spirit really obtained by the destructive distillation of an ' acetate, and has found it eflBcacious, but that he orders as a general rule the cheaper spirit which is obtained from wood.
CIIAPTER III.
VALUE OE MEDICINAL NAPHTHA IN THE EAIILY STAGES OF PATHISIS PULMONALIS.
I wiLL now pass on to cousicler the facts I hâve collected coiicerning tlie value of the médicinal naphtlia in cases of genuine tubercular phthisis; premising that I hâve endeavoured to compress the details into as narrow a compass as will be sufficient to show the nature of the disease, and the operation of the remedy, as my object is not to illustrate the varieties of consumption apart from the considération of the influence of naphtha on the varions physical signs, symptoms., and stages, Scc.
I will commence with some cases in the earlier stages of tubercular déposition. It will be seen that these are the cases in which the bénéficiai and curative influence of the médicinal naphtha is most prompt and decided. In almost every case the morbid general symptoms, and the physical signs hâve disappeared from its employaient in a short time, and the patients, considering themselves perfectly cured, hâve ceased attending. In one or two instances, where the medicine has been left off prematurely (for it is difficult to persuade the poor to take medicine the moment they feel themselves nearly well), there has been a relapse, and it has been necessary to re-commence the treatment which has again produced its beneflcial elfects.
The physical signs in these cases will be found to hâve chiefly been more or less flattening of the upper and anterior part of the chest, from a diminution of the antero-posterior diameter^ aflecting most commonly the right side alone, then both sides, and less commonly the left side alone ; diminished respiratory play of the affected portion of the chest ; more or less dulness and résistance on percussion of the sternal end of the clavicle, and of the sub-clavicular région (especially at a little distance from the sternum) of the afifected side ; increased résonance of the voice and heart sounds over the dull portions ; alteration of the
normal characters and rhythm of respiration, viz. — loudness, harshness, and sometimes dryness of both the inspiratory and expiratory murmurs with prolongation of the expiratory — sometimes weakness or suppression of the respiratory murmurs — these states passing into the slight diflfused broncophony and bronchial breathing, which increases with the increase of the condensation, till the bronchial characters are more intense, and the voice is transmitted with the characters to which Laennec applied the name of imperfect pectoriloquy. These patients suffer from hectic fever in different degrees, pain in one or both shoulders, cough, generally hæmoptysis, and difficulty or rather shortness of breathing (breathlessness) with mucus expectoration, They hâve generally near relatives, who are suffering or who hâve died of consumption, (especially if they hâve attended much on their sick friends), and are often the children of phthisical parents.
Case 1 , Tubercular déposition in the upper and anterior portion of the superior lobe of the right lung. Complété recovery from the influence of Naphtha. — Henry Bonnar, ætat, 23, admitted under my care, at the Blenheini-street Infirmary, on the 2nd of March^ 1844, résides at 50, Salisbury-street, Lisson-grove, Complains of indisposition, hectic symptoms, pain behind the centre of the sternum, and in the right shoulder, with slight cough, especially in the early moming, with expectoration of transparent mucus, These symptoms hâve corne on gradually during the last two or three months, His father is at présent (March) under my care, in an advanced stage of phthisis,
Physical signs. — Slight dulness of the sternal end of the clavicle, and of the upper and sternal portion of the sub-clavicnlar région of the right side on percussion ; morhidly increased résonance of the voice and heart sounds ; murmurs harsh, expiration prolonged,
Ordered Naphthæ Medic, v ex cyatho aquæ ter die,
March 9th. Slightly improved, To continue as before, March 30th, Chest symptoms relieved ; general health much improved, To continue,
April 6th, Complains of much general indisposition, and pain in the right shoulder, The dulness on percussion is sensibly
diminished since Üie last examination ; murmurs less harsh ; voice highly résonant.
To take an ounce three times a-day of the following mixture : — Çt. Inf. Gent. Comp. 3viij, Naph. Med. 5üj- M., to apply a blister over the sternum.
April 13th. General and local symptoms improved. To continue, and to produce and keep up an éruption over the front of the chest with the Ung. Autim. Pot. Tart.
April 20th. Improvement continues.
May 4th. Has neither pain nor uneasiness about the chest or shoulders ; cough and shortness of breath greatly relieved ; little or no expectoration ; still continues to be fatigued, and to perspire freely from slight causes, and is subject to attacks of faintness. The dulness has entirely disappeared ; the murmurs are soft and normal, but the voice is still slightly more résonant over the right sub-clavicular région than over the left.
May 11. Feels perfectly well, and has continued in the enjoyment of perfect health up tothe présent time (Sept. 1844.)
Case 2. Tubercular consolidation of the superior lobe of the right lung ; complété cure under the employment of naphtha. — Thomas Hills, ætat. 18, residing at 19, Riding-house-lane. was admitted under my care at the Blenheim-street Infirmary, on the 15th of January, 1844. He was seized with hœmoptysis about five months previously, wliilst occupying himself in bis mastePs stable, bringing up about “ half a tea-cup full ” of florid blood, since which period he has suffered from cough^ attended by expectoration streaked with blood, apnæa, loss of health, émaciation, quickness of the puise, and night sweats.
Physical signs. — Slight flattening of the antero-superior part of the right side of the chest, with diminished respiratory motion : dulness on percussion of the sternal end of the clavicle, and the superior portions of the sub-clavicular région. Respiratory murmurs harsh and loud ; expiratory prolonged. Increased résonance of the voice and heart sounds over the dull portions.
Was ordered, Naph. Med. xv ter. die., in half a wineglass of water.
January 31st. Hectic cough, and shortness of breath much relieved ; expectoration diminished, and no longer streaked with
blood ; feels much better, Dulness on percussion diminished ; cxpiratory murmur less harsh and prolonged tlian previously ; otlier signs as before.
February 7th. Com plains of pain in the epigastric région ; cough mucli less severe ; expectoration diminisbed ; breath mucli casier. General liealtli very mucli improved. Dulness bas nearly disappeared ; murmurs nearly normal.
February 14. States liimself to be perfectly well. Dulness liad disappeared ; murmurs normal ; voice equally résonant on both sides.
Case 3. Tubercular consolidation of the upper and anterior portion of the superior lobe of the right lung ; slight anasarca ; cure by Naphtha, — Mrs. Hogan, ætat. 33, was admitted under my care on tbe 17th of February, 1844. Slie states her résidence to be at No. 16, King-street, Drury-lane. The présent symptoms, of which she complains, are cough, which is not severe except in the early morning, expectoration, shortness of breath, and slight anasarca; the lower extremities, especially the feet and ancles, are ædematous towards night, and the face and eye-lids in the morning. The urine is voided in diminished quantity, is high coloured, free from albumen, and deposits the lithates on cooüng. Countenance pale, anxious, and sallow ; puise soft and feeble.
Physical signs. — The right upper and anterior surface of the chest is slightly fiattened. The sternal end of the right clavicle and the right sub-clavicular région are duller, and offer more résistance to the percussing fingers than the similar régions on the left side. E-espiratory murmurs harsh, loud, and slightly bronchial; expiratory murmur is, in addition, much prolonged. Increased résonance of the voice and heart sounds. Eespiratory murmurs on the left side strictly healthy, but somewhat louder and fidler than usual — id est exaggerated or puerile.
History. — About eight months since she sufifered severely from menorrhagia and leucorrhœa, and although the menorrhagia was suppressed in a fevv week s, it left her in a very reduced and debilitated condition. She dates her présent constitutional and local aliments to this illness. Her cough commenced about eight weeks since, and lias been attended by
slight hæmoptysis (coughing up one or two tea-spoonfuls of briglit florid blood) on three or four occasions during the interval between its commencement and the présent time, (February, 1844.) She first observed the ædema about a fortnight ago. None of lier relatives^ as far as she knows, died of consomption.
She was ordered two table-spoonsfuls three times a-day of the followingmixture: — Ç,Naphthæ Med.5ij,Inf.Gent.Comp. ^viij, M.
February 24tb. Cough more troublesome ; shortness of breath relieved ; ædema diminished ; health improved.
March 2nd. Cough much less troublesome^ expeetoration very trifling ; bas nearly lost her shortness of breath ; ædema has completely disappeared. Dulness on percussion has disappeared ; murmurs nearly normal; voice scarcely more résonant on one side than the other.
March 9th. States herself to be quite well. Auscultatory phenomena as before — some slight harshness and prolongation of the expiratory murmur remaining. Has not re-applied since.
Case 4. Tubercular consolidation of the upper lobe of tae right lung. Cure by Naphtha. — J. Jones, ætat. 18, residing at 20, New-street, was admitted as my patient at the Blenheim-street Infirmary, on the 17th of February, 1844. Complains of much breathlessness, and cough chiefly at night and in the early morning, attended with but scanty expectoration of mucus. Also of general indisposition, and hectic perspirations. His father is at présent in a very advanced stage of phthisis. The présent symptoms commenced three months since with trifling cough in the morning.
Physical signs. — The upper and anterior part of the right side of the ehest renders a shorter and duller sound on precussion than the left, especially marked over the sternal end of the clavicle, and in the sub-clavicular région about an inch from the line of the sternum. Respiratory murmurs harsh and loud over the dull portions ; expiratory prolonged. Voice and heart sounds unduly résonant.
He was ordered two table spooiisful of the following mixture three times a-day : — R Mixt. Expect. (contains vin. Ipecac. and Træ Camph. Co.) Jviij, Naphthæ Med. 5ij, M.
February 24th. His Health is greatly improved, and he feels much better in every respect. His breathing is much freer ; cough and quantity of sputa diminished. To continue.
Marcb 2nd. The improvement in the general and local syraptoms hâve continued in the same ratio. The dulness has disappeared on percussion, and the murmurs normal with the exception of slight prolongation of the expiratory.
March 9th. Feels quite well. Murmurs normal; voice only very slightly more résonant than over the same régions on the left side.
Continued quite well in June.
Case 5. Slight tubercular consolidation of the superior lobe of the right lung. Great relief from Naphtha ; omission of the medicine on every improvement; abscesses by the side of the vagina. — Mary Ann Sly, ætat. 26, residing at 62, Newmanstreet, Oxford-street, was admitted under my care at the Blenheim-street Infirmary on the 17th of April, 1844. She has suffered from cough occasionally during the last two years, which commenced gradually, and has been accompanied on several occasions by the expectoration of small quantifies of bright scarlet blood. Her father died of consumption, and several of her immédiate relatives are subject to ‘^coughs.”
At présent she coughs chiefly in the early morning, and expectorâtes a thick, tenacious mucus, in which she has often noticed small solid bodies of a whitish colour. Nine months ago she gave birth to an infant rather prematurely, and shortly afterwards an abscess formed by the side of the vagina, and burst between it and the rectum. Since then she has had two similar attacks, and has suffered continually in the vagina, and about the anus. She complains also of shortness of breath, pain in the right shoulder, and of constitution al dépréssion, and night sweats, &c.
On making an examination two fistulous passages were discovered on either side of the anus, about half an inch in depth — but neither passed deeper than the sphincter — also superficial ulcération about the entrance of the vagina, and its posterior Wall. I was assisted in the examination by my colleague, Mr. Storks.
She was ordered fifteen minims of Naphtha Med. in a half wine-glassful of water three times a-day ; also a solution of the nitrate of silver (grains ij to the ounce of water) as an injection into the vagina.
Physical signs. — Shght dulness on percussion of the sternal end of the right clavicle, and upper part of the sub-claAdcular région; harshness of the respiratory murmurs, and prolongation of the expiratory. Increased résonance of the voice and heart sounds over the dull portions.
May Ist. Catamenia (which were previously suppressed) hâve recurred very profusely since she commenced the use of Naphtha. Feels slightly better; breath and cough relieved.
May 24th. An abscess lias burst into the vagina, preceded and followed by leucorrhæa. Catamenia hâve again returned, and with much relief to the local symptoms. Feels considerably better ; lier breath and cough are very much relieved, and she lias quite lost the pain in her right shoulder. Has been free for some time from the evening chill, followed by beat, and nocturnal perspiration, which she suffered from a few weeks back. The dulness on percussion has nearly disappeared, and the voice, &c., though still more résonant on the right than the left side, are less so than on the previous examination. To continue.
September llth. Having felt herself nearly well, she has discontinued the medicine for some months. Again, she is not so well from some return of the cough, shortness of breath, &c. Complains of a return of pain also in the point of the right shoulder.
Right sub-clavicular région flattened ; respiratory motions slightly less free than on the left side : some dulness on percussion over the clavicle and the sub-clavicular région. Voice unduly résonant, and heart- sounds transmitted with morbid clearness. Respiratory sounds harsh ; expiratory murmur prolonged. To return to the Naphtha mixture. — Believes herself to be again prégnant.
Case 6. Tubercular Consolidation of the superior portions of the upper lobes of both lungs. Cure by Naphtha. Jane Comber, ætat. 18, residing at 25, Little Portland-street,
Soho, was admitted under my carc at the Blenheim-street Infirmary on the 17th of April, 1844'. Has had cough, difficulty of breathing, mucus expectoration, and hectic symptoms for some months ; these symptoms having first commenced about six months since. In the commencement of her illness she was seized with a sense of oppression, and of load at the epigastrium, with sickness, and vomited about a tea-cupful of dark-colourcd blood, and had two attacks of a similar nature folio wing each other at short inter vais. She is of a phthisical family, several near relatives having died of phthisis. The catamenia are suppressed, and hâve been so since the commencement of her illness. She is very fair, and présents a very exsanguine appearance.
Physical signs. — Considérable dulness and résistance on percussion of the sternal ends of the cl avides, and the subclavicular régions of both sides ; bronchial breathing and broncophony ; heart-sounds transmitted with morbid clearness.
She was ordered xv nt of Naphtha Med. three times a-day in half a glassful of water ; Emplast. Cantharid. Sterno.
April 23rd. Has felt much better ever since she commenced the drops ; has much more freedom of breathing : cough less, expectoration diminished ; pain in the shoulders has disappeared.
May Ist. The catamenia bave recurred since last date, and although her breath and cough are better, still she does not feel so well generally. To continue drops, and to rub the Unguent. Antim. Pot. Tart. in over the front of the chest.
May 24th. Has been in the country during the last three weeks, and has returned, feeling much better.
June 5th. Has continued to improve in the same ratio in ail respects. The dulness on percussion has nearly disappeared ; respiratory murmurs normal, but loud ; voice and heart sounds much less résonant than on previous examination.
June 12th. Still improving. To continue.
September 4th. Has passed the last two or three months in the country, and now feels quite well, only has a very slight cough occasionally. Dulness on percussion has entirely disappeared ; murmurs normal ; résonance of voice healthy.
Case 7. Tuhercular consolidation of the upper part of the
superior lobes of both lungs, especially of the right side. Cure by Naphtha. Louisa Willett, ætat 22, residmg at No. 422, Oxford-street, was admitted on the 27th of Mardi, 1844. She coœplaiiis of cough, shortness of breath, expeetoratioii of transparent mueus, and pain in the upper part of the chest by both shoulders. These symptoms commenced about six months since. Her mother is at présent ill with consumption ; other friends healthy. Face florid ; slight émaciation, puise 100, and feeble; sutfers from hectic symptoms.
She was directed the Emplastrum Canth to the front of the chest, and five grains of the Pii. Conii Comp. twice a-day.
April 13th. Physical signs. — Sternal ends of both clavicles and the sub-clavicular régions dull on percussion, especially on the right side ; respiratory murmurs harsh and loud, and the expiratory prolonged on the right side anteriorily, with diffused broncophony, and heart-sounds transmitted with unnatural clearness. Feebleness of the respiratory murmurs on the left side anteriorily ; sibilant rhoncus of the left scapular région.
Ordered Emp. Canth. to the front of the chest ; Naphtha Med. XV u]^. three times a-day ex aquâ.
April 17th. Chest symptoms improved, but complains of head-ache, from which she has suffered occasionally for some years.
April 20th. Head-ache continues ; health improved ; cough and breath better. Emp. Canth. Nuchæ. To continue.
April 27th. Cough very troublesome; head-ache better; pain in the chest ; bowels confined. Unguent. Antim, Pot Tart. to the front of the chest ; Pulv. Jalapæ Com. 9j, p. r n.
May Ist. Symptoms continue as before ; but complains of uterine irritation, and great nervous excitability. To continue ; also five grains of Compound Galbanum pill twice a-day.
May 8th. Feels better in ail respects ; head-ache less, but complains of beat of head and pulsation ; countenance flushed. Four ounces of blood to be taken from the nucha by cupping. To continue, drops, &c.
May 15th. Head less troublesome ; less pain in the shoulders ; breath much casier ; cough troublesome. Less dulness on percussion ; respiratory murmurs nearly normal ;
voice slightly more résonant on the right than the left side. To add one minim of Hydro-cyanic acid (Scheele’s strength) to tlie Naplitha.
May 18th. Cough less troublesome ; feels generally much better ; breatbing difficult only on occasions.
May 25tb. Cbest symptoms continue to improve; more pain in tbe bead. To continue ; also Cucurbitulæ Crueiit. Nuebæ. ad. 5iv. Pii. Coloc. Comp. x grs. (in two pills) to be taken occasionally.
June Ist. Some improvement.
June 8tb. Cbest symptoms better; bead-acbe continues. Sounds on percussion nearly normal, on tbe rigbt side alone being sligbtly duller tban natural, and tban tbe left side, wben tbe cbest is fiUed at tbe end of inspiration. Inspiratory murmur somewbat loud during ordinary breatbing ; expiratory relatively normal during ordinary breatbing, but prolonged after a deep inspiration ; voice and beart sounds sbgbtly more résonant tban natural on tbe rigbt side.
June 12tb. Complains mucb of beadacbe, and does not feel so well. A seton to be placed in tbe back of the neck. 22nd. Cbest symptoms nearly well ; beadacbe continues. Under my colleague, Mr. Stork^s, care for diseased tbumb (tbe left) wbich came on from a slight burn, and bas evidently given rise to diseased bone. Auscultatory pbenomena as before; viz., prolonged expiratory murmur after a forced inspiration, with slight dulness on percussion. To continue.
29th. Not quite so well ; to bave eigbt minims of the Liq. Opii. Sedit. added to each dose of tbe drops. July 3rd. Headache very bad ; seton bas been removed from the inflamed state of the back of the neck. To continue the drops, and to take Quinæ Disulph j grn., Hydrag. e Cretâ iij grs Omni Nocte. also Pulv. Jalapæ Comp. 3i. p. r. n. 17th. Cbest symptoms nearly well ; beadacbe continues ; tbumb exceedingly bad. To continue. 27th. Respiratory murmurs on tbe right side are now perfectly normal during ordinary breatbing ; expiratory very sligbtly prolonged after forced inspiration ; voice sounds alike on both sides ; no dulness on percussion.
Aug. 17th. Cbest symptoms quite well ; beadacbe mucb
better ; sounds on percussion alike on both sides, also voice and heart sounds; murmurs perfectly normal. Tliumb continues very b ad. Going to tlie Margate Infirmary to-morrow.
Remarks. In selecting the seven cases I hâve here narrated of phthisis in its early stages, I hâve rejected every case in which I hâve exhibited the médicinal naphtha, where the slightest doubt could be entertained, by even the most prejudiced person, of the nature of the affection. I hâve used the remedy, however, in a still earlier stage of the disease, with even more rapid and raarked success. In my own mind I had no douht of the phthisical nature of the cases to which I allude, but as a doubt might hâve been raised in the minds of others, and the diseases were entered in my own books as phthisis ? I deemed it best entirely to omit their considération. I shall mention, however, every case of undoubted tubercular phthisis, whether favourable or unfavourable to the employment of naphtha.
Of these seven cases it will be seen that the disease was confined to the superior lobe of the right lung in five, and aflfected the superior lobe of both lungs in two cases only — tue disease apparently commencing and being most advanced and marked in the right lung in every instance. In every case also on the right side, the respiratory murmur was harsh and loud, and the expiratory not only much louder and harsher than natural, but also prolonged in a marked degree. In the two cases which also aflfected the left as well as the right lung, the respiratory murmurs were very faint on the left side in one instance, bronchial in the other.
In healthy chests a différence has been ascertained frequently in the manner in which respiration is accomplished under the two clavicles. Dr. Gerhard of Philadelphia, in his work on the “ Diagnosis of Diseases of the Chest,” States that lie has known for some years the remarkable fact, that the respiration is always blowing at the apex of the right lung, and not at the left. He attributes this peculiarity to three circumstances. — “ Ist. The vicinity of the bronchi to the trachea ; 3nd. the straightness of their course ; 3rd. their greater width.” In order to ascertain with accuracy the characters of this différence, Louis submitted to very careful examinations twenty-two young females from 15 to 20, who
îiadneverexperienccclthc symptoms of any affection of thethoracic organs. In ail, witli the exception of tAvo cases, the inspiratory murmur was gentle and soft under botli clavicles, and to the same amount under each. One of the exceptional cases was tliin in person, aged 20, in whom inspiration was less soft, and stronger than in the natural state under the right clavicle. The other was that of an equally young female, in whom the sound of inspiration was stronger and fuller under the left than the right clavicle, The sound of expiration was nearly inaudible under the left clavicle in the raajority of cases — thirteen times out of twenty-two ; whcreas the contrary was the case on the right side, where the sound of expiration was inappréciable in five cases only. In the others expiration was distinctly audible, and sometimes very much prolonged. This sound posteriorily was inaudible on the left side in fourteen cases ; it was only five times wanting on the right side ; and in cases where expiration was audible on both sides, this was more marked and prolonged, sometimes to a very considérable degree, on the right than the left side. In one young girl, besides being prolonged under the right clavicle, expiration was harsh, and as it Avere bronchial in that situation.
Louis infers from these experiments “that slightly prolonged expiration at the upper part of the right side of the chest is, considered in itself, of little value as a diagnostic sign of tubercles ; and that it is much more significant on the left”
In these twenty-two subjects also Louis found marked résonance of the voice under the right clavicle ten times — in four to a considérable amount ; whereas it existed in one case only on the left side (and here to a slight amount only) in a thin female of 24 years of âge. Posteriorily, on the left side, résonance of the voice existed to a very shght amount in this woman only at the apex of the lung j whereas it existed on the right side in the corresponding situation, and with much greater intensity in eight individuals, in whom the expiration was prolonged. Hence it follows that slight résonance of the voice is not a phenomenon of equal diagnostic value at the right and left apexes of the chest. It is likewise inferrible that it always possesses a certain share
t)f importance on theleft side, more especially if it be not présent on the riglit ; wbereas tlie contrary is the case witli tlie latter side.
In ail tbe cases I bave hitherto uarrated, in wbich naphtlia was given, prolonged expiration was by no means an isolated phenoinenon ; it was invariably attended by barshness of botb inspiratory and expb’atory murmurs. Dr. Walsbe (Diagnosis of Diseases of tbe Lungs, page 194) states tbat be bas never y et met witb any expiratory murmur of notably increased duration unattended by a change of spécial character, and tberefore cannot but strongly doubt tbe eorrectness of tbose vvriters — for example M. M. Bartb and Roger — wbo describe prolonged expiration as an isolated pbenomenon. He admits, bowever, tbat in some cases tbe increase of duration is mucb more marked, and tberefore more important in diagnosis. Dr. Walsbe also very justly remarks tbat tbe value of tbe prolonged expiratory sound bas been exaggerated as a diagnostic sign of tubercles. Wbat may appear in one person (in comparison witb anotber) as prolonged expiration, is really in bim a natural state ; many eonfound witb it tbe pbaryngeal expiratory sound, and few seem to be aware tbat under wbatever circumstances an obstruetion exists to tbe free circulation of air in tbe lungs, tbe expiration will be prolonged.
Prolonged expiration may witb care be readily distinguisbed from pbaryngeal murmurs. No interval of time exists between tbe inspiratory and expiratory murmurs, tbe termination of tbe former being lost in tbe eommeneement of tbe latter Tbe oecurrence of a distinct interval of time between inspiration and expiration, and tbe sensation of distant production, wbicb is a feature of pbaryngeal murmurs, are suffieient to distinguisb tbem from true pulmonary sounds. Tbe inexperienced may avoid error by directing tbe patient to close bis moutb if previously open, or open it if closed ; true pulmonary sounds will be unaffected by tbe ebauge, but if in tbe pharynx tbey will be altered in character.
Dulness on percussion existed in each of the seven cases witb more or less increase in tbe natural résistance of tbe percussed parts. This was ascertained by eareful comparative pereussion of different parts of the same side of tbe chest, and of similar parts of tbe two sides.
Slight flattening of the antero-supcrior parts of thc affectcd sidc of the chest, from diminution of the antero-posterior diameter, oecurred in three instances, (cases of Hills, Hogan, and Sly), and was attended by a perceptible diminution of the respiratory movements in Hills and Sly, when the fingers were placcd on corresponding portions of the two sides of the chest and the patient breathed deeply. The time at which this flattening occurs is by no means always uniform, being sometimes much earlier in one case than another. In the case of Hills, the earliest symptom of any chest affection was hæmoptysis, which oecurred five months previous to my first seeing him. In the case of Hogan, she had been ill eight months, but had experienced cough only eight weeks. No flattening was présent, at the end of May, in the case of Sly, but having omitted to continue her medicine from June to September, her disease, which had been previously relieved but not cured, advanced in the interval, and some decided flattening was présent when she again came under my care. In this last instance only was there any complaint of pain in the shoulder, whilst this symptom was equally urgent in ail the other cases, with one exception, where flattening of the chest did not exist ; hence if this pain in the shoulder be regarded as an indication of pleuritic inflammation, and its absence as a presumption that no such complication at that time existed, there would seem to be no necessary connexion between the flattening which so commonly occurs in an early stage, and the existence of plastic exudation which has bound down, and contracted the affected portion of lung.
In Mr. Sibson’s interesting paper in the I2th vol. of the “ Trans. of the Provincial Medical and Surgical Association ” he asks the question, Why does the bulk of the affected portion of lung dimiuish in phthisis before the stage of softening and évacuation of the morbid structiire?” This gentleman believes that the non-expansion of the unafifected air-cells that compass those diseased is the cause of the contraction of the diseased portion of lung, when it has not advanced to softening and expulsion. The inflamed or distended condition of the lung tissue would be stretched and irritated by the inspiratory distension of the air-cells.
Fournct has, ho'vvever, invariably found tlic apex of the lung invested with thick and dense false membrane in cases of dépréssion, and lie attributes the cliief sliare in its production to the contraction of the plastic matter forming this membrane. Dr. Walshe, also, lias ne ver seen notable dépréssion (exclusively of cases of cavity) unless wheii there was pleural false membrane in considérable quantity présent, and believes that both the atrophy of the lung and contraction of plastic matter exuded into its substance hâve their influence in producing the dépréssion, Not having had- any opportunity of examining, post-mortem, the chest of any individual, at so early a period as those cases I hâve narrated, in which I had remarked flattening during life, I am unable to décidé the point from my own expérience. In more advanced disease, and at a much later stage, however, I believe the statement to be correct.
In most of the casés, where disease was confined to one lung, the respiration in the corresponding portions of the opposite healthy organ, although strictly normal in character, lias been somewhat eæaggerated or puerile. Mr. Sibson imagines that the fainter forms of pleuritic friction sounds are often mistaken for puerile respiration. This I should be inclined to doubt very much. “ It is,” he remarks, “ usually over the most healthy (the least diseased), the most expanded, and expanding, and the most résonant lung, that the friction sound — commonly taken for puerile respiration — is heard ; it is, too, on the least diseased side that the crepitating noise is generally noticed.^’ — page 498. He describes it as of a hissing or rushing, slightly interrupted character, resembling puerile respiration. It is louder during inspiration than expiration, but is usually présent during expiration, and is audible when the patient whispers — occasionally giving a peculiar, fine, buzzing accompaniment to the vocal vibrations.
As we hâve seen the voice may be slightly more résonant on the right side of the chest superiorly in a perfectly healthy condition of the lungs, than on the left. In every case the voice and heart-sounds were undnîy résonant, much more so than they ever occur in a state of health. Undue résonance of the heart sounds on the right side is, taken with other signs, of consider-
able value, inasrauch as it uever occurs except the portion of lung corresponcling to it be in a state of unnatural solidification.
Hamoptysis occurred in tlic cases of Hills, Hogau, and Slj' — more or Icss scarlet blood, in a pure state, being couglicd up, whilst liæmatamesis was an early symptom in tlie case of Comber. The catamenia were suppressed in botli Sly and Comber at tlie time of tlie bæmorrliagc. Plæmoptysis was tlie earliest symptom in Hills, a very early one in Hogan, also an eai'ly one in Sly. The case of Comber (althougli slie bclievcd herself to bave vomited tlie blood, and it was dark-coloured) raay bave been bæmoptysis, since Louis states that the blood voided by bæmoptysis is sometimes blackisb and coagulated, and accompanied witb contraction of the diapbragm, whereby the patients are led to suppose tbey bave vomited the fluid disebarged.
Louis’ expcrience Icads bim to believe tbat genuine bæmoptysis scarcely, if ever, occurs, uulcss tubercular disease bc présent, except in indmduals wbo liave rcceivcd somc severe contusion of the cbest, or in women wbose catamenia bave been suddenly suppressed, and be is “ of opinion that bæmoptysis, if it be somewhat severe, and bave not occurred under the exceptional circumstances alluded to, dénotés witb infinité probability, no matter wbat bave been the period of its occurrence, the actual presence of some tubercles in the lungs. I do not say tbat it does so witb certainty, for several cases, of the correct observation of whicb no doubt can be entertained, appear to constitute fortunate exceptions to the general rule.” — (Walsbe’s Translation, page 168, 2nd édition). Hæmoptysis is not an invariable symptom of tubercular déposition in the lung, but an eæceedinylg common or usual symptom of sucb change, and one whicb very rarely occurs from other diseases.
The catamenia were suppressed in two qut of the tbree cases occurring in females, whicb I bave described ; in both the fonction was restored, and at first somewhat profusely, from the influence of napbtha. I attribute this to the bénéficiai influence of the remedy on the general bealth, and not to any spécifie influence of the napbtha on the utérus — altbougb I bave not tried the remedy in any case of simple amenorrbæa.
The peculiar pain in one or both shoulders vvliich phthisical patients so commonly sniïer from, occurred in four ont of the seven cases. I bave found that wlienever the tuberciilar disease is sufficiently advanced (especially when softening of the tubercular masses bas or is taking place) that percussion, practiced over the diseased portions, generally gives rise to a sense of irritation and uneasiness, with a disposition to cough, and sometimes actual pain.
Ail the cases, with the exception of Hills and Hogan, were of phthisical familles. One or both parents were phthisical in Bonnar, Jones, Sly, and Willett, besides having other near relatives phthisical. Neither parent was phthisical, ouly near relatives, in the case of Comber. The father was phthisical in three of the four cases, the mother in one only. Hills and Hogan spoke doubtfully, they had lost many near relatives, but did not know whether they died of consumption or not.
I bave several times diagnosed a very early stage of tubercular phthisis (where the progress of the case has shewn its accm’acy) from hæmoptysis, slight cough withont expectoration, or very slight mucus sputa, hectic, shortness of breath, &c., occuring in an individual of a phthisical family, with some increased résonance of the heart-sounds and voice over the superior régions of one side of the chest, harshness of the respiratory murmurs, and prolongation of the expiratory, or weakness or suppression of the murmurs, before there has been any alteration of shape or duluess on percussion.
